Interventional rads push for new standards in children

August 1, 2006
C. P. Kaiser

Complications in children's interventions cost hundreds of millions of dollars each year

While interventional radiology standards exist for adult procedures, they are curiously absent for pediatric exams. This spring, the Society of Pediatric Radiology invited pediatric interventionalists or general interventionalists with an interest in pediatric radiology to form a group to help craft standards. It will be a subcommittee of the Society of Interventional Radiology's standards committee.

The journals of SIR and the SPR agreed in May at the International Society of Pediatric Radiology meeting to consider publishing the standards once they are developed.

"Our target is to have the subcommittee fully formed by the end of this year and to develop one or two standards for pediatric interventional radiology by the end of 2007," said Dr. Richard Towbin, the lone pediatric interventional radiologist on the SIR standards committee and the radiology chair emeritus at Children's Hospital of Philadelphia.

Standards for pediatric interventional procedures do not exist now for several reasons. The field is relatively young, the number of pediatric IRs is small, and published data are skimpy. But Towbin is betting that the field has developed enough to begin.

"It may still be too early and prove too difficult, but there is a growing momentum to do it, and that is a good start," he said.

While the literature for pediatric interventions is sparse, Towbin anticipates finding enough mature data on some of the more common procedures, including venous access, gastrostomy, nephrostomy, biopsy, and abscess drainage. Any discrepancies among committee members will be settled by consensus.

Pediatric interventional complications can add up in economic and patient costs. In Pennsylvania, catheter-related bloodstream infections associated with venous access add approximately $28,000 toward each patient's care. These patients are 15 times more likely to die than those without infections. The total cost in the U.S. for this complication is $60 to $300 million, said Dr. Kevin Baskin, a pediatric interventionalist at CHOP. Standards help local practitioners compare themselves with global expectations. Below-standard performance could occur for a number of reasons, including patient acuity or other legitimate factors. But the global metrics should provoke IRs to scrutinize their practice to ensure they are not committing avoidable complications.

Organizers want pediatric interventionalists from many institutions to contribute to the effort, thereby accurately representing the cross section of patient problems and practice. For example, some IRs perform liver biopsy using the subxiphoid anterior approach to the left lobe, while others use an intercostal approach to the right lobe in the midaxillary line. Gastrostomies also have two approaches: antegrade or retrograde. The results of the various approaches are probably comparable, Baskin said, but they haven't been widely quantified.

Standards could also affect hospital credentialing and reimbursement. Without standards, it's difficult to hold credentialing committees accountable for whom they hire. With standards, decisions are made less arbitrarily, Baskin said.