Introduction: Great effort has been dedicated to reducing shunt failure rate through both technique and equipment modification, but unfortunately, the need for revision remains high. Pediatric fellowship training was shown to improve outcomes and lower the cost of healthcare for several other surgical specialties. We reviewed 20 years of cerebrospinal fluid shunting procedures to elucidate risk factors for failure and differences in care delivered between a pediatric neurosurgeon and faculty without fellowship accreditation.
Methods: A large retrospective database was created for pediatric patients who underwent placement of cerebrospinal fluid shunts from January 1990 through January 2011 at our institution. Patients were identified using billing codes for shunting. The study author HJS was the only member of the faculty who completed a pediatric fellowship and was the subject of this investigation.
Results: We reviewed 343 patients who underwent a total of 849 procedures. Including HJS who performed 352 procedures (41.5%), there were 23 total surgeons. Overall, there was a 57% shunt failure rate with a mean follow up of 9.3 years. While HJS experienced 147 (42.8%) failures, other faculty members collectively performed 322 revisions (67.5%, p <0.0001). A Kaplan-Meier Curve showed a corresponding beneficial difference in survival (Figure 1, p = 0.037). There was also a trend for shorter length of stay associated with procedures by HJS (median 4 days versus 6, p = 0.096). Several factors may have contributed to these differences including a more diverse patient population from referrals, the predilection for frontal catheter placement, and the use of medium pressure valves or antibiotic impregnated catheters.
Conclusions: Pediatric subspecialization appeared to positively impact shunt survival. While the explanation is likely multifactorial, we demonstrated that our single pediatric trained faculty member had a lower revision rate and trended towards shorter length of stay. This equates to decreased patient morbidity and tremendous cost savings.
Patient Care: This work targets the quality of care regarding cerebrospinal fluid shunting in pediatric patients. We demonstrated that pediatric fellowship training in one individual improved the revision rate and reduced patient length of stay. These are important metrics of patient morbidity and have a great impact in health care costs.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance and economic impact of subspecialty training in relation to pediatric cerebrospinal fluid shunting. 2) Discuss, in small groups, risk factors for shunt failure and longer length of stay. 3) Identify an effective and durable treatment for hydrocephalus.