Purpose: The decision about whether to perform or not perform a gastric fundoplication has enormous clinical and cost implications. Children who are having a gastrostomy procedure are often considered candidates for fundoplication, yet there is no clinical consensus as to who needs a fundoplication. Our purpose was to examine subjective and objective factors influencing the decision of pediatric surgeons to perform or not perform a gastric fundoplication in children undergoing a gastrostomy procedure.
Method: A pre-operative self-administered 34 item questionnaire on objective and subjective decisional influences was completed by the attending pediatric surgeon on two groups of patients: those having a gastrostomy with a fundoplication, and those having a gastrostomy without a fundoplication. All six surgeons who perform fundoplication at a major children’s hospital participated.
Result: From July 1, 2009 through June 30, 2010, 169 patients met eligibility criteria and 161 surveys (95%) were completed. The mean age of the patients was 2.9 years (median=0.8 years), 59% were male, 57% had Medicaid, and 62% were neurologically impaired. Of the cohort, 66% were referred as an inpatient, and >50% had at least two pediatric subspecialists involved in their care. For 86% of cases the surgeons reported that the input of another physician had somewhat or a lot of influence on their decision about fundoplication. Specifically, they mentioned the input of several pediatric specialists: Neonatologists (24%), Hospitalists (25%), Pulmonologists (18%), Primary Care Physicians (16%), and Gastroenterologists (9%). The opinion of parents contributed somewhat or a lot to the decision 72% of the time. Among the 89% of the cohort that had an upper GI contrast study, surgeons stated that the results had a lot of influence 45% of the time. Multivariable logistic regression showed the following factors were associated with the patient receiving a fundoplication, involvement of a pulmonologist (OR 1.7, 95% CI: 1.1-2.6), neonatologist (OR 1.9, 95% CI: 1.3-2.9) and PCP (OR 0.6, 95% CI: 0.4-0.9).
Conclusion: Most decisions to perform a fundoplication occur in the inpatient setting and are impacted by a variety of objective and subjective factors, most notably the opinions of other physicians. The high level of input that pediatric subspecialists have on the decision and the patterns of referral to the surgeons have important implications for the development and implementation of a shared decision making tool.