S. M. Stokes1, S. S. Short1, D. C. Barnhart1, E. R. Scaife1, B. T. Bucher1 1University Of Utah School Of Medicine,Division Of Pediatric Surgery,Salt Lake City, UT, USA
Introduction: The surgical management of infants with uncomplicated gastroschisis is not well defined. There remains a lack of strong evidence favoring primary versus delayed closure of the abdominal wall defect, and the decision is often based on surgeon preference. We proposed that institutional propensity for a particular closure method would help identify disparities in patient outcomes and resource utilization.
Methods: We performed a retrospective cohort analysis of infants with gastroschisis at children’s hospitals from 2010-2014 using the Pediatric Health Information Systems Database. Patients were excluded if they underwent an intestinal resection, had a significant cardiac or neurologic anomaly, or expired during the hospital admission. Patients were classified as either primary closure (≤ 24 hours from admission to closure) or delayed closure (> 24 hours from admission to closure). The proportion of patients managed in a delayed fashion for each hospital was calculated as the hospital’s delayed closure rate. Primary outcomes included length of stay (LOS), total parental nutrition (TPN) days, and ventilator days. Multivariate hierarchical linear regression with random effects was used to determine the effect of hospital delayed closure rate on the primary outcomes after controlling for various patient and hospital level factors.
Results: There were 1812 infants treated at 41 children’s hospitals during the study period and 1080 (60%) underwent delayed gastroschisis closure. Infants who underwent delayed closure were more likely to be lower birthweight (2451g vs 2567g, p<0.0001) and younger gestational age (35.9 weeks vs 36.1 weeks, p=0.03). Infants managed in a delayed fashion had longer LOS (43.2±24.1 vs. 35.3±19.6, p<0.001), greater TPN days (32.3±18.4 vs. 27.0±16.4, p<0.001) and greater ventilator days (7.7±10.1 vs. 4.5±3.6, p<0.0001). The percentage of infants managed in a delayed fashion at each hospital is shown in the Figure and ranged from 27.5% to 100%. There was no significant correlation between hospital delayed closure rate and average LOS (p=0.67), TPN days (p=0.33), or ventilator days (p=0.96). After accounting for various patient and hospital level factors, hospital delayed closure rate was not significantly associated with LOS (p=0.09), TPN days (p=0.42) or ventilator days (p=0.84).
Conclusion: Significant practice variation exists in the management of gastroschisis in US children’s hospitals. An institution’s propensity for a specific closure method is not significantly associated with adverse patient outcomes or increased resource utilization.
