title: Perioperative outcomes for pediatric neurosurgical procedures: analysis of the National Surgical Quality Improvement Program-Pediatrics.
abstract: OBJECTIVE Existing studies have shown a high overall rate of adverse events (AEs) following pediatric neurosurgical procedures. However, little is known regarding the morbidity of specific procedures or the association with risk factors to help guide quality improvement (QI) initiatives. The goal of this study was to describe the 30-day mortality and AE rates for pediatric neurosurgical procedures by using the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatrics (NSQIP-Peds) database platform. METHODS Data on 9996 pediatric neurosurgical patients were acquired from the 2012-2014 NSQIP-Peds participant user file. Neurosurgical cases were analyzed by the NSQIP-Peds targeted procedure categories, including craniotomy/craniectomy, defect repair, laminectomy, shunts, and implants. The primary outcome measure was 30-day mortality, with secondary outcomes including individual AEs, composite morbidity (all AEs excluding mortality and unplanned reoperation), surgical-site infection, and unplanned reoperation. Univariate analysis was performed between individual AEs and patient characteristics using Fischer's exact test. Associations between individual AEs and continuous variables (duration from admission to operation, work relative value unit, and operation time) were examined using the Student t-test. Patient characteristics and continuous variables associated with any AE by univariate analysis were used to develop category-specific multivariable models through backward stepwise logistic regression. RESULTS The authors analyzed 3383 craniotomy/craniectomy, 242 defect repair, 1811 laminectomy, and 4560 shunt and implant cases and found a composite overall morbidity of 30.2%, 38.8%, 10.2%, and 10.7%, respectively. Unplanned reoperation rates were highest for defect repair (29.8%). The mortality rate ranged from 0.1% to 1.2%. Preoperative ventilator dependence was a significant predictor of any AE for all procedure groups, whereas admission from outside hospital transfer was a significant predictor of any AE for all procedure groups except craniotomy/craniectomy. CONCLUSIONS This analysis of NSQIP-Peds, a large risk-adjusted national data set, confirms low perioperative mortality but high morbidity for pediatric neurosurgical procedures. These data provide a baseline understanding of current expected clinical outcomes for pediatric neurosurgical procedures, identify the need for collecting neurosurgery-specific risk factors and complications, and should support targeted QI programs and clinical management interventions to improve care of children.
authors.affiliation: Division of Global Neurosurgery and Neuroscience and.|Global Health Institute, Duke University, Durham, North Carolina.|Duke-NUS Medical School, Singapore;
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Kuo
authors.affiliation: Division of Global Neurosurgery and Neuroscience and.|Global Health Institute, Duke University, Durham, North Carolina.
authors.forename: Joao Ricardo N
authors.initials: JR
authors.lastname: Vissoci
authors.affiliation: Global Health Institute, Duke University, Durham, North Carolina.
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Egger
authors.affiliation: Division of Global Neurosurgery and Neuroscience and.|Global Health Institute, Duke University, Durham, North Carolina.
authors.forename: Emily R
authors.initials: ER
authors.lastname: Smith
authors.affiliation: Department of Neurosurgery, Stanford University, Stanford, California.
authors.forename: Gerald A
authors.initials: GA
authors.lastname: Grant
authors.affiliation: Division of Global Neurosurgery and Neuroscience and.|Global Health Institute, Duke University, Durham, North Carolina.|Departments of 4 Neurosurgery and.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Haglund
authors.affiliation: Global Health Institute, Duke University, Durham, North Carolina.|Surgery, Duke University Medical Center, Durham, North Carolina; and.
authors.forename: Henry E
authors.initials: HE
authors.lastname: Rice
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D019635:Neurosurgical Procedures / Q000401:mortality / Q000592:standards / Q000639:trends*; D010372:Pediatrics / Q000592:standards / Q000639:trends*; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control*; D058996:Quality Improvement / Q000592:standards / Q000639:trends*; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: ACS = American College of Surgeons; AE = adverse event; AOR = adjusted OR; ASA = American Society of Anesthesiologists; CI = confidence interval; CPT = Current Procedural Terminology; IQR = interquartile range; NICU = neonatal intensive care unit; NSQIP = National Surgical Quality Improvement Program; NSQIP-Peds = NSQIP-Pediatrics; National Surgical Quality Improvement Program; OR = odds ratio; PICU = pediatric intensive care unit; QI = quality improvement; SSI = surgical site infection; WBC = white blood cell; quality improvement; risk-adjustment; surgical outcome; wRVU = work relative value unit