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Standardized Perioperative Protocols and Variance in Pediatric Surgery
Leigh Selesner1, Anthony Gutierrez1,2, Cortnie Vaughn1
1Department of Surgery, Division of General Surgery, School of Medicine, Oregon Health & Science University, Portland.
Insights
The Minimizing Variance in Pediatric Surgery (MViPS) program reduced hospital costs and length of stay for pediatric surgery patients. This initiative improved efficiency and outcomes across multiple institutions.
Area of Science:
- Pediatric Surgery
- Healthcare Quality Improvement
- Surgical Outcomes Research
Background:
- Standardized perioperative pathways are crucial for reducing variation and enhancing patient outcomes in surgery.
- Implementation of these pathways in pediatric surgery has lagged, necessitating broader evaluations.
Purpose of the Study:
- To assess the impact of the Minimizing Variance in Pediatric Surgery (MViPS) program on clinical outcomes, length of stay (LOS), and costs.
- To evaluate the effectiveness of a multi-institutional, multiprotocol initiative in pediatric surgery.
Main Methods:
- A cohort study comparing pediatric surgery patients before and after the implementation of the MViPS program across two academic tertiary referral centers.
- Data collected from October 2012 to November 2021, analyzing outcomes such as LOS, total hospital costs (THC), complications, and protocol compliance.
Main Results:
- The MViPS program demonstrated 82% protocol compliance.
- Post-implementation, study LOS decreased by 23% (191 hospital days), and total hospital costs (THC) were reduced by 10% ($266,709).
- Complication rates remained similar between pre- and post-protocol groups.
Conclusions:
- The MViPS initiative successfully reduced total hospital costs and length of stay in pediatric surgery.
- Standardized protocols are valuable for improving both outcomes and efficiency in pediatric surgical care across institutions.
Importance:
Standardized perioperative pathways are increasingly used in surgery to reduce unwarranted variation, promote evidence-based practice, and improve patient outcomes, yet pediatric implementation has lagged, with most studies focused on single conditions or institutions. Broader evaluation of multiprotocol, multi-institution initiatives is needed.
Objective:
To evaluate the association of the Minimizing Variance in Pediatric Surgery (MViPS) program with clinical outcomes, length of stay (LOS), and cost.
Design, Setting, And Participants:
This cohort study was conducted from October 2012 to November 2021 at 2 academic pediatric tertiary referral centers in Oregon. Data analysis was completed in May 2024. Pediatric surgery patients treated for protocol-specified conditions or procedures, with age cutoffs varying by protocol (typically <18 years). Exclusions included failure to meet protocol criteria, nonpediatric surgery management, and insufficient documentation.
Intervention:
Implementation of standardized perioperative protocols targeting a range of pediatric surgical conditions.
Main Outcomes And Measures:
Outcomes included LOS, total hospital costs (THC), complications, and protocol compliance. LOS was characterized as study LOS, defined as postprocedure LOS for patients who underwent a procedure and total hospital stay for those who did not, and total LOS, representing the entire period of hospitalization. Hospital days and cost differences were calculated from total LOS and THC.
Results:
A total of 1081 pediatric surgery patients were included (519 postprotocol and 562 preprotocol; median [IQR] age, 3 [0-10] years; 668 [62%] male). No significant demographic differences were found between preprotocol and postprotocol groups. Protocol compliance was 82% (426/519). Complication rates were similar between groups, but study LOS was 23% shorter in the postprotocol group (incidence rate ratio [IRR], 1.23; 95% CI, 1.11-1.38; P < .001), with a reduction of an estimated 191 hospital days. THC was 10% lower in the postprotocol group (IRR, 1.10; 95% CI, 1.01-1.20; P = .03), with an estimated reduction of $266 709. Extrapolation to 3167 patients treated according to protocol since the end of the study (up to April 2024) reveals an estimated reduction of $2 236 583 and 1584 hospital days.
Conclusions And Relevance:
In this study, the MViPS initiative was associated with reduced THC and LOS while maintaining outcomes. These findings support the value of standardized protocols in improving pediatric surgical outcomes and efficiency across institutions.
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