Rahul K. Shah

American College of Surgeons National Surgical Quality Improvement Program Pediatric: A beta phase report

PURPOSE The American College of Surgeons (ACS) National Surgical Quality Improvement Program Pediatric (NSQIP-P) expanded to beta phase testing with the enrollment of 29 institutions. Data collection and analysis were aimed at program refinement and development of risk-adjusted models for inter-institutional comparisons. METHODS Data from the first full year of beta-phase NSQIP-P were analyzed. Patient accrual used ACS-NSQIP methodology tailored to pediatric specialties. Preliminary risk adjusted modeling for all pediatric and neonatal operations and pediatric (excluding neonatal) abdominal operations was performed for all cause morbidity (other than death) and surgical site infections (SSI) using hierarchical logistic regression methodology and eight predictor variables. Results were expressed as odds ratios with 95% confidence intervals. RESULTS During calendar year 2010, 29 institutions enrolled 37,141 patients. 1644 total CPT codes were entered, of which 456 accounted for 90% of the cases. 450 codes were entered only once (1.2% of cases). For all cases, overall mortality was 0.25%, overall morbidity 7.9%, and the SSI rate 1.8%. For neonatal cases, mortality was 2.39%, morbidity 18.7%, and the SSI rate 3%. For the all operations model, risk-adjusted morbidity institutional odds ratios ranged 0.48-2.63, with 9/29 hospitals categorized as low outliers and 9/29 high outliers, while risk-adjusted SSI institutional odds ratios ranged 0.36-2.04, with 2/29 hospitals low outliers and 7/29 high outliers. CONCLUSION This report represents the first risk-adjusted hospital-level comparison of surgical outcomes in infants and children using NSQIP-P data. Programmatic and analytic modifications will improve the impact of this program as it moves into full implementation. These results indicate that NSQIP-P has the potential to serve as a model for determining risk-adjusted outcomes in the neonatal and pediatric population with the goal of developing quality improvement initiatives for the surgical care of children.

Paranasal sinus development: A radiographic study

Objective To demonstrate the development of the paranasal sinuses in a pediatric population by computed tomography scans.

Classification and Consequences of Errors in Otolaryngology

Objective: To develop a preliminary classification system for errors in otolaryngology.

Nonsurgical therapies for lymphangiomas: a systematic review.

Objective Systematically review the published literature regarding the efficacy of nonsurgical therapies in the treatment of head and neck (H&N) lymphatic malformations (LM) in children. Data Source MEDLINE. Review Methods MEDLINE was searched for literature relating to nonsurgical treatments for H&N LM. Results The initial search returned 1876 articles, with 22 meeting criteria. The majority (20) were case series. All therapies were percutaneous, with OK-432 or bleomycin sclerotherapy being most common. Random-effects modeling revealed 43% (CI = 28.9%-57%) of patients undergoing OK-432 for LM achieved a complete/excellent response, 23.5% (CI = 5.8%-41.3%) achieved a good response, 16.9% (CI = 10.3%-23.4%) achieved a fair/poor response, and 15.4% (CI = 8.6%-22.2%) observed no response. In the bleomycin group, the results were: 35.2% (CI = 15.7%-54.6%) excellent, 37.1% (CI = 22%-52.3%) good, 18.4% (CI = 2.7%-34.2%) fair/poor, and 11.6% (CI = 3.5%-19.6%) no response. Seven major complications were noted out of the 289 patients in the series, including two mortalities. Conclusions The literature indicates that sclerotherapy for H&N LM achieves excellent/good clinical response in a majority of patients, with few complications, and anecdotally does not complicate future surgery.

Epiglottitis in the Hemophilus influenzae Type B Vaccine Era: Changing Trends †

Objective To describe the epidemiology, natural history, and treatment of epiglottitis in the Hemophilus influenzae type B (Hib) vaccine era.

Hereditary Hemorrhagic Telangiectasia: A Review of 76 Cases†

Objectives/Hypothesis Hereditary hemorrhagic telangiectasia has long been viewed as a rare condition. Recent evidence indicates that the disorder is more frequent than previously thought. Recalcitrant epistaxis is a salient feature of this disease, and the otolaryngologist is often called on to make the diagnosis and guide the primary management of patients with hereditary hemorrhagic telangiectasia. Wider recognition of this condition, awareness of the natural history and associated findings, appropriate workup and screening for arteriovenous malformations (lungs, brain, liver), and knowledge of appropriate interventions can help avoid the considerable morbidity associated with hereditary hemorrhagic telangiectasia.

Risk-Adjusted Hospital Outcomes for Children’s Surgery

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children’s surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance. METHODS: Participating institutions included children’s units within general hospitals and free-standing children’s hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models. RESULTS: In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible. CONCLUSIONS: The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children’s surgery performance indicator. Programmatic improvements have resulted in actionable data.

Tracheotomy-related catastrophic events: Results of a national survey†‡

To gather qualitative and semiquantitative information about catastrophic complications during and following tracheotomy.

Systematic Review of Complications of Tonsillotomy versus Tonsillectomy

Objective. Intracapsular tonsillotomy continues to gain acceptance as an alternative to traditional tonsillectomy. Despite large clinical studies, there is a lack of consensus as to which technique offers lower complication rates. This study seeks to analyze the available data and surmise the complication rates of partial tonsillectomy as compared with traditional tonsillectomy. Data Sources. MEDLINE was searched using multiple search terms. Review Methods. After the MEDLINE search, the following inclusion criteria were applied: English language, human subjects, and related to partial tonsillectomy. Multiple tonsillotomy techniques were included. The results of these studies were summated and the results analyzed. Subgroup analysis was then performed. Results. Thirty-three studies met inclusion criteria. Tonsillotomy had a lower postoperative bleeding rate, lower postoperative dehydration rate requiring medical care, reduced days of analgesic use, and reduced days to return to normal diet compared with tonsillectomy. When separated into higher versus lower quality studies, the differences in bleeding and dehydration were negligible, while differences in return to diet and days of analgesic use persisted. Mean intraoperative blood loss was similar for both techniques. Insufficient data were available to assess tonsil regrowth rates. Conclusions. Tonsillotomy appears to be a safe technique that may offer some advantages over tonsillectomy in terms of postoperative morbidity, but differences in hemorrhage and dehydration were not evident in high-quality studies. Data regarding tonsil regrowth rates and efficacy in treating sleep-disordered breathing are not yet sufficient for formal analysis, which may preclude widespread acceptance of this technique.

Epiglottitis in the United States: national trends, variances, prognosis, and management.

To study national trends, variances, and outcomes in patients admitted with epiglottitis in the United States. We hypothesize that the incidence of epiglottitis has decreased, mortality has decreased, and that there has been a shift toward older patients being admitted with epiglottitis.