Selesner Leigh, Gutierrez Anthony, Vaughn Cortnie, Graveson Amanda, Yoo Ashley, Wooten Asia, Wilson Rachel, Jafri Mubeen, Azarow Kenneth, Krishnaswami Sanjay, Fialkowski Elizabeth
Department of Surgery, Division of General Surgery, School of Medicine, Oregon Health & Science University, Portland.
School of Medicine, Oregon Health & Science University, Portland, Oregon.
JAMA Surg. 2025 Aug 20. doi: 10.1001/jamasurg.2025.2927.
Standardized perioperative pathways are increasingly used in surgery to reduce unwarranted variation, promote evidence-based practice, and improve patient outcomes, yet pediatric implementation has lagged, with most studies focused on single conditions or institutions. Broader evaluation of multiprotocol, multi-institution initiatives is needed.
To evaluate the association of the Minimizing Variance in Pediatric Surgery (MViPS) program with clinical outcomes, length of stay (LOS), and cost.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted from October 2012 to November 2021 at 2 academic pediatric tertiary referral centers in Oregon. Data analysis was completed in May 2024. Pediatric surgery patients treated for protocol-specified conditions or procedures, with age cutoffs varying by protocol (typically <18 years). Exclusions included failure to meet protocol criteria, nonpediatric surgery management, and insufficient documentation.
Implementation of standardized perioperative protocols targeting a range of pediatric surgical conditions.
Outcomes included LOS, total hospital costs (THC), complications, and protocol compliance. LOS was characterized as study LOS, defined as postprocedure LOS for patients who underwent a procedure and total hospital stay for those who did not, and total LOS, representing the entire period of hospitalization. Hospital days and cost differences were calculated from total LOS and THC.
A total of 1081 pediatric surgery patients were included (519 postprotocol and 562 preprotocol; median [IQR] age, 3 [0-10] years; 668 [62%] male). No significant demographic differences were found between preprotocol and postprotocol groups. Protocol compliance was 82% (426/519). Complication rates were similar between groups, but study LOS was 23% shorter in the postprotocol group (incidence rate ratio [IRR], 1.23; 95% CI, 1.11-1.38; P < .001), with a reduction of an estimated 191 hospital days. THC was 10% lower in the postprotocol group (IRR, 1.10; 95% CI, 1.01-1.20; P = .03), with an estimated reduction of $266 709. Extrapolation to 3167 patients treated according to protocol since the end of the study (up to April 2024) reveals an estimated reduction of $2 236 583 and 1584 hospital days.
In this study, the MViPS initiative was associated with reduced THC and LOS while maintaining outcomes. These findings support the value of standardized protocols in improving pediatric surgical outcomes and efficiency across institutions.
标准化围手术期路径在外科手术中越来越多地被采用，以减少不必要的差异、促进循证实践并改善患者预后，但儿科领域的实施进展滞后，大多数研究集中于单一疾病或机构。需要对多协议、多机构的举措进行更广泛的评估。
评估儿科手术最小化差异（MViPS）项目与临床结局、住院时长（LOS）和成本之间的关联。
设计、设置和参与者：这项队列研究于2012年10月至2021年11月在俄勒冈州的2家学术性儿科三级转诊中心进行。数据分析于2024年5月完成。接受针对特定协议条件或手术治疗的儿科手术患者，年龄界限因协议而异（通常<18岁）。排除标准包括未达到协议标准、非儿科手术管理以及记录不充分。
针对一系列儿科手术情况实施标准化围手术期协议。
结局包括住院时长、总住院费用（THC）、并发症和协议依从性。住院时长分为研究住院时长（定义为接受手术患者的术后住院时长以及未接受手术患者的总住院时长）和总住院时长（代表整个住院期间）。根据总住院时长和总住院费用计算住院天数和成本差异。
共纳入1081例儿科手术患者（协议实施后519例，协议实施前562例；中位[IQR]年龄，3[0 - 10]岁；668例[62%]为男性）。协议实施前和实施后两组之间未发现显著的人口统计学差异。协议依从率为82%（426/519）。两组之间的并发症发生率相似，但协议实施后组的研究住院时长缩短了23%（发病率比[IRR]，1.23；95%CI，1.11 - 1.38；P <.001），估计减少了191个住院日数。协议实施后组的总住院费用降低了10%（IRR，1.10；95%CI，1.01 - 1.20；P = 0.03），估计减少了266,709美元。自研究结束（截至2024年4月）以来，对按照协议治疗的3167例患者进行推断，估计减少了2,236,583美元和1584个住院日数。
在本研究中，MViPS项目在维持结局的同时与总住院费用和住院时长的降低相关。这些发现支持了标准化协议在改善各机构儿科手术结局和效率方面的价值。
