Institutional practice and outcome variation in the management of congenital diaphragmatic hernia and gastroschisis in Canada: a report from the Canadian Pediatric Surgery Network.

Abstract

BACKGROUND:

Perinatal management of congenital diaphragmatic hernia (CDH) and gastroschisis (GS) remains nonstandardized and institution specific. This analysis describes practice and outcome variation across a national network.

METHODS:

A national, prospective, disease-specific database for CDH and GS was evaluated over 4 years. Centers were evaluated individually and defined as low (low-volume center [LVC]) or high (high-volume center [HVC]) volume based on case mean.

RESULTS:

Congenital diaphragmatic hernia. Two hundred fifteen liveborn cases were studied (mean, 14.3 cases/center) across 15 centers (8 LVCs and 7 HVCs). Significant interinstitutional practice variation was noted in rates of termination (0%-40%) and cesarean delivery (0%-61%). Centers demonstrated marked variation in ventilation strategies, vasodilator and paralytic use, timing of surgery, and rates of primary closure. Overall survival was 81.4% (LVC, 76.9%; HVC, 82.4%; P = .43). Gastroschisis. Four hundred sixteen cases were investigated (mean, 26 cases/center; range, 6-72) across 16 centers (10 LVCs and 6 HVCs). Cesarean delivery rates varied widely between centers (0%-86%) as did timing of closure (early vs delayed, 1%-100%). There was no difference in length of stay, days on total parenteral nutrition, and overall survival (94.3% vs 97.2%; P = .17) between LVCs and HVCs.

CONCLUSIONS:

The existence of perinatal practice and outcome variation for GS and CDH suggests targets for improved delivery of care and justifies efforts to standardize treatment on a national basis.

• Authors: Robert Baird, Gareth Eeson, Arash Safavi, Pramod Puligandla, Jean-Martin Laberge, Erik D Skarsgard, Canadian Pediatric Surgery Network
• Journal: Journal of pediatric surgery (J Pediatr Surg) Vol. 46 Issue 5 Pg. 801-7 (May 2011) ISSN: 1531-5037 [Electronic] United States
• PMID: 21616230 (Publication Type: Journal Article, Multicenter Study, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2011 Elsevier Inc. All rights reserved.

Chemical References

• Neuromuscular Agents
• Vasodilator Agents

Topics

• Abortion, Eugenic (statistics & numerical data)
• Canada (epidemiology)
• Cesarean Section (statistics & numerical data)
• Combined Modality Therapy
• Databases, Factual
• Disease Management
• Drug Utilization (statistics & numerical data)
• Gastroschisis (embryology, mortality, surgery)
• General Surgery (organization & administration)
• Hernia, Diaphragmatic (embryology, mortality, surgery)
• Hernias, Diaphragmatic, Congenital
• Humans
• Infant, Newborn
• Institutional Practice (standards, statistics & numerical data)
• Neuromuscular Agents (therapeutic use)
• Pediatrics (organization & administration)
• Prenatal Diagnosis
• Prospective Studies
• Respiration, Artificial (methods, statistics & numerical data)
• Societies, Medical
• Survival Rate
• Treatment Outcome
• Vasodilator Agents (therapeutic use)