Surgical Outcomes in Children According to Hospital Location and Designation: A National Study

Abstract

Introduction: The effects of hospital location and specialty designation on post-operative outcomes in children have not been extensively evaluated. We hypothesized that outcomes would be improved at urban centers, and that outcomes would differ at urban centers for children from rural versus urban counties. Methods: We conducted a retrospective cohort study of children undergoing non-incidental appendectomy (n=129,507) and pyloromyotomy (n=17,109) using the 2006 and 2009 Kid's Inpatient Database and 2007, 2008 and 2010 Nationwide Inpatient Sample. Hospitals were defined as non-children's, children's unit in a general hospital, or freestanding children's hospitals, and were classified as urban or rural based on census data. Patient County of residence was classified as urban or rural based on census data. Outcomes included post-operative complications defined by ICD-9 codes and total hospital length of stay. Multivariate logistic and linear regression models were used to adjust for confounding. Results: Among appendectomy patients, 12.1% were treated at rural hospitals, while 3.4% of pyloromyotomy patients received their operation at a rural hospital. For appendectomy patients, treatment at urban relative to rural hospitals was associated with a reduced odds of any post-operative complication (OR=0.82, 95% C.I. 0.73 - 0.92) and anesthesia-related complications (OR=0.75, 95% C.I. 0.59 - 0.96). This association was strongest in the youngest children (<5 years) and at freestanding children's hospitals, specifically. Among children receiving appendectomy at urban centers, adjusted length of stay was half a day shorter for urban children than for rural children (p<0.001). For pyloromyotomy patients, urban hospitals were associated with a reduced odds of any complication (OR=0.33, 95% C.I. 0.20 - 0.55), anesthesia-related complications (OR=0.12, 95% C.I. 0.05 - 0.29), and duodenal perforation (OR=0.36, 95% C.I. 0.16 - 0.82). These associations were strongest at freestanding children's hospitals. Conclusion: Post-operative outcomes are improved at urban specialty hospitals for certain common procedures in children, and this effect seems to be most important in younger children. The specific factors responsible for these improved outcomes must be identified in order to improve care for children treated in all practice settings.