title: The Preventable Shunt Revision Rate: a potential quality metric for pediatric shunt surgery.
abstract: OBJECTIVE Shunt surgery consumes a large amount of pediatric neurosurgical health care resources. Although many studies have sought to identify risk factors for shunt failure, there is no consensus within the literature on variables that are predictive or protective. In this era of "quality outcome measures," some authors have proposed various metrics to assess quality outcomes for shunt surgery. In this paper, the Preventable Shunt Revision Rate (PSRR) is proposed as a novel quality metric. METHODS An institutional shunt database was queried to identify all shunt surgeries performed from January 1, 2010, to December 31, 2014, at Le Bonheur Children's Hospital. Patients' records were reviewed for 90 days following each "index" shunt surgery to identify those patients who required a return to the operating room. Clinical, demographic, and radiological factors were reviewed for each index operation, and each failure was analyzed for potentially preventable causes. RESULTS During the study period, there were 927 de novo or revision shunt operations in 525 patients. A return to the operating room occurred 202 times within 90 days of shunt surgery in 927 index surgeries (21.8%). In 67 cases (33% of failures), the revision surgery was due to potentially preventable causes, defined as inaccurate proximal or distal catheter placement, infection, or inadequately secured or assembled shunt apparatus. Comparing cases in which failure was due to preventable causes and those in which it was due to nonpreventable causes showed that in cases in which failure was due to preventable causes, the patients were significantly younger (median 3.1 vs 6.7 years, p = 0.01) and the failure was more likely to occur within 30 days of the index surgery (80.6% vs 64.4% of cases, p = 0.02). The most common causes of preventable shunt failure were inaccurate proximal catheter placement (33 [49.3%] of 67 cases) and infection (28 [41.8%] of 67 cases). No variables were found to be predictive of preventable shunt failure with multivariate logistic regression. CONCLUSIONS With economic and governmental pressures to identify and implement "quality measures" for shunt surgery, pediatric neurosurgeons and hospital administrators must be careful to avoid linking all shunt revisions with "poor" or less-than-optimal quality care. To date, many of the purported risk factors for shunt failure and causes of shunt revision surgery are beyond the influence and control of the surgeon. We propose the PSRR as a specific, meaningful, measurable, and-hopefully-modifiable quality metric for shunt surgery in children.
authors.affiliation: College of Medicine and 
authors.forename: Garrett T
authors.initials: GT
authors.lastname: Venable
authors.affiliation: Departments of 2 Neurosurgery and.
authors.forename: Nicholas B
authors.initials: NB
authors.lastname: Rossi
authors.affiliation: Departments of 2 Neurosurgery and.|Clinical Pharmacy, University of Tennessee Health Science Center;
authors.forename: G
authors.initials: G
authors.lastname: Morgan Jones
authors.affiliation: Departments of 2 Neurosurgery and.
authors.forename: Nickalus R
authors.initials: NR
authors.lastname: Khan
authors.affiliation: College of Medicine and 
authors.forename: Zachary S
authors.initials: ZS
authors.lastname: Smalley
authors.affiliation: College of Medicine and 
authors.forename: Mallory L
authors.initials: ML
authors.lastname: Roberts
authors.affiliation: Departments of 2 Neurosurgery and.|Semmes-Murphey Neurologic & Spine Institute; and.|Le Bonheur Children's Hospital, Memphis, Tennessee.
authors.forename: Paul
authors.initials: P
authors.lastname: Klimo
mesh_terms: D000293:Adolescent; D000328:Adult; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects / Q000592:standards / Q000639:trends*; D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual / Q000639:trends; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011787:Quality of Health Care / Q000592:standards / Q000639:trends*; D012086:Reoperation / Q000592:standards / Q000639:trends*; D012189:Retrospective Studies; D055815:Young Adult
keywords: EMR = electronic medical records; HCRN = Hydrocephalus Clinical Research Network; IQR = interquartile range; KID = Kids' Inpatient Database; LBCH = Le Bonheur Children's Hospital; LOS = length of hospital stay; NSQIP-P = National Surgical Quality Improvement Program–Pediatrics; PHHP = posthemorrhagic hydrocephalus of prematurity; PSRR = Preventable Shunt Revision Rate; RQ = Revision Quotient; SAR = Surgical Activity Rate; UTHSC = University of Tennessee Health Science Center; hydrocephalus; neurosurgery; pediatrics; shunt malfunction; ventriculoperitoneal shunt