P102 LOW PROPORTION OF TOTAL ABDOMINAL COLECTOMIES IN PEDIATRIC ULCERATIVE COLITIS OCCUR AT HIGH VOLUME CENTERS IN THE U.S.

Abstract

The volume-outcome relationship for surgical procedures is well established in the U.S. healthcare system. Studies of adult ulcerative colitis (UC) demonstrate that high volume centers consistently produce better surgical outcomes with fewer complications than low volume centers. Recently, published guidelines from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend that pediatric UC surgeries be completed at high volume centers performing ≥10 pediatric colorectal surgeries annually. We aimed to evaluate the annual pediatric UC colectomy volume in hospitals across the U.S. and explore volume trends over time in high volume centers. We performed a cross-sectional analysis of pediatric (≤18 years) UC hospitalizations using the Kids’ Inpatient Database (KID), a nationally representative pediatric database that allows for valid nationwide estimates of pediatric inpatient hospitalization data. The KID includes approximately 7 million unique hospitalizations from up to 4,200 U.S. hospitals annually. We identified pediatric hospitalizations with a primary UC (International Classification of Diseases, Ninth Revision (ICD-9): 556.X) diagnosis and procedural code for total abdominal colectomy (TAC) (ICD-9: 45.8X) on a triennial basis between 1997 and 2012. We identified unique hospitals on an annual basis using a hospital ID-year combination. We defined high volume centers as performing ≥10 pediatric UC colectomies annually in accordance with ESPGHAN guidelines. A total of 517 unique hospital-year combinations accounted for 945 colectomies from 1997 to 2012. Weighted, this accounted for an estimated 1,610 pediatric UC colectomies (mean 268 colectomies per year). For hospitals performing 1 or more colectomies per year, the median annual hospital colectomy volume was 2 (IQR = 1,4). Less than 20% of colectomies were performed at high volume centers while 26.5% of colectomies occurred at centers performing ≤2 colectomies per year. High volume centers were more likely to be located in the Northeast and Midwest as compared to the South or West (p<0.01). No other patient or hospital characteristics were associated with having surgery at a high or low volume center (Table 1). Over the 15-year study period, there was a trend towards fewer colectomies being performed at high volume centers, though this trend appears to be reversing in more recent years (Figure 1). An alarmingly low proportion of colectomies in children with UC are performed at high volume centers. Hence the surgical care delivered to the vast majority of pediatric UC patients in the U.S. is not consistent with current guidelines. National efforts to re-direct care to high volume centers of excellence may lead to improved outcomes for pediatric UC patients. aLow Volume: < 10 colectomies annually; High volume: ≥ 10 colectomies annually. bRaw data is taken from the actual database. National Estimate reflects KID weighting of raw data to produce a national estimate. cData missing from 2012. Figure 1: Annual percentage estimates and standard errors of colectomies at high volume centers in the 1997-2012 KID database. Smoothing line demonstrates a decreasing proportion of colectomies in pediatric UC hospitalizations occurring at high volume centers over the 15-year study period with a modest increase in recent years.