J O U R N A L O f s U R G ic A L R E sEAR C h ● JANUA R y 2021 (257) 379

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Relationships Between Hospital and Surgeon

Operative Volumes and Surgical Outcomes in
Hirschsprungs Disease

Jordan C. Apfeld, MD,a Richard J. Wood, MD,b Devin R. Halleran, MD,a

Katherine J. Deans, MD, MHSc,a,b Peter C. Minneci, MD, MHSc,a,b
and Jennifer N. Cooper, PhDa,*
a
Center for INNOVATION in PEDIATRIC PRACTICE, The RESEARCH Institute AT NATIONWIDE Childrens HOSPITAL, Columbus,
Ohio
b
DEPARTMEnt of Surgery, NATIONWIDE Childrens HOSPITAL, Columbus, Ohio

A R T I C L E I N F O A B S T R A C T

Article history:
BACKGROUND: The impact of surgical volume on outcomes in Hirschsprung’s disease (HD)
Received 18 February 2020
remains uninvestigated. We aimed to determine whether higher surgeon and hospital-
Received in revised form
level HD operative volumes are associated with improved surgical outcomes following
14 July 2020
primary surgery for neonatal HD.
Accepted 2 August 2020
MATERIALS AND methods: Neonates who underwent either an ostomy or pull-through (PT)
Available online xxx
procedure for HD before 60 d of life and a PT procedure by age 1 y were identified in
the Pediatric Health Information System (PHIS). Index admissions from January
Keywords:
2000 to September 2012 across 41 tertiary childrens hospitals were included. Surgeon and
Enterocolitis
hospital- level HD operative volume were defined as the average annual number of PT
Hirschsprung’s disease
procedures performed for HD in the 2 y preceding each included case. We examined the
Pediatric surgery
relationship between operative volumes and all-cause readmission, readmission for
Neonatology
Hirschsprung’s associated enterocolitis (HAEC), and rates of reoperation within 30 d and
Pull-through procedure
2 y.
Volume-outcome
Results: A total of 1268 infants were included. There were 218 patients (17.2%)
readmitted to the hospital within 30 d and 540 (42.6%) within 2 y. A total of 119 patients
(9.4%) had HAEC- related readmission within 30 d, and 271 (21.4%) had HAEC-related
readmission within 2 y. A total of 57 patients (4.5%) had a reoperation within 30 d and 129
(10.2%) within 2 y. In risk- adjusted analyses, there were no significant associations
between either surgeon or hos- pital HD operative volumes and readmission/reoperation
rates within 30 d or 2 y.
Conclusions: Neither surgeon nor hospital PT volumes were significantly associated
with readmission or reoperation rates for infants with Hirschsprung’s disease. Future
work is needed to evaluate whether operative volumes are associated with functional
outcomes following PT for HD.
ª 2020 Elsevier Inc. All rights reserved.
 * Corresponding AUTHOR. Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at
Nationwide Childrens Hospital, 700 Children’s Drive, FB Suite 3A.3, Columbus, OH, 43205. Tel.: þ1614 355-4526; fax: þ1614 722-3544.
E-mail address: jennifer.cooper@nationwidechildrens.org (J.N. Cooper).
0022-4804/$ e see front matter ª 2020 Elsevier Inc. All rights
reserved. https://doi.org/10.1016/j.jss.2020.08.014
380 R C h ● J A NUARY 2 0 2 1 ( 2 5 7 ) 3 7 9 e3 8 8
Introduction
Hirschsprung’s disease (HD) is a rare congenital anomaly (1 in
5000 live births) associated with the failure of neural crest
cells to migrate along the full length of the large intestine.1
The definitive treatment of Hirschsprung’s disease involves
a surgical “pull-through” (PT) procedure, where the
diseased segment of distal intestine is removed, and healthy
inner- vated intestine is brought down and connected above
the anal opening.2 Perioperative complications are common
and include preoperative Hirschsprung’s-associated
enterocolitis (HAEC, estimated incidence 6 to 60%),
postoperative HAEC (25%-37%), need for reoperation or
repeat PT procedure (5%- 15%), and readmissions for other
reasons including inconti- nence (5%-25%) and constipation
(10%-30%).3-13 Furthermore, long-term functional outcomes
have not been well-studied.14 Higher surgeon and hospital
operative volume have been associated with improved
outcomes in high-risk adult surgical procedures.15-17
Relationships between operative volumes and outcomes in
neonatal and pediatric surgery remain an ongoing debate. If
volume-outcomes relationships do exist, then local pediatric
surgical subspecialization or regionaliza- tion of care may be
warranted.18-25 However, given the rarity of congenital
surgical anomalies, future recommendations must take into
account how regionalization of care in the United States
could limit families’ access to care and could
limit pediatric surgical trainee case exposure. 26-29
Relationships between hospital or surgeon operative vol-
ume and outcomes in neonatal and pediatric surgery have
been reported in several studies examining surgical repair of
biliary atresia (BA), craniosynostosis, cleft lip, congenital dia-
phragmatic hernia (CDH), gastroschisis, pyloric stenosis, and
thyroidectomy.30-40 However, other studies of these same
procedures, namely surgical repair of BA, CDH, and gastro-
schisis, and a recent study examining repair of esophageal
atresia/tracheoesophageal fistula (EA/TEF), have failed to
show such a relationship. 32,40-47 Outcomes after Hirsch-
sprungs PT may depend on surgical and pathological exper-
tise, as well as perioperative care, and therefore, may be
related to surgeon or hospital experience. 48-50 We aimed to
determine whether surgeon or hospital-level HD operative
volumes are associated with surgical outcomes following
pull- through in infants with HD.
Materials and Methods
Cohort identification
We performed a multiinstitutional retrospective cohort study
of infants with Hirschsprungs disease (HD) who underwent
operative treatment. The study cohort was identified using
previously validated methods. 51 We included infants
admitted by age 60 d during the period from January 2000 to
September 2012. Data came from the Pediatric Health Infor-
mation System (PHIS), a hospital discharge database con-
taining inpatient, observation, ambulatory surgery, and
emergency department encounters at 52 tertiary childrens
hospitals across the United States. 51,52 We selected infants
with an International Classification of Diseases, ninth edition,
Clinical Modification (ICD-9-CM) diagnosis code for Hirsch-
sprung’s Disease (751.3), who were aged ≤60 d at the time of
their admission for an ostomy procedure or pull-through
procedure, and who were cared for at a hospital that began
contributing inpatient data to PHIS at least 2 y before the
included admission. Primary surgeries for HD included pull-
through (ICD-9-CM codes 48.41, 48.65, 48.49, 45.95, 48.40,
48.43, 48.5, 48.50, 48.51, 48.52, 48.59, 48.42, 48.69, 48.61, 45.90,
45.92, 45.93, 45.94) and stoma/ostomy creation (ICD-9-CM
codes 46.03, 46.10, 46.11, 46.13, 46.20, 46.21, 46.23, 46.40,
46.41, 46.43). We excluded patients who had both a pull-
through or total colectomy and an ostomy procedure docu-
mented on the date of their initial HD-related surgery. We
also excluded patients with particular data quality issues.
First, we excluded patients with duplicate MRNs or incorrect
dates of service. We then excluded patients whose surgeon
was missing a physician identification number or whose
surgeon did not have operative cases recorded in PHIS in at
least 22 of the preceding 24 mo. This latter exclusion was
necessary to ensure that a surgeons annual PT volume in the
years pre- ceding each included case could be accurately
determined. We did, however, include these latter two
groups in calculations of hospital PT volumes.
Definitions of hospital and surgeon volumes
Surgeon HD operative volume was defined as the average
annual number of PT procedures performed by the surgeon
in patients of any age during the preceding 2 y. This average
was taken over 2 y rather than 1 y in order to smooth out
year-to- year variation in volume while minimizing the
number of patients excluded due to their surgeons cases not
being identifiable in the PHIS database during the entire look-
back period.47 Hospital volume was defined similarly but at
the hospital level.
Patient characteristics and outcomes
Evaluated baseline patient clinical, sociodemographic, and
disease-specific characteristics were defined using ICD-9-CM
diagnosis and procedure codes, as well as Clinical Trans-
action Codes (CTC), which are unique to the PHIS and useful
for examining resource utilization. Preoperative factors of
interest were birth-related characteristics (birthweight,
gestational age, fetal growth restriction/malnutrition), age at
surgery, associated congenital anomalies, and diagnoses
reflective of overall illness severity (mechanical ventilation,
total parenteral nutrition [TPN], extracorporeal membrane
oxygenation [ECMO], etc). Postoperative outcomes included
reoperation within 30 d or 2 y of PT surgery, all-cause read-
mission within 30 d or 2 y, and HAEC-related readmission
within 30 d or 2 y. In a sensitivity analysis, these outcomes
were evaluated at 4 y among a slightly smaller cohort whose
outcomes could be tracked over this duration of time. ICD-9-
CM procedure and diagnosis codes used to identify primary
PT operations, reoperations, and HAEC-related readmissions
are listed in the Online Tables 1e3.
Statistical analysis
Associations between preoperative characteristics and out-
comes were evaluated using chi-square or Fisher exact tests
for categorical variables and Wilcoxon rank sum tests for
continuous variables. A multivariable logistic regression
model was fit for each outcome of interest. These models
included all preoperative characteristics that were present in
at least 10 patients and associated with any outcome at
P < 0.10 in bivariate analyses. In addition to patient charac-
teristics, the multivariable models initially included surgeon
HD pull-through operative volume, then alternately included
hospital HD pull-through operative volume. Each of these
volume variables was evaluated using restricted cubic splines
with quartile knots. We examined the potentially nonlinear
relationship between surgeon or hospital operative volume
and the risk of each outcome in order to identify any
inflection points that could be used to categorize operative
volumes. Upon identifying no inflection points, both surgeon
and hos-
pital operative volumes were dichotomized at their top
patient-level tertiles. As in previous studies, we created a
multi-level categorical variable that accounted for both sur-
geon and hospital-level operative volume. 39,47 A multinomial
logistic regression model that included all evaluated patient-
level preoperative characteristics was then used to estimate
each patient’s probability of having their surgery performed
by a lower or higher volume surgeon and at a lower or higher
volume hospital. We then used an inverse probability of
treatment weighting using estimated propensity scores to
concurrently estimate the effects of both surgeon and
hospital
HD Diagnosis Code (751.3) +
Age at admission ≤60 days + Discharged at least 2 years aGer their hospital began contributing clinical and resource utilization data to PHIS
Operated on by a surgeon who did not have evidence of having performed surgeries at the patient’s hospital during
Fig. 1 e Neonatal Hirschsprungs disease - cohort selection flow chart.
operative volume on patients surgical outcomes. For these
analyses, a Bonferroni correction for multiple comparisons
was applied, such that P < 0.0083 was considered
statistically significant. Finally, two sensitivity analyses were
performed. First, to test whether outcomes changed over the
study period, time in years was added to each multivariable
model as a continuous variable. Second, an indicator variable
for whether
a patient was treated at a hospital with a dedicated
colorectal program was included in each multivariable
model, in place of hospital volume. However, because most
of these programs began toward the end of or after the
study period, and because surgeon identification numbers
changed partway through the study period, we were able to
include only 47 patients treated at a children’s hospital that
had an established colorectal center at the time. Therefore,
the study was underpowered to evaluate the impact of this
structural hospital characteristic. SAS Enterprise Guide
version 7.11 (SAS Institute Inc., Cary, NC) was used for the
statistical analyses.
Results
Our study cohort included 1268 patients treated across 41
tertiary children’s hospitals. Figure 1 describes our study
cohort selection. The baseline characteristics of the entire
study cohort are shown in Table 1. Of note, 225 patients
(17.7%) had a congenital cardiac anomaly, 93 (7.3%) had an
additional gastrointestinal anomaly, 152 (12.0%) had Down’s
syndrome, 189 (14.9%) had preoperative enterocolitis, 108
(8.5%) had meconium ileus, and 190 (15.0%) had a
documented
PHIS Database: Data from 41 hospitals*
Jan 2000 – Sept 2012
N = 3321
N = 840
No pull through procedure by age 1 yea
N = 2481
N = 277
N = 2204 No ostomy or pull through procedure by age 6
N = 41
Pull through or total colectomy AND ostomy procedure on firs
N = 2163
N = 23
Data quality issues (incorrect dates of service or dup
N = 2140
N = 60
Operated on by a surgeon without a surgeo
N = 2080
N = 812
N = 1268
Table 1 e Characteristics of neonatal Hirschsprungs disease study cohort (n [ 1268).
Variable Median (IQR) or n (%)
Single stage procedure (no ostomy) 857 (67.6)
Age in days at first HD surgery 11 (7-23)
Age in days at pull through 24 (9-111)
Male 1007 (79.4)
Race
White 774 (61.0)
Black 216 (17.0)
Other/Unknown 278 (21.9)
Insurance status at first pull-through admission
Public insurance 620 (48.9)
Private insurance 480 (37.9)
Other 168 (13.3)
Birth weight* 3323.5 (2950-3690)
Gestational age at birth in total completed weeksy 39 (38-40)
Associated birth diagnoses documented before first pull through z
Prematurity 108 (8.5)
Slow fetal growth or fetal malnutrition 24 (1.9)
Any congenital anomaly (other than HD) 419 (33.0)
Cardiac anomalyx 225 (17.7)
Prior cardiac surgery 7 (0.5)
GI anomaly (other than HD) 93 (7.3)
Other structural anomaly 196 (15.5)
Down’s syndrome 152 (12.0)k
z
Associated other diagnoses documented before first pull through
Enterocolitis 189 (14.9)
Necrotizing enterocolitis (NEC) 17 (1.3)
Meconium aspiration 1 (0.1)
Meconium ileus 108 (8.5)
Bronchopulmonary dysplasia 34 (2.7)
Associated maternal diagnoses z
Perinatal infection 190 (15.0)
Multiple gestation 2 (0.2)
Maternal conditions that affected fetus or newborn 14 (1.1)
Maternal procedures that affected fetus or newborn 0 (0)
Maternal noxious influences 8 (0.6)
Pregnancy and labor complications 17 (1.3)
Resource utilization prior to pull-through procedure {
Any preop mechanical ventilation 247 (19.5)
Preop mechanical ventilation at the PT admission 83 (6.6)
Any preop TPN 942 (74.3)
Preop TPN at the PT admission 549 (43.3)
Any preop ECMO 0 (0)
Any preop blood transfusion 108 (8.5)
Preop blood transfusion at the PT admission 40 (3.2)
Any preop NICU stay 904 (71.3)
Preop NICU stay at the PT admission 538 (42.4)
Surgeon average annual HD pull-through volume in the previous 2 y 1.5 (1-2.5)
Hospital average annual HD pull-through volume in the previous 2 y 9.5 (7-13)
*
n ¼ 1108.
y
n ¼ 804.
z
Based on ICD-9-CM diagnosis codes at the first admission for pull through or any previous hospital admission to that hospital.
x
Cardiac anomalies include all coded cardiac defects, including those that did not require correction at birth.
k
There were 11 (0.9%) additional chromosomal anomalies.
{
Preop resource utilization is defined based on CTC codes for resources utilized on dates prior to the date of surgery as no time
information is available in PHI.
 30 days of all-cause
30 days of all-cause
A 1 B 1
0.9 0.9
0.8 0.8

Probability
Probability 0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4

readmission within
readmission within

0.3 0.3
0.2 0.2
0.1 0.1
0 0

0 5 10 15 20 05101520253035
Surgeon volume Hospital volume
2 years of all-cause

2 years of all-cause
C 1
0.9
D 1
0.9
0.8 0.8
Probability

Probability
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
readmission within

readmission within
0.3 0.3
0.2 0.2
0.1 0.1
0 0

0 5 10 15 20 05101520253035
Surgeon volume Hospital volume

Fig. 2 e Relationship between the surgeon and hospital pull-through volumes and all-cause readmission with 30 d and 2 y,
respectively, for infants with Hirschsprungs disease.
30 daysof HAEC-related

30 daysof HAEC-related

A 1
0.9
B 1
0.9
0.8 0.8
0.7 0.7
0.6 0.6
Probability

0.5 0.5
Probability

0.4 0.4
0.3 0.3
0.2 0.2
readmission within

readmission within

0.1 0.1
0 0

0 5 10 15 20 05101520253035
2 yearsof HAEC-related
2 yearsof HAEC-related

Surgeon volume Hospital volume

C 1
0.9
D 1
0.9
0.8 0.8
0.7 0.7
Probability
Probability

0.6 0.6
0.5 0.5
0.4 0.4
readmission within
readmission within

0.3 0.3
0.2 0.2
0.1 0.1
0 0

0 5 10 15 20 05101520253035
Surgeon volume Hospital volume

Fig. 3 e Relationship between the surgeon and hospital pull-through volumes and HAEC-related readmission with 30 d and
2 y, respectively, for infants with Hirschsprungs disease.
 A 1 B 1
0.9 0.9
0.8 0.8
within 2 yearsProbability of reoperation within 30 days Probability of reoperation

within 30 days Probability of reoperation

0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0

0 5 10 15 20 05101520253035
Surgeon volume Hospital volume

C 1
0.9 D 1
0.9
0.8 0.8

Probability of reoperation within 2 years

0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0

0 5 10 15 20 05101520253035
Surgeon volume Hospital volume

Fig. 4 e Relationship between the surgeon and hospital pull-through volumes and reoperation with 30 d and 2 y,
respectively, for infants with Hirschsprungs disease.

perinatal infection. At the time of HD pull-through, 247

and patients classified into four groups based on their sur-
infants (19.5%) had required mechanical ventilation, and 549
geon’s and hospital’s PT volumes, we found in propensity-
(43.3%) had required TPN at some point during their hospital
score-weighted analyses that there were no differences in
admis- sion or admissions at which HD-related surgery was
any evaluated outcomes across these four groups (Table 2).
performed.
In the sensitivity analysis following a smaller cohort (n ¼
The median annual surgeon PT volume was 1.5 procedures
1094) out to 4 y, we also did not find differences in any
(IQR 1-2.5), and the median annual hospital PT volume was 9.5
evaluated 4- year outcomes across these four groups (Online
procedures (IQR 7-13). Over two-thirds of infants (n ¼ 679,
Table 4). Finally, when either year of surgery or treatment at
67.7%) were treated by surgeons who had performed an a hospital with a pediatric colorectal program were added to
average of two or fewer HD pull-throughs per year during the the fitted multivariable models these variables, these
preceding 2 y. Over half of infants (n ¼ 649, 51.2%) were variables were not
treated at hospitals that had performed an average of less than
found to be statistically significant in any model (P > 0.10, data
10 HD pull-throughs per year during the preceding 2 y. A total not shown).
of 218
patients (17.2%) were readmitted to the hospital for any
reason within 30 d, and 540 patients (42.6%) were readmitted Discussion
within 2 y. A total of 119 patients (9.4%) had HAEC-related
readmission within 30 d, and 271 patients (21.4%) had HAEC- This study of more than 1000 infants with Hirschsprungs
related readmission within 2 y. A total of 57 patients (4.5%) disease found no association between surgeon or hospital
had a reoperation within 30 d, and 129 patients (10.2%) had a HD pull-through volumes and the postoperative outcomes of
reoperation within 2 y. reoperation, all-cause readmission, and HAEC-related read-
Risk-adjusted relationships were evaluated between the mission. This suggests that the established volume-outcome
surgeon and hospital PT volumes and all-cause readmission relationship previously shown in adult colorectal surgery
(Fig. 2); HAEC-related readmission (Fig. 3); and reoperation may not exist for neonates with HD, or at least not those in-
(Fig. 4) at 30 d and 2 y. There were no statistically significant fants who are treated at the moderate to large-sized tertiary
relationships between either surgeon PT volume or hospital children’s hospitals that contribute data to the PHIS. 53-57 The
PT volume and any outcome evaluated. When surgeon and lack of a volume-outcome relationship in HD aligns with past
hospital PT volumes were dichotomized at their top tertiles studies of complex neonatal surgical diseases like CDH, EA/
 TEF, and gastroschisis.42-44,46,47,58 However, competing
Table 2 e Adjusted readmission and reoperation rates by the surgeon and hospital volume category.

P ¼ 0.76*
2-year reoperation

P ¼ 0.99y
studies on complex birth defects have demonstrated a
volume- outcome relationship, underscoring the
persistent need to identify, measure, and track
competencies in managing complex surgical
anomalies.35,36,40,59-61
These findings are consistent with those of another recent
10.0

12.0

10.8

12.8
study utilizing the PHIS, which assessed risk factors for recur-
rent HAEC-related admissions and repeated pull-through
30-day reoperation

P ¼ 0.76*

P ¼ 0.99y

pro- cedures and found no relationship between these

outcomes and either surgeon or hospital volume.62 However,
in contrast to this previous study, the present study assessed
nonlinear volume-outcome relationships and used
4.1

6.4

4.9

4.8

propensity score an- alyses to account for the probability of

treatment to allow concurrent estimation of the impact of
surgeon and hospital operative volumes. Second, the present
2-year HAEC- related readmission

P ¼ 0.24*

P ¼ 0.65y

study examined neonatal HD, thereby avoiding misclassifying

redo HD surgeries as primary HD surgeries for patients
treated at multiple hospi- tals. Third, in the present study,
surgeon, and hospital PT vol- umes were calculated as
patient-level time-dependent variables based on volumes in
22.1

26.0

18.0

19.5

the 2 y preceding each included patients PT. Such definitions

were appropriate and necessary because hospitals began
contributing to PHIS at different times throughout the study
Estimates shown are risk-adjusted (propensity score weighted) estimates of the percentages of patients with the outcome.
P-value across 4 categories for hospital and surgeon volume (hospital volume <12 and ≤ 12, surgeon volume <2 and ≤ 2).

period, and surgeon identification numbers changed midway

30-day HAEC- related readmission

P ¼ 0.19*

P ¼ 0.52y

the study period. Fourth, the present study relied on uniform

30-day and 2-year follow-up periods, whereas in the
previous study, average durations of follow-up varied
substantially across hospitals. Last, we included an expanded
list of infectious diagnoses in our definition of HAEC- related
7.7

10.4

8.7

14.3

readmissions, and such diagnoses were found in more than

25% of the identified HAEC-related readmissions.
Interestingly, studies examining some of the most com-
mon pediatric surgical procedures have reported
2-year all cause readmission

P ¼ 0.44*

P ¼ 0.32y

significant volume-outcome relationships, whereas, with

the exception of congenital heart disease, these
relationships are less clear for rare surgical congenital
anomalies.30,31,37,38,42,45,63 While studies show significant
regionalization for both common pediatric and rare
42.0

48.7

42.4

42.5

neonatal surgical procedures to high- volume centers,

Comparison of higher hospital volume to lower hospital volume groups.

further regionalization of complex neonatal surgery would

30-day all cause readmission

P ¼ 0.18*

potentially limit patients access to care and surgical

P ¼ 0.53y

trainees’ exposure to these procedures.18,19 Without

implementing additional “within-hospital” subspecialization,
it may not be feasible to increase surgeons disease-specific
caseload to a level that provides sufficient statistical power
16.0

20.1

14.0

21.6

for studies to demonstrate volume-outcome relationships

in rare neonatal surgical populations. Surgeon and hospital-
Hospital and surgeon volume category

level HD pull-through volumes appear to be quite low even

at moderate to large-sized tertiary childrens hospitals,
suggest- ing a lack of centralization or surgeon
Hospital volume <12

subspecialization in this procedure at most

institutions.18,19,27,28,64
These data can help to inform the ongoing ACS
Childrens Surgery Verification initiative, which aims, in
5) Surgeon volume > 2 (n ¼ 230)

part, to identify pediatric surgical procedures that may

benefit from further subspecialization.21,23,24 For neonatal
HD, there is currently no evidence, including from this
study, to justify transfers of neonates from one tertiary
*

childrens hospital to another based on hospital or surgeon

HD pull-through volumes as a proxy for experience.
However, this study provides general- izable estimates of
y
postoperative morbidity after HD pull- through, which
could be used to benchmark rates of read- mission or
reoperation after HD pull-through.
 This study is not without limitations. First, due to our use
of administrative data, we were unable to incorporate
disease- specific clinical information on infants with HD in
our ana- lyses. For example, we could not definitively adjust
for the severity of disease or identify patients with long-
segment HD or total colonic aganglionosis (TCA), both of
which have been linked to higher rates of HAEC and other
complications.65,66 However, these higher-risk HD infants are
comparatively rare, and there is no clear indication that long-
segment dis- ease is selectively triaged to higher-volume
centers. Second, due to the types of hospitals that contribute
to the PHIS, our findings are not necessarily applicable to
smaller pediatric hospitals and units within general acute
care hospitals. Similarly, this study is not statistically powered
to differen- tiate outcomes between “high-volume” and
“super-volume” centers, such as those with dedicated
colorectal centers/sur- geons. Thus, this study contributes
limited information to- ward answering the question of
whether the centralization of surgical care for children with
HD would improve outcomes. We did evaluate the full range
of surgeon and hospital vol- umes using cubic splines and did
not detect inflection points at high volumes. However,
determining whether centers with dedicated colorectal
programs have better outcomes than other childrens
hospitals would require additional analyses using more
recent data. This study also lacked information on the
provider or institution-level factors besides operative volume
that may have impacted HD patient outcomes. Finally, this
study was unable to identify reoperations that occurred at
hospitals other than where the initial PT occurred or to
assess functional outcomes, both of which will be better
understood through enhanced prospective data gathering
initiatives.67-69
Conclusions
In conclusion, our analysis demonstrates that surgeon and
hospital Hirschsprungs PT operative volumes are not signifi-
cantly associated with rates of readmission or reoperation
after this procedure. Future studies evaluating the effects of
volume on long-term functional outcomes and reoperations
are needed.
Acknowledgment
Authors’ contributions: J.N.C. had full access to all of the data
in the study and takes responsibility for the integrity of the
data and the accuracy of the data analysis. JCA, RJW, DRH,
KJD, and PCM all contributed to the following: study concept
and design, acquisition, analysis, or interpretation of data,
draft- ing of the article, critical revision of the article for
important intellectual content, and statistical analysis.
Disclosure
The authors reported no proprietary or commercial interest
in any product mentioned or concept discussed in this
article.
Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jss.2020.08.014.
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