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PEDIATRICS Vol. 107 No. 2 February 2001, pp. 299-303
,
From the * Department of Pediatrics, Oregon Health Sciences
University and Doernbecher Children's Hospital, Portland, Oregon;
Departments of Anesthesiology and § Surgery, University of
Washington and Children's Hospital and Regional Medical Center,
Seattle, Washington; and Department of Radiology, University of
Arkansas Medical Sciences and Arkansas Children's Hospital, Little
Rock, Arkansas.
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ABSTRACT |
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Abstract
Methods
Results
Discussion
Conclusion
References
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Objective. To determine whether the risk of operative management of children with intussusception varies by hospital pediatric caseload.
Design. A cohort of all children with intussusception in Washington State from 1987 through 1996.
Setting. All hospitals in Washington State.
Methods. Five hundred seventy children with a hospital discharge diagnosis of intussusception were identified. Sixty-two were excluded because of missing data. Procedure codes for operative management and radiologic management were also identified.
Results. Fifty-three percent of the children had operative reduction and 20% had resection of bowel. Children with operative reduction did not differ from those with nonoperative care by median age or gender; however, children with operative care were significantly more likely to receive care in hospitals with smaller pediatric caseloads and to have a coexisting condition associated with intussusception. Sixty-four percent of children who received care in a large children's hospital had nonoperative reduction, compared with 36% of children who received care in hospitals with 0 to 3000 annual pediatric admissions and 24% of children who had care in hospitals with 3000 to 10 000 annual pediatric admissions. Median length of stay and charges were significantly less in the large children's hospital, compared with other centers.
Conclusions. Children who received care for intussusception in a large children's hospital had decreased risk of operative care, shorter length of stay, and lower hospital charges compared with children who received care in hospitals with smaller pediatric caseloads. Key words: intussusception, enema, children.
Intussusception is a common cause of bowel obstruction in
young children. Compared with operative reduction, radiologic
(nonoperative) reduction is associated with less patient discomfort,
shorter hospital length of stay (LOS), lower hospital charges, and
decreased risk of subsequent complications. Reports of successful
radiologic reduction exceed 70% in some populations.1-5
Such patient clinical features as duration of symptoms, age, and
presence of bowel obstruction, and such radiologic features as
reduction technique and operator experience6,7 may affect
the success rate of nonoperative management.
We examined all cases of intussusception in children from Washington
State over a 10-year period to evaluate the association between
hospital pediatric caseload and other factors with the success of
nonoperative reduction for intussusception. The proportion of children
requiring bowel resection, LOS, and hospital charges were also examined
for this cohort of children.
After institutional review board approval by the University of
Washington, Children's Hospital and Regional Medical Center (CHRMC)
and the State of Washington Health and Human Services Department, we
obtained for the years 1987 through 1996 computerized information
available for all persons hospitalized in Washington State.
Participants were included if they had a principle diagnosis code for
intussusception (codes 560.0 from the International
Classification of Diseases)8 and if they were <17
years of age. Variables that were examined in the analysis included
age, gender, and hospital of admission. A maximum of 6 International Classification of Diseases diagnosis codes and
6 procedure codes were examined, as well as LOS, charges, and survival.
Nonoperative management was defined as a radiologic procedure code
87.64 for a lower gastrointestinal examination and the absence of any
procedure codes for surgery.8 Operative management was
defined as any of the following procedure codes: open reduction without
bowel resection (46.80-46.82, 45.00-45.03) and open reduction with
bowel resection (45.60-46.30).8 Specific diagnosis codes
for the following conditions associated with intussusception were also
noted: Meckel's diverticulum, hemolytic uremic syndrome, idiopathic
thrombocytopenia purpura, ulcerative colitis, Crohn's disease, and
Henoch-Schönlein anaphylactic purpura (HSP).8 One
author (C.M.H.) reviewed all cases from CHRMC, Seattle, Washington to
determine the accuracy of the dataset. The hospital discharge dataset
was not altered for CHRMC patients based on the chart review to prevent
a bias in the dataset.
Hospital pediatric caseload for each hospital in the state was
categorized as 0 to 3000, 3001 to 10 000, and >10 000 annual admissions of children <17 years of age based on 1996 hospital admissions. Children who were transferred from one inpatient facility to another were only counted once and were assigned to the final hospital for analysis.
The Mann-Whitney U test and Kruskal-Wallis H test were used
to compare skewed continuous data and a Bonferonni's adjustment was
used for multiple pair-wise comparisons. The median values with 25th
and 75th quartiles are reported in the manuscript. Categorical data
were examined using the Five hundred seventy children were identified. No procedure codes
were recorded in the dataset for 200 children, of whom 138 children had
a hospital LOS of 1 day. One hundred four of the 138 children (76%)
without any procedure codes who were hospitalized for 1 day were
admitted to CHRMC; all of these 104 patients had successful
nonoperative reduction confirmed by review of the medical records. Two
children admitted to CHRMC for 1 day underwent operative reduction
after failed radiologic treatment. Both cases were correctly recorded
in the dataset as operative reduction. Therefore, children admitted to
any hospital in the state for intussusception for only 1 day who did
not have a procedure code were considered to have nonoperative
management for analysis. The remaining 62 children without listed
procedure codes and with hospitalization >1 day were excluded from
further analysis. Children who were excluded did not significantly
differ from those included participants by age, gender, coexisting
conditions, insurance status, or hospital pediatric caseload.
Review of the 276 charts of the CHRMC patients demonstrated that data
present in the hospital discharge data were generally accurate. There
were no errors regarding patient age, hospital LOS, or need for bowel
resection. The payer was inaccurately recorded in 12 cases (4%),
surgical reduction was not coded in 8 cases (3%), and the diagnosis of
intussusception was miscoded in 3 cases (1%).
There were 16 hospitals with 0 to 3000 annual pediatric admissions, 13 with 3001 to 10 000, and 1 with >10 000 annual admissions. The
demographic features of the remaining 508 children are presented in
Table 1. The median age was .8 years (.5, 2.3 years), and two thirds of the patients were male. Thirty-five
children (6%) had recurrent intussusception during the study. The
median time to relapse was 118 days (23, 314 days). One 6-month-old
child with a Meckel's diverticulum, who had both surgery and bowel
resection, died of sepsis.
TABLE 1
METHODS
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Abstract
Methods
Results
Discussion
Conclusion
References
2 test. The
relationships between hospital pediatric caseload and success of
nonoperative management of children with intussusception and risk of
bowel resection among children who had surgery were examined by
calculating adjusted odds ratio (OR) using multiple logistic regression
(SPSS, Version 7.5 for Windows; SPSS Inc, Chicago, IL) to
control for potential confounding variables. Children with HSP were
excluded from the final analysis regarding risk of operative management
and bowel resection because they are routinely treated with operative
care rather than radiologic reduction. The adjusted OR was reported
with 95% confidence intervals (CIs). Statistical significance was
defined as P < .05.
RESULTS
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Abstract
Methods
Results
Discussion
Conclusion
References
Demographic and Clinical Features of Patients With Intussusception
Operative reduction occurred in 270 children (53%), of whom 104 (20%) required bowel resection (Table 2). Children who required operative reduction had similar median age compared with children who had nonoperative reduction (. 7 years [.4, 2.5 years] vs .9 years [.5,2.0 years], respectively), although children ages 1 to 2 years were least likely to have operative reduction. Children who had operative reduction were more likely to have either a coexisting condition associated with intussusception or be transferred from another inpatient facility than children who did not have operative care. Children in a health maintenance organization (HMO) were less likely to have operative care than were children with commercial insurance or Medicaid. Both hospital charges and LOS were significantly longer for children who required surgery, compared with children who had nonoperative reduction.
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One hundred four children had bowel resected. These children were significantly older (median age: 1.0 years [.5,5.3 years]) compared with children who had operative reduction without bowel resection (median age: .8 years [.5,1.9 years]). Children who had bowel resected were more likely to have a coexisting condition associated with intussusception than were children who underwent operative reduction without resection (34% vs 7%, respectively). Children with bowel resection had greater hospital median LOS (6 days [4,8]) and median charges ($7760 [$5786,$12 872]) compared with children without bowel resection (4 days [3,5] and $4531 [$3332,$6625]).
Patient demographic features and outcome are compared by hospital pediatric caseload in Table 3. Children treated in a large referral center with >10 000 annual pediatric admissions were less likely to require operative reduction or bowel resection; however, among children who had surgery, the proportion with bowel resection was similar for the various pediatric caseload groups. Children treated at the large pediatric referral center had shorter LOS (median stay of 1 day) compared with those treated at centers with 0 to 3000 annual pediatric admissions (median stay of 3 days) and those treated at centers with 3001 to 10 000 annual pediatric admissions (median stay of 4 days). Similarly, median hospital charges were less ($1875 vs $3718 and $4532, respectively).
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The adjusted analyses of factors associated with operative reduction and bowel resection are in Table 4. Children with HSP (n = 3) were excluded from the analysis. Children over 4 years of age were >3 times as likely to have bowel resection, compared with younger children. Children with coexisting conditions that are associated with intussusception had a fivefold greater risk of operative reduction compared with children without such conditions, and they were almost 5 times as likely to require bowel resection. Patients who were transferred from another inpatient facility were 5 times more likely to have operative management but were not significantly more likely to have bowel resection. Children treated at facilities with smaller pediatric caseloads had increased risk of operative reduction after adjustment for age and other conditions associated with intussusception. However, among children who had operative reduction, there was no increased risk of bowel resection at hospitals with <10 000 annual pediatric admissions.
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If children with a coexisting condition associated with intussusception were excluded from the analysis, then the risk of operative reduction for children with intussusception in a hospital with 0 to 3000 annual pediatric cases remained 3.2 (95% CI: 1.9-5.3) times greater than for children who received care in a hospital with >10 000 annual admissions. The risk of operative management for children with intussusception in a hospital with 3000 to 10 000 annual admissions was 5.7 (95% CI: 3.5-9.3) times greater than for children with intussusception who received care in a hospital with >10 000 annual admissions (data not shown).
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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We found that children with intussusception who received care in a large pediatric hospital had a lower risk of requiring operative intervention compared with children who received care in hospitals with smaller pediatric caseloads. Children had between 1.7 and 2 times greater unadjusted risk of operative care when they were treated in smaller hospitals compared with a large children's hospital and the estimated risk was greater after adjustment for potential confounding features, such as age and coexisting conditions. As expected, nonoperative management was associated with shorter LOS and lower hospital charges.9
The explanation for this finding cannot be determined from the information that we have available for study. We could not determine when in the course of the disease the children presented for care, whether the diagnosis was recognized and appropriate consultation obtained without delay, and, finally, what specific radiologic techniques were used and how experienced the radiologic interventionists were. This information was not available in the hospital discharge data and may have differed among hospitals with differing pediatric caseloads.
Studies have shown that radiologists with a large experience treating intussusception have improved reduction rates compared with those with less2,5 and that repeated radiologic attempts are frequently successful after a failed initial attempt.1,10 Pediatric radiologists are reported to repeat attempts for radiologic reduction more frequently than do operators with less experience.5 Although we believe that increased radiologic experience at a large pediatric center explains part of the difference in the rates of nonoperative management, the state hospital discharge dataset does not provide direct information to confirm this.
Use of hospital discharge data has another limitation (ie, missing data). We excluded all cases of >1 day hospital LOS without listed procedure codes, ~10% of the cases, because we could not assume that they had nonoperative management. If we were to assume that all children without a procedure code who were admitted for 2 days or less had nonoperative management, then only 25 children (4%) would have been excluded. When the logistic analysis was repeated using this assumption, the risk of surgery and of bowel resection by age, insurance status, and hospital pediatric caseload did not substantively change. The presence of missing data, therefore, does not seem to alter our conclusions.
Other important findings of the study include the effect of age and cocoexisting conditions on the risk of operative management of intussusception. As previously reported,11 we found that median age did not differ between children who had operative reduction, compared with nonoperative reduction; however, the relatively small number of older children had an increased risk of bowel resection, compared with the younger children. This difference was similar to previous reports.7,12 Children ages 1 to 2 years had the lowest risk of operative care. This age group has the highest incidence of intussusception and a low rate of coexisting conditions associated with intussusception.
We were surprised to find that children with HMO medical coverage had a decreased risk of surgery compared with children with Medicaid or no insurance, but that children with commercial insurance did not have a decreased rate. Other studies have shown that patients with Medicaid have increased risk for perforation with acute appendicitis.13-15 Potential explanations for the decreased risk among children with HMO insurance include better access to primary care and higher parental economic status compared with Medicaid patients. The lower risk among HMO patients may be because of greater HMO insurance in western Washington, which is more urban than the remainder of the state. However, we cannot determine the specific causes for this association.
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CONCLUSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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We found that children with the diagnosis of intussusception who received care in a specialized pediatric facility had a lower risk of operative reduction, decreased LOS, and lower hospital charges compared with children treated in other facilities. The risk of surgical management in the small and medium pediatric experience facilities were not statistically different from each other. Numerous studies of specific procedures have demonstrated that hospitals with more experience have lower mortality compared with less experienced centers.16-18 Other studies have shown that pediatric radiologists who have more experience with intussusception have greater radiologic reduction rates than do radiologists with less experience.1,3,5
We believe that greater physician experience in the large referral center explains some of the difference in nonoperative management by hospital pediatric caseload in our study. We examined the radiologic reduction rates at 2 medium caseload centers in Washington that have radiologists with pediatric training on staff. The rates of operative management were 87% and 80%, suggesting that experience rather than training may be key. However, other important features may have contributed to lower risk of operative care in a large pediatric center that we were unable to evaluate in this study.
We suggest that transfer to a center with a high pediatric volume be considered if a child has an intussusception that cannot be radiographically reduced if the patient is hemodynamically stable and the time needed for transport is acceptable to the involved surgical and radiologic staff.
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FOOTNOTES |
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Received for publication Mar 15, 2000; accepted Jun 6, 2000.
Reprint requests to (S.L.B.) Department of Pediatrics, University of Michigan, F-6884, Mott/0243, 1500 E Medical Center Dr, Ann Arbor, MI 48109. E-mail: sbratton{at}umich.edu
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ABBREVIATIONS |
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LOS, length of stay; CHRMC, Children's Hospital and Regional Medical Center; HSP, Henoch-Schönlein purpura; OR, odds ratio; CI, confidence interval; HMO, health maintenance organization.
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REFERENCES |
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Results
Discussion
Conclusion
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