C. A. Gutierrez1, P. P. Chiu2, R. Dasgupta3, H. C. Jen4, D. H. Rothstein1,5 1State University Of New York At Buffalo,Department Of Surgery,Buffalo, NY, USA 2Hospital For Sick Children,Department Of Surgery,Toronto, Ontario, Canada 3Cincinnati Children’s Hospital Medical Center,Department Of Surgery,Cincinnati, OH, USA 4Tufts Medical Center,Floating Hospital For Children,Boston, MA, USA 5Women And Children’s Hospital Of Buffalo,Department Of Surgery,Buffalo, NY, USA
Introduction:
While free-standing children’s hospitals may provide superior care to young and specialized patients, it is not clear whether this salutary benefit extends to young adults treated at those same institutions. This study asks what patient and hospital factors influence the type of hospital providing surgical care to young adults, and what factors influence postoperative complications in this group.
Methods:
A retrospective cohort study was performed using the 2012 Kid’s Inpatient Database to quantify and qualify operations performed on patients aged 18-20 years. Obstetric operations were excluded. Patient variables included age, gender, race/ethnicity, payer status, type of operation performed and illness severity (as measured by the All Patient Refined-Diagnosis Related Groups severity score). Hospital variables included U.S. region, urban/rural location and specialty designation. Outcomes included operations performed at a free-standing children’s hospital and complications. Odds ratios (OR), along with 95% confidence intervals (C.I.), were calculated using multivariate logistic regression analysis to adjust for confounders.
Results:
Among patients aged 18-20, non-whites (OR = 0.83, 95% C.I. 0.77-0.89), those with private insurance (OR = 0.71, 95% C.I. 0.66-0.77), and those receiving care in rural areas (OR = 0.67, 95% C.I. 0.60-0.75) were less likely to undergo operations at free-standing children’s hospital than other hospitals. Patients undergoing elective operations (OR = 5.93, 95% C.I. 5.52-6.38), those living in the Midwest or West U.S. regions compared to the Northeast, and those with progressively higher APR-DRG severity scores were more likely to undergo operations at free-standing children’s hospitals.
Postoperative complications in this group of patients were more likely to occur when operations were performed at free-standing children’s hospitals (OR = 1.68, 95% C.I. 1.41-1.99), were elective (OR = 1.62, 95% C.I. 1.44-1.82), or involved non-white patients (OR = 1.12, 95% C.I. 1.00-1.26). Payer status, rural hospital location and U.S. region did not appear to influence complication likelihood. Higher APR-DRG severity scores were associated with progressively higher odds of incurring postoperative complications.
Conclusion:
Race/ethnicity, payer status, hospital location and APR-DRG severity scores may play a role in determining the type of hospital where young adult patients receive surgical care. Paradoxically, receiving care at a free-standing children’s hospital may confer a higher risk of postoperative complications in this specific group as compared to care at other types of hospitals. Further stratification of patients by type of operation required or region of country may help direct resource utilization and improve outcomes. More work is needed to determine optimal delivery of care for patients who are poised for transition between pediatric and adult surgical services.