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Considering the Ability of General Surgeons to Add Value to Pediatric Surgery.

In this issue of JAMA Surgery, Akhtar-Danesh et al1 report a population-based study of Canadian children undergoing laparoscopic cholecystectomy from 2008 to 2015. The researchers found that children cared for by high-volume general surgeons experienced fewer complications and lower costs. This study introduces the novel concept that highvolume adult general surgeons might add value to the surgical management of pediatric biliary disease by decreasing postoperative morbidity and health care costs. Value in health care is defined as patient health outcomes achieved per dollar spent.2 Minimizing complications and decreasing health care costs is an overarching goal of patients, surgeons, hospitals, and payers. Currently, the American College of Surgeons Children’s Surgery Verification Quality Improvement Program is under way with the goal of improving surgical outcomes for children by increasing the availability of pediatric surgical specialists, resources, and care coordination.3 While the trend toward regionalization of pediatric surgical care likely has the greatest benefits for neonates and children with complex medical comorbidities, its role in the care of a healthy child undergoing a low-risk operation is less well known. Furthermore, the cost of moving low-risk pediatric surgical patients to high-volume specialty centers has yet to be quantified. It could be that delivering a spectrum of pediatric surgical care distributed among multiple hospitals within a region would have highest value, with older, healthier children who are undergoing low-risk surgery funneled to highvolume general surgeons. To truly measure value in pediatric surgery to inform policies that will facilitate improved clinical outcomes, more granular, robust models of those outcomes must be pursued. In the article by Akhtar-Danesh et al,1 the primary outcome was allcause morbidity, which was defined as a composite of previously validated postoperative outcomes (including pain and nausea primarily, as well as gastrointestinal injuries, infection, and bleeding) that resulted in a hospital stay longer than 24 hours or an additional, unplanned surgical procedure. While the composite outcome measures reported are clinically relevant, they might not completely reflect surgeon performance, because anesthesia and procedure duration4 may primarily drive nausea and pain. Moreover, many things influence hospital length of stay, including the patterns of practice of surgeons and pediatricians; for example, a pediatric specialist might be more likely than an adult specialist or high-volume general surgeon to admit a pediatric patient for pain control as a result of differences in general practice patterns and training in the respective specialties. This could explain a longer length of stay for the complaints of pain among children treated by pediatric surgeons. In addition, hospital volume and specialty may have overlapping influences on individual surgeon performance and patient outcomes.5 Furthermore, outpatient cholecystectomy, which was excluded from this analysis, composes just 10% of all pediatric cholecystectomies in Canada but a much larger proportion of in the United States.6 This diminishes the external validity of the present findings. Finally, any cost analysis must include an assessment of outlier costs, as the most medically complex children will likely accrue the highest costs and will be cared for primarily by pediatric surgeons. In future studies, more comprehensive models that test for multicollinearity of regression variables, quantify the contribution of each variable, and reduce statistical noise in risk-adjusted outcomes7 will be paramount to informing surgeons and policy makers on surgeon and hospital factors that truly drive outcomes in pediatric surgical care.