Navigating Limited Resources-Outpatient Pediatric Cholecystectomies at Rural Hospitals

Rural facilities that provide pediatric surgical services are a critical resource to local communities. Our aim was to characterize differences in outpatient pediatric cholecystectomy outcomes performed at rural and urban hospitals with the hypothesis that rural hospitals would have similar outcomes.

The Nationwide Ambulatory Surgery Sample (NASS), which contains ambulatory surgery encounters at hospital-owned facilities, was used to perform a retrospective cohort analysis of pediatric patients age 18-years and younger who had a cholecystectomy (n = 15,449) between 2016 and 2018. Survey-weighted multivariate regression analyses were used to evaluate the association of rural and urban hospital locations with the primary outcome of routine discharge. Models were adjusted for sex, age, comorbidities, insurance, income quartile, indication for operation, and hospital characteristics.

Patients receiving care at rural hospitals were more commonly in the lowest two median income quartiles compared to urban hospitals (91.1 % versus 58.2 %, p < 0.01) and had more complex chronic comorbidities (63.1 % versus 57.2 %, p < 0.01). In both settings, the most common surgical indication was cholecystitis followed by biliary dyskinesia; nearly all procedures were performed laparoscopically (>99 %), and complications were rare with no deaths. Survey weight multivariate regression analysis showed patients cared for at rural hospitals had a higher odds ratio of routine discharge compared to those cared for at urban hospitals (adjusted OR 2.27, 95 %CI 1.04-4.99, p = 0.04).

Pediatric patients at rural hospitals have lower median income and a higher mean morbidity index. Despite these challenges, outpatient cholecystectomy was safe at rural hospitals and associated with increased odds of routine discharge when compared with urban hospitals.