In the Journals

GERD diagnostics, use of surgery ‘highly variable’ in infants

Mehul V. Raval, MD, MS, FAAP
Mehul V. Raval

A new study showed “notable variation” in the overall use of antireflux surgery in infants with GERD, and in the surgical approach and diagnostic testing.

These findings highlight the need for consensus guidelines and further research on GERD management in infants, investigators concluded.

“Antireflux surgery (ARS) is performed frequently in infants on the basis of the presence of subjective symptoms without confirmatory diagnostic testing before surgery. There is no high-quality evidence demonstrating positive outcomes in these patients after ARS surgery,” Mehul V. Raval, MD, MS, FAAP, assistant professor of surgery and pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, told Healio Gastroenterology. “One thought to decrease practice variation is to determine if using more objective diagnostic tests for reflux in infants is associated with lower use of surgery.”

Such diagnostic tests, like pH probes to measure acid reflux severity or manometry studies to evaluate pressures in the esophagus and stomach, are commonly used in adults but not in children due to limited availability and data supporting their use, Raval added.

“Our study quantifies the frequency at which diagnostic tests are used in infants before ARS and characterizes the variability in ARS utilization for the treatment of gastroesophageal reflux disease,” he said.

He and colleagues evaluated data on more than 5 million infants in the Pediatric Health Information System, identifying 149,190 (2.9%) diagnosed with GERD in the U.S. between January 2011 and March 2015. Among these, 4,518 (3%) had ARS.

Although they saw reductions in annual rates of GERD and ARS, they also saw a wide range of diagnoses (1.8% to 6.2%) and ARS use (0.2% to 11.2%). Further, they found facility variation in the use of laparoscopic vs. open ARS (mean, 66%; range, 23% to 97%), which persisted in adjusted analysis.

“We found that fewer than 4% of infants with GERD undergo diagnostic testing,” Raval said.

Diagnostic testing was performed on 3.8% of patients overall, compared with 22.8% of patients who underwent ARS.

“Furthermore, facility-level utilization of diagnostic studies was not associated with utilization of surgery,” Raval added. “This means that hospitals that use more diagnostic tests don’t necessarily use surgery more judiciously.

“Last, we did find that hospitals that used minimally invasive surgical techniques to perform ARS (ie, surgeries done laparoscopically) were more likely to offer surgery to infants with reflux compared to hospitals where the ARS is typically performed with an open approach,” he said.

The percentage of laparoscopic surgeries was independently associated with use of ARS (OR = 1.57; 95% CI, 1.21-2.02).

“Thus, surgeon skill and bias may be driving some of the practice variation we are seeing,” Raval said. “These data can be used to focus future research to better clarify the role of preoperative diagnostic testing and the appropriateness of ARS in this delicate pediatric population.” – by Adam Leitenberger

Disclosures: Raval reports he receives intramural funding and support from the Department of Surgery at Emory University School of Medicine and the Emory + Children’s Pediatric Research Center which includes Children’s Healthcare of Atlanta.

Mehul V. Raval, MD, MS, FAAP
Mehul V. Raval

A new study showed “notable variation” in the overall use of antireflux surgery in infants with GERD, and in the surgical approach and diagnostic testing.

These findings highlight the need for consensus guidelines and further research on GERD management in infants, investigators concluded.

“Antireflux surgery (ARS) is performed frequently in infants on the basis of the presence of subjective symptoms without confirmatory diagnostic testing before surgery. There is no high-quality evidence demonstrating positive outcomes in these patients after ARS surgery,” Mehul V. Raval, MD, MS, FAAP, assistant professor of surgery and pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, told Healio Gastroenterology. “One thought to decrease practice variation is to determine if using more objective diagnostic tests for reflux in infants is associated with lower use of surgery.”

Such diagnostic tests, like pH probes to measure acid reflux severity or manometry studies to evaluate pressures in the esophagus and stomach, are commonly used in adults but not in children due to limited availability and data supporting their use, Raval added.

“Our study quantifies the frequency at which diagnostic tests are used in infants before ARS and characterizes the variability in ARS utilization for the treatment of gastroesophageal reflux disease,” he said.

He and colleagues evaluated data on more than 5 million infants in the Pediatric Health Information System, identifying 149,190 (2.9%) diagnosed with GERD in the U.S. between January 2011 and March 2015. Among these, 4,518 (3%) had ARS.

Although they saw reductions in annual rates of GERD and ARS, they also saw a wide range of diagnoses (1.8% to 6.2%) and ARS use (0.2% to 11.2%). Further, they found facility variation in the use of laparoscopic vs. open ARS (mean, 66%; range, 23% to 97%), which persisted in adjusted analysis.

“We found that fewer than 4% of infants with GERD undergo diagnostic testing,” Raval said.

Diagnostic testing was performed on 3.8% of patients overall, compared with 22.8% of patients who underwent ARS.

“Furthermore, facility-level utilization of diagnostic studies was not associated with utilization of surgery,” Raval added. “This means that hospitals that use more diagnostic tests don’t necessarily use surgery more judiciously.

“Last, we did find that hospitals that used minimally invasive surgical techniques to perform ARS (ie, surgeries done laparoscopically) were more likely to offer surgery to infants with reflux compared to hospitals where the ARS is typically performed with an open approach,” he said.

The percentage of laparoscopic surgeries was independently associated with use of ARS (OR = 1.57; 95% CI, 1.21-2.02).

“Thus, surgeon skill and bias may be driving some of the practice variation we are seeing,” Raval said. “These data can be used to focus future research to better clarify the role of preoperative diagnostic testing and the appropriateness of ARS in this delicate pediatric population.” – by Adam Leitenberger

Disclosures: Raval reports he receives intramural funding and support from the Department of Surgery at Emory University School of Medicine and the Emory + Children’s Pediatric Research Center which includes Children’s Healthcare of Atlanta.