Patients Who Undergo Colectomy for Pediatric Ulcerative Colitis at Low-Volume Hospitals Have More Complications

Abstract

BACKGROUND & AIMS:Adults with ulcerative colitis (UC) who undergo colectomy at high-volume centers have better outcomes and fewer complications than those at low-volume centers. We aimed to evaluate the hospital volume of total abdominal colectomy (TAC) for pediatric patients with UC and explore time trends in the proportion of colectomies performed at high-volume centers. We then evaluated the association between hospital colectomy volume and complications. METHODS:We performed a cross-sectional analysis of pediatric patients (age, £18 y) hospitalized for UC using the Kids' Inpatient Database, a nationally representative database of pediatric hospitalizations. We identified UC hospitalizations with a procedural code (International Classification of Diseases, 9th or 10th revision) for TAC from 1997 through 2016. We defined complications using diagnosis codes adapted from published algorithms. We defined high-volume as hospitals that performed 10 or more TACs annually. We used multivariate statistics to evaluate the association between hospital volume and in-hospital complications. RESULTS:A total of 1453 hospitalizations of children with UC included a TAC (2306 colectomies nationwide). A total of 766 hospitals performed 1 or more annual colectomies and only 36 (4.7%) were high-volume hospitals, accounting for 21% of colectomies. The proportion of colectomies at high-volume hospitals decreased over time. The absolute risk of complication was 16% at high-volume centers compared with 22% at low-volume centers (adjusted odds ratio, 0.7; 95% CI, 0.5-0.9). The effect of annual TAC volume on complication risk was not statistically significant for nonemergent admissions. CONCLUSIONS:Pediatric patients with UC who undergo colectomy at high-volume centers have fewer complications. However, only a small proportion of pediatric colectomies (<5%) are performed at high-volume centers.

Procedural Volume and Colectomy Complications

“…As pediatricians, we note that the data in Table 1 from Egberg et al 2 show that a child on Medicaid is 60% more likely to receive a colectomy in a low-volume hospital. Similarly, African Americans were 40% more likely and Hispanics were 84% more likely to receive their colectomy in a low-volume hospital.…”

“…Very few health care providers would seriously doubt that such a relationship exists for children, and in fact many would assume that it is even more pronounced among our youngest patients. By using epidemiologic methods to study the problem and its magnitude, Egberg et al 2 have provided us with an opportunity to further explore variations in surgical availability and outcomes of colectomy performed for pediatric ulcerative colitis.…”

“…Egberg et al 2 performed an analysis of the Kids Inpatient Database (KID). The KID 3 is one of a family of databases that contain limited data from the discharge records of a representative group of our nation's hospitals as part of the Health Care Cost and Utilization Project.…”

“…In understanding any analysis of surgical outcomes, patient selection and preoperative care are always of paramount importance. As pointed out by Egberg et al, 2 the KID database does not capture information that would help us to risk stratify the subjects studied. Furthermore, among the KID's inherent limitations are findings that might be influenced by the rapid changes in health care.…”

“…Preoperative patient selection also may have confounded the results seen in the emergent colectomy group of Egberg et al 2 There appears to be a trend in many pediatric IBD centers for patients to be admitted for scheduled colectomies. Based on the definitions used in this study, these patients are at risk of being mischaracterized as emergent as opposed to being semi-elective and occurring when the patient has been optimized for surgery.…”