P2.P320: Hospital volume and region associated with variation in VACTERL screening among newborns with anorectal malformations – an opportunity to optimize screening practices

Background: Patients born with anorectal malformation (ARM) have frequent associations with other congenital anomalies such as VACTERL and spinal cord anomalies however screening practices are not standardized. This study evaluates the rate of screening echocardiograms, renal imaging, and spinal cord imaging as well as any factors associated with completion of these evaluations during the newborn hospitalization of ARM patients across neonatal intensive care units (NICU) in the United States using the Pediatric Health Information Systems (PHIS) database.

Methods: Rates of VACTERL screening among newborn ARM patients admitted to PHIS NICUs between 1/2012 – 12/2022 were identified and compared using a retrospective, multi-institutional cohort design. Relevant ICD9/10 diagnostic and procedure codes were used to identify ARM patients. The primary outcome was completion of a VACTERL workup (echocardiogram + renal imaging + spinal cord imaging) during index NICU hospitalization. Covariables included patient demographics, year of admission, hospital volume (number of ARM admissions during the study period; low ≤25, medium 26-75, high >75 patients), hospital region, and hospital length of stay. Rates of imaging were calculated by year, hospital volume, and hospital region. Descriptive statistics were performed. Multivariable regression was used to identify factors independently associated with completion of a full VACTERL workup. Subgroup analyses were performed for each imaging component.

Results: During the study period, 1,955 newborns (35% female) with ARM were admitted across 44 PHIS hospitals. The proportion of patients treated at a low, medium, and high-volume hospital was 14%, 65%, and 21%, respectively. 80% of patients had a length of stay greater than one week and 54% required mechanical ventilation. Overall, the full VACTERL screening rate was 78% (96% echo, 97% renal imaging, 82% spinal imaging). Screening rates increased over time, with full screening rates as low as 60% in 2013 and approaching 86% by 2022. (Fig 1). Figure 2 summarizes screening rates by hospital volume and region. Factors independently associated with completion of screening were high hospital volume of ARM patients [aOR 4.1, 95% CI 2.6-3.6, p < 0.001] and length of stay greater than one week [aOR 1.6, 95% CI 1.2-2.2, p < 0.001]. Odds of full screening were 50% lower in hospitals in the Midwest, South, and West, compared to the Northeast [all p< 0.001]. Patients who required mechanical ventilation also had lower full screening rates [aOR 0.72, CI 0.55-0.93, p=0.01].

Conclusion: Most patients born with ARM undergo full screening for VACTERL anomalies, which has improved over time however there is still variation in which patients receive a full work up across region and hospital volume, especially with respect to spinal cord screening. Implementation of standardized guidelines or provider education may reduce this variation and improve care.