H. L. Short1, W. Zhu1, C. McCracken2, C. Travers2, L. Waller1, M. V. Raval1 1Emory University School Of Medicine,Pediatric Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Pediatrics,Atlanta, GA, USA
Introduction: There is significant variation surrounding the indications, surgical approaches, and outcomes for children undergoing antireflux procedures (ARPs) resulting in differences in geographic utilization in the United States. Our purpose was to examine regional and state-level trends in utilization of ARPs and to determine if overall surgical utilization was correlated with use of laparoscopy.
Methods: A cross-sectional analysis of the 2009 Kid’s Inpatient Database was performed to identify patients <21 years old with one of the following diagnoses of interest: esophagitis, esophageal stricture, dysphagia, aspiration, apnea, failure to thrive, Barrett’s esophagus, gastroesophageal reflux (GERD), esophageal ulcer, or hiatal hernia. We then determined which of these patients underwent an ARP and the surgical approach utilized (laparoscopic versus open). A mixed effects model was used to determine which regions and individual states were high utilizers of surgery and to identify patient and hospital factors associated with open versus laparoscopic procedures.
Results: Of the 148,959 patients with one or more of the diagnoses of interest, 4,848 (3.3%) patients underwent an ARP with 2376 (49%) undergoing a laparoscopic procedure. GERD was the most common indication (79%) for ARPs. Older children (ages 11-20 years) had lower ARP utilization compared to children <1 year old (Odds Ratio (OR) 0.37; 95% Confidence Interval (CI) 0.33-0.40). The Northeast and Midwest had the lowest overall utilization of surgery (2.5%), compared to the West (3.8%) and South (3.8%). After adjustment for age, case-mix, and surgical approach and allowing for state specific utilization rates, regional variation persisted with the West and the South demonstrating close to 2 times the odds of undergoing an ARP compared to the Northeast (Table). Surgical utilization rates appeared to be independent of state-level case volume with some of the highest case volume states (Florida, New York and Ohio) having surgical utilization rates below the national rate. In the West, the use of laparoscopy appeared to correlate with overall utilization of surgery, while surgical approach was not correlated with ARP use in the South.
Conclusion: Significant regional variation in ARP utilization exists that cannot be explained entirely by differences in patient age, patient race/ethnicity, case-mix, and surgical approach. In order to decrease variation in care and potentially improve care, further research is warranted to delineate local factors driving surgical utilization of ARP in children. Consensus guidelines regarding indications and appropriateness for use are needed.
