Common Pediatric Surgical Procedures Research Articles

Continued Prescribing of Periprocedural Codeine and Tramadol to Children after a Black Box Warning

BackgroundCodeine and tramadol are commonly used analgesics in surgery. In 2013, the Food and Drug Administration (FDA) issued a contraindication to the use of codeine in tonsillectomy and adenoidectomy patients aged below 18 y. This warning was expanded in April 2017 to include tramadol and all children aged below 12 y. We sought to describe the prescribing of codeine and tramadol to contraindicated populations in Wisconsin before and after the release of the expanded FDA warning. Materials and methodsUsing a statewide Wisconsin claims database, we identified common pediatric ambulatory surgical procedures across the specialties of otolaryngology, urology, general surgery, orthopedics, and ophthalmology. For these procedures, we examined the rates of perioperative codeine and tramadol prescription fills and change in prescribing after the FDA contraindication. ResultsSurgeons in all of the specialties studied continued to prescribe codeine to pediatric patients after the contraindication, but tramadol was rarely prescribed. Procedures with relatively high rates of codeine fills were strabismus repair (65% of opioid fills), circumcision >1 yo (22%), and laparoscopic appendectomy (15%). Codeine fills significantly declined after the contraindication to 6% for circumcision >1 yo and 5% for orchiopexy and inguinal hernia repair. Otolaryngology, which was subject to the 2013 codeine contraindication, has low rates of codeine fills (under 2.5%) for the whole period studied. Codeine prescribing for strabismus repair showed no significant decline. ConclusionsCodeine, and to a lesser extent tramadol, continue to be prescribed to contraindicated populations of children. This represents a target for future de-implementation interventions.

Inclusion of surgical antibiotic regimens in pediatric urology publications: A systematic review

Perioperative antibiotics prevent infections after surgery. Guidelines for antibiotic use allow the surgeon to balance the risks of adverse events and drug resistance with the benefit of reduced infection rates. However, due to a lack of evidence-based guidelines within pediatric urology, antibiotic practices vary widely. We performed a systematic literature review to investigate when and how authors report their antibiotic usage and infectious outcomes. Our aim was to analyze the available data on perioperative antibiotics and infection rates within pediatric urology. This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search strategy was devised to identify reports of pediatric urology surgery and use of antibiotics or infectious outcomes. Embase and Medline were queried with no year restrictions with subject heading terms to identify publications on common pediatric urology surgeries. The procedures studied were hypospadias repair, pyeloplasty, orchidopexy, ureteral reimplant, and circumcision. Two independent reviewers screened all titles and abstracts, followed by relevant full texts, for eligibility. Articles were included if the procedure was performed on the majority of study patients, the procedure was performed by urologic surgeons, and the population studied was a pediatric population defined as 0-18 years of age. Case reports, meta-analyses, and editorials were excluded. Data was extracted by one independent reviewer into a preformatted database. Collected data included journal type, date of publication, patient demographics, preoperative and postoperative antibiotic details including regimens, and infection outcomes. The primary outcome was reporting of antibiotic use preoperatively or postoperatively. Secondary outcomes included: reporting of infection, antibiotic class and dosage. Since all studies were diverse, only qualitative analysis was conducted. We identified 1483 publications with 297 meeting inclusion criteria. Of these, 9% reported their use of preoperative antibiotics, and 34% reported their use of postoperative antibiotics. Only 6% of studies reported the specific antibiotic class, 15% reported duration, and 1% reported dosage and frequency. Infection outcomes were reported in 58% of studies. Only 57% of studies that reported on infection outcomes described their antibiotics practices. Surgical antibiotic regimens and infection outcomes are infrequently included in pediatric urology studies, limiting the data available for development of evidence-based guidelines. Routine incorporation of antibiotic regimens, infection outcomes and adverse events in the pediatric urology literature will increase our ability to identify indications for antibiotics. Reporting of perioperative antibiotic outcomes in pediatric urology procedures will allow the eventual development of strong evidence-based guidelines.

AMBULATORY SURGERY TRENDS IN PEDIATRIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: WHERE’S IT HAPPENING AND HOW MUCH CAN WE SAVE?

Background:Benefits of ambulatory surgery include more efficient operations, lower cost, and patient preference. The national frequency of anterior cruciate ligament (ACL) reconstruction in children has increased three-fold compared other pediatric orthopaedic procedures, a trend that is likely attributable to an increased rate of ACL tears associated with year-round training and competition in young athletes.Hypothesis/Purpose:The goal of this study was to utilize the Pediatric Health Information System (PHIS) to analyze the national trends towards ambulatory surgery for ACL reconstruction procedures and quantify the cost savings associated with the trend.Methods:The PHIS database was queried using Common Procedural Terminology (CPT) and International Classification of Disease (ICD-9 and 10) codes for ACL reconstruction from 2009-2017. Patient information including gender, age at surgery, region (Northeast, South, Midwest, West) and hospital cost data for each procedure was collected. Cases were classified as ambulatory or non-ambulatory (inpatient or observation). Annual rates of ambulatory surgery were calculated for each procedure regionally for hospitals with cases included in each year of the query. The Consumer Price Index (CPI) was used to adjust procedural costs for inflation. Ambulatory and non-ambulatory costs were analyzed with the Wilcoxon Signed-Rank test. Trends in rates of ambulatory surgery were compared using joinpoint regression and annual percent change (APC).Results:A total of 21,582 cases of ACL Reconstruction were identified from 33 different children’s hospitals from 2009-2017. More than half (50.3%) of the patients were female, and the average age at surgery was 15.4 years (± 2.1 years). The overall rate of ambulatory pediatric ACL reconstructions across the United States increased by 14.7% (APC 1.6%, 95% C.I. 0.8-2.4, p<0.01) from 2009 to 2017. Overall, this trend was most significant in the West (APC 2.0%, 95% C.I. 1.2-2.7, p<0.01), however in more recent years (2012-2017), there has been a similar significant increase in ambulatory pediatric ACL reconstruction in the South (APC 3.0%, 95% C.I. 1.7-4.3, p<0.01). The mean difference in median procedural cost between ambulatory and non-ambulatory ACL reconstructions was $3,145 ($13,866 vs. $10,721, p<0.01). This corresponds to national annual savings of 4.1% associated with the shift towards ambulatory surgery.Conclusions:From 2009-2017, there was a national trend towards performing pediatric ACL reconstruction in the ambulatory setting, which was accompanied by an annual 4.1% procedural cost savings. The feasibility of ambulatory surgery for other common pediatric orthopaedic surgeries should be explored in order to reduce healthcare costs.Figure 1.Comparison of National Ambulatory Pediatric ACL Reconstruction Rates and Procedural Costs over Time

64. Prescribing Patterns for Common Pediatric and Adolescent Gynecology Surgical Procedures

64. Prescribing Patterns for Common Pediatric and Adolescent Gynecology Surgical Procedures

Patient-oriented online resources in pediatric surgery: Are we failing the readability test?

BackgroundThe study aim was to evaluate the readability of patient-oriented resources in pediatric surgery from children's hospitals in the US. MethodsThe websites of 30 children's hospitals were evaluated for information on 10 common pediatric surgical procedures. Hospitals of varying characteristics including bed number, geographic location and ACS Children's Surgery Verification (CSV) were selected for the study. Readability scores were calculated using validated algorithms, and text was assigned an overall grade level. ResultsOf 195 patient-oriented resources identified, only three (2%) were written at or below the recommended sixth grade level. Larger hospitals provided patient information at a higher grade level than medium and smaller sized centers (10.7 vs 9.3 vs 9.0 respectively, p < 0.001). Hospital size also correlated with availability of information, with large and medium sized hospitals having information more often. Hospitals with ACS CSV had information available more often, and written at a lower grade level, compared to nonverified centers (78% vs 62%, p = 0.023; 9.0 vs 10.0, p = 0.013). ConclusionMost hospital provided patient-oriented resources in pediatric surgery are written at a grade level well above the national guidelines. Centers with ACS CSV status have improved availability and readability of this material, while larger hospitals have improved availability, but decreased readability. Type of studyModeling study. Level of evidenceIII

Pattern of antibiotic prophylaxis usage and timing of administration in common paediatric surgeries: a retrospective cross-sectional study in teaching hospitals

Surgical site infections (SSIs) are among the common problems associated with paediatric surgeries and significantly contribute to postsurgical morbidity and mortality. This study was conducted to assess antimicrobial prophylaxis practices and compliance rates with international guidelines in common paediatric surgical procedures. A retrospective cross-sectional study was conducted in paediatric patients aged < 18 years in whom four common surgeries (inguinal hernia, appendectomy, bariatric surgery and pancreaticoduodenectomy) were performed at paediatric wards during August 2015 to August 2016 in two tertiary care teaching hospitals. Compliance with antimicrobial prophylaxis practice guidelines (selection, timing and pattern of antimicrobial usage) was evaluated. The charts of 1152 eligible paediatric patients were reviewed. Among these, 66.5% (n = 766) were male and 33.5% (n = 386) were female, with a mean age of 8.4 years (standard deviation ± 5.6). Inguinal hernia was the most frequent surgical procedure conducted (36.3% of patients), followed by appendectomy (25.4%), bariatric surgery (21.9%) and pancreaticoduodenectomy (16.5%). Complete compliance with guidelines was observed in 11.2% of patients (129 of 1152). The choice of antimicrobial prophylaxis administration was appropriate in 380 cases (33%), with a higher rate of guideline adherence with appendectomy than with inguinal hernia, pancreaticoduodenectomy, and bariatric surgical procedures (55.8% vs 32%, 23.1% and 15.5%; p < 0.0001). The timing was appropriate in 490 patients (42.5%), with a higher rate in appendectomy (51%) than in other paediatric procedures (p < 0.0001). The majority of patients were managed with ceftriaxone (46%) or cefazolin (26.5%). A statistically significant difference was observed regarding antimicrobial prophylaxis prescribing practices in the hospitals (p < 0.0001). Low rates of adherence to guidelines in selected paediatric surgeries were observed. Increased awareness among surgeons and formulation of institutional and national antimicrobial prophylaxis guidelines are required.

Hospital-level factors associated with nonoperative management in common pediatric surgical procedures

PurposeOur purpose was to examine patient- and hospital-level factors associated with nonoperative management in common pediatric surgical diagnoses. MethodsUsing the 2012 Kid's Inpatient Database (KID), we identified patients <20 years old diagnosed with cholecystitis (CHOL), bowel obstruction (BO), perforated appendicitis (PA), or spontaneous pneumothorax (SPTX). Logistic regression models were used to identify factors associated with nonoperative management. ResultsOf 36,026 admissions for the diagnoses of interest, 7472 (20.7%) were managed nonoperatively. SPTX had the highest incidence of NONOP (55.9%; n = 394), while PA had the lowest incidence (9.2%; n = 1641). Utilization of operative management varied significantly between hospitals. Patients diagnosed with BO (OR 0.41; 95% CI 0.30–0.56) and SPTX (OR 0.28; 95% CI 0.14–0.56) had decreased odds of operative management when treated at an urban, teaching hospital compared to a rural hospital. Patients with PA had increased odds of operative management when treated at an urban, teaching hospital (OR 2.42; 95% CI 1.78–3.30). Hospital-level factors associated with decreased odds of nonoperative management included urban, nonteaching status (OR 0.54; 95% CI 0.31–0.91) and location in the South (OR 0.53; 95% CI 0.34–83) and West (OR 0.47; 95% CI 0.30–0.74). ConclusionsDespite representing more than 20% of pediatric surgical care for several conditions, nonoperative management is an understudied aspect of care with significant variation that warrants further research. Level of evidenceIII

Resident Independence Performing Common Orthopaedic Procedures at the End of Training: Perspective of the Graduated Resident.

The Accreditation Council for Graduate Medical Education (ACGME) has established minimum exposure rates for specific orthopaedic procedures during residency but has not established the achievement of competence at the end of training. The determination of independence performing surgical procedures remains undefined and may depend on the perspective of the observer. The purpose of this study was to understand the perceptions of recently graduated orthopaedic residents on the number of cases needed to achieve independence and on the ability to perform common orthopaedic procedures at the end of training. We conducted a web survey of all 727 recently graduated U.S. orthopaedic residents sitting for the 2018 American Board of Orthopaedic Surgery Part I Examination in July 2018. The surveyed participants were asked to assess the ability to independently perform 26 common adult and pediatric orthopaedic procedures as well as to recommend the number of cases to achieve independence at the end of training. We compared these data to the ACGME Minimum Numbers and the average ACGME resident experience data for residents who graduated from 2010 to 2012. For 14 (78%) of the 18 adult procedures, >80% of respondents reported the ability to perform independently, and for 7 (88%) of the 8 pediatric procedures, >90% reported the ability to perform independently. The resident-recommended number of cases for independence was greater than the ACGME Minimum Numbers for all but 1 adult procedure. For 18 of the 26 adult and pediatric procedures, the mean 2010 to 2012 graduated resident exposure was significantly less than the mean number recommended for independence by 2018 graduates (p < 0.05). Overall, recently graduated residents reported high self-perceived independence in performing the majority of the common adult and pediatric orthopaedic surgical procedures included in this study. In general, recently graduated residents recommended a greater number of case exposures to achieve independence than the ACGME Minimum Numbers.

Deriving literature-based benchmarks for pediatric appendectomy and cholecystectomy complications from national databases in high-income countries: A systematic review and meta-analysis

BackgroundHealth systems must identify preventable adverse outcomes to improve surgical safety. We conducted a systematic review to determine national rates of postoperative complications associated with two common pediatric surgery operations in High-Income Countries (HICs). MethodsNational database studies of complication rates associated with pediatric appendectomies and cholecystectomies (2000–2016) in Canada, the US, and the UK were included. Outcomes included mortality, length of hospital stay (LOS), and other surgical complications. Outcome data were extracted and comparisons made between countries and databases. ResultsThirty-three papers met inclusion criteria (1 Canadian, 1 UK, and 4 US Databases). Mean LOS was 3.00 (±1.42) days and 3.44 (±1.55) days for appendectomy and cholecystectomy, respectively. Mortality was 0.06% after appendectomy and 0.24% after cholecystectomy. Readmission and reoperation rates were 6.79% and 0.32% for appendectomy, and 1.37% and 0.71% for cholecystectomy. For appendectomies, LOS was shorter in Canadian and UK studies compared to US studies, and mortality and readmission rates were lower (OR 0.46 95%CI 0.23 to 0.93, OR 3.63 to 3.77 95%CI) in UK studies compared to US studies. ConclusionsOutcomes after pediatric appendectomy and cholecystectomy are good but vary between HICs. Understanding national outcomes and intercountry differences is essential in developing health system approaches to pediatric surgical safety. Level of evidenceII

Endoscopic butterfly graft myringoplasty in small to medium perforation in adolescent chronic otitis media: our experience in 15 cases

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Chronic otitis media is one of the most common paediatric conditions but ear surgery in children is challenging. The high rates of failure have often questioned surgical management of dry asymptomatic perforations in pediatric age group. This study aimed to assess the results of butterfly cartilage myringoplasty in adolescent population with small to medium perforation in chronic otitis media.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; We studied 15 cases in our prospective cross sectional observational study performed in the department of ENT at a secondary health centre in the eastern suburbs of Mumbai between October 2016 and September 2017. Children aged between 12 to 18 years with chronic otitis media mucosal inactive type with a central, small to medium sized tympanic membrane perforation and mild to moderate conductive hearing loss were included in this study.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Results showed that the average age was 14.63 (SD=1.79 years) with an M: F ratio of 1:1.14. The mean hearing gain in cases with medium perforation was 11.75 dB and 5.7 dB in cases having small perforations two cases showed residual crescentic perforation.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Our study shows that endoscopic butterfly graft myringoplasty in small to medium perforation in adolescent age group has good success rate and is safe, quick and minimally invasive day care procedure.&lt;/p&gt;

Epidemiology of common otologic surgical procedures in pediatric patients: A population-based birth cohort study

ObjectiveIt is generally recognized the most common pediatric otologic surgical procedure is ventilation tube insertion (VTI). Tympanoplasty and mastoidectomy are more frequently performed on adults. In this study we examined the incidence and age distribution of these procedures by use of a population-based birth cohort design, in order to provide an overall view of the role of these procedures in the pediatric population. Materials and methodsWe used the national health insurance research database in Taiwan. We retrieved data on all patients born in the years 2000 and 2001, subsequently underwent VTI, tympanoplasty or mastoidectomy from 2000 to 2013. The incidence and age distribution of these procedures were analyzed. ResultsThe cumulative incidence of VTI, tympanoplasty, and mastoidectomy was 0.41%, 0.02% and 0.025%, respectively. VTI were more often performed on children 4 or 5 years of age. Tympanoplasties are frequently done on children older than 5, and 30.7% of them had earlier VTI. The time interval from VTI to tympanoplasty was 5.18 ± 2.27 years (mean ± SD). Mastoidectomies are more often performed on children from 2 to 9 years of age. ConclusionsVTI was the most frequent otologic surgery for the pediatric population, and was more often performed on children 4–5 years old. Also, tympanoplasty is more frequently performed on children older than 5, and a third of them had prior VTI. Overall, the time interval from VTI to tympanoplasty was 5.18 years. Furthermore, children with cleft palate and congenital metabolic disorder were more prone to otologic surgical procedures.

Effect of acupressure on post tonsillectomy pain in adolescents: a randomized, single-blind, placebo-controlled trial study.

Tonsillectomy is one of the most common pediatric surgeries in the world and pain control following tonsillectomy is very important. The aim of this study is to investigate the effect of acupressure on the amount of pain following tonsillectomy in children. One hundred and forty-four children aged 5-12 years old were assigned into one of three groups: interventions, control and placebo. In the intervention group, acupressure was applied at three acupoints and in the placebo group, sham acupressure was applied. In the control group routine care only was applied. There was a significant difference between an average of changes in pain score before and after the intervention during the 3 time periods after the tonsillectomy operation in the acupressure group (p = 0.002). The results showed that acupressure had a positive effect on pain reduction after tonsillectomy in children in the intervention group.

Novel evidence depicting adverse long-term outcomes linked to tonsillectomy: a spotlight on overtreatment

Tonsillectomies (TEs) are the first line of treatment when patients present with recurrent tonsillitis, peritonsillar abscesses or obstructive sleep apnea. Though TEs have modest efficacy, they remain a common pediatric surgery in Canada. TEs are now viewed as a prophylactic measure used to prevent tonsil-related diseases. Simultaneously, there is a lack of evidence-based decision-making when recommending TEs, leading to overtreatment. Novel findings indicate that pediatric TE patients have an increased risk of complications and poor long-term outcomes including respiratory, infectious, and allergic disorders. A need for alternatives to TEs is evident; less invasive interventions with fewer perioperative complications and lifelong morbidities warrant further research. To prevent unnecessary adverse outcomes, healthcare providers should opt for more selective and evidence-based TE recommendations. Meanwhile, it is also imperative that physicians clearly communicate the potential quality of life implications associated with TEs. Healthcare and social mores surrounding TEs need to change towards a more evidence-based practice that focuses on improving patients’ quality of life. This commentary examines the current role of TEs, their long-term outcomes, and the implications of overtreatment.

Obstructive sleep apnea syndrome in the pediatric age: the role of the otorhinolaryngologist.

Obstructive sleep apnea (OSA) is the primary indication for tonsillectomy, one of the most common pediatric surgical procedures, commonly performed in association with adenoidectomy. The objective of this review article is to evaluate the role of the otorhinolaryngologist in pediatric OSA. A literature review has been performed on the following topics: peculiarities of sleep-disordered breathing in pediatric age; discrimination of sleep disorders; adenotonsillar hypertrophy; surgical techniques; adjuvant surgical procedures. The role of the otorhinolaryngologist in pediatric OSA is important for the evaluation of the upper airways and of essential biometric and polysomnographic data and for indication and execution of appropriate surgical treatment. In the majority of healthy children, adenotonsillectomy for OSA results in a dramatic improvement in respiratory parameters as measured by polysomnography. When post-surgical residual OSA occurs, it is essential to monitor patients by means of drug-induced sleep endoscopy (DISE). Otolaryngologic assessment is of paramount importance to correctly classify a child with OSA. Correct inspection of the upper airway and quantification of the quality of sleep through polysomnography lead to the right therapeutic choice. Knowledge of different surgical techniques helps to deal with residual OSA after studying the obstruction sites by drug-induced sedation endoscopy.

Gastrostomy tubes appear to be safe following pediatric orthotopic heart transplant.

Gastrostomy tube (GT) placement is a common pediatric surgical procedure typically indicated for oral aversion. This may develop in patients with congenital heart disease (CHD) who require an orthotopic heart transplant (OHT). The safety profile of GT placement in OHT patients who are immunosuppressed is unknown. Given the potential increased risk of wound site complications on a patient receiving immunosuppression, we sought to determine the safety profile of GT placement in pediatric patients with OHT. We performed a retrospective case series of all pediatric OHT recipients who subsequently underwent GT placement from January 1, 2009, to August 1, 2018, at the University of Virginia Children's Hospital. Major GT complications of wound breakdown, wound infection, peristomal GT leakage, ileus, or persistent emesis, and minor GT complication including the presence of granulation tissue are reported. Six patients who had a pediatric OHT subsequently underwent GT placement over the study period. There were no major 30-day or 90-day GT complications. One patient had excessive granulation tissue at their GT site. There were no accounts of acute kidney injury, urinary tract infection, sepsis, or pneumonia. Gastrostomy tube (GT) placement appears to be safe in pediatric OHT patients who are on immunosuppressive medications and unable to feed orally. This is the first study documenting the safety profile of GTs in pediatric OHT patients and may aid clinicians to make decisions regarding this intervention.

Optimizing postoperative follow-up in pediatric surgery (OFIPS)

Background/PurposeThe purpose of the study was to determine variables associated with attending postoperative clinic follow-up (POFU) in pediatric surgical patients, predictors of clinical value, and visit cost estimates. MethodsPOFU patterns of children undergoing eight common pediatric surgical procedures over one year at a tertiary pediatric hospital were examined retrospectively. Variables associated with attending POFU and associated with predetermined measures of clinical value and cost were determined. Driving distance to hospital was chosen as a proxy measure of cost to the family. ResultsSix-hundred-thirty-three patients were included, and 58% attended POFU. Variables independently associated with attending follow-up included: procedure type (orchidopexy, complicated appendicitis), living close to the hospital, having a defined follow-up order, individual surgeon attending. Clinical value was identified in 16.4% of patient visits and associated with orchidopexies, having required an earlier urgent postoperative visit and longer cases considered “complex”. Significant costs to the health care system (~$125,000) and families (~$15,000) could be estimated from follow-up cases that had no clinical issues identified nor required an intervention. ConclusionPOFU of common pediatric surgical procedures may have limited clinical value while coming at significant costs to families and the health care system. Further study is needed to define optimal needs and means of follow-up of these common pediatric surgical procedures. Level of evidenceLevel III.

Risk of post-operative hemorrhage after adenoidectomy and tonsillectomy: Value of the preoperative determination of partial thromboplastin time and prothrombin time

IntroductionTonsillectomy and adenoidectomy (T& A) are the most common pediatric surgical procedures performed world-wide. Bleeding remains the most common complication of these procedures with 1–5.7% prevalence. MethodsWe recruited 1269 patients who were scheduled for either tonsillectomy, adenoidectomy or both. All patients had preoperative CBC, PT, and aPTT ordered. According to the results, patients were labelled as either “abnormal group” or “normal group”. Results35 patients had abnormal lab results 18 of these patients were diagnosed with coagulation disorders on further laboratory testing.9 of these patients had no pertinent history of bleeding. Even though an association is noted between abnormal lab tests and preoperative history of risk of bleeding, the correlation did not have high sensitivity (28.6%). ConclusionThis study provides evidence that preoperative history can give some information on patients with abnormal coagulation profile but may underestimate the prevalence of such diseases. In addition, patients with abnormal coagulation profile have more risk of postoperative bleeding even after adequate medical treatment perioperative. Thus, identifying these patients will help the clinician in providing the best surgical management with the least morbidity and mortality.

Highs and Lows of Discharge Opioid Prescribing in Common Pediatric Surgical Procedures

Anderson, Kathryn T. MD, MPH, MS; Bartz-Kurycki, Marisa A. MD; Ferguson, Dalya M. MD; Kawaguchi, Akemi L. MD, FACS; Austin, Mary T. MD, MPH; Kao, Lillian S. MD, MS, FACS; Lally, Kevin P. MD, FACS; Tsao, KuoJen MD, FACS Author Information

National Review of Readability for Common Pediatric Surgical Procedures

National Review of Readability for Common Pediatric Surgical Procedures

How Much Will My Child's Operation Cost? Availability of Consumer Prices From US Hospitals for a Common Pediatric Orthopaedic Surgical Procedure.

Price transparency allows patients to make value-based health care decisions and is particularly important for individuals who are uninsured or enrolled in high-deductible health care plans. The availability of consumer prices for children undergoing orthopaedic surgery has not been previously investigated. We aimed to determine the availability of price estimates from hospitals in the United States for an archetypal pediatric orthopaedic surgical procedure (closed reduction and percutaneous pinning of a distal radius fracture) and identify variations in price estimates across hospitals. This prospective investigation utilized a scripted telephone call to obtain price estimates from 50 "top-ranked hospitals" for pediatric orthopaedics and 1 "non-top-ranked hospital" from each state and the District of Columbia. Price estimates were requested using a standardized script, in which an investigator posed as the mother of a child with a displaced distal radius fracture that needed closed reduction and pinning. Price estimates (complete or partial) were recorded for each hospital. The number of calls and the duration of time required to obtain the pricing information was also recorded. Variation was assessed, and hospitals were compared on the basis of ranking, teaching status, and region. Less than half (44%) of the 101 hospitals provided a complete price estimate. The mean price estimate for top-ranked hospitals ($17,813; range, $2742 to $49,063) was 50% higher than the price estimate for non-top-ranked hospitals ($11,866; range, $3623 to $22,967) (P=0.020). Differences in price estimates were attributable to differences in hospital fees (P=0.003), not surgeon fees. Top-ranked hospitals required more calls than non-top-ranked hospitals (4.4±2.9 vs. 2.8±2.3 calls, P=0.003). A longer duration of time was required to obtain price estimates from top-ranked hospitals than from non-top-ranked hospitals (8.2±9.4 vs. 4.1±5.1 d, P=0.024). Price estimates for pediatric orthopaedic procedures are difficult to obtain. Top-ranked hospitals are more expensive and less likely to provide price information than non-top-ranked hospitals, with price differences primarily caused by variation in hospital fees, not surgeon fees. Level II-economic and decision analyses.