Search

Purpose: We aim to assess the healthcare value achieved from a shared savings program for pediatric appendectomy., Methods: All appendectomy patients covered by our health plan were included. Quality targets were 15% reduction in time to surgery, length of stay, readmission rate, and patient satisfaction. Quality targets and costs for an appendectomy episode in two 6-month performance periods (PP1, PP2) were compared to baseline., Results: 640 patients were included (baseline:317, PP1:167, PP2:156). No quality targets were met in PP1. Two quality targets were met during PP2: readmission rate (-57%) and patient satisfaction. No savings were realized because the cost reduction threshold (-9%) was not met during PP1 (+1.7%) or PP2 (-0.4%)., Conclusions: Payer-provider partnerships can be a platform for testing value-based reimbursement models. Setting achievable targets, identifying affectable quality metrics, considering case mix index, and allowing sufficient time for interventions to generate cost savings should be considered in future programs., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Clinical prediction of disease severity is important as one considers nonoperative management of simple appendicitis. This study assesses the accuracy of surgeons' prediction of appendicitis severity., Methods: From February to August 2016, pediatric surgeons at a single institution were asked to predict whether patients had simple or complex appendicitis preoperatively based on clinical data, imaging, and general assessment. Receiver operating characteristic curves were generated to determine area under the curve (AUC) and optimal cutoff points of clinical findings for diagnosing simple appendicitis. Outcomes included sensitivity and specificity of variables to identify simple appendicitis. Predictions were compared to operative findings using χ 2 . A p-value<0.05 was considered statistically significant., Results: Of 125 cases (median age 9 years [IQR 7-13], 58% male), simple appendicitis was predicted in 77 (62%) and complex appendicitis in 48 (38%). Predictions were accurate in 59 (77%) simple cases and 45 (94%) complex cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly sensitive (95%) for diagnosing simple appendicitis, specificity was only 71%. Lower WBC (<15.5 × 10 3 /μL, AUC 0.61, p = 0.05), afebrile (<100.4 °F, AUC 0.86, p < 0.01), and shorter symptom duration (≤ 1.5 days, AUC 0.71, p < 0.001) were associated with simple appendicitis. Of 18 complex cases (14%) inaccurately predicted as simple, 17 (94%) lacked diffuse tenderness, 15 (83%) were well-appearing, 11 (61%) had ultrasound findings of simple appendicitis, 11 (61%) had ≤2 days of symptoms, and 8 (44%) were afebrile (<100.4 °F)., Conclusion: While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data alone, diagnostic accuracy is still limited., Type of Study: Prospective survey., Level of Evidence: II., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Patient-controlled analgesia (PCA) is often used in children with perforated appendicitis. To prevent urinary retention, some providers also routinely place Foley catheters. This study examines the necessity of this practice., Methods: We retrospectively reviewed all children (≤18 years old) with perforated appendicitis and postoperative PCA from 7/2015 to 6/2016 at two academic children's hospitals. Urinary retention was defined as the inability to spontaneously void requiring straight catheterization or placement of a Foley catheter., Results: Of 313 patients who underwent appendectomy for perforated appendicitis (Hospital 1: 175, Hospital 2: 138), 129 patients received an intraoperative Foley (Hospital 1: 22 [13%], Hospital 2: 107 [78%], p < 0.001). Age, gender, and BMI were similar between those with an intraoperative Foley and those without. There were no urinary tract infections in either group. Urinary retention rate in patients with an intraoperative Foley following removal on the inpatient unit (n = 3, 2%) and patients without an intraoperative Foley (n = 10, 5%) did not reach significance (p = 0.25). On univariate analysis, demographics, intraoperative findings, PCA specifics, postoperative abscess formation, and postoperative length of stay, were not significant risk factors for urinary retention., Conclusions: The risk of urinary retention in this population is low despite the use of PCA. Children with perforated appendicitis do not require routine Foley catheter placement to prevent urinary retention., Level of Evidence: II., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Obtaining informed consent for surgical procedures is often compromised by patient and family educational background, complexity of the forms, and language barriers. We developed and tested a visual aid in order to improve the informed consent process for families of children with appendicitis., Methods: Families were randomized to receive either a standard surgical consent or a standard consent plus visual aid. Univariate and multivariate analyses were performed to assess the effectiveness of adding the visual aid to the consent procedure., Results: Parents in both cohorts were similar in age, gender and education level (p > 0.05). On multivariate analysis, visual consent had the strongest influence on parent/guardian comprehension (OR 4.0; 95%CI 2.2-7.2; p < 0.01), followed by post-secondary education (OR 2.7; 95%CI 1.5-4.9; p < 0.01), and use of external resources to look up appendicitis (OR 2.0; 95%CI 1.1-3.6; p = 0.02)., Conclusion: Visual aids improve understanding and retention of information given during the informed consent process of children with appendicitis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Healthcare reform policies are emphasizing value-based healthcare delivery. We hypothesize that time-driven activity-based costing (TDABC) can be used to appraise healthcare interventions in pediatric appendicitis., Methods: Triage-based standing delegation orders, surgical advanced practice providers, and a same-day discharge protocol were implemented to target deficiencies identified in our initial TDABC model. Post-intervention process maps for a hospital episode were created using electronic time stamp data for simple appendicitis cases during February to March 2016. Total personnel and consumable costs were determined using TDABC methodology., Results: The post-intervention TDABC model featured 6 phases of care, 33 processes, and 19 personnel types. Our interventions reduced duration and costs in the emergency department (-41min, -$23) and pre-operative floor (-57min, -$18). While post-anesthesia care unit duration and costs increased (+224min, +$41), the same-day discharge protocol eliminated post-operative floor costs (-$306). Our model incorporating all three interventions reduced total direct costs by 11% ($2753.39 to $2447.68) and duration of hospitalization by 51% (1984min to 966min)., Conclusion: Time-driven activity-based costing can dynamically model changes in our healthcare delivery as a result of process improvement interventions. It is an effective tool to continuously assess the impact of these interventions on the value of appendicitis care., Level of Evidence: II, Type of study: Economic Analysis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: As reimbursement programs shift to value-based payment models emphasizing quality and efficient healthcare delivery, there exists a need to better understand process management to unearth true costs of patient care. We sought to identify cost-reduction opportunities in simple appendicitis management by applying a time-driven activity-based costing (TDABC) methodology to this high-volume surgical condition., Methods: Process maps were created using medical record time stamps. Labor capacity cost rates were calculated using national median physician salaries, weighted nurse-patient ratios, and hospital cost data. Consumable costs for supplies, pharmacy, laboratory, and food were derived from the hospital general ledger., Results: Time-driven activity-based costing resulted in precise per-minute calculation of personnel costs. Highest costs were in the operating room ($747.07), hospital floor ($388.20), and emergency department ($296.21). Major contributors to length of stay were emergency department evaluation (270min), operating room availability (395min), and post-operative monitoring (1128min). The TDABC model led to $1712.16 in personnel costs and $1041.23 in consumable costs for a total appendicitis cost of $2753.39., Conclusion: Inefficiencies in healthcare delivery can be identified through TDABC. Triage-based standing delegation orders, advanced practice providers, and same day discharge protocols are proposed cost-reducing interventions to optimize value-based care for simple appendicitis., Level of Evidence: II., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose Standardized clinical pathways for simple appendicitis decrease length of stay and result in cost savings. We performed a prospective cohort study to assess a same day discharge (SDD) protocol for children with simple appendicitis. Methods All children undergoing laparoscopic appendectomy for simple appendicitis after protocol implementation (February 2016 to January 2017) were assessed. Length of stay (LOS), 30-day resource utilization (ED visits and hospital readmissions), patient satisfaction, and hospital accounting costs for SDD were compared to non-SDD patients. Results Of 602 children treated at our institution, 185 (31%) were successfully discharged per protocol. SDD patients had longer median PACU duration (3.0 vs. 1.0 h, p < 0.001), but postoperative LOS (4.4 vs. 17.4 h, p < 0.001) and overall LOS (17.1 vs. 31.2 h, p < 0.001) were significantly shorter. Complication rates (1.6% vs. 3.1%), ED visits (4.3% vs. 6.0%), and readmissions (0.5% vs. 2.4%) were not significantly different for SDD compared to non-SDD patients. However, SDD decreases total cost of an appendectomy episode ($8073 vs $8424, p = 0.002), and patients report high satisfaction with their hospital experience (mean 9.4 out of 10). Conclusions Safe and satisfactory outpatient management of pediatric simple appendicitis is achievable with appropriate patient selection. An SDD protocol can lead to significant generation of value to the healthcare system. Level of Evidence Prognosis study, Level II. [ABSTRACT FROM AUTHOR]