Ventricular shunting for hydrocephalus in children: patients, procedures, surgeons and institutions in English Canada, 1989–2001

Abstract

Ventricular shunting remains the principle and most generally applicable method to treat hydrocephalus in children. This report describes the demographics of this treatment in English Canada during the period of 1989 to 2001. Hospital discharge records were obtained for patients less than 18 years who had a shunt inserted or revised. A database was constructed relating to patients and procedures. 5,947 patients underwent ventricular shunting for hydrocephalus during this period. Two hundred sixty-one surgeons working in 73 institutions provided 12,106 interventions (ventriculoperitoneal shunts, 5,009; ventriculoatrial, 119; ventriculopleural, 28; revisions, 6,950). Infections occurred in 1,059 procedures. Over the study period, the median number of procedures per surgeon per year was 2, with 75% of surgeons performing 5 or fewer procedures in children per year. Although many surgeons operated on children throughout the study period, many did not acquire substantial cumulative experience. Overall infection rate was 8.6%. Surgeon infection rates were greater than or equal to 20% during the first 4 years of practice and thereafter fell to and remained in the 10% range. The mean shunt survival rate at 12 months of individual surgeons varied between 50% and 60%, regardless of the number of years of experience. However, performance variability as measured by the standard deviation of 12-month survival rates for all surgeons, adjusted for years of experience, varied widely until the fifth year of practice. The average number of procedures per year for treating hospitals was 2 with 75%, 50% of the institutions provided 10 or fewer procedures. The mean institutional infection rate was 11.4%. It is concluded that quality monitoring of infection rate and duration of shunt function remains critical because many surgeons and hospitals provide care to children with hydrocephalus infrequently. Variability in infection rates and shunt survival at 12 months are a function of surgeon experience, measured by years of practice. Variability in outcome decreases with increasing surgeon experience.—Thomas A. Angerpointner