Who Should Treat Children?
Source: Brain AJL, Roberts DS. Who should treat pyloric stenosis: The general or specialist pediatric surgeon? J Pediatr Surg 1996;31:1535-1537.
One of the consequences of the changes in health care in the United States has been an increasing tendency to use subspecialists trained in adult medicine and surgery to treat diseases that occur primarily in infants and children. Thus, insurance companies and managed care plans may insist that children with pediatric diseases be seen by adult-oriented subspecialists who may have little experience in the diagnosis and treatment of those diseases. While we as pediatricians believe this may not be good care, there are few studies that prove children are better served by pediatric-oriented and trained physicians and surgeons.
Brain and Roberts, pediatric surgeons, present compelling data on the benefits and cost savings resulting from surgery for hypertrophic pyloric stenosis being performed by surgeons with pediatric training and continuing experience. In the United Kingdom, until recently, these operations were usually done by general surgeons.1
They compared the results in a single institution before 1988, when general surgeons performed pylorotomies, with results from 1988-1994, when surgery was done by trained pediatric surgeons. Since these were not concurrent periods, they chose for analysis 39 consecutive cases immediately before and after the change in operators.
There were no differences in the two groups with respect to gender, age, or weight distribution. However, the group operated on by the pediatric surgeons had marked (and significant) differences in complications such as breaks in the duodenal mucosa (0% vs 12.8%) and the incidence of wound infection (2.8% vs 15.8%). Although the average length of stay was not different in the two groups, 14 of 39 general surgical patients had hospital stays of more than three days compared with only four of 39 children operated on by the pediatric surgeons.
Although the differences could have merely reflected different degrees of surgical skill, the rate of complications associated with the general surgeons was not different from previously published general surgical series.
The authors conclude that when operations for hypertrophic pyloric stenosis were performed by pediatric as opposed to general surgeons, there was a considerably decreased morbidity rate as well as reduced emotional and financial costs.
I hope that managed care companies and HMOs pay heed to this important message. hap
Reference
1. Janghiri M, et al. Infantile hypertrophic pyloric stenosis: Where should it be treated? Ann Royal Coll Surg Eng 1993;75:34-36.
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