Paediatric surgical care in Sweden. Studies on incidence, outcome and access

Abstract: Abstract Background: Advanced paediatric surgery is increasingly centralised in Sweden in order to improve treatment outcomes and reduce surgical risks. However, the overall need for surgery in the paediatric population has not been estimated, and the association between geographic access to surgical facilities and timely treatment for common surgical conditions in children is largely unknown. Aims: To estimate the overall incidence of surgery for Swedish children (I); to describe disease-specific incidences, treatment characteristics and surgical risks for one paediatric non-emergent surgical condition (cryptorchidism) (II) and one acute surgical condition (appendicitis) (III); and to assess for associations between distance to surgical facility and timely treatment with adjustment for medical and socioeconomic risk (IV-V). Methods: National healthcare and population registers of the total Swedish paediatric population, or subsets of it, for the years 2001-2014, were analysed in five observational cohort studies. The overall incidence of surgery was estimated in the Swedish paediatric population, and the disease-specific incidences were analysed for cryptorchidism and appendicitis. Treatment characteristics and surgical risks were presented, and the associations between travel time to hospital and treatment delay were analysed for these two conditions. Regression methods and survival analysis have been applied to estimate associations and calculate cumulative incidences. Results: On average, every year of childhood, 1 in 20 children had some kind of surgical procedures (6784 operations per 100,000 person-years), and 27% of all paediatric hospital admissions involved surgical procedures. >67% of all operations were performed as day surgery. 1.4% of Swedish boys were treated for cryptorchidism by age 14, and 1.8% were treated by 18 years of age, with prematurity and low birth weight being strongly associated with this risk. Only a minority (<6%) were treated during their first year of life according to the recommendations, with considerable regional variations. There was no postoperative mortality detected, and the risk of postoperative infection was low (1.4%), with no geographic variations. There was an association between travel time to hospital and timely treatment at 3 years of age, adjusted for birth-related risk factors and socioeconomic determinants (per 30-minute increase in travel time: aHR 0.91 [95% CI 0.88-0.95], p<0.001). 1 in 40 Swedish children (2.5%) had appendicitis during childhood. One in 6 (17%) had a more severe type of appendicitis, with increased postoperative infection rate (5.9% versus 2.3%, aOR 2.6 [2.2-3.2]) and readmission rate (5.5% versus 1.2%, aOR 4.8 [95% CI 4.1-5.5]), and higher risk for small bowel obstruction later on (0.2% versus 0.7%, aHR 3.9 [95% CI 2.6-5.8]). These risks were also associated with treatment modality; postoperative infection rates (aOR 0.6 [95% CI 0.5-0.8]) and small bowel obstruction rates (aHR 0.3 [95% CI 0.1-0.6], p=0.002) were lower after laparoscopic surgery, as compared to open appendectomy. There was no observed association between travel time to treatment and the risk for more severe type of paediatric appendicitis in Sweden. Significance: In this thesis, the overall incidence of surgery in Swedish children has been estimated. One elective condition and one emergency surgical condition have been anlysed for outcomes in terms of timing of treatment and surgery-related risks. Access to timely surgical treatment have been estimated in the elective and the emergancy care settings. Findings from these studies may be relevant to consider on a regional and national level in future planning of paediatric surgery.