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Departments of Surgery (J.A.S., C.T.T., D.C.T., L.B., S.A.R.) and Pediatrics (S.R.), Yale University School of Medicine, New Haven, Connecticut 06510; and Department of Surgery (T.S.W.), Medical College of Wisconsin, Milwaukee, Wisconsin 53226
Address all correspondence and requests for reprints to: Tracy S. Wang, M.D., M.P.H., Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, Wisconsin 53226. E-mail: tswang{at}mcw.edu.
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
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Objective: The objective was to examine the clinical and demographic predictors of outcomes after pediatric thyroidectomy/parathyroidectomy.
Design: This study is a cross-sectional analysis of Healthcare Cost and Utilization Project–National Inpatient Sample hospital discharge information from 1999–2005. All patients who underwent thyroidectomy/parathyroidectomy were included. Bivariate and multivariate analyses were performed to identify independent predictors of patient outcomes.
Subjects: Subjects included 1199 patients 17 yr old or younger undergoing thyroidectomy/parathyroidectomy.
Main Outcome Measures: Outcome measures included in-hospital patient complications, length of stay (LOS), and inpatient hospital costs.
Results: The majority of patients were female (76%), aged 13–17 yr (71%), and White (69%). Whites were more often in the highest income group (80% vs. 8% for Hispanic and 6% for Black; P < 0.01) and had private/HMO insurance (76% vs. 10% for Hispanic and 5% for Black; P < 0.001) rather than Medicaid (13% vs. 32% for Hispanic and 41% for Black; P < 0.001). Ninety-one percent of procedures were thyroidectomies and 9% parathyroidectomies. Children aged 0–6 yr had higher complication rates (22% vs. 15% for 7–12 yr and 11% for 13–17 yr; P < 0.01), LOS (3.3 d vs. 2.3 for 7–12 yr and 1.8 for 13–17 yr; P < 0.01), and higher costs. Compared with children from higher-income families, those from lower-income families had higher complication rates (11.5 vs. 7.7%; P < 0.05), longer LOS (2.7 vs. 1.7 d; P < 0.01), and higher costs. Children had higher endocrine-specific complication rates than adults after parathyroidectomy (15.2 vs. 6.2%; P < 0.01) and thyroidectomy (9.1 vs. 6.3%; P < 0.01).
Conclusions: Children undergoing thyroidectomy/parathyroidectomy have higher complication rates than adult patients. Outcomes were optimized when surgeries were performed by high-volume surgeons. There appears to be disparity in access to high-volume surgeons for children from low-income families, Blacks, and Hispanics.
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Health care disparities among children are well documented in the literature. Racial and/or ethnic minorities often have compromised access to high-quality healthcare. These disparities have been associated with sociodemographic factors, health insurance, cultural differences, the potential lack of cultural competency among providers, and other healthcare system barriers to access (6, 7, 8, 9, 10, 11). Racial and ethnic minorities have been noted to have higher rates of ruptured appendicitis and lower rates of laparoscopic vs. open appendectomy (12, 13, 14, 15). Hospital volume has been associated with outcome disparities, such that children treated at higher-volume centers tend to fare better (12, 16, 17, 18).
For adults, several recent studies have measured clinical and economic outcomes after endocrine surgery; for children, there is a paucity of outcomes literature, with studies focusing primarily on thyroid cancer (19, 20, 21, 22, 23, 24). To address this issue, we have performed the first population-based study to examine the clinical and economic outcomes after pediatric thyroid and parathyroid procedures for both benign and malignant disease.
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Subjects and Methods |
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This study is a cross-sectional analysis of 1999–2005 hospital discharge information from the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) database, a stratified 20% sample of inpatient admissions to acute care hospitals maintained by the Agency for Healthcare Research and Quality. HCUP-NIS is the largest all-payer inpatient database in the United States. Patients under the age of 18 yr were the focus of our analysis; adult patients were defined as at 18 yr or older. International Classification of Diseases (ICD-9) procedure codes for nine primary surgical procedures were used to abstract all patients who underwent thyroidectomy or parathyroidectomy (Table 1
). Thyroidectomy included partial (lobectomy, partial thyroid resection, and excision of thyroid lesion), total, and substernal thyroidectomy. Parathyroidectomy included total and subtotal parathyroid resection.
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18 yr), gender, race (White, Black, Hispanic, and other, which included but was not limited to Asians, Pacific Islanders, and Native Americans), median household income ($1–35,999, $36,000–44,999, $45,000–59,000, and more than $59,000), admission type (routine vs. nonroutine), and payer (private/HMO, Medicaid, self-pay, Medicare, no charge, and other). Children with Medicare included those with end-stage renal disease who underwent parathyroidectomy for secondary hyperparathyroidism. Thyroid diagnoses were divided into benign and malignant. Patient comorbidity was categorized as minor, moderate, or major loss of function based on the All Patient Refined Diagnosis Related Group (APRDRG-3M) severity of illness measure. Independent hospital-provider variables included hospital region (Northwest, Midwest, South, and West), hospital location (urban vs. rural), teaching status (teaching vs. nonteaching), and hospital volume. Hospital volume was based on the annual number of pediatric and adult thyroid and parathyroid procedures. High-volume hospitals were in the top 10% based on their volume of thyroidectomies and parathyroidectomies (>51 procedures/yr). Surgeons were divided into three categories: high-volume, pediatric, and other. High-volume surgeons performed more than 30 cervical endocrine procedures per year in adults and children combined. Pediatric surgeons restricted more than 90% of their practice to patients 17 yr old or younger. Other surgeons fell into neither category. There was no overlap between these groups; in particular, there were no pediatric surgeons in the high-volume group.
Outcome variables
Primary outcomes of interest were 1) in-hospital patient complications, 2) mean length of stay (LOS), and 3) total inpatient hospital costs. Postoperative complications were categorized as general (cardiovascular, endocrine, gastrointestinal, hematological, vascular, neurologicl, urological, respiratory, infections, and wound) or endocrine-specific (recurrent laryngeal nerve injury, voice disturbance, hypoparathyroidism, hypocalcemia, and tetany). Complications were treated as a dichotomous variable (none vs. one or more); information regarding severity was not available. Total inpatient costs were calculated using the HCUP-NIS-adjusted, hospital-specific cost-to-charge ratios. Costs were then adjusted for inflation, converting all costs to 2005 dollars, using rates from the Bureau of Labor Statistics (25).
Data analysis
Bivariate analysis of the independent variables by our outcomes of interest was performed by 
2 statistical analysis for categorical variables and ANOVA for continuous variables. Multivariate linear regression models were used to adjust for significant independent variables for LOS and total inpatient costs. Multivariate logistic regression models were used to adjust for independent variables for both general and endocrine complications. Data analysis and management were performed using SPSS version 14.0 (Chicago, IL). All tests were two sided, with statistical significance set at a probability value of 
0.05. This study was deemed exempt from Institutional Review Board approval at our institution because HCUP-NIS is a public database with no personal identifying information.
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Results |
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From 1999–2005, 1199 children who underwent thyroid and parathyroid procedures were identified in HCUP-NIS. The majority of patients were female (76%) and between 13 and 17 yr (71%), 22% were 7–12 yr, and 7% were 0–6 yr (Table 2). The majority of children were White (69%); Hispanics represented 14%, Blacks 8%, and others 9%. Children from families with the highest median annual income (more than $59,000) comprised 42% of cases. Eighty percent of children in the highest median household income group were White; just 8% were Hispanic, and 6% were Black (P < 0.01). In contrast, 58% of children in the lowest income group were Black, and 46% were Hispanic; just 16% were White. Most children had private/HMO insurance (74%); 76% were White, 10% Hispanic, and 5% Black. Among the 18% of children covered by Medicaid, 41% were Black, 32% Hispanic, and 13% White (P < 0.001).
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Access to high-volume surgeons
Surgeon identifiers were available for 607 of 1199 children. There were no significant differences in patients with or without surgeon identifiers with respect to other demographic and clinical predictors of outcomes.
There were apparent differences in access to high-volume surgeons based on race and other measures of socioeconomic status (Table 3). White children more often underwent thyroidectomy or parathyroidectomy by high-volume surgeons compared with Black and Hispanic children (23.4 vs. 15.2 and 9.7%, respectively; P < 0.05). Similarly, children from families with median household incomes higher than $59,000 had significantly better access to high-volume surgeons compared with children from lower-income families (P < 0.01). Although differences in access by primary payer were not significant, there was a trend toward children with Medicaid having less access to high-volume surgeons (P = 0.07; nonsignificant).
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The most common complications after thyroidectomy and parathyroidectomy in children were endocrine specific. Hypocalcemia accounted for 68.6% of all complications, voice disturbance overall represented 6.2%, and frank stridor was seen in 2.3% of children. The next most common postoperative complications were related to respiratory issues (5.2%) and bleeding (3.4%).
There were significant differences in unadjusted clinical and economic outcomes among children undergoing thyroidectomy and parathyroidectomy (Table 4). Overall, children aged 0–6 yr had more general complications (22%) than children aged 7–12 yr (15%) and 13–17 yr (11%, P < 0.01). Notably, the rates of recurrent laryngeal nerve-related injuries were highest for the 0–6 yr group at 3.8%, followed by the 7–12 yr group (1.1%) and the 13–17 yr group (0.6%, P < 0.05). Hypocalcemia was higher in children undergoing total thyroidectomy (15.7%) and parathyroidectomy (15.2%) compared with partial thyroidectomy (3.4%; P < 0.01). Children who sustained a complication had a significantly longer LOS (4.2 vs. 1.7 d; P < 0.01).
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LOS was significantly shorter for White children (1.9 vs. 2.5 d for Black and 2.6 d for Hispanic), children from the highest-income families (1.6 vs. 2.9 d for lowest income), and children with routine admissions (1.3 vs. 8.3 d for nonroutine), children with minor loss of function (1.5 vs. 2.7 d for moderate and 7.5 d for major), and children who underwent partial thyroidectomy (1.6 vs. 2.2 d for total thyroidectomy and 3.4 d for parathyroidectomy) (all P < 0.01). Nonteaching hospitals had shorter LOS (1.7 vs. 2.1 d), as did high-volume thyroid surgeons compared with pediatric and other surgeons (1.5 vs. 2.3 and 2 d, respectively; P < 0.01). High-volume hospitals had fewer general (10 vs. 14%; P < 0.05) and endocrine-specific complications (8 vs. 11%; P < 0.05). They also had shorter LOS (1.8 vs. 2.1 d; P 0.05).
Costs were significantly higher for children on Medicare ($32,945 vs. $14,381 private/HMO and $16,973 Medicaid; P < 0.01), with nonroutine admissions, major loss of function, and undergoing parathyroidectomy or thyroidectomy for cancer. In addition, thyroidectomy and parathyroidectomy in children cost more in the Northeast and West ($17,218 and $16,908, respectively; P < 0.01). Teaching hospitals and hospitals in urban locations had significantly higher costs; similarly, pediatric surgeons had higher costs than high-volume and other surgeons. All these findings were highly significant (P < 0.01).
Adjusted patient outcomes
All variables found to be significant on bivariate analyses were included in a multivariate regression analysis to identify independent predictors of clinical and economic outcomes after thyroidectomy and parathyroidectomy in the pediatric population. Eleven children were excluded from the multivariate analysis because their LOS and costs were greater than 3 SD above the mean values. Six were aged 0–6 yr, 10 had surgery at teaching hospitals, and all were at urban centers. Only three children were White.
In the multivariate analysis, independent predictors of longer LOS included lower median household income, higher APRDRG status, procedure type (total thyroidectomy), hospital teaching status, and surgery performed by a non-high-volume surgeon (Tables 5 and 6). Independent predictors of higher costs included higher APRDRG status, procedure type (total thyroidectomy), hospital teaching status, and surgery by a non-high-volume surgeon (Tables 5 and 6).
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Pediatric vs. adult outcomes
To benchmark our findings, complications, LOS, and costs for the cohort of 1199 children were compared with 96,002 adults who underwent the same thyroid and parathyroid procedures during our study period (Fig. 1). Although the most common complications in children were endocrine specific, bleeding and respiratory-related events were most frequent in adults. Compared with adults, children had significantly higher general (21.0 vs. 12.0%; P < 0.01) and endocrine-specific complication rates (15.2 vs. 6.2%; P < 0.01) after parathyroidectomy. Their endocrine-specific complication rates also were higher after thyroidectomy (9.1 vs. 6.3%, P < 0.01), although the overall complication rates after thyroidectomy were comparable (11.6 vs. 10.7%; nonsignificant). Notably, the rate of hypocalcemia was higher among children (9.3%) than adults (5.7%; P < 0.01). There was no difference in the rate of recurrent laryngeal nerve-related complications.
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Discussion |
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According to the 2000 Census Bureau, there are 72.3 million children in the United States who comprise one quarter of the population (25). Racial/ethnic minorities account for 40%; 17% live in families with incomes below the federal poverty level (26). The National Healthcare Disparities Report, published by the Agency for Healthcare Research and Quality and the U.S. Department of Health and Human Services, cited children as a priority population. Disparities were pervasive with regard to access to care and, as a result, quality of care (27). Elimination of these disparities was a primary goal of the Healthy People 2010 initiative (28).
The etiology of these disparities is complex, as education, income, and race/ethnicity are closely intertwined. Public policy programs, such as the State Children’s Health Insurance Program (SCHIP), have been implemented to provide health insurance to low-income children who are not eligible for Medicaid and do not have private coverage. According to a 2007 Congressional Budget Office report, 5–6 million children eligible for Medicaid and/or SCHIP remain uninsured (29).
Weineck and Krauss (7) examined the relationships between health insurance and socioeconomic status in disparities in access to care using the Medical Expenditure Panel Survey. In multivariate analyses, racial and ethnic differences remained independent predictors of lack of routine access to healthcare, particularly for Black and Hispanic children. In a study of trends in asthma, Akinbami and Schoendorf (30) found that although the overall burden of disease plateaued, the division of the burden of disease was disproportionate; Black children were more than three times as likely to be hospitalized and more than four times as likely to die from asthma as White children. This was attributed in part to the fact that minority children with asthma are less likely to receive continuity of quality preventive care.
Cultural issues are a factor in health disparities among racial/ethnic minority children. Gaps in cultural competence exist between patients and providers and include differing paradigms of illness, health illiteracy, and differences in cultural beliefs resulting in mistrust of healthcare providers and/or the healthcare system. Cultural competence training is crucial for bridging cross-cultural gaps between patients and providers (11, 31). In a study of 1-yr-old Medicaid-enrolled infants over a 21-month period, Cohen and Christakis (10) found that infants of parents whose primary language was not English were half as likely to receive all recommended visits when compared with parents whose primary language was English.
Racial/ethnic disparities have been observed in the diagnosis and management of surgical diseases in children. Smink et al. (12) analyzed HCUP–Kids’ Inpatient Database to determine the association of perforated appendicitis with race and insurance status in 33,184 children with acute appendicitis. On multivariate analyses, race and insurance status were independent predictors of higher rates of perforation; this was particularly true for Black and Hispanic children and children enrolled in Medicaid. This was corroborated by Jablonski and Guagliardo (13), who found that Black children had a 38% higher rate of appendiceal rupture than White children; relative odds for Hispanic and Asian children were 24 and 32% higher, respectively. Furthermore, with 97% higher mean total hospital charges and 175% longer mean LOS, the burden of appendiceal rupture appeared to fall disproportionately on minority children.
Hagendorf et al. (15) identified 72,189 children in the HCUP-NIS who underwent appendectomy for appendicitis; 11,714 (16%) underwent laparoscopic appendectomy. White children were more likely to undergo laparoscopic appendectomy than Black children (P = 0.01). Children with Medicaid/Medicare treated at non-children’s hospitals were less likely to undergo a laparoscopic procedure than those with private insurance (P < 0.001), whereas children with Medicaid/Medicare or private insurance at the children’s unit of an adult hospital were more likely to undergo laparoscopic appendectomy (P < 0.01) (15).
Berry et al. (18) examined the relationship between hospital volume and outcomes for common pediatric specialty operations. For tracheostomy and posterior spinal fusion, at least one fourth of hospitals performed only one procedure per year; half of all hospitals treated fewer than four per year. A trend toward higher postoperative complication and mortality rates was seen in children who underwent tracheostomy in lower-volume hospitals. In a separate study, children with pyloric stenosis had significantly lower mucosal perforation rates and shorter LOS when treated by high-volume surgeons and in high-volume hospitals (17).
Disparities after endocrine surgery in adults appear to be associated with surgeon and/or hospital volume and patient race/ethnicity (19, 20, 21, 22); few studies exist for outcomes in pediatric endocrine surgery. In a study of HCUP-NIS data over 7 yr, Tuggle et al. (23) looked at outcomes among high-volume endocrine surgeons, pediatric surgeons, and other general surgeons. High-volume endocrine surgeons had significantly shorter LOS (1.5 vs. 2.3 d for pediatric, 2.0 for other; P = 0.01) and lower costs ($12,474 vs. $19,594 for pediatric, $13,614 for other; P < 0.01) than both pediatric and other surgeons. High-volume endocrine surgeons also had fewer complications, although the difference was not significant (23).
In our study, children appear to have worse outcomes than adults. One in five children (21%) undergoing parathyroidectomy have a postoperative complication; the rate in adults is 12% (P < 0.01). Endocrine complications are also significantly higher for both thyroidectomy and parathyroidectomy in children. Children aged 0–6 yr fare worse than older children, with higher complication rates and longer LOS.
Children may fare worse after thyroidectomy and parathyroidectomy for several reasons. There may be a reticence to operate on children for benign disease, given the quality of life implications of recurrent laryngeal nerve injury and hypoparathyroidism. Therefore, they may present for surgery at a later stage of endocrine disease (3, 4). In a population of 52 children with primary hyperparathyroidism, Kollars et al. (5) found that 79% were symptomatic at presentation, 33% had nephrolithiasis, 7% had pancreatitis, and one third of children had fractures and/or radiological evidence of bone involvement. Hypocalcemia is the most common complication after thyroidectomy and parathyroidectomy; postoperative management of hypocalcemia in children can be challenging, because it is difficult to ensure that young children comply with oral calcium and vitamin D supplementation. As a result, treatment may require iv calcium, necessitating extended inpatient stays.
Complication rates and LOS after thyroidectomy and parathyroidectomy were higher for Blacks, Hispanics, and children from lower-income families. It is unclear whether outcome disparities can be muted by providing health insurance to children who are otherwise uninsured. In a telephone survey of parents after enrollment in the New York State SCHIP program, Szilagyi et al. (32) found that enrollment led to improved access, continuity, and quality of care. In a similar study stratified by race/ethnicity, SCHIP enrollment led to an elimination of disparities in access, unmet needs, and continuity of care; discrepancies in quality remained (9).
There are limitations to our study, including those inherent to the use of a large administrative database. Although HCUP-NIS is widely used in health services research, it constitutes only a 20% sample of U.S. hospitals, exclusive of federal hospitals. This consideration is less pertinent for this study, because Veterans Administration hospitals are less likely to treat children. Other measures of socioeconomic status, such as patient education, and parents’ occupation and wealth, are unavailable. It is not possible to follow longitudinally a patient’s course of disease; readmission for postoperative complications, for example, is an independent admission. Therefore, complication rates may be underestimated.
In summary, this is the first description at the population level of pediatric clinical and economic outcomes after thyroidectomy and parathyroidectomy in the United States. Overall, children appear to have higher complication rates than adults. Our observations illustrate major limitations in extrapolating adult outcome data to the pediatric population.
Children undergoing endocrine surgery appear to do better in the hands of high-volume surgeons. In particular, total thyroidectomy for malignancy, parathyroidectomy, and surgery in the youngest children are fraught with risk. For example, surgery in patients with hereditary neonatal hyperparathyroidism or multiple endocrine neoplasia types 2A and 2B is unavoidable; therefore, referral should be made to the highest-volume surgeons.
The unfortunate reality is that minority children and children from lower socioeconomic status have compromised access to these providers. More data are needed to clarify the association between these factors and outcomes to move toward improved equity in pediatric endocrine surgery delivery. These efforts will need to involve collaboration on the part of families, providers, payers, and policymakers.
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Footnotes |
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First Published Online June 3, 2008
Abbreviations: APRDRG-3M, All Patient Refined Diagnosis Related Group; HCUP-NIS, Healthcare Cost and Utilization Project National Inpatient Sample; ICD, International Classification of Diseases; LOS, length of stay; SCHIP, State Children’s Health Insurance Program.
Received March 24, 2008.
Accepted May 22, 2008.
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