Variability in outcomes after gastroschisis closure across U.S. children's hospitals

doi:10.1016/j.jpedsurg.2017.04.012

Journal of Pediatric Surgery

Volume 53, Issue 3, March 2018, Pages 513-520

https://doi.org/10.1016/j.jpedsurg.2017.04.012 Get rights and content

Abstract

Background

In patients undergoing gastroschisis closure, the effects of timing of closure and patient and hospital-level characteristics on length of stay (LOS) and time to enteral autonomy are unknown.

Study design

Using the Pediatric Health Information System, we compared neonates who underwent early (within 1 day of birth) versus delayed (> 1 day after birth) gastroschisis closure from 2005 to 2013. We evaluated the relationship between time to closure and both LOS and days on total parenteral nutrition (TPN).

Results

Of 4459 neonates with gastroschisis, 43.9% underwent early closure and 56.1% underwent delayed closure. Delayed closure, complicated gastroschisis, government insurance, lower birth weight, older age at closure, and complex chronic conditions were associated with longer LOS and days on TPN (all p < 0.05). There was significant inter-hospital variability in both outcomes, after adjusting for patient- and hospital-level characteristics, including hospitals' gastroschisis and neonatal volumes, median age at closure, and percentages of complicated and delayed gastroschisis patients, (p < 0.01).

Conclusion

Delayed gastroschisis closure is associated with longer LOS and duration of TPN, even after excluding complicated cases. Furthermore, after controlling for hospital volume, rate of complicated gastroschisis, and timing of closure, the persistent inter-hospital variability suggests that practice variability is partially responsible for these differences.

Type of study

Retrospective study.

Level of evidence

III

Section snippets

Data source and cohort identification

We utilized the Pediatric Health Information System (PHIS) to conduct a retrospective multi-institutional cohort study of neonates with gastroschisis. The PHIS is a multi-institutional hospital discharge database that includes data from 49 tertiary children's hospitals on inpatient, observation, emergency department, and ambulatory surgery encounters. Diagnoses and procedures in this database can be identified using International Classification of Disease, 9th Edition, Clinical Modification

Results

From 2005 through 2013, there were 4525 patients with gastroschisis who underwent surgical closure at one of the 37 included hospitals (Fig. 1). Of those patients, 4493 were managed at 35 hospitals that treated at least 30 cases. The final analyses included 4459 patients with gastroschisis managed with either early (N = 1956) or delayed (N = 2503) closure. Table 1 describes the baseline characteristics of the patients in our cohort. The median age at closure was 3 days. While a slightly higher

Discussion

In this multi-institutional cohort of neonates with gastroschisis, delayed gastroschisis closure was associated with longer LOS and more days on TPN compared to early closure. Furthermore, across tertiary children's hospitals, significant variability exists in outcomes for neonates undergoing gastroschisis closure, even after adjusting for patient- and hospital-level characteristics available in the PHIS. When the cohort was narrowed to a subset of patients with only simple gastroschisis, our

Conclusion

References (36)

P. Gamba et al.
Abdominal wall defects: prenatal diagnosis, newborn management, and long-term outcomes
Semin Pediatr Surg
(2014)
J.H. Aldrink et al.
Variability in gastroschisis management: a survey of north American pediatric surgery training programs
J Surg Res
(2012)
C.N. Emami et al.
A risk-stratified comparison of fascial versus flap closure techniques on the early outcomes of infants with gastroschisis
J Pediatr Surg
(2015)
L.A. Lusk et al.
Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: a report from the University of California Fetal Consortium (UCfC)
J Pediatr Surg
(2014)
K. Murthy et al.
The association of type of surgical closure on length of stay among infants with gastroschisis born >/=34 weeks' gestation
J Pediatr Surg
(2014)
K.C. Orion et al.
Outcomes of plastic closure in gastroschisis
Surgery
(2011)
A.C. Pastor et al.
Routine use of a SILASTIC spring-loaded silo for infants with gastroschisis: a multicenter randomized controlled trial
J Pediatr Surg
(2008)
J. Riboh et al.
Outcomes of sutureless gastroschisis closure
J Pediatr Surg
(2009)
A. Sandler et al.
A "plastic" sutureless abdominal wall closure in gastroschisis
J Pediatr Surg
(2004)
J. Stanger et al.
Practice variation in gastroschisis: factors influencing closure technique
J Pediatr Surg
(2014)

M.H. Tsai et al.

Clinical features of newborns with gastroschisis and outcomes of different initial interventions: primary closure versus staged repair

Pediatr Neonatol

(2010)

A. Aljahdali et al.

Effect of timing of enteral feeding on outcome in gastroschisis

J Pediatr Surg

(2013)

B.T. Bucher et al.

Effect of time to surgical evaluation on the outcomes of infants with gastroschisis

J Pediatr Surg

(2012)

A. Bianchi et al.

Elective delayed reduction and no anesthesia: 'minimal intervention management' for gastrochisis

J Pediatr Surg

(1998)

S.N. Kunz et al.

Primary fascial closure versus staged closure with silo in patients with gastroschisis: a meta-analysis

J Pediatr Surg

(2013)

J. Baerg et al.

Gastroschisis: a sixteen-year review

J Pediatr Surg

(2003)

B.H. Eggink et al.

Outcome of gastroschisis: a 20-year case review of infants with gastroschisis born in Galveston, Texas

J Pediatr Surg

(2006)

C.P. Driver et al.

The contemporary outcome of gastroschisis

J Pediatr Surg

(2000)

Cited by (18)

Relationship between volume and outcome for gastroschisis: A systematic review
2022, Journal of Pediatric Surgery
Citation Excerpt :
LOS was analyzed in eleven studies [29-32,47-50,52,53]. However, results of seven studies [30-32,47-49,52] were mainly used for summarizing findings as data used in the other studies [29,50,53] are probably completely or largely included in data used within these seven studies. Analyses and statistical measures differed across studies.
Newborns with gastroschisis need surgery to reduce intestines into the abdominal cavity and to close the abdominal wall. Due to an existing volume-outcome relationship for other high-risk, low-volume procedures, we aimed at examining the relationship between hospital or surgeon volume and outcomes for gastroschisis.
We conducted a systematic literature search in Medline, Embase, CENTRAL, CINAHL and Biosis Previews in June 2021 and searched for additional literature. We included (cluster-) randomized controlled trials (RCTs) and prospective or retrospective cohort studies analyzing the relationship between hospital or surgeon volume and mortality, morbidity or quality of life. We assessed risk of bias of included studies using ROBINS-I and performed a systematic synthesis without meta-analysis and used GRADE for assessing the certainty of the evidence.
We included 12 cohort studies on hospital volume. Higher hospital volume may reduce in-hospital mortality of neonates with gastroschisis, while the evidence is very uncertain for other outcomes. Findings are based on a low certainty of the evidence for in-hospital mortality and a very low certainty of the evidence for all other analyzed outcomes, mainly due to risk of bias and imprecision. We did not identify any study on surgeon volume.
The evidence suggests that higher hospital volume reduces in-hospital mortality of newborns with gastroschisis. However, the magnitude of this effect seems to be heterogeneous and results should be interpreted with caution. There is no evidence on the relationship between surgeon volume and outcomes.
Gastroschisis: Progress and Challenges
2022, Journal of Pediatrics
Influence of birthplace on gastroschisis outcomes in a state in the southeastern region of Brazil
2021, Jornal de Pediatria
To characterize the influence of birthplace on outcomes of patients with gastroschisis admitted to three hospitals in a state in Brazil’s southeastern region, according to condition inborn (born in a reference center) or outborn (born outside the reference center).
Retrospective multicenter cohort study of patients with gastroschisis. The sample size utilized was of patients admitted in three hospitals with a diagnosis of gastroschisis ICD 10 Q79.3 between January 2000 to December 2018. Patients were divided into two groups, inborn and outborn. Characteristics of prenatal, perinatal and postoperative were compared using statistical tests. The level of significance adopted was P-value < 0.05.
In total, 144 cases of gastroschisis were investigated. The outborn patients group had higher rates of absence of antenatal diagnosis (p = 0.001), vaginal delivery (p = 0.001), longer time between birth and abdominal wall closure surgery (p = 0.001), to silo removal (p = 0.001), to first enteral feeding (p = 0.008), for weaning from mechanical ventilation (p = 0.034), used less peripherally inserted central catheter (PICC) and required more venous dissections (p = 0.001), and lower mean of serum sodium (p = 0.015). There were no differences in mortality rates and length of hospital stay between the inborn and outborn groups.
Although outborn patients with gastroschisis were less likely to have an antenatal diagnosis and were more prone to a longer time to undergo surgical and feeding procedures, and to spend more time in mechanical ventilation, these disadvantages seemed not to reflect on the death rate and the length of hospital stay of patients from this group.
Estimating Length of Stay for Simple Gastroschisis
2021, Journal of Surgical Research
Citation Excerpt :
To our knowledge, this methodology has not been used for hospital-based discharges or estimating LOS for a rare population such as gastroschisis. As seen in Figure, our model estimates the mean LOS for a hypothetical population of neonates with simple gastroschisis is 4-5 wk and reflects reports by other tertiary centers that routinely care for this population.3-5 We acknowledge several study limitations.
Length of stay (LOS) is an important measure of quality; however, estimating LOS for rare populations such as gastroschisis is problematic. Our objective was to identify explanatory variables for LOS and build a model to estimate LOS in neonates with simple gastroschisis.
In 73 neonates with simple gastroschisis (47% female, 67% White), statistical correlations for 31 potential explanatory variables for LOS were evaluated using multivariate linear regression. Poisson regression was used to estimate LOS in predetermined subpopulations, and a life table model was developed to estimate LOS for simple gastroschisis.
Female sex (−2.4 d), “time to silo placement” (0.9 d), total parenteral nutrition days (0.6 d), need for any nasogastric feedings (11.4 d) and at discharge (−7 d), “feeding tolerance” (0.4 d), days to first postoperative stool (−0.3 d), and human milk exposure (−3.4 d) associated with LOS in simple gastroschisis. Estimated LOS for preterm neonates was longer than term infants (5.4 versus 4.6 wk) but similar for estimates based on sex and race. Based on these associations, we estimate that >50% of neonates with simple gastroschisis will be discharged by hospital day 35.
We identified several associations that explained variations in LOS and developed a novel model to estimate LOS in simple gastroschisis, which may be applied to other rare populations.
Minimizing Variance in Gastroschisis Management Leads to Earlier Full Feeds in Delayed Closure
2021, Journal of Surgical Research
Limited guidance exists regarding appropriate timing for feed initiation and advancement in gastroschisis. We hypothesized that implementation of a gastroschisis management protocol would allow for standardization of antibiotic and nutritional treatment for these patients.
We conducted a retrospective comparison of patients with simple gastroschisis at two pediatric hospitals before and after initiation of our gastroschisis care protocol. Complicated gastroschisis and early mortality were excluded. The control group extended from January 2012 to January 2014 and the protocol group from July 2014 to July 2016. Variables of interest included time to feed initiation, time to goal feeds, length of stay, and National Surgical Quality Improvement Program–defined complications. We performed a subgroup analysis for primary versus delayed gastroschisis closure. Statistical analyses, including F-tests for variance, were conducted in Prism.
Forty-seven patients with simple gastroschisis were included (control = 22, protocol = 25). Protocol compliance was 76% with no increase in complication rates. There was no difference in length of stay or time from initiation to full feeds overall between the control and protocol groups. However, neonates who underwent delayed closure reached full feeds significantly earlier, averaging 9 d versus 15 d previously (P = 0.04).
For infants undergoing delayed closure, the time to full feeds in this group now appears to match that of patients undergoing primary closure, indicating that delayed closure should not be a reason for slower advancement. Additional studies are needed to assess the impact of earlier full enteral nutrition on rare complications and rates of necrotizing enterocolitis.
Approaches for Closing Gastroschisis
2020, Advances in Pediatrics

View all citing articles on Scopus

^☆: Conflicts of interest: none.

^☆☆: Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

^★: Meeting presentation: Presented during the scientific forum at the American College of Surgeons Clinical Congress 2016 in Washington, DC in October 2016.

View full text

Neonatal/InfantVariability in outcomes after gastroschisis closure across U.S. children's hospitals☆,☆☆,★

Abstract

Background

Study design

Results

Conclusion

Type of study

Level of evidence

Section snippets

Data source and cohort identification

Results

Discussion

Conclusion

Semin Pediatr Surg

J Surg Res

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Surgery

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Pediatr Neonatol

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Neonatal/Infant
Variability in outcomes after gastroschisis closure across U.S. children's hospitals☆,☆☆,★