title: Assessment of variation in care and outcomes for pediatric appendicitis at children's and non-children's hospitals.
abstract: BACKGROUND
  Variation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children's hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children's hospitals (CHs) and NCH.
  
  
  METHODS
  Using the 2012 Kids' Inpatient Database, 11,216 children with perforated appendicitis were identified. Comparisons between CH and NCH were made in regard to operative approach (open versus laparoscopic), central line (CL) and total parenteral nutrition (PN) use, complication rates, length of stay (LOS), and total costs.
  
  
  RESULTS
  NCHs cared for 8051 patients (72%) with perforated appendicitis. CHs were more likely to perform a laparoscopy compared to NCHs (odds ratio (OR) 10.2, 95% confidence interval (95% CI) 5.7-18.2), and to utilize CL or PN than NCHs (CL OR 2.4 (95% CI 1.5-3.8), PN OR 2.6 (95% CI 1.4-4.9)). Composite complication rates were lower at CH (OR 0.5 (95% CI 0.4-0.6)). While LOS was not different between CH and NCH in the fully adjusted model, costs were higher at CH (OR 6.8 (95% CI 3.9-12.2)). Low and high outliers could be identified for each variable and outcome of interest with no consistent performance regardless of CH or NCH status.
  
  
  CONCLUSIONS
  Variation in operative approach, resource use, complications, LOS, and costs exist in the management of pediatric perforated appendicitis with greatest variation observed at NCH. Future quality improvement efforts should be tailored for implementation at both CH and high-volume NCH.
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, GA, United States.
authors.forename: Yao
authors.initials: Y
authors.lastname: Tian
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States.
authors.forename: Kurt F
authors.initials: KF
authors.lastname: Heiss
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States.
authors.forename: Mark L
authors.initials: ML
authors.lastname: Wulkan
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States. Electronic address: mehulvraval@emory.edu.
authors.forename: Mehul V
authors.initials: MV
authors.lastname: Raval
mesh_terms: D000293:Adolescent; D001062:Appendectomy / Q000379:methods / Q000592:standards*; D001064:Appendicitis / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D016001:Confidence Intervals; D016208:Databases, Factual; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data; D006761:Hospitals / Q000592:standards / Q000706:statistics & numerical data; D006776:Hospitals, Pediatric / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D010535:Laparoscopy / Q000706:statistics & numerical data*; D007902:Length of Stay; D008297:Male; D010289:Parenteral Nutrition, Total / Q000706:statistics & numerical data; D058996:Quality Improvement
keywords: Appendectomy; Appendicitis; Kids' Inpatient Database; Pediatric surgery; Quality; Quality improvement