Does Increased Pediatric Subspecialization Decrease Complications in Urologic Surgery?

Patients who are treated by urologists with a greater degree of pediatric subspecialization have lower rates of postoperative complications than those treated by health care professionals who operate on fewer pediatric patients, according to a study published in December 2016 in the Journal of Pediatric Urology. The study reflects ongoing efforts to better understand the importance of pediatric subspecialization in urologic surgeries, many of which are performed by general urologists.

Although previous studies have shown that increased pediatric subspecialization is associated with decreased mortality in pediatric urologic surgeries, this study is the first to examine the likelihood of surgical complications. This is particularly important for pediatric urologic surgeries, which rarely result in mortality but do carry the risk of complications.

“In pediatric urology, we typically intervene to improve a child’s quality of life rather than to save their life,” explains lead author Jonathan Routh, MD, a pediatric urologist at Duke. “As a result, complications are a tremendously important marker of the quality of care we provide to children. While it seems intuitive that more specialized pediatric care would result in better care, the literature has actually shown mixed results to date.”

To assess surgical outcomes in pediatric patients, Routh and his colleagues reviewed the National (Nationwide) Inpatient Sample—a nationally representative database—for pediatric admissions for urologic surgeries from 1998 to 2009, identifying a total of 71,479 inpatient admissions and 2,168 urologists. The urologists’ degree of pediatric subspecialization or Pediatric Proportion Index was calculated as a ratio of the number of pediatric patients to total patients operated on. The incidence of surgical complications was then evaluated for associations with the Pediatric Proportion Index.

The researchers found that patients treated by a more specialized urologist were less likely to experience in-hospital mortality, renal and ureteral complications, renal failure, sepsis, respiratory complications, postoperative bleeding, and respiratory insufficiency. Furthermore, although treatment by a more specialized provider was more costly, these patients had shorter lengths of hospital stay.

“Care provided by pediatric specialists was associated with better outcomes and improved quality of care,” Routh says. “We suspect that the increased cost of pediatric specialized care was related to specialized providers treating more complex patients; we are actively investigating this topic now. We are also trying to verify our results by examining complication rates among other pediatric surgical specialties.”