Differences in outcome with subspecialty care: pyloromyotomy in North Carolina

Proponents of subspecialization in surgery claim that fellowship training improves the quality of care. Others claim that general training is adequate for most routine surgical procedures. The authors questioned whether there were differences in outcomes when general surgeons (GEN) operate on children and infants with common surgical conditions compared with the care of their pediatric surgical (PED) colleagues.

The authors retrospectively reviewed the Healthcare Investment Analysts North Carolina Information Network database to identify patients who underwent pyloromyotomy for congenital hypertrophic pyloric stenosis in North Carolina during the period from October 1995 through September 1998 (n = 780). Information obtained included demographics, insurance type, hospital, length of stay, total hospital charges, occurrence of mucosal perforation, and type of surgeon (general v pediatric).

Of the 780 pyloromyotomies performed, 363 (48%) were performed by pediatric surgeons. Pediatric surgeons cared for more Medicaid patients than general surgeons (PED, 52% v GEN, 40%; P =.001). Infants treated by pediatric surgeons had a lower incidence of mucosal perforation (PED, 0.5% v GEN, 2.9%; P =.0015), which was associated with decreased overall total hospital charges (no perforation, $4,806 plus minus 79 v perforation, $6,592 plus minus 492; P =.002). When patients with uncomplicated pyloric stenosis were evaluated (96% of cases), those cared for by pediatric surgeons had lower total hospital charges (PED, $4,496 plus minus 95 v GEN, $5,121 plus minus 121; P =.0001) and shorter length of stay (PED, 2.7 plus minus 0.1 days v GEN, 3.1 plus minus 0.1 days; P =.01).

In North Carolina, general surgeons treat more than half the patients who have pyloric stenosis, though fewer with Medicaid. The cost and incidence of mucosal perforation were increased in infants with pyloric stenosis when care was provided by general rather than pediatric surgeons.