Date of Award

1-1-2012

Document Type

Campus Access Dissertation

Department

Health Services and Policy Management

First Advisor

Saundra L Glover

Second Advisor

Janice C Probst

Abstract

Background: Endoscopic Third Ventriculostomy (ETV) is well established as an alternative to cerebrospinal fluid shunting in the treatment of children with obstructive hydrocephalus, due to various etiologies producing obstruction of CSF fluid flow in the region of the cerebral aqueduct. Clinical studies have shown both the high success rates of use of the ETV procedure, and also demonstrated the risk of mortality associated with ETV. The study objective was to identify the non-clinical factors associated with the use and outcome of the ETV procedure, and to provide a more nuanced representation of the comprehensive factors associated with ETV utilization and outcome in the United States pediatric population. Methods: Data analyzed were pediatric discharge records from 2003, 2006 and 2009 Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID). The International Classification of Diseases, 9th revision, Clinical Modification (ICD-9CM) was used to identify cases of pediatric obstructive hydrocephalus. Patients greater than 18 years of age were excluded. Univariate and bivariate analyses were employed to investigate associations among selected variables. Logistic regression analyses were used to model ETV use on individual level and hospital level characteristics, and also to enumerate in-patient mortality associated with the use of ETV for treatment of pediatric obstructive hydrocephalus. All analyses incorporated sampling weights to adjust for the sampling frame. Results: Analyses indicated that approximately 6.4% of all pediatric patients diagnosed with obstructive hydrocephalus were treated by Endoscopic Third Ventriculostomy (ETV). Analyses considered weighted data from the KID database from 2003 (9,565 patients), 2006 (10,823 patients), and 2009 (11,224 patients), on pediatric obstructive hydrocephalus admissions in the United States. Of these admissions 6.2%, 6.2% and 6.7% were treated by use of ETV for each respective year. An increase in use of ETV from 2006 to 2009 was observed, but this increase was not statistically significant. Data also showed that while pediatric patients with obstructive hydrocephalus who were treated by ETV accounted for approximately 6.4% of all pediatric obstructive hydrocephalus admissions, these patients accounted for 12.08% of all pediatric obstructive hydrocephalus patient charges, and 9.64% of all pediatric obstructive hydrocephalus patient days. Significant patient-level predictors of ETV use for treatment of pediatric obstructive hydrocephalus included, co-morbidity count and type of insurance held, while hospital-level predictors of ETV use in treatment of pediatric obstructive hydrocephalus included hospital designation as teaching or non-teaching, and hospital bed size. Analyses of the hospitals in which individuals in the pediatric age group diagnosed with obstructive hydrocephalus were treated by ETV revealed that approximately 34% of the ETV procedures were performed in teaching & freestanding children hospitals (T&FSCH), 48% were performed in teaching and children hospital units (T&CHU), 13% were performed in teaching and non-children hospitals (T&NCH), and 5% in non teaching hospitals (NT). After adjusting for individual-level characteristics, multivariate analyses showed that those admitted to a nonteaching hospital (NT), were less likely to be treated by ETV, than those admitted to a (T&FSCH) (OR=0.81; CI 0.71,0.92) (p=0.001). Adjusted analysis on outcome of ETV use showed that pediatric patients with obstructive hydrocephalus treated by use of ETV had higher odds of in-patient mortality than those not treated by ETV (OR=4.07; 95% CI 3.44, 4.96) (p

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