Paulette I. Abbas

Risk-stratification of severity for infants with CDH: Prenatal versus postnatal predictors of outcome

PURPOSE The purpose of this study was to compare the predication accuracy of a newly described postnatally-based clinical prediction model to fetal imaging-based predictors of mortality for infants with CDH. METHODS We performed a retrospective review of all CDH patients treated at a comprehensive fetal care center from January 2004 to January 2014. Prenatal data reviewed included lung-to-head ratio (LHR), observed/expected-total fetal lung volume (O/E-TFLV), and percent liver herniation (%LH). Based on the postnatal prediction model, neonates were categorized as low, intermediate, and high risk of death. The primary outcome was 6-month mortality. RESULTS Of 176 CDH patients, 58 had a major cardiac anomaly, and 28 had a genetic anomaly. Patients with O/E-TFLV <35% and %LH >20% were at increased risk for mortality (44% and 36%, respectively). There was a significant difference in mortality between low, intermediate, and high-risk groups (4% vs. 22% vs. 51%; p<0.001). On multivariate regression, the O/E-TFLV and postnatal-based mortality risk score were the two independent predictors of 6-month mortality. CONCLUSION The CDH Study Group postnatal predictive model provides good discrimination among three risk groups in our patient cohort. The prenatal MRI-based O/E-TFLV is the strongest prenatal predictor of 6-month mortality in infants with CDH and will help guide prenatal counseling and discussions regarding fetal intervention and perinatal management.

Time-driven activity-based costing to identify opportunities for cost reduction in pediatric appendectomy

PURPOSE As reimbursement programs shift to value-based payment models emphasizing quality and efficient healthcare delivery, there exists a need to better understand process management to unearth true costs of patient care. We sought to identify cost-reduction opportunities in simple appendicitis management by applying a time-driven activity-based costing (TDABC) methodology to this high-volume surgical condition. METHODS Process maps were created using medical record time stamps. Labor capacity cost rates were calculated using national median physician salaries, weighted nurse-patient ratios, and hospital cost data. Consumable costs for supplies, pharmacy, laboratory, and food were derived from the hospital general ledger. RESULTS Time-driven activity-based costing resulted in precise per-minute calculation of personnel costs. Highest costs were in the operating room (

Successful endoscopic ablation of a pyriform sinus fistula in a child: case report and literature review

747.07), hospital floor (

A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough? ☆ ☆☆ ★

388.20), and emergency department (

Evaluating the impact of infliximab use on surgical outcomes in pediatric Crohn's disease.

296.21). Major contributors to length of stay were emergency department evaluation (270min), operating room availability (395min), and post-operative monitoring (1128min). The TDABC model led to

Time-driven activity-based costing: A dynamic value assessment model in pediatric appendicitis☆

1712.16 in personnel costs and

Evaluating a management strategy for malrotation in heterotaxy patients

1041.23 in consumable costs for a total appendicitis cost of

Persistent hypercarbia after resuscitation is associated with increased mortality in congenital diaphragmatic hernia patients

2753.39. CONCLUSION Inefficiencies in healthcare delivery can be identified through TDABC. Triage-based standing delegation orders, advanced practice providers, and same day discharge protocols are proposed cost-reducing interventions to optimize value-based care for simple appendicitis. LEVEL OF EVIDENCE II.

Ovarian lesion volumes as a screening tool for malignancy in adolescent ovarian tumors

Recurrent thyroid infections are rare in children. When present, patients should be evaluated for anatomic anomalies such as pyriform sinus fistulae. We describe a 12-year-old girl with history of recurrent thyroid abscesses secondary to a pyriform sinus fistula and managed with concurrent endoscopic ablation and incision and drainage.

Evaluating the effect of time process measures on appendectomy clinical outcomes

BACKGROUND/PURPOSE Surgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions. METHODS A before-and-after study from 2011-2014 at eleven childrens hospitals was conducted. The SWC recorded in the hospitals intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohens weighted kappa and chi square. RESULTS Surgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p<0.01) and weighted kappa from 0.45 (95% CI 0.42-0.48) to 0.73 (95% CI 0.70-0.75). Median (range) improvement per institution was 23% (7-35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution. CONCLUSIONS Intraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.