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Variability in the management of adhesive small bowel obstruction in children
Jordan C Apfeld1, Jennifer N Cooper1, Lindsay A Gil1
1Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH 43205, USA; Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH 43205, USA.
Insights
Surgical intervention rates for pediatric adhesive small bowel obstruction (ASBO) vary widely among US children's hospitals. This significant variability in operative versus nonoperative management is likely due to differing clinical practices rather than patient or hospital factors.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Health Services Research
Background:
- Adhesive small bowel obstruction (ASBO) is a common surgical diagnosis in children.
- Management strategies, including operative versus nonoperative approaches, can vary significantly.
- Understanding inter-hospital variability in ASBO management is crucial for standardizing care.
Purpose of the Study:
- To assess the extent of inter-hospital variability in the operative versus nonoperative management of pediatric adhesive small bowel obstruction (ASBO).
- To identify patient and hospital factors associated with the chosen management strategy for pediatric ASBO.
Main Methods:
- A multi-institutional retrospective study was conducted using data from the Pediatric Health Information System (PHIS) from 2010 to 2019.
- Patients aged 1-21 years presenting with ASBO were included.
- Multivariable mixed-effects logistic regression was employed to analyze inter-hospital variability in management decisions.
Main Results:
- Out of 6410 pediatric ASBO admissions across 46 hospitals, 50.5% underwent surgery.
- Hospital-specific surgery rates ranged from 35.3% to 74.7%, indicating significant variability.
- Factors influencing operative management included surgical service admission, congenital anomalies, advanced imaging, non-emergent status, and comorbidities; nonoperative management was associated with higher hospital ASBO volume, older age, public insurance, and specific comorbidities.
Conclusions:
- Significant inter-hospital variability exists in the surgical management of pediatric ASBO across US tertiary children's hospitals.
- This variability appears independent of patient and hospital characteristics.
- Practice variation is likely the primary driver of differing management approaches for pediatric ASBO.
Background:
This study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO).
Methods:
A multi-institutional retrospective study was performed examining patients 1-21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO.
Results:
Among 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5-42.6%) to 74.7% (66.3-81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3-45.1%) to 73.9% (66.7-79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4-3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1-3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5-1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3-1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2-1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97-0.99], p = 0.002), older age (OR 0.97 [0.96-0.98], p < 0.001), public insurance (OR 0.87 [0.78-0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47-0.68], p < 0.001).
Conclusions:
Rates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation.
Level Of Evidence:
III.
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