Exploring regional variability in utilization of antireflux surgery in children

There is significant variation surrounding the indications, surgical approaches, and outcomes for children undergoing antireflux procedures (ARPs) resulting in geographic variation of care. Our purpose was to quantify this geographic variation in the utilization of ARPs in children.

A cross-sectional analysis of the 2009 Kid's Inpatient Database was performed to identify patients with gastroesophageal reflux disease or associated diagnoses. Regional surgical utilization rates were determined, and a mixed effects model was used to identify factors associated with the use of ARPs.

Of the 148,959 patients with a diagnosis of interest, 4848 (3.3%) underwent an ARP with 2376 (49%) undergoing a laparoscopic procedure. The Northeast (2.0%) and Midwest (2.2%) had the lowest overall utilization of surgery, compared with the South (3.3%) and West (3.4%). After adjustment for age, case-mix, and surgical approach, variation persisted with the West and the South demonstrating almost two times the odds of undergoing an ARP compared with the Northeast. Surgical utilization rates are independent of state-level volume with some of the highest case volume states having surgical utilization rates below the national rate. In the West, the use of laparoscopy correlated with overall utilization of surgery, whereas surgical approach was not correlated with ARP use in the South.

Significant regional variation in ARP utilization exists that cannot be explained entirely by differences in patient age, race/ethnicity, case-mix, and surgical approach. In order to decrease variation in care, further research is warranted to establish consensus guidelines regarding indications for the use ARPs for children.