Disparity in management and long-term outcomes of pediatric splenic injury in California.
OBJECTIVE
To determine the impact of evidence-based guidelines on the disparities in management of pediatric splenic injuries (PSI).


BACKGROUND
Several studies have highlighted a disparity in the utilization of nonoperative management (NOM) for PSI based on hospital and surgeon characteristics. Whether evidence-based guidelines had an impact on mitigating this disparity is uncertain.


METHODS
From 1999 to 2006, children < or = 18 years with PSI were extracted from California's Patient Discharge Database (n = 5089). Patient demographics, injury grade, immediate and delayed operations, readmissions, and complications were analyzed.


RESULTS
The overall rates of immediate operative management (IOM) decreased significantly from 23% in 1999 to 15% in 2006 (P < 0.001). This decline was attributed entirely to reduction of IOM at non-children's hospitals (NCH) (29% to 20%, P < 0.001). In contrast, IOM rates were low and unchanged at children's hospital (CH) (9%, P = NS). Failed NOM (3.3%), readmissions for complications (0.6%), and operations (0.3%) were rare and unaffected by NOM increase. NCH had increased risk of IOM compared to CH in multivariate analysis (OR: 2.00, 99% CI: 1.09-3.57). The rate of delayed splenic rupture was 0.2%. There were no differences when comparing the rates of readmissions (1.0% vs. 0.4%, P = NS) and readmit operations (0.3% vs. 0.3%, P = NS) between IOM versus NOM.


CONCLUSIONS
A steady increase in the utilization of NOM for PSI in California over time was attributed entirely to changing practices at NCH. Increasing NOM has occurred without a concurrent increase in complications. Delayed splenic ruptures were rare. Although IOM rates at NCH decreased over time, disparity in NOM utilization still exists between NCH and CH.
Jen
Howard C
HC
Division of Pediatric Surgery, University of California Los Angeles School of Medicine, Los Angeles, CA 90095, USA.
Tillou
Areti
A
Cryer
Henry G
HG
Shew
Stephen B
SB
D000293:Adolescent; D002140:California; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007415:Intestinal Obstruction / Q000209:etiology; D008297:Male; D010359:Patient Readmission; D011183:Postoperative Complications; D017410:Practice Guidelines as Topic; D013154:Spleen / Q000293:injuries* / Q000601:surgery; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000601:surgery / Q000628:therapy*