Samuel Rice-Townsend

Variation in practice and resource utilization associated with the diagnosis and management of appendicitis at freestanding children's hospitals: implications for value-based comparative analysis.

Objective:To characterize the scope and magnitude of practice variation associated with the diagnosis and treatment of appendicitis at freestanding childrens hospitals. Background:Variation in care has been associated with poor outcomes and is believed to be a key driver of excess health care spending. Methods:Retrospective cohort study of 13,328 patients treated with appendicitis at 34 childrens hospitals (9/2010–9/2011). Patients were divided into complicated and uncomplicated cohorts and examined for interhospital variation in the use of diagnostic imaging (computed tomography or ultrasonography), laboratory tests, parenteral nutrition (PN), peripherally inserted central catheters (PICC), and hospital cost. The number and distribution of statistical outliers were calculated for all measures. Results:Significant variation was found for all measures, including a 3.5-fold difference in preoperative imaging (aggregate rate: 49.0%, range across hospitals: 21.2%–73.5%, P < 0.001) and a 5-fold difference in preoperative laboratory utilization (aggregate median: 2 tests/encounter, range: 1–5 tests/encounter, P < 0.001). For patients with complicated appendicitis, we characterized a 12-fold difference in postoperative imaging (aggregate rate: 19.4%, range: 4.9%–61.6%, P < 0.001), a 48-fold difference in PICC lines (aggregate rate: 18.9%, range: 1.7%–81.8%, P < 0.001), and a 100-fold difference in PN utilization (aggregate rate: 9.3%, range: 0.4%–42.0%, P < 0.001). Median hospital cost differed 4-fold for patients with uncomplicated disease (aggregate median:

Variation in risk-adjusted hospital readmission after treatment of appendicitis at 38 children's hospitals: an opportunity for collaborative quality improvement.

6804, range:

Variation in practice patterns and resource utilization surrounding management of intussusception at freestanding Children's Hospitals.

4200–

Relationship between unplanned readmission and total treatment-related hospital days following management of complicated appendicitis at 31 children's hospitals

16,796, P < 0.001) and 4.6-fold for patients with complicated disease (aggregate median:

Delayed presentation of traumatic infrapopliteal arteriovenous fistula and pseudoaneursym in a 10-year-old boy managed by coil embolization.

13,138, range:

Hernia recurrence following inguinal hernia repair in children

5419–

Nutrition Support During Pediatric Extracorporeal Membrane Oxygenation

24,779, P < 0.001). Statistical outliers on the basis of high and low utilization were identified for all measures. Conclusions:Significant variation exists in practice, resource utilization, and treatment-related cost associated with the management of appendicitis at freestanding childrens hospitals. Value-based measures are needed for benchmarking and to prioritize collaborative quality improvement efforts.

Thoracoscopic division of vascular rings

Objectives:To identify risk factors associated with readmission for children treated with appendicitis, and to characterize variation in risk-adjusted readmission rates between childrens hospitals. Background Data:Hospital readmission has been increasingly targeted as a marker for quality of care, yet little is known regarding risk factors associated with readmission or the degree of performance variation that exists between hospitals for this cohort of patients. Methods:Retrospective cohort study of 47,866 patients treated at 38 childrens hospitals (2006–2010). Multivariate regression was used to examine and adjust for the influence of risk factors on 30-day readmission rates. Hospitals were considered performance outliers if their readmission rate and 95% confidence interval (CI) did not include the overall rate. Results:Factors associated with readmission included disease severity [high vs. low: odds ratio (OR) 4.57, 95% CI: 3.72–5.60; moderate vs. low: OR 2.29, 95% CI: 2.00–2.61] and insurance status (public vs. private: OR 1.14, 95% CI: 1.0–1.29). After adjustment for these factors, the relative decile-based performance rankings changed for 17 (45%) of the 38 hospitals and six (16%) hospitals changed the outlier status based on their standardized readmission rates. A 3.8-fold variation in standardized readmission rates was found across the 38 hospitals after adjustment (overall rate: 8.9%, range: 4.1%–15.4%, P < 0.0001), and 24 (63%) hospitals were identified as outliers (12 low performers and 12 high performers). Conclusion:Significant variation in risk-adjusted readmission rates exists among childrens hospitals after treatment of appendicitis, and outliers can be identified at both ends of the performance spectrum. These findings may have important implications for the identification and dissemination of “best practices” from exemplar hospitals.

Hospital readmission after management of appendicitis at freestanding children's hospitals: contemporary trends and financial implications

PURPOSE To characterize variation in practice patterns and resource utilization associated with the management of intussusception at Childrens Hospitals. METHODS A retrospective cohort study (1/1/09-6/30/11) of 27 Childrens Hospitals participating in the Pediatric Health Information System database was performed. Hospitals were compared with regard to their rates of operative management following attempted enema reduction, prophylactic antibiotic utilization, same-day discharge for those successfully managed non-operatively, 48-h readmission rates, and case-related cost and charges. RESULTS 2544 patients were identified (median: 93 cases/center) with a median age of 17 months. The rate of operation following attempted enema reduction varied significantly across hospitals (overall rate: 21.1%: range: 11%-62.8%; p<0.0001). For patients managed non-operatively, significant variability was found for prophylactic antibiotic utilization (overall rate: 23.3%; range: 1.4%-93.2%; p<0.0001), same-day discharge (overall rate: 15.2%; range: 0%-83.8%; p<0.0001), readmission rates (overall rate: 17.5%; range: 5.3%-32.1%; p<0.0001), treatment-related costs (overall median:

Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures

2490; range: