O2167: Navigating Limited Resources- Outpatient Pediatric Cholecystectomies at Rural Hospitals

Background: More children are undergoing cholecystectomies due to increasing rates of cholelithiasis and biliary dyskinesia. As the number of hospitals performing routine pediatric surgery declines, rural facilities that provide pediatric surgical services are a critical resource to local communities. Our aim was to characterize differences in outpatient pediatric cholecystectomy outcomes performed at rural and urban hospitals with the hypothesis that rural hospitals would have similar outcomes.

Methods: The National Ambulatory Surgery Sample (NASS), which contains ambulatory surgery encounters at hospital-owned facilities, was used to perform a retrospective cohort analysis of pediatric patients age 18-years and younger who had a cholecystectomy (n=15,449) between 2016-2018. Survey-weighted multivariate regression analyses were used to evaluate the association of rural and urban hospital locations with the primary outcome of routine discharge among patients who had cholecystectomies. The secondary outcomes included the use of laparoscopy and complications. Models were adjusted for sex, age, comorbidities, insurance, income quartile, indication for operation, and hospital characteristics.

Results: Patients receiving care at rural hospitals were more commonly in the lowest two median income quartiles compared to urban hospitals (91.1% vs 58.2%, p< 0.01) and had more complex chronic comorbidities (63.1% vs 57.2%, p< 0.01). The most common surgical indication was cholecystitis followed by biliary dyskinesia in both settings. There were no mortalities in either cohort. On bivariate analysis, there were no differences detected in the use of laparoscopy (OR 4.30, 95% CI 0.98 – 18.8, p=0.05) or complications (OR 2.11, 95% CI 0.77 – 5.80, p=0.15). Survey weight multivariate regression analysis showed that patients cared for at rural hospitals had a higher odds ratio of having routine discharge compared to those cared for at urban hospitals (adjusted OR 2.27, 95%CI 1.04- 4.99, p=0.04).

Conclusion: Despite challenges of pediatric patients receiving care at rural hospitals having lower median income and more comorbidities, outpatient cholecystectomy is a safe option in appropriately selected pediatric patients and associated with increased odds of routine discharge. Further research is needed to evaluate barriers to patients receiving care in rural hospitals and maintain this critical resource in rural communities.