Optimizing resources for the surgical care of children: An American Pediatric Surgical Association Outcomes and Clinical Trials Committee Consensus Statement

Published:February 28, 2014DOI:


      The United States’ healthcare system is facing unprecedented pressures: the healthcare cost curve is not sustainable while the bar of standards and expectations for the quality of care continues to rise. Systems committed to the surgical treatment of children will likely require changes and reorganization. Regardless of these mounting pressures, hospitals must remain focused on providing the best possible care to each child at every encounter. Available clinical expertise and hospital resources should be optimized to match the complexity of the treated condition. Although precise criteria are lacking, there is a growing consensus that the optimal combination of clinical experience and hospital resources must be defined, and efforts toward this goal have been supported by the Regents of the American College of Surgeons, the members of the American Pediatric Surgical Association, and the Society for Pediatric Anesthesia (SPA) Board of Directors. The topic of optimizing outcomes and the discussion of the concepts involved have unfortunately become divisive. Our goals, therefore, are 1) to provide a review of the literature that can provide context for the discussion of regionalization, volume, and optimal resources and promote mutual understanding of these important terms, 2) to review the evidence that has been published to date in pediatric surgery associated with regionalization, volume, and resource, 3) to focus on a specific resource (anesthesia), and the association that this may have with outcomes, and 4) to provide a framework for future research and policy efforts.

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        • Luft H.S.
        • Bunker J.P.
        • Enthoven A.C.
        Should operations be regionalized? The empirical relation between surgical volume and mortality.
        N Engl J Med. 1979; 301: 1364-1369
        • Altman L.K.
        Policing Health Care.
        NY Times. 1999
        • Milstein A.
        • Galvin R.S.
        • Delbanco S.F.
        • et al.
        Improving the safety of health care: the leapfrog initiative.
        Eff Clin Pract. 2000; 3: 313-316
        • Birkmeyer J.D.
        • Finlayson E.V.
        • Birkmeyer C.M.
        Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative.
        Surgery. 2001; 130: 415-422
        • Khuri S.F.
        Invited commentary: Surgeons, not General Motors, should set standards for surgical care.
        Surgery. 2001; 130: 429-431
        • Halm E.A.
        • Lee C.
        • Chassin M.R.
        Is volume related to outcome in health care? A systematic review and methodologic critique of the literature.
        Ann Intern Med. 2002; 137: 511-520
        • Birkmeyer J.D.
        • Stukel T.A.
        • Siewers A.E.
        • et al.
        Surgeon volume and operative mortality in the United States.
        N Engl J Med. 2003; 349: 2117-2127
        • Dimick J.B.
        • Welch H.G.
        • Birkmeyer J.D.
        Surgical mortality as an indicator of hospital quality: the problem with small sample size.
        JAMA. 2004; 292: 847-851
        • Elixhauser A.
        • Steiner C.
        • Fraser I.
        Volume thresholds and hospital characteristics in the United States.
        Health Aff (Millwood). 2003; 22: 167-177
        • McAteer J.P.
        • Lariviere C.A.
        • Drugas G.T.
        • et al.
        Influence of surgeon experience, hospital volume, and specialty designation on outcomes in pediatric surgery: a systematic review.
        JAMA Pediatr. 2013; 167: 468-475
        • Alexander F.
        • Magnuson D.
        • DiFiore J.
        • et al.
        Specialty versus generalist care of children with appendicitis: an outcome comparison.
        J Pediatr Surg. 2001; 36: 1510-1513
        • Kokoska E.R.
        • Minkes R.K.
        • Silen M.L.
        • et al.
        Effect of pediatric surgical practice on the treatment of children with appendicitis.
        Pediatrics. 2001; 107: 1298-1301
        • Emil S.G.S.
        • Taylor M.B.
        Appendicitis in children treated by pediatric versus general surgeons.
        J Am Coll Surg. 2007; 204: 34-39
        • Somme S.
        • To T.
        • Langer J.C.
        Effect of subspecialty training on outcome after pediatric appendectomy.
        J Pediatr Surg. 2007; 42: 221-226
        • Brain A.J.
        • Roberts D.S.
        Who should treat pyloric stenosis: the general or specialist pediatric surgeon?.
        J Pediatr Surg. 1996; 31: 1535-1537
        • Pranikoff T.
        • Campbell B.T.
        • Travis J.
        • et al.
        Differences in outcome with subspecialty care: pyloromyotomy in North Carolina.
        J Pediatr Surg. 2002; 37: 352-356
        • Langer J.C.
        • To T.
        Does pediatric surgical specialty training affect outcome after Ramstedt pyloromyotomy? A population-based study.
        Pediatrics. 2004; 113: 1342-1347
        • Cosper G.H.
        • Hamann M.S.
        • Stiles A.
        • et al.
        Hospital characteristics affect outcomes for common pediatric surgical conditions.
        Am Surg. 2006; 72: 739-745
        • Whisker L.
        • Luke D.
        • Hendrickse C.
        • et al.
        Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital.
        J Pediatr Surg. 2009; 44: 362-367
        • Collins H.L.
        • Almond S.L.
        • Thompson B.
        • et al.
        Comparison of childhood appendicitis management in the regional paediatric surgery unit and the district general hospital.
        J Pediatr Surg. 2010; 45: 300-302
        • Ly D.P.
        • Liao J.G.
        • Burd R.S.
        Effect of surgeon and hospital characteristics on outcome after pyloromyotomy.
        Arch Surg. 2005; 140: 1191-1197
        • Raval M.V.
        • Cohen M.E.
        • Barsness K.A.
        • et al.
        Does hospital type affect pyloromyotomy outcomes? Analysis of the Kids' Inpatient Database.
        Surgery. 2010; 148: 411-419
        • Garrity C.
        • Singh K.
        • Stevens A.
        • et al.
        Effects of Performing Complex Pediatric Intracavitary (IC) Surgical Procedures in Specialized versus Non-specialized Centers in High Risk Children: Cochrane Response Rapid Review.
        in: Cochrane Response Rapid Review Report. 2013: 1-33
        • Oldham K.T.
        • et al.
        Optimal Resources For Children’s Surgical Care in the United States.
        JAMA. 2013; ([In Press])
        • Rhee D.
        • Papandria D.
        • Yang J.
        • et al.
        Comparison of pediatric surgical outcomes by the surgeon's degree of specialization in children.
        J Pediatr Surg. 2013; 48: 1657-1663
        • Posner K.L.
        • Geiduschek J.
        • Haberkern C.M.
        • et al.
        Unexpected cardiac arrest among children during surgery, a North American registry to elucidate the incidence and causes of anesthesia related cardiac arrest.
        Qual Saf Health Care. 2002; 11: 252-257
        • Morray J.P.
        • Geiduschek J.M.
        • Ramamoorthy C.
        • et al.
        Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry.
        Anesthesiology. 2000; 93: 6-14
        • Bhananker S.M.
        • Ramamoorthy C.
        • Geiduschek J.M.
        • et al.
        Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry.
        Anesth Analg. 2007; 105: 344-350
        • Keenan R.L.
        • Shapiro J.H.
        • Dawson K.
        Frequency of anesthetic cardiac arrests in infants: effect of pediatric anesthesiologists.
        J Clin Anesth. 1991; 3: 433-437
        • Mamie C.
        • Habre W.
        • Delhumeau C.
        • et al.
        Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery.
        Paediatr Anaesth. 2004; 14: 218-224
        • Auroy Y.
        • Ecoffey C.
        • Messiah A.
        • et al.
        Relationship between complications of pediatric anesthesia and volume of pediatric anesthetics.
        Anesth Analg. 1997; 84: 234-235
        • Holzman R.S.
        Morbidity and mortality in pediatric anesthesia.
        Pediatr Clin North Am. 1994; 41: 239-256
        • Keenan R.L.
        • Shapiro J.H.
        • Kane F.R.
        • et al.
        Bradycardia during anesthesia in infants. An epidemiologic study.
        Anesthesiology. 1994; 80: 976-982
        • van der Griend B.F.
        • Lister N.A.
        • McKenzie I.M.
        • et al.
        Postoperative mortality in children after 101,885 anesthetics at a tertiary pediatric hospital.
        Anesth Analg. 2011; 112: 1440-1447
      1. The American Board of Anesthesiology.
        • Mayer M.L.
        • Beil H.A.
        • Allmen von D.
        Distance to care and relative supply among pediatric surgical subspecialties.
        J Pediatr Surg. 2009; 44: 483-495