title: Influence of sub-specialty surgical care on outcomes for pediatric emergency general surgery patients in a low-middle income country.
abstract: BACKGROUND
  Whether adult general surgeons should handle pediatric emergencies is controversial. In many resource-limited settings, pediatric surgeons are not available. The study examined differences in surgical outcomes among children/adolescents managed by pediatric and adult general surgery teams for emergency general surgical (EGS) conditions at a university-hospital in South Asia.
  
  
  METHODS
  Pediatric patients (<18y) admitted with an EGS diagnosis (March 2009-April 2014) were included. Patients were dichotomized by adult vs. pediatric surgical management team. Outcome measures included: length of stay (LOS), mortality, and occurrence of ≥1 complication(s). Descriptive statistics and multivariable regression analyses with propensity scores to account for potential confounding were used to compare outcomes between the two groups. Quasi-experimental counterfactual models further examined hypothetical outcomes, assuming that all patients had been treated by pediatric surgeons.
  
  
  RESULTS
  A total of 2323 patients were included. Average age was 7.1y (±5.5 SD); most patients were male (77.7%). 1958 (84.3%) were managed by pediatric surgery. The overall probability of developing a complication was 1.8%; 0.9% died (all adult general surgery). Patients managed by adult general surgery had higher risk-adjusted odds of developing complications (OR [95%CI]: 5.42 [2.10-14.00]) and longer average LOS (7.98 vs. 5.61 days, p < 0.01). 39.8% fewer complications and an 8.2% decrease in LOS would have been expected if all patients had been managed by pediatric surgery.
  
  
  CONCLUSIONS
  Pediatric patients had better post-operative outcomes under pediatric surgical supervision, suggesting that, where possible in resource-constrained settings, resources should be allocated to promote development and staffing of pediatric surgical specialties parallel to adult general surgical teams.
authors.affiliation: Mayo Clinic, Division of General Surgery, Phoenix, AZ, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Surgery, Aga Khan University, Karachi, Pakistan. Electronic address: adl_ajz@yahoo.com.
authors.forename: Adil A
authors.initials: AA
authors.lastname: Shah
authors.affiliation: Department of Pediatrics, West Virginia University School of Medicine, Charleston, WV, USA. Electronic address: amarah_16@yahoo.com.
authors.forename: Amarah
authors.initials: A
authors.lastname: Shakoor
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA. Electronic address: czogg@jhmi.edu.
authors.forename: Cheryl K
authors.initials: CK
authors.lastname: Zogg
authors.affiliation: Children's Mercy Hospitals and Clinics, Kansas City, MO, USA. Electronic address: taoyetunji@cmh.edu.
authors.forename: Tolulope
authors.initials: T
authors.lastname: Oyetunji
authors.affiliation: Mayo Clinic, Division of General Surgery, Phoenix, AZ, USA. Electronic address: ashfaq.awais@mayo.edu.
authors.forename: Awais
authors.initials: A
authors.lastname: Ashfaq
authors.affiliation: Mayo Clinic, Division of General Surgery, Phoenix, AZ, USA. Electronic address: garvey.erin@mayo.edu.
authors.forename: Erin M
authors.initials: EM
authors.lastname: Garvey
authors.affiliation: Department of Anesthesiology and Critical Care Medicine & Center for Global Health, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: alatif1@jhmi.edu.
authors.forename: Asad
authors.initials: A
authors.lastname: Latif
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA. Electronic address: riviello@post.harvard.edu.
authors.forename: Robert
authors.initials: R
authors.lastname: Riviello
authors.affiliation: Department of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA. Electronic address: faisal.qureshi@UTSouthwestern.edu.
authors.forename: Faisal G
authors.initials: FG
authors.lastname: Qureshi
authors.affiliation: Department of Surgery, Aga Khan University, Karachi, Pakistan. Electronic address: arif.mateen@aku.edu.
authors.forename: Arif
authors.initials: A
authors.lastname: Mateen
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA. Electronic address: ahhaider@partners.org.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
authors.affiliation: Department of Surgery, Aga Khan University, Karachi, Pakistan. Electronic address: hasnain.zafar@aku.edu.
authors.forename: Hasnain
authors.initials: H
authors.lastname: Zafar
mesh_terms: D000293:Adolescent; D000328:Adult; D001210:Asia, Southeastern; D002648:Child; D002675:Child, Preschool; D003906:Developing Countries; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D013502:General Surgery / Q000706:statistics & numerical data*; D006295:Health Resources / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D017063:Outcome Assessment, Health Care; D010154:Pakistan / Q000453:epidemiology; D000070316:Pediatric Emergency Medicine / Q000600:supply & distribution*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies
keywords: Adult general surgery; Emergency general surgery; Low- and middle-income country; Pediatric surgery; Surgical outcomes