L. R. Putnam1,3,4, L. K. Nguyen2, K. P. Lally1,3,4, L. Franzini2, K. Tsao1,3,4, M. T. Austin1,3,4 4Children’s Memorial Hermann Hospital,Houston, TX, USA 1University Of Texas Health Science Center At Houston,Department Of Pediatric Surgery,Houston, TX, USA 2University Of Texas School Of Public Health,Department Of Management, Policy, And Community Health,Houston, TEXAS, USA 3Center For Surgical Trials And Evidence-based Practice,Houston, TX, USA
Introduction:
Appendicitis is the most common surgical disease in children, yet few data exist to support care by pediatric surgeons or within children’s hospitals (specialized care). We hypothesized that children treated with specialized care are younger, have more severe disease, and experience equal or better outcomes than children treated by general surgeons or in non-children’s hospitals.
Methods:
A retrospective cohort study of Texas Blue Cross / Blue Shield (BCBS) claims data from 2008 – 2012 was performed of all children (< 18 years) who underwent appendectomy for acute appendicitis. Children’s hospitals were identified based on the number and/or percentage of pediatric admissions over a five year period. Hospital length of stay (LOS) was used as a surrogate for disease severity; complicated appendicitis was defined as LOS ≥ 3 days. Primary outcomes included adverse events, 30-day readmissions, and LOS. Chi-square, Student’s t-test, and multivariate regression were performed.
Results:
Of the 3,886 pediatric appendectomies, 894 (23%) were performed by pediatric surgeons and 1558 (40%) were performed in children’s hospitals. Children treated by pediatric surgeons were younger (10.9 ± 0.1 vs 12.0 ± 0.1 years, p<0.01), had more severe disease (48% vs 42% complicated, p=0.01), underwent fewer computed tomography (CT) exams (64% vs 71%, p<0.01), and were hospitalized longer (3.6 ± 3.3 days vs. 3.0 ± 2.1 days, p<0.01). Similarly, children treated in children’s hospitals were younger (11.1 ± 3.4 vs 12.2 ± 3.4, p<0.01), underwent fewer CTs (59% vs 77%, p<0.01), were more likely to undergo laparoscopic appendectomy (82% vs 75%, p<0.01), and were hospitalized longer (3.3 ± 2.8 days vs 3.0 ± 2.2 days, p<0.01). On multivariate analysis, specialized care did not predict adverse events or 30-day readmissions. However, longer hospital LOS was associated with treatment by pediatric surgeons (0.5 days, p<0.01) or within a children’s hospital (0.2 days, p<0.01).
Conclusion:
Privately-insured children in Texas treated for appendicitis by pediatric surgeons or in children’s hospitals were younger, had more severe disease, and were hospitalized longer but were less likely to undergo preoperative CT. While outcomes were similar between children receiving specialized and non-specialized care, there is likely a role for specialized care for younger children and for those with more severe disease. Future studies should evaluate costs and efficiency of specialized care given fewer CTs but longer LOS for children.