title: Risk-adjusted hospital outcomes for children's surgery.
abstract: BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children's surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance.
  
  
  METHODS
  Participating institutions included children's units within general hospitals and free-standing children's hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models.
  
  
  RESULTS
  In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible.
  
  
  CONCLUSIONS
  The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children's surgery performance indicator. Programmatic improvements have resulted in actionable data.
authors.affiliation: Division of Pediatric Surgery, Washington University, St. Louis, MO, USA.
authors.forename: Jacqueline M
authors.initials: JM
authors.lastname: Saito
authors.forename: Li Ern
authors.initials: LE
authors.lastname: Chen
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Hall
authors.forename: Kari
authors.initials: K
authors.lastname: Kraemer
authors.forename: Douglas C
authors.initials: DC
authors.lastname: Barnhart
authors.forename: Claudia
authors.initials: C
authors.lastname: Byrd
authors.forename: Mark E
authors.initials: ME
authors.lastname: Cohen
authors.forename: Chunyuan
authors.initials: C
authors.lastname: Fei
authors.forename: Kurt F
authors.initials: KF
authors.lastname: Heiss
authors.forename: Kristopher
authors.initials: K
authors.lastname: Huffman
authors.forename: Clifford Y
authors.initials: CY
authors.lastname: Ko
authors.forename: Melissa
authors.initials: M
authors.lastname: Latus
authors.forename: John G
authors.initials: JG
authors.lastname: Meara
authors.forename: Keith T
authors.initials: KT
authors.lastname: Oldham
authors.forename: Mehul V
authors.initials: MV
authors.lastname: Raval
authors.forename: Karen E
authors.initials: KE
authors.lastname: Richards
authors.forename: Rahul K
authors.initials: RK
authors.lastname: Shah
authors.forename: Laura C
authors.initials: LC
authors.lastname: Sutton
authors.forename: Charles D
authors.initials: CD
authors.lastname: Vinocur
authors.forename: R Lawrence
authors.initials: RL
authors.lastname: Moss
mesh_terms: D000293:Adolescent; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D039702:Current Procedural Terminology; D005260:Female; D017052:Hospital Mortality; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D015233:Models, Statistical; D011183:Postoperative Complications / Q000401:mortality* / Q000517:prevention & control; D011446:Prospective Studies; D058996:Quality Improvement; D020379:Risk Adjustment; D014481:United States
keywords: benchmark; outcome assessment; pediatric; risk-adjustment; surgical procedures