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PEDIATRICS Vol. 109 No. 5 May 2002, pp. 988-989

Appendicitis—Pediatric Surgeons Versus General Surgeons

To the Editor—

In the present era of concern about children’s access to pediatric subspecialists, ¹ empirical research such as that presented by Kokoska et al, ² comparing the efficiency of pediatric surgeons with general surgeons in the care of children with acute appendicitis, is commendable. Its application on a statewide basis goes beyond previous evidence in support of surgical specialists limited to a single institution, ³ enhancing this study’s generalizability as well as its statistical power.

The main finding of the study was that hospital length of stay was shorter, leading to lower total costs, for young children cared for by pediatric surgeons compared with general surgeons. The authors subsequently conclude that care delivered by pediatric surgeons was more "cost-effective." This is a misuse of the term. Cost-effectiveness analysis requires examination of both costs and outcomes, which were not jointly analyzed by Kokoska and colleagues. In fact, it could be argued that outcomes were worse for pediatric surgeons, who had higher rates of perforated appendix than general surgeons. The authors explain the increased rate of perforation encountered by pediatric surgeons as possibly linked to diminished access to care for urban children who are uninsured or have Medicaid ⁴; however, they provide no evidence from their data to support this assertion. Rather than speculating, the authors could have used insurance information collected in their data source, the Missouri Department of Health Patient Abstract System.

Data on charges were derived solely from the hospitalization. A stronger analysis would have considered the full episode of care that patients experienced, rather than the hospitalization alone. For instance, if patients in large urban settings (where all pediatric surgeons in the study practiced, versus just 59% of general surgeons) had greater use of the emergency department, the costs they incurred may have been displaced from hospitalization costs, with the overall cost of the episode similar across settings and provider types.

The authors did not adjust the analyses for clustering of multiple cases by individual surgeons or hospital centers. A few efficient pediatric surgeons, with high patient volumes, could have driven the study findings. Moreover, the statistical tests reported in this study assume that each observation (ie, the cost of each case of appendicitis) is independent. However, because individual surgeons presumably operated on and managed multiple children, this assumption is violated, which increases the chances of a type I error (falsely concluding that there is a true difference between practitioner types). A hierarchical linear model, accounting for the nested study design, would have been a more appropriate analytic approach.

The pediatric community should applaud efforts at substantiating the value of pediatric medical subspecialists and surgical specialists, but must also demand rigor in the process of evaluation.

Scott A Shipman, MD, MPH
Christopher B Forrest, MD, PhD
Departments of Health Policy and Management and Pediatrics
Johns Hopkins Medical Institutions
Baltimore, MD 21205, USA

REFERENCES

1. Gilchrist G, Fierson W, Spencer CH, et al. The future of pediatric education (FOPE) II report summary and pediatric subspecialists [commentary]. Pediatrics.2001; 107 :1179 –1180[Free Full Text]
2. Kokoska ER, Minkes RK, Silen ML, et al. Effect of pediatric surgical practice on the treatment of children with appendicitis. Pediatrics.2001; 107 :1298 –1301[Abstract/Free Full Text]
3. Snow BW, Catwright PC, Young MD. Does surgical subspecialization in pediatrics provide high-quality, cost-effective patient care? Pediatrics.1996; 97 :14 –17[Abstract/Free Full Text]
4. Braveman P, Schaaf VM, Egerter S, Bennett T, Schecter W. Insurance-related differences in the risk of ruptured appendix. N Engl J Med.1994; 331 :444 –449[Abstract/Free Full Text]

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In Reply—

We appreciate the comments from Drs Shipman and Forrest. Our study supports the conclusion that younger children with appendicitis have a reduced length of hospitalization and charges when treated by pediatric surgeons versus general surgeons. However, as we were not able to specifically address surgical outcome in this study, the statement that pediatric surgeons may be more "cost-effective" may be inaccurate. Our data also suggests that pediatric surgeons treated perforated or complicated appendicitis more frequently when compared with general surgeons. Our explanation for this observation was that inner-city academic centers are more likely to treat children with limited access to health care as a result of insurance or financial status. The concept that patients (and children) with Medicaid coverage are associated with a higher incidence of complicated appendicitis is well-established in the literature. ^1–3 While insurance data was not collected and/or analyzed in our study, the suggestion to support this concept using the Missouri Department of Health (MDOH) Patient Abstract System is excellent.

With regard to the comment concerning total hospital charges, our impression from the MDOH was that the charge associated with hospitalization would have included an emergency department charge but likely would not include a preceding clinic visit. Thus, in this respect, total charges in the current study would be higher for those children who received their primary care via an emergency room versus a clinic. Finally, we agree that a hierarchical linear model for statistical analysis would have been preferable. However, to accomplish our study with the MDOH, the following methods were used. We sent the MDOH a list of board-certified general surgeons (GS) and pediatric surgeons (PS), and the raw data returned to us was coded as either GS or PS. Thus, we were blinded to the surgeon and institutional name and could not account for the clustering of multiple cases by individual surgeons or hospitals.

Evan R Kokoska, MD
James Whitcomb Riley Hospital for Children
Indianapolis, IN, USA

Thomas R Weber, MD
Cardinal Glennon Children’s Hospital
St Louis, MO, USA

REFERENCES

1. Braverman P, Schaaf VM, Egerter S, Bennett T, Schecter W. Insurance-related differences in the risk of ruptured appendix. N Engl J Med.1994; 331 :444 –449
2. O’Toole SJ, Karamanoukian HL, Allen JE, et al. Insurance-related differences in the presentation of pediatric appendicitis. J Pediatr Surg.1996; 31 :1032 –1034[CrossRef][Medline]
3. Bratton SL, Haberkern CM, Waldhausen JHT. Acute appendicitis risks of complications: age and Medicaid insurance. Pediatrics.2000; 106 :75 –78[Abstract/Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Shipman, S. A Articles by Weber, T. R Search for Related Content PubMed PubMed Citation Articles by Shipman, S. A Articles by Weber, T. R Social Bookmarking                         What's this?