67.09 The Effect of Insurance Type on Access to Inguinal Hernia Repair Under the Affordable Care Act

Posted on January 18, 2018

W. Hsiang1, S. Lee1, C. McGeoch1, W. Cheung1, R. Becher1, K. A. Davis1, K. Schuster1  1Yale University School Of Medicine,General Surgery, Trauma And Surgical Critical Care,New Haven, CT, USA

Introduction:
The expansion of Medicaid under the Affordable Care Act (ACA) extended coverage to any individual with incomes up to 138% of the federal poverty level. As of January 2017, 31 states and the District of Columbia have elected to expand Medicaid. Our study investigated the impact of the type of insurance on access to elective inguinal hernia repair and the disparities in access between expansion and non-expansion states.

Methods:
Using the Amercian College of Surgeons directory, 240 hernia repair surgeons across eight states (four which have expanded Medicaid [NY, CA, OH, IL] and four which have not [TX, FL. NC, GA]) were randomly selected. Investigators posed as simulated patients seeking an evaluation for an inguinal hernia and phoned selected surgeons. Physician offices were contacted using a standardized script from a caller ID-blocked phone number at three separate occasions to assess responses to three different insurance types (Blue Cross, Medicaid, Medicare). Appointment success rates and waiting periods were compared between published Medicaid and Blue Cross or Medicare scenarios.

Results:
Of 240 surgeons contacted, 75.4% scheduled appointments for Medicaid patients, compared to 98.8% for Medicare patients and 98.3% for those with Blue Cross (p<0.001). In states that expanded Medicaid, fewer offices accepted Medicaid patients compared to those in non-expanded States (68.3% vs 82.5%, P=0.011). No differences in wait times between expanded and non-expanded states were observed. Surgeons in urban settings were less likely to accept Medicaid patients than non-urban offices (70.6% vs 82.5%, P=0.036) while solo practices were less likely to accept Medicaid patients than group practices (50.0% vs 79.0%, P<0.001). No differences in the acceptance of Medicaid patients between academic and private practice surgeons were noted (P=0.516).

Conclusion:
Simulated Medicaid patients were less successful at scheduling appointments for surgical consultation than Blue Cross or Medicare patients. Despite expanded Medicaid, fewer surgeons in expansion states accepted Medicaid patients. These findings should be further investigated with future changes in Medicaid to understand impact on access to surgical care.
 

67.10 A Comparison of Index and Redo Operations in Crohn's Patients Following Bowel Surgery.

Posted on January 18, 2018

B. Sherman2, A. Harzman1, A. Traugott1, S. Husain1  1Ohio State University,Division Of Colon And Rectal Surgery,Columbus, OH, USA 2Ohio Health,Doctor’s Hospital,Columbus, OH, USA

Introduction: Due to chronic, recurrent nature of Crohn’s disease, many patients undergo repeat operations. These “redo” surgeries can be technically difficult due to the presence of adhesive disease and inflammatory / fibrotic changes. Thus, subsequent operative interventions are commonly perceived to be wrought with worse outcomes. While there is a plethora of literature on outcomes after index operations for Crohn’s disease, there is a scarcity of articles describing outcomes of redo operations and how they compare with index operations. An in-depth knowledge of these variables is critical for managing patient expectations and optimal perioperative planning from the surgeon’s perspective.

Methods: All Crohn’s patients undergoing surgery with the two participating surgeons over a period of six years were included. A retrospective chart review was conducted including patient demographics, comorbidities, postoperative complications, operative time, length of stay, and estimated blood loss. A comparison of in index versus redo operations was performed utilizing t-test for continuous variables and Fisher's exact test for categorical variables.

Results: We identified a total of 118 patients during the approved study period. Out of these 66 (55%) underwent index operation and 52 (45%) were redo operations. Overall complication rate was 29.66% (n=35), mean operative time was 220 minutes, average length of hospital stay was 8.36 days and EBL was 189.62 ml. There was no statistically significant difference between index and redo operations in terms of complication rates (27.27% vs 32.69%, p=0.55), EBL (211 vs 231 ml, p=0.85) and operative time (211 vs 231 min, p=0.28). However, the difference in length of stay between index operations (mean=6.79 days) and redo surgeries (mean=10.93 days) was statistically significant (p=0.0005). Laparoscopic approach was utilized at a significantly higher rate for index operations (61/66, 92.42%) compared to redo operations (35/52, 67.30%, p=0.007). Conversion rates were much higher for redo operations (3/35, 8.57%) than index operations (3/61, 4.91%). Use of laparoscopic approach narrowed the gap in length of stay between the index and redo groups from 4.14 days for the entire group to 1.8 days in patients who were treated laparoscopically.

Conclusion: Contrary to common perception, repeat operations in Crohn’s disease have similar outcomes as index operations however redo surgeries are associated with a much longer length of stay compared to initial surgeries. Utilization of laparoscopic technique reduces the gap in length of stay between index and redo operations however laparoscopy is associated with higher a conversion rate in redo operations.

67.06 The costs of complications on post-acute care spending after major surgery

Posted on January 18, 2018

A. E. Kanters1, A. Cain-Nielsen2, S. Regenbogen1  1University Of Michigan,General Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction:  With increasing scrutiny on total spending for episodes of care, it is recognized that post-acute care (PAC) is the principal source of variation in payments around surgery. Studies have demonstrated that hospital quality is associated with episode spending, however the extent to which quality improvement measures to decrease postoperative complications can affect PAC costs has not been quantified. 

Methods:  This cross-sectional cohort study included Medicare beneficiaries undergoing colectomy, coronary artery bypass grafting (CABG), or total hip replacement (THR) between January 2009 and June 2012. Each patient with a recorded postoperative complication was matched 1:1 with one who underwent the same operation, but without complication, according to preoperative predictors of PAC spending (including Elixhauser comorbidities, age and type of admission). We computed average prize-standardized PAC spending within 90 days from index operation and compared adjusted payments and rates of use of each type of PAC between those with and without complications. PACs were dichotomized as inpatient (skilled nursing facility [SNF], inpatient rehabilitation [IPR], or long term acute care [LTAC]) versus outpatient settings (outpatient rehabilitation [OPR] or home health [HH]).

Results: After risk-matching, 73,858 CABG patients, 62,948 colectomy patients, and 3,192 THR patients were included. Price-standardized PAC payments increased $5,590 for CABG (p<0.001), $6,600 for colectomy (p<0.001), and $2,051 for THR patients (p<0.001) with postoperative complications. Among patients with complications, the likelihood of inpatient PAC was increased by 9.6% after CABG (p<0.001), 7.3% after colectomy (p<0.001), and 5.3% after THR (p=0.001); accordingly, there was a decrease in likelihood of outpatient PAC by 10.4% after CABG (p<0.001) and 6.2% after colectomy (p<0.001). There was no significant change in outpatient PAC utilization for THR patients (Figure).

Conclusion: Postoperative complications after major surgery are associated with significantly greater PAC spending, and increased use of high-cost, inpatient care settings. Reductions in PAC spending will be central to hospitals’ efforts to reduce episode costs around major surgery. Thus, quality improvement efforts that reduce postoperative complications will be a key component of success in emerging payment reform.

 

67.07 Needlescopic analgesia of abdominal wall for laparoscopic surgery

Posted on January 18, 2018

J. Nagata1, Y. Sawatsubashi1, M. Akiyama1, Y. Akiyama2, K. Arase2, N. Minagawa2, T. Torigoe2, Y. Nakayama1, K. Hirata2  1Wakamatsu Hospital Of University Of Occupational And Environmental Health, Japan,Surgery,Kitakyushu, FUKUOKA, Japan 2University Of Occupational And Environmental Health, Japan,Surgery,Kitakyushu, FUKUOKA, Japan

Introduction: Ultrasound-guided percutaneous rectus sheath block and transversus abdominis plane block have become increasingly popular and used to provide analgesia for laparoscopic surgery. We report a novel transperitoneal approach of analgesia for laparoscopic abdominal surgery.

Methods: Observation was performed retrospectively. Two groups were compaired. One is the group with only conventional anesthesia, and the other was patients with novel nerve block. Under general anesthesia, a laparoscopic puncture needle was inserted via 3 or 5mm abdominal port, and 10 – 20mL levobupivacaine was injected into the correct plane through the peritoneum. This procedure was performed under combined images of laparoscopy and ultrasound. Postoperatively, the patient’s pain intensity assessed by the numeric rating scale.

Results: A total of 100 consecutive patients were enrolled. Colorectal surgery was 50 cases, gastric surgery was 15 cases, repair of inguinal hernia was 25 cases and other was 10. All operation was performed successfully and a novel laparoscopic anesthesia did not prevent completing operative procedure. Postoperatively, the patient’s mean pain intensity by the scale was measured. Numeric rating scale was smaller in the group of novel anesthesia (0.4 vs 0.8 at 6hrs postoperative on moving, p=0.29). Total volume of intravenous fentanyl?(10mL vs 5mL/2days) and frequency of pain killer was reduced?(1.5 vs 2.8?times/day, p=0.03). The mean time of novel block technique was 4.5 minutes

Conclusion: This novel analgesia technique would be considered as an optional regimen in laparoscopic surgery. Additional prospective studies are required to evaluate the benefit of this new laparoscopic block.
 

67.08 Patient Education Materials Among Surgical Subspecialties Lack Readability

Posted on January 18, 2018

C. A. Perkins1, A. Liwo1, C. A. Gamuko2, J. A. Cannon1, J. Grams1, G. Kennedy1, M. Morris1, J. Richman1, D. I. Chu1  1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Nursing,Birmingham, Alabama, USA

Introduction:  Health literacy is a major determinant of health outcomes through its influence on patient understanding of their care and aftercare instructions.  Patients’ understanding can be affected by the readability of health education material, which the American Medical Association (AMA) and National Institute of Health (NIH) recommends to be at a 6th grade reading level or lower. It is unclear whether surgical education materials follow this recommendation. We hypothesized that surgical patient education materials across surgical specialties are written above a 6th grade reading level. 

Methods:  Routine patient education materials were collected from surgical specialty clinics at a single, tertiary-care referral center. The Flesch-Kincaid Grade Level (FKGL) instrument was used to analyze the texts to generate a FKGL score without any correction of misspellings or grammatical errors. We averaged the FKGL for each sample to obtain a mean for each surgical specialty. Specialties were compared using two-sided one sample t-tests and ANOVA, as appropriate.  

Results: We collected 112 patient education materials from 13 surgical specialties. Of these, 29 were pre-operative, 58 were post-operative and 25 were clinical in nature. The overall average FKGL for all the patient education materials was 8.08 (standard deviation [SD] 2.08), exceeding the NIH/AMA standards sixth grade level by an average of 2.08 grade levels (95% CI=7.69-8.47; P <0.0001). Among specialties, the highest mean FKGLs were Neurosurgery (mean=9.83, SD=3.29, CI=1.65-18.01) and Thoracic (mean=9.61, SD=0.75, CI=9.03-10.19) while the lowest were Plastic Surgery (mean=6.34, SD=1.54, CI=5.61-7.09) and Endocrine (mean=7.08, SD=1.62, CI= 5.92-8.24) (Table 1). Surgical specialties with the highest percentage of reading materials at or below a 6th grade level were Plastics (47.4%), ENT (25.0%), GI-General (23.1%), Endocrine (20.0%) and Transplant (12.5%). The other 8 specialties had no materials at or below a 6th grade level.

Conclusion: The readability of patient education material across surgical subspecialties at a single institution is poor and deviates significantly from AMA/NIH recommendations. No surgical specialties had a majority of their material at the recommended 6th grade level and all surgical specialties had an average FKGL above the 6th grade level. Targeting patient education material to reduce the FKGL may be an actionable improvement to impact health literacy and potentially health outcomes.

 

67.04 Impact of Preoperative and Postoperative Opioid Use on Surgical Readmissions

Posted on January 18, 2018

E. A. Dasinger1,2, L. A. Graham1,2, T. S. Wahl1,2, S. J. Baker1,2, M. T. Hawn3, T. Hernandez-Boussard3, K. Desai3, J. S. Richman1,2, K. M. Itani4, G. L. Telford5, S. J. Knight1,2, M. S. Morris1,2  1University Of Alabama At Birmingham,Birmingham, AL, USA 2Birmingham VA Medical Center,Birmingham, AL, USA 3VA Palo Alto Healthcare Systems,Palo Alto, CA, USA 4VA Boston Healthcare System,West Roxbury, MA, USA 5Clement J Zablocki Veterans Affairs Medical Center,Milwaukee, WI, USA

Introduction: The number of patients taking opioids has risen drastically over the last decade and recent literature suggests that preoperative opioid use is associated with higher readmission rates. Although opioids are widely used to manage acute postsurgical pain, some patients remain opioid dependent following surgery. This study examines the relationship between opioid use and surgical readmissions and evaluates the incidence of new persistent opioid use in a veteran population.

Methods:  We performed a national retrospective cohort study of general, orthopedic, and peripheral vascular inpatient surgeries occurring in the VA Healthcare System between October 2007 and September 2014. Pharmacy outpatient data within the VA Corporate Data Warehouse was used to calculate the proportion of days covered (PDC) for opioid medications in the six months prior to surgery and six months post-discharge. Patients were stratified into four groups defining preoperative opioid usage: no use, infrequent use (< 2 prescription fills or < 30 days of supply), frequent but not daily use (≥ 3 prescription fills with < 80% PDC), and daily use (≥ 3 prescription fills with ≥ 80% PDC). Our primary outcome of interest was unplanned 30 day readmission rates. Univariate and bivariate statistics along with adjusted logistic models were used to examine odds of pain-related readmission.

Results: A total of 237,441 patients were included in the analysis. In the six months prior to surgery, 59.8% showed no evidence of opioid use, 18.5% were considered infrequent users, 7.9% were frequent users, and 13.8% were considered daily opioid users. The adjusted odds of pain-related readmission within 30 days of discharge were higher for those with opioids on hand at admission and for the three groups with exposure to opioids within the six months prior to surgery as compared to the opioid naïve group: opioids on hand at admission (OR 1.17; 95% CI 1.05-1.31), infrequent (OR 1.12; 95% CI 1.02-1.23), frequent (OR 1.24; 95% CI 1.08-1.42), and daily (OR 1.40; 95% CI 1.23-1.59). Overall, patients who filled opioids at discharge had higher odds of pain related readmission within 30 days of discharge (adjusted OR 1.51; 95% CI 1.29-1.78). Of the previously opioid naïve patients, 6.8% became frequent users and 2.8% became daily opioid users at six months post-surgery. Of the previously infrequent opioid users, 19.4% became frequent users and 7.5% became daily opioid users at six months post-surgery. 

Conclusion: Preoperative and postoperative opioid use is associated with an increased risk for readmission. Decreasing the use of opioids before and after surgery may improve surgical quality and lead to better outcomes. Persistent opioid use following surgery is common and providers should minimize the amount of opioids prescribed and consider alternative pain management strategies to prevent patients from moving beyond acute opioid use.

67.05 Improved Peri-Operative Outcomes with Extended Lymph Node Dissection for Gastric Cancer in the U.S.

Posted on January 18, 2018

C. Granruth1, P. Friedmann1, P. Muscarella1, J. C. McAuliffe1, H. In1  1Montefiore Medical Center,Department Of Surgery,Bronx, NY, USA

Introduction:
Controversy remains regarding the extent of lymphadenectomy that should be performed at the time of gastrectomy for gastric adenocarcinoma. Although guidelines promote lymph node dissections of ≥15, extended lymph node dissection (ELND) has been reported to confer increased morbidity without oncologic benefit, contributing to poor uptake of this guideline. We utilized the National Cancer Data Base (NCDB) to examine peri-operative mortality and long-term mortality for gastrectomies with ELND compared to those without.

Methods:
Gastric adenocarcinoma patients diagnosed between 2004 and 2013 were identified. Analysis was limited to patients who were candidates for ELND, including ages of 18 – 74, stage II or III, and without any Charlson comorbidities. Demographis and outcomes were compared between patients who had ELND (≥16) to those who did not. Logistic regression, Kaplan-Meier and Cox regression analyses were performed using SAS 9.4 (Cary, NC).

Results:
Of 10,921 patients, 5,364 (49.12%) underwent ELND. They were more likely to be treated at academic/research institutions (48.64% vs. 37.92%), higher volume hospitals (25.82 vs. 17.01), and to have been transferred prior to treatment (55.59% vs. 49.90%). They were more likely to be stage III (64.60% vs. 53.14%), have tumor size >40mm (59.71% vs. 52.80%), and have positive regional lymph nodes (83.59% vs. 74.21%). Multivariate analyses showed that ELND was associated with improved 30-day mortality [aOR: 0.783 (95% CI: 0.607-1.009)], 90-day mortality [aOR: 0.694 (95% CI: 0.579-0.832)], and overall survival [aHR: 0.788 (95% CI 0.749-0.829)].

Conclusion:
We found improved peri-operative outcomes in those patients undergoing ELND. While these findings may reflect that ELND is more commonly performed in specialized centers, they suggest that ELND is safe, should be performed in appropriately selected patients. 
 

67.03 Redefining Surgical Quality Metrics: Optimal Length of Surveillance for Complications After Surgery

Posted on January 18, 2018

M. A. Chaudhary1, W. Jiang1, S. Lipsitz1, Z. Hashmi1, T. Koehlmoos2, P. Learn2, A. J. Schoenfeld1, A. H. Haider1  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Uniformed University Of Health Sciences,Bethesda, MD, USA

Introduction:

Thirty-day complications are reported by National Surgical Quality Improvement Program (NSQIP) and widely used in the surgical literature as a quality indicator for benchmarking surgical care. However, there is little evidence to suggest that the 30-day time point is the optimum length of surveillance to capture complications after surgery. The objective of this study was to determine the optimum surveillance period for complications in a national sample of high volume surgical patients.

Methods:

The TRICARE insurance database (2007-2014), with 9 million enrollees (military personnel and their dependents), was queried for adult (age 18-64 years) patients who underwent 1 of 11 high volume surgical procedures (including, general surgery, neurosurgery, orthopedic, cardiothoracic and urological procedures). Kaplan Meier (KM) curves were constructed to visualize the inflection point in the proportion of patients with a complication  (wound, infectious, neurological, cardiopulmonary, vascular and genitourinary complications) at each incremental follow-up day. Multiple linear spline regression modeling, based on observed survival at each incremental follow-up day, was performed and adjusted R-squared values calculated. Optimum length of surveillance was defined as the follow-up day for which the model had the highest R-squared value. Bootstrapping (non-parametric random resampling of the data) with 300 repetitions was performed to generate a 95% confidence interval around the optimal length of surveillance estimate.

Results:

Of the 100,098 patients included in the analysis, 21.8% had at least one complication within 90 days from the day of procedure. 49% of complications were captured within the first 15 days while 74% were captured in 30 days. Visual inspection of the KM curve (Figure) exhibited a demonstrable change in slope before the 20-day mark. In the spline model, day 15(C.I.: 14-15) had the highest R-squared value (0.98), indicating an inflection point.

Conclusion:

The data demonstrates that 75% of complications occur within 30 days. However, the majority of complications (nearly 2/3rd) actually occur within 15 days after surgery. Thus, a shorter follow up period for complications may be acceptable. 

 

67.01 Non-Invasive Neurally Adjusted Ventilator Assist after Congenital Diaphragmatic Hernia Repair

Posted on January 18, 2018

R. Amin1, M. Arca1  1Medical College of Wisconsin,Milwaukee, WI, USA

Background: Conventional modes of ventilation can result in patient-ventilator asynchrony, which may be overcome using neurally-adjusted ventilator assist (NAVA) methodology. The use of NAVA in congenital diaphragmatic hernia (CDH) patients is controversial, as the trigger for breaths is diaphragmatic muscle activity.  We report on our experience in using NAVA in CDH patients.

Methods: We performed an IRB-approved retrospective review of newborns with CDH from 1/1/2012-1/1/2017 at a Level I Children’s Surgery Center who underwent operative repair.  Data obtained include demographics, hernia defect, type of repair, pre and post-operative respiratory support, and outcomes.

Results: Thirty-seven patients underwent operative repair. Post-operatively, none required NAVA while on conventional mechanical ventilation (CMV), but 7 were placed on noninvasive-NAVA (NIV-NAVA) after extubation. Three patients were male. Three patients had right sided CDH. Average estimated postmenstrual age and weight at birth were 38 2/3 weeks [range 35 3/7-40/17] and 2.96 kg [2.21-3.5], and 40 2/3 [38 3/7-41 6/7] and 3.08kg [2.21-3.84] at repair.  The average initial arterial pCO2 was 72.2 mmHg.  High frequency oscillatory ventilation was used in 5 patients preoperatively; six were transitioned to CMV prior to repair.  Preoperatively, all required inhaled nitric oxide. Four required extracorporeal life support (ECLS) and one was repaired on ECLS.  All patients underwent open repair via abdominal approach, with patch repair in 5 infants. All were on CMV postoperatively.

Specified reasons for using NAVA post-extubation include increased work of breathing after extubation and previous failed extubation requiring reintubation. Five patients were extubated to NAVA directly. Average time on NAVA support was 9.4 days [5-21], with initial NAVA level of 3.1 [1-5], and NAVA level of 2 [0-3] at the end of support.

Four patients were weaned to room air [3-32 days] prior to discharge, and two were weaned to room air within a year.  Five patients went home on enteral feeds.  One patient had seizure activity, but none had intraventricular hemorrhage or periventricular leukomalacia. There was one hernia recurrence in the patient who was repaired on ECLS. There were no deaths.

Conclusion: This is the first report of NAVA being successfully utilized as an adjunct to wean infants from CMV after CDH repair, even in those who required a patch. 

 

67.02 Use of the Alvarado Score in Elderly Patients with Complicated and Uncomplicated Appendicitis

Posted on January 18, 2018

A. Deiters1, A. Drozd1, P. Parikh1, R. Markert1, J. K. Shim1  1Wright State University,Dayton, OH, USA

Introduction:   With increasing life expectancy, elderly patients experience a higher incidence of diseases previously associated with the younger population. With an incidence of acute appendicitis in this age group of approximately 9.3%, high rates of perforated and gangrenous appendicitis have been reported. The purpose of this study was to determine whether the Alvarado Score is beneficial in identifying complicated versus uncomplicated acute appendicitis in elderly patients. Early diagnosis of patients with complications from acute appendicitis would lead to early treatment.

Methods:   We conducted a retrospective review of patients 65 years and older who underwent an appendectomy for pathologically confirmed appendicitis. Patient data were collected from five local hospitals within one healthcare network. A review of 310 operative reports and patient charts from October 1, 2012 – December 31, 2016 yielded 216 patients who qualified for the study. Patients were grouped based on complicated (perforated or gangrenous or abscessed) versus uncomplicated appendicitis. An Alvarado Score is calculated from 8 sub-scores – signs, symptoms, and lab values (e.g., RLQ tenderness, leukocytosis >10,000). Eighty-six patients had complete data, and 130 patients had one or more missing sub-score. Multiple imputation was used to replace all missing sub-scores (12% of values).

Results:  The 110 of 216 patients (51%) with complicated appendicitis had a mean age of 72.9 years, while the 106 uncomplicated patients (49%) had a mean age of 73 (p=0.97), and the two groups did not differ significantly on mean duration of symptoms (complicated = 2.70 days vs. uncomplicated = 2.09 days; p=0.17). Among the 110 complicated patients 76% had perforated appendicitis, 38% were gangrenous, and 35% had an abscess.  

The mean Alvarado Score of the two groups did not differ (complicated = 6.86 vs. uncomplicated = 6.58, p=0.32). An Alvarado Score of 7 or higher indicates acute appendicitis. Within the complicated group, patients ≥76 years old were similar to those ≤75 years in proportion with an Alvarado Score ≥7  (≥76 years = 54% vs. ≤75 years = 53%, p=0.93).  However, within the uncomplicated group, younger patients were more likely than older patients to have an Alvarado Score ≥7  (≥76 years = 28% vs. ≤75 years = 54%, p=0.02). The complicated group was more likely to have postoperative complications (41% vs. 25%, p=0.012).  Mean hospital length of stay was greater in those with complicated appendicitis compared to uncomplicated (5.34 days vs. 3.12 days, p<0.001).

Conclusion:  We found that the Alvarado Score did not differentiate complicated from uncomplicated appendicitis in elderly patients. The scoring system also did not provide an accurate diagnosis of acute appendicitis in approximately half our patient population. Future studies should investigate why a high percentage of elderly patients present initially with complicated appendicitis. 

66.09 The Family Financial Burden of Outpatient Pediatric Surgical Care and Interest in Telemedicine

Posted on January 18, 2018

K. Harris1, E. C. Hamilton1, A. C. Fonseca1, S. Mahajan1, A. A. Eguia1, M. T. Harting1, K. Tsao1, M. T. Austin1  1McGovern Medical School At The University Of Texas Health Science Center At Houston,Department Of Pediatric Surgery,Houston, TEXAS, USA

Introduction: Telemedicine has the potential to decrease the burden of postoperative outpatient care for families of pediatric surgical patients. The purpose of this study was to determine travel and work-related costs related to pediatric surgical clinic visits and parents’ attitudes towards telemedicine.

Methods: A non-random sample of parents of patients presenting to our outpatient pediatric surgery clinic for postoperative, preoperative, and new consults were administered a previously published 29-question survey to assess the burden of attending clinic and their preferences towards telemedicine for postoperative care. Pearson chi-square test and univariate logistic regression were used for statistical analysis.

Results:Among 186 survey respondents, most were Hispanic (n=125) followed by non-Hispanic white (NHW) (n=31), non-Hispanic black (NHB) (n=14) and 16 other/unknown. Eighty-one (44%) parents traveled < 25 miles, 78 (43%) traveled between 26-50 miles, and 24 (13%) traveled > 50 miles. The majority of respondents (n=58, 33%) spent $25 to $50 on travel and additional ancillary expenses. Considering all expenses, including missed work, most parents felt that the overall cost of coming to pediatric general surgery clinic was medium (n=75, 42%). Regarding telemedicine in the form of video conferencing for postoperative care, most parents were comfortable using telemedicine to discuss general questions that arose (n=122, 75%) and for routine follow-up (n=94, 56%). Fewer parents were comfortable with the use of telemedicine to assess acute problems (n=72, 45%). Comfort in using telemedicine for postoperative care was not associated with perceived total costs, distance traveled, education level, income level, race, or age. The strongest predictor for comfort in using telemedicine for postoperative care was being comfortable communicating by email and/or telemedicine to discuss medical issues(Table 1). Spanish-only speaking parents were significantly more likely than English speaking parents to be comfortable using telemedicine for routine postoperative follow-up (OR 2.17; 95% CI 1.01-4.61). There was no significant difference between Spanish-only speaking parents and English-speaking parents when assessing comfort with using telemedicine for acute problems (OR 1.7; 95% CI 0.79-3.65) or general questions (OR 0.88; 95% CI 0.38-2.02).

Conclusion:Clinic visits result in significant costs for parents of pediatric surgical patients. Overall, comfort in using communication technologies was the strongest predictor for comfort using telemedicine for postoperative care. Spanish-only speaking parents were more likely to be comfortable using telemedicine for routine postoperative follow-up as compared to English-speaking parents. 

 

66.10 Does path to Ileo-pouch anal anastomoses in the treatment of pediatric Ulcerativc colitis matter?

Posted on January 18, 2018

N. Bismar1, A. S. Patel1,2, D. Schindel1,2  2Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA

Introduction:
To compare the outcomes of pediatric medically-refractory ulcerative colitis treated by a traditional (TIPAA) surgical approach (1st stage: laparoscopic proctocolectomy/ileo pouch-anal anastomosis with a protective loop ileostomy; 2nd stage:  stoma closure) versus a nontraditional (NIPAA) approach (1st stage: laparoscopic colectomy/ileostomy; 2nd stage:  completion proctectomy/ileo-pouch anal anastomosis without a stoma).  

Methods:

After IRB approval, a review of patients who underwent an ileo-pouch anal anastomosis, cared for at a children’s hospital from 2002-2017 was performed. Patient demographics, diagnosis at time of surgery, type of surgery (TIPAA vs NIPAA), time to full diet, level of continence, use of anti-diarrhea medications, and complications were recorded. A statistical analysis was performed using Graphpad® San Diego, CA. 

Results:

Forty-one children were identified (NIPAA; n=14; TIPAA; n=27). Following re-establishing bowel continuity, there were no significant differences in time to appetite recovery, continence, or incidence of complications between the TIPAA and NIPAA groups. The number of anti-diarrhea medications prescribed was significantly higher in the group following a TIPAA versus the NIPAA (p=0.01).  Nine patients (22%) required dilatation of an ileoanal anastomotic stricture, three following NIPAA and six following TIPAA (p=NS).  In addition to strictures, the most common complications observed were pouchitis and small bowel obstruction. Thirteen patients (31.7%) were treated for pouchitis: four following a NIPAA  and nine in the TIPAA group (p=NS). Of the 41 patients there were 11 who required additional surgical interventions (lysis of adhesions; stoma revisions), two (18.2%) had received a NIPAA approach and nine (81.8%) had received a TIPAA.  Two children having TIPPA, because of chronic pain and failure to achieve full continence elected placement of a diverting ileostomy.  

Conclusions:

This study suggests that children with medically-refractory UC treated by either NIPAA or TIPAA have similar outcomes.  Minimal differences in overall outcome following either apporach are noted.  However, performing an ileo-pouch anastomosis as a second stage procedure without a stoma may be associated with reduced reliance on antidiarrhea medications once intestinal continuity is restored.

66.06 Impact of Insurance Status on Pediatric Mortality Following Non-accidental Trauma

Posted on January 18, 2018

K. A. Sonderman1, L. L. Wolf1, A. L. Beres2  1Brigham And Women’s Hospital,Boston, MA, USA 2University Of Texas Southwestern Medical Center,Children’s Health Dallas,Dallas, TX, USA

Introduction: Non-accidental trauma (NAT) is the leading cause of injury and death in early childhood. Previous studies have shown varied findings regarding the impact of insurance status, socioeconomic status, and race on mortality following NAT in children. As insurance is a modifiable factor, we sought to understand the independent impact of insurance status on mortality in a national sample of pediatric NAT.

Methods: We performed a retrospective cohort study using the 2012-2014 National Trauma Databank, including children ≤18y with NAT as defined by ICD-9 codes (967-968). Our primary outcome was death. We compared age, sex, race, insurance status, transfer status, and injury severity score (ISS) between patients that died and those that survived. We used multivariable logistic regression to calculate the adjusted odds of death by insurance status, controlling for the above variables with significant univariate associations.

Results:  We identified 5,017 children with NAT. Mean age was 1.6y (SD 3.7), with 41% female, 51% white, 30% black, and 18% Hispanic. Majority of patients were publically insured (76%), 17.8% private, and 5.7% were uninsured. Mean injury severity score was 13.7 (SD 10.4). Half of patients were transferred to a higher level facility (49.1%). Overall, 414 (8%) patients died following NAT. Patients that died were younger (mean age 1.2y vs. 1.6y), more likely to be uninsured (13% vs. 5%), more likely to be transferred (55% vs. 49%) and more severely injured (mean ISS 25.6 vs. 12.6, Table).  After adjusting for these factors, patients with no insurance had 3.6 greater odds of death compared to those with public insurance. There was no significant difference in the odds of death based on age, race, transfer status and ISS.

Conclusion: Pediatric patients who do not have insurance have significantly greater odds of death following NAT compared to children with public insurance. Further research may better elucidate the characteristics of these uninsured children that lead to greater likelihood of death following NAT.

66.07 Prenatal Intervention Improves Initial Outcomes in Postnatal Management of Congenital Chylothorax

Posted on January 18, 2018

B. Carr1, L. Sampang1, J. Church1, R. Mon1, S. K. Gadepalli1, M. Attar1, E. E. Perrone1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:
Congenital chylothorax, an accumulation of lymphatic fluid in the pleural space arising before birth, is a poorly understood phenomenon that can have devastating consequences for neonates.  We sought to determine the outcomes of neonates treated at our institution with both operative and nonoperative measures.   We also sought to determine the role of prenatal intervention in mitigating outcomes.

Methods:
Under an IRB-approved protocol (HUM00093133), patients treated at our institution 09/2006 – 04/ 2016 with congenital chylothorax were reviewed.  Demographic information, intervention history, and perinatal outcomes were collected. All statistical analysis was performed using STATA v14 (StataCorp LLC, College Station, TX), and p<0.05 was considered significant.  

Results:

A total of 26 patients were identified and 12 (46%) were female. Average gestational age at birth was 34.1±2.7 weeks, and average birth weight was 2815±614 grams. Overall mortality was 23% (6 patients).  Twenty-two patients (85%) were prenatally diagnosed, and 14 patients (64%) underwent prenatal intervention for congenital chylothorax.  In the intervention group, median gestational age was 33.5 weeks [IQR 31-35], with median birth weight 2479 grams [IQR 2170-3025].  In the no intervention group, median gestational age was 32 weeks [IQR 32.5-36] with median birth weight 2975 grams [IQR 2575-3383].

In the intervention group, median Apgar score at 1 minute was 4 [IQR 3-7], compared to 2 [IQR 1-2] in the no intervention group (p=0.006).  Median Apgar score at 5 minutes in the intervention group was 8 [IQR 6-8], compared to 3.5 [IQR 2.5-5.5] in the no intervention group (p=0.003).   All patients in the no intervention group required chest tubes, while 3 patients (21%) in the intervention group avoided chest tube placement. Mortality in the intervention group was 3 patients (21%), compared to 4 patients (50%) in the no intervention group (p=0.34).  Of those patients who survived, median length of stay was 34 days [IQR 16-69] in the intervention group and 58.5 days [IQR 27-92] in the no intervention group (p=0.55), while median ventilator days were 3 [IQR 0-40] in the intervention group and 30.5 [IQR 10-58] in the no intervention group (p=0.47). There was no significant difference in need for chest compressions, need for surgery, or frequency of infections or pneumothoraces.

Conclusion:
Prenatal intervention for congenital chylothorax is associated with improved Apgar scores during resuscitation, but does not definitely improve overall outcomes. Our data support that clinicians must weigh the risks of prenatal intervention against the risks of difficult resuscitation in the first minutes of life.

66.08 Quality of Life Outcomes in Hepatoblastoma: Conventional Resection versus Liver Transplantation

Posted on January 18, 2018

M. R. Threlkeld1, N. Apelt1, N. Kremer1, S. F. Polites1, M. Troutt1, J. Geller1, K. Burns1, A. Pai1, R. Nagarajan1, A. J. Bondoc1, G. M. Tiao1  1Cincinnati Childrens’s Hospital Medical Center,Pediatric Surgery,Cincinnati, OH, USA

Introduction: Liver transplantation and complex surgical resection of advanced stage hepatoblastoma have equivalent five-year survival. Both modalities are associated with treatments and complications that impact quality of life. The differences in quality of life outcomes between these two treatments has not been studied and could aid in guiding future therapeutic decisions. We sought to compare the quality of life outcomes for long term survivors who underwent transplantation compared to surgical resection for PRETEXT III or IV hepatoblastoma.

Methods: Following approval from our institutional review board, patients with PRETEXT III and IV hepatoblastoma who underwent surgical therapy from 2000-2013 and survived 2 or more years post-operatively were identified. Patients were grouped into transplant or resection by intention to treat based on the primary operation. Informed consent was obtained from patients over 18 years and parents of the surviving patients younger than 18 years. Assent was obtained from children over 8 years old. Age and treatment appropriate Pediatric Quality of Life Inventory 4.0 (PedsQL™) modules were mailed to consenting participants. Parent reports were used for patients 4 years or younger. Both parents and patients reported for patients over 4 years old. Scoring was performed according to the PedsQL module manual.

Results: We identified 70 patients who met inclusion criteria, 29 (41.4%) were deceased or lost to follow up. Of the 41 remaining patients approached, 33 (80.5%) agreed to participate. At least one questionnaire was completed by 28 (84.8%) patients and or parents; 12 of 14 in the resection and 16 of 19 in the transplant group. There was no statistical difference in age at diagnosis, gender, or response rate between groups. The transplant group was older than the resection group with a respective median age of 10.2 (9.3-13.9, IQR) versus 6.4 (5.1-10.5, IQR) years (p=0.03).  We found no statistical difference in the scores between transplant and resection or between patient and parent reports where applicable (Table).

Conclusion: We found no difference in the long term quality of life outcome scores in patients primarily treated with liver transplant compared to radical surgical resection. The therapeutic decision to perform transplant as a primary surgery should not be influenced by the concern of decreased quality of life, but rather predictability of an R0 resection. 

 

66.05 Curettage and Cautery as an Alternative to Primary Closure for Pediatric Gastrocutaneous Fistulae

Posted on January 18, 2018

N. Denning4, I. A. El-shafy2, J. G. Hagen3, S. Stylianos5, J. M. Prince1,4, A. M. Lipskar1,4  1Cohen Children’s Medical Center, Northwell Health System,Department Of Pediatric Surgery,New Hyde Park, NY, USA 2Maimonides Medical Center,Department Of Surgery,Brooklyn, NY, USA 3Cohen Children’s Medical Center, Northwell Health System,Department Of Anesthesia,New Hyde Park, NY, USA 4Hofstra University School Of Medicine-Northwell Health System,Department Of Surgery,Manhasset, NY, USA 5Morgan Stanley Children’s Hospital Of New York-Presbyterian, Columbia University Medical Center,Division Of Pediatric Surgery,New York, NY, USA

Introduction: The development of a gastrocutaneous fistula (GCF) after gastrostomy tube removal is a frequent complication that occurs 5-45% of the time. Conservative therapy with chemical cauterization is frequently unsuccessful and surgical GCF repair with open primary layered closure of the gastrotomy is often required. We describe an alternative approach of GCF closure that is an outpatient, less invasive procedure that allows patients to avoid an inpatient hospitalization and intra-abdominal surgery.

Methods: This is an IRB approved retrospective review of all patients who underwent GCF closure from 1/2010 to 7/2016 at a tertiary care children’s hospital.  Demographics including age, weight, BMI, comorbidities, and initial indication for gastrostomy tube were recorded.  Operative details such as ASA score, operative duration, type of anesthetic and airway were noted.  Based on surgeon preference two types of operative closure were used during that timeframe: primary layered closure or curettage and cautery (C&C).  The latter is a procedure in which the fistula tract is first scraped with a fine curette and then the fistula opening and tract are cauterized circumferentially. Finally, the presence of a persistent fistula and the need for formal reoperation were determined.

Results: Sixty-five unique patients requiring GCF closure were identified. Of those, 44 patients (67.6%) underwent primary closure and 21 patients (32.3%) underwent C&C.   The success rate of primary closure was 97% with one patient experiencing wound breakdown with persistent fistula.  The overall success rate of C&C was 66.7% (14/21).  Among those fourteen patients 11 (52.4%) GCF were closed by one month.  An additional two patients’ GCF were closed by four months (61.9%).   One GCF was successfully closed with a second C&C procedure.   7/21 patients (33.3%) required subsequent formal layered surgical closure.  C&C had significantly shorter operative times (13.5±14.7 min vs 93.4 ±61.8, p < 0.0001) and significantly shorter times in the post-anesthesia care unit (101.8±42.4 min vs 147 ± 86, p < 0.0001). Patients were intubated with an endotracheal tube 88.6% of the time for primary closure and 23.8% of the time for C&C.  Among patients admitted for an elective procedure, the average length of stay for primary closure was 1.9 days as compared to 0 days for the C&C group. Among patients who underwent C&C with a persistent fistula, there were no significant differences in time since initial creation of gastrostomy, age, BMI, or ASA score.

Conclusion: Our study verifies that primary closure remains the gold standard for persistent gastrocutaneous fistula. However, C&C is a safe, outpatient procedure that effectively treats a GCF the majority of the time in children.  We suggest that in select patients it may be an appropriate initial and definitive procedure for GCF closure.

 

66.04 A High Ratio of Plasma:RBC Improves Survival in Massively Transfused Injured Children

Posted on January 18, 2018

M. E. Cunningham1, E. H. Rosenfeld1, B. Naik-Mathuria1, R. T. Russell2, A. M. Vogel1  1Baylor College Of Medicine,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Hospital Of Alabama,Department Of Pediatric Surgery,Birmingham, AL, USA

Introduction: Massive transfusion protocols (MTP) with balanced high blood product ratios (plasma and platelets to red blood cells (RBC)) have been associated with improved outcomes in adult trauma. Their impact in pediatric trauma is unclear. The purpose of this study is to evaluate the effect of blood product ratios in severely injured children.

Methods: The 2015-2016 American College of Surgeons Trauma Quality Improvement Program research dataset was used to identify trauma patient’s ≤ 18 years of age who received a massive transfusion (≥40ml/kg/24-hours total blood products). Children with burns and non-survivable injuries were excluded. Plasma:RBC and platelet:RBC ratios were categorized into low (<1:2), medium (≥1:2 to <1:1), and high (≥1:1). Trauma-related clinical and outcome data was collected and analyzed using descriptive statistics, Kruskal-wallis test, Chi-Square, Fisher’s exact test, and Kaplan-Meier analysis. Continuous variables are presented as median [IQR]; p<0.05 is significant.

Results:Of 473 patients, the median age was 9 [3,16] years, 159 (34%) were female, and 350 (74%) were blunt injuries. Gender, mechanism of injury, ISS, GCS, and age-adjusted vitals were similar amongst the low, medium, and high plasma:RBC and platelet:RBC cohorts. Children in the low plasma:RBC group were younger compared to those in the medium and high groups (6 [2,13] vs 13 [6,17] & 12 [6,17]; p<0.01). Analysis of the plasma:RBC groups showed those with low ratios had a lower incidence of acute kidney injury (AKI) (0% vs 4% & 5%; p=0.01) compared to medium and high ratios, and fewer ventilator-free days (6 [0,23] vs 17 [17,23]; p=0.03) compared to high ratios. Those with medium plasma:RBC ratios had greater total blood transfusion volumes (ml/kg/24-hours) (89 [56,156] vs 68 [50,105] & 69 [50,115]; p<0.01). There was no difference in ICU-free days or other in-hospital complications between the groups. Analysis of the platelet:RBC ratios showed no significant difference in total blood volume received, ventilator free-days, ICU-free days, AKI, or other in-hospital complications. Hemorrhage control procedures were less common in the low plasma:RBC cohort (34% vs: 56% & 51%; p<0.01), while there was no difference between the platelet:RBC cohorts. Survival was improved in the high plasma:RBC cohort early on (Fig. 1), but became insignificant as time passed. There was no improvement in survival between the platelet:RBC cohorts at any time.

Conclusion: A high ratio of plasma:RBC may result in improved early survival in injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.

66.01 Risk Factors for Adverse Outcomes in Children Undergoing Resection of Primary Liver Tumors

Posted on January 18, 2018

K. Culbreath1, A. Garcia1, I. Leeds1, T. Crawford1, E. Boss2, D. Rhee1  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Otolaryngology,Baltimore, MD, USA

Introduction: Children with primary malignant tumors of the liver often present with an incidental abdominal mass and anemia, with failure to thrive in more advanced disease. Complete tumor resections are major operations that offer the best chance of long-term disease-free survival. This study analyzes the effect of preoperative anemia and parenteral nutrition on surgical outcomes in these patients undergoing a major liver resection.

Methods: This is a retrospective cohort study of children undergoing a major liver resection for primary malignant hepatic tumors. Data was collected using the National Surgical Quality Improvement Program Pediatric database from 2012-2015. Demographics, comorbidities, and 30-day outcomes were compared by anemia (defined by age-specific clinical practice guidelines) and preoperative total parenteral nutrition (TPN) using Fishers exact test.  Outcomes include post-operative complications and hospital readmissions.   Propensity score matching was performed to control for significant confounders.

Results: A total of 110 children were included in the study with 80 (72.7%) undergoing lobectomy and 30 (27.3%) trisegmentectomy. The mean age was 3.5 years (range 4 days to 17.7 years). Thirty-one patients (30.4%) were born prematurely with 18 (16.4%) being born before 30 weeks gestational age. 76 (69.1%) patients had preoperative anemia, and 36 (32.7%) were receiving TPN. Children with pre-operative TPN were more likely to have cardiac (p= 0.01), respiratory (<0.01), neurologic (p<0.01), and hematologic co-morbidities (p=0.02). There were 22 (20.0%) post-operative complications and 6 (5.5%) hospital readmissions. After propensity score matching, there were 34 matched pairs for anemia, and 36 matched pairs for TPN. There was no significant difference in post-operative complications between anemic and non-anemic patients (20.6% vs 35.3%, p=0.28). Patients receiving pre-operative TPN had an increased rates of post-operative complications compared to those not (33.3% vs 11.1%, p=0.04). Neither anemia (p=0.61) nor pre-operative TPN use (p=0.05) had a significant association with readmissions.

Conclusion: Anemia and pre-operative TPN are common in children undergoing major resection of primary malignant hepatic tumors, with TPN use being associated with several comorbidities. Patients on pre-operative TPN are at higher risk of complications after surgery and may warrant special attention to their overall conditioning and nutritional status when planning their operation.

 

66.02 Delivery of Care for Biliary Atresia in 21st Century: An Analysis of Hospital Caseload in the US

Posted on January 18, 2018

T. Chkhikvadze1, C. J. Greig1, J. Shi2, R. A. Cowles1  1Yale University School Of Medicine,Section Of Pediatric Surgery, Department Of Surgery,New Haven, CT, USA 2Ohio State University,The Research Institute At Nationwide Children’s Hospital,Columbus, OH, USA

Introduction:  Biliary atresia (BA) is a rare disease affecting infants and is the most common indication for pediatric liver transplantation in the United States. Due to the lack of an organized method for centralization of care for this disease, we hypothesized that care for BA patients would be distributed in a diffuse manner. The Kids’ Inpatient Database (KID) was analyzed to assess the distribution of care and hospital volume for BA in the United States.

Methods:  The KID database, published triennially, was queried from 2000-2012 using the ICD-9-CM code for BA (751.61) and ICD-9 procedural codes for hepatic duct-GI anastomosis (51.37), and other bile duct anastomosis (51.39) in infants less than 1 year of age. National and regional estimates were calculated from captured discharges. We identified all hospitals caring for biliary atresia patients and subdivided into those providing overall care and those providing surgical care per year.

Results: The number of hospitals participating in KID increased over time as did the number of hospitals providing overall and surgical care for BA (Table). Operative caseload estimates from 2000 showed that 48 of 55 (87.3%) hospitals performed 1-2 cases/year and 7 of 55 (12.7%) performed 3-9 cases/year. Estimates from 2012 showed that 53 of 72 (73.6%) hospitals performed 1-2 cases/year and 19 of 72 (26.4%) performed 3-9 cases/year. 

Conclusion: Infants with BA are cared for in 5-6% of hospitals reporting into the KID database. Surgical care appears to be further limited to approximately 2% of total KID participating hospitals. Although the care for BA appears to be self-centralized into only a very small subset of hospitals in the United States, nearly 75% of infants with this disease receive their surgical care in hospitals that perform fewer than three portoenterostomy procedures per year. Given the cost and long-term morbidity of BA treatment, a national cross-sectional study of care patterns and outcomes is desperately needed to assure that optimal care is being rendered under the current system.

66.03 Impact of Growth and Nutrition on Risk of Acquired Diseases of Prematurity and Perinatal Mortality

Posted on January 18, 2018

T. J. Sinclair1,2, C. Ye5, F. Salimi Jazi2, J. Taylor2, K. Bianco4, G. Shaw3, D. K. Stevenson3, R. Clark6, K. G. Sylvester2  1Stanford University School Of Medicine,Department Of General Surgery,Stanford, CA, USA 2Stanford University School Of Medicine,Division Of Pediatric Surgery,Stanford, CA, USA 3Stanford University School Of Medicine,Department Of Pediatrics,Stanford, CA, USA 4Stanford University School Of Medicine,Department Of Obstetrics & Gynecology,Stanford, CA, USA 5Hangzhou Normal University,School Of Medicine,Hangzhou, ZHEJIANG, China 6Pediatrix-Obstetrix Center For Research, Education And Quality,Sunrise, FL, USA

Introduction:

Birth weight and gestational age are the predominant clinical factors used to risk stratify infants for acquired diseases of prematurity including necrotizing enterocolitis (NEC), chronic lung disease (CLD), and retinopathy of prematurity (ROP). We sought to further elucidate the relative impact of size (birth weight, BW), prematurity (gestational age, GA), pre- and postnatal growth, and postnatal nutrition on the risk of perinatal mortality and development of acquired diseases of prematurity. 

Methods:

We performed a retrospective longitudinal cohort study by querying a multicenter, longitudinal database that included 995 preterm infants (<32 weeks gestation). Detailed clinical and nutritional data were collected on subjects for the first 6 weeks of life. Comparator groups were generated based on the following variables: BW (top vs. bottom quartiles), GA (23-26 vs. 29-32 weeks), fetal growth restriction (small for gestational age (SGA defined as <10th percentile BW for GA) vs. appropriate for gestational age (AGA, BW 10-90th percentile for GA)), growth velocity (top vs. bottom quartile of change in weight z-score from birth to day of life 42), and total calories (<100 vs >120 kcal/kg/day averaged from day of life 2-42). Cases of NEC, CLD (need for supplemental oxygen at day of life 42), [DS1] and ROP were identified. Odds Ratios (OR) with 95% confidence intervals (CI) were calculated using the defined comparator groups for the outcomes of NEC, CLD, ROP, mortality (during the study period), and a composite of the disease and mortality outcomes. Statistical significance was defined as p-value < 0.05. Mortality outcome was excluded from the growth velocity and total calorie analyses given the longitudinal nature of the variable definitions.

Results:

Infants in the top quartile for BW or born at 29-32 weeks gestation were found to be at a significantly reduced risk for all disease outcomes, mortality, and the composite outcome. However, when fetal growth restriction was present there was an increased risk of ROP and mortality, but not for NEC[DS1] , CLD, or the composite outcome. Similarly, being in the bottom quartile for post-natal growth velocity was associated with an increased risk of developing ROP, but not for the other outcomes. Finally, receiving greater than 120 kcal/kg/day on average was associated with a decreased risk for all outcomes, except for NEC which approached but did not reach statistical significance. See Table 1.

Conclusion:

These results suggest that postnatal caloric delivery is a significant modifier of premature newborns’ risk of acquired major perinatal disease and mortality. These findings may be of particular importance given that postnatal caloric delivery may be modifiable.

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