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Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures.

Publication ,  Journal Article
Tejwani, R; Wang, H-HS; Young, BJ; Greene, NH; Wolf, S; Wiener, JS; Routh, JC
Published in: J Pediatr Urol
December 2016

INTRODUCTION: Increased case volumes and training are associated with better surgical outcomes. However, the impact of pediatric urology sub-specialization on perioperative complication rates is unknown. OBJECTIVES: To determine the presence and magnitude of difference in rates of common postoperative complications for elective pediatric urology procedures between specialization levels of urologic surgeons. The Nationwide Inpatient Sample (NIS), a nationally representative administrative database, was used. STUDY DESIGN: The NIS (1998-2009) was retrospectively reviewed for pediatric (≤18 years) admissions, using ICD-9-CM codes to identify urologic surgeries and National Surgical Quality Improvement Program (NSQIP) inpatient postoperative complications. Degree of pediatric sub-specialization was calculated using a Pediatric Proportion Index (PPI), defined as the ratio of children to total patients operated on by each provider. The providers were grouped into PPI quartiles: Q1, 0-25% specialization; Q2, 25-50%; Q3, 50-75%; Q4, 75-100%. Weighted multivariate analysis was performed to test for associations between PPI and surgical complications. RESULTS: A total of 71,479 weighted inpatient admissions were identified. Patient age decreased with increasing specialization: Q1, 7.9 vs Q2, 4.8 vs Q3, 4.8 vs Q4, 4.6 years, P < 0.01). Specialization was not associated with race (P > 0.20), gender (P > 0.50), or comorbidity scores (P = 0.10). Mortality (1.5% vs 0.2% vs 0.3% vs 0.4%, P < 0.01) and complication rates (15.5% vs 11.7% vs 9.6% vs 10.9%, P < 0.0001) both decreased with increasing specialization. Patients treated by more highly specialized surgeons incurred slightly higher costs (Q2, +4%; Q3, +1%; Q4 + 2%) but experienced shorter length of hospital stay (Q2, -5%; Q3, -10%; Q4, -3%) compared with the least specialized providers. A greater proportion of patients treated by Q1 and Q3 specialized urologists had CCS ≥2 than those seen by Q2 or Q4 urologists (12.5% and 12.2%, respectively vs 8.4% and 10.9%, respectively, P = 0.04). Adjusting for confounding effects, increased pediatric specialization was associated with decreased postoperative complications: Q2 OR 0.78, CI 0.58-1.05; Q3 OR 0.60, CI 0.44-0.84; Q4 OR 0.70, CI 0.58-0.84; P < 0.01. DISCUSSION: Providers with proportionally higher volumes of pediatric patients achieved better postoperative outcomes than their less sub-specialized counterparts. This may have arisen from increased exposure to pediatric anatomy and physiology, and greater familiarity with pediatric techniques. LIMITATION: The NIS admission-based retrospective design did not enable assessment of long-term outcomes, repeated admissions, or to track a particular patient across time. The study was similarly limited in evaluating the effect of pre-surgical referral patterns on patient distributions. CONCLUSIONS: Increased pediatric sub-specialization among urologists was associated with a decreased risk of mortality and surgical complications in children undergoing inpatient urologic procedures.

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Published In

J Pediatr Urol

DOI

EISSN

1873-4898

Publication Date

December 2016

Volume

12

Issue

6

Start / End Page

388.e1 / 388.e7

Location

England

Related Subject Headings

  • Urology & Nephrology
  • Urologic Surgical Procedures
  • Retrospective Studies
  • Postoperative Complications
  • Pediatrics
  • Medicine
  • Male
  • Humans
  • Hospitalization
  • Female
 

Citation

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ICMJE
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Tejwani, R., Wang, H.-H., Young, B. J., Greene, N. H., Wolf, S., Wiener, J. S., & Routh, J. C. (2016). Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures. J Pediatr Urol, 12(6), 388.e1-388.e7. https://doi.org/10.1016/j.jpurol.2016.05.034
Tejwani, R., H. -. H. S. Wang, B. J. Young, N. H. Greene, S. Wolf, J. S. Wiener, and J. C. Routh. “Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures.J Pediatr Urol 12, no. 6 (December 2016): 388.e1-388.e7. https://doi.org/10.1016/j.jpurol.2016.05.034.
Tejwani R, Wang H-HS, Young BJ, Greene NH, Wolf S, Wiener JS, et al. Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures. J Pediatr Urol. 2016 Dec;12(6):388.e1-388.e7.
Tejwani, R., et al. “Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures.J Pediatr Urol, vol. 12, no. 6, Dec. 2016, pp. 388.e1-388.e7. Pubmed, doi:10.1016/j.jpurol.2016.05.034.
Tejwani R, Wang H-HS, Young BJ, Greene NH, Wolf S, Wiener JS, Routh JC. Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures. J Pediatr Urol. 2016 Dec;12(6):388.e1-388.e7.
Journal cover image

Published In

J Pediatr Urol

DOI

EISSN

1873-4898

Publication Date

December 2016

Volume

12

Issue

6

Start / End Page

388.e1 / 388.e7

Location

England

Related Subject Headings

  • Urology & Nephrology
  • Urologic Surgical Procedures
  • Retrospective Studies
  • Postoperative Complications
  • Pediatrics
  • Medicine
  • Male
  • Humans
  • Hospitalization
  • Female