Standardized Perioperative Protocols and Variance in Pediatric Surgery.

Importance: Standardized perioperative pathways are increasingly used in surgery to reduce unwarranted variation, promote evidence-based practice, and improve patient outcomes, yet pediatric implementation has lagged, with most studies focused on single conditions or institutions. Broader evaluation of multiprotocol, multi-institution initiatives is needed. Objective: To evaluate the association of the Minimizing Variance in Pediatric Surgery (MViPS) program with clinical outcomes, length of stay (LOS), and cost. Design, Setting, and Participants: This cohort study was conducted from October 2012 to November 2021 at 2 academic pediatric tertiary referral centers in Oregon. Data analysis was completed in May 2024. Pediatric surgery patients treated for protocol-specified conditions or procedures, with age cutoffs varying by protocol (typically <18 years). Exclusions included failure to meet protocol criteria, nonpediatric surgery management, and insufficient documentation. Intervention: Implementation of standardized perioperative protocols targeting a range of pediatric surgical conditions. Main Outcomes and Measures: Outcomes included LOS, total hospital costs (THC), complications, and protocol compliance. LOS was characterized as study LOS, defined as postprocedure LOS for patients who underwent a procedure and total hospital stay for those who did not, and total LOS, representing the entire period of hospitalization. Hospital days and cost differences were calculated from total LOS and THC. Results: A total of 1081 pediatric surgery patients were included (519 postprotocol and 562 preprotocol; median [IQR] age, 3 [0-10] years; 668 [62%] male). No significant demographic differences were found between preprotocol and postprotocol groups. Protocol compliance was 82% (426/519). Complication rates were similar between groups, but study LOS was 23% shorter in the postprotocol group (incidence rate ratio [IRR], 1.23; 95% CI, 1.11-1.38; P < .001), with a reduction of an estimated 191 hospital days. THC was 10% lower in the postprotocol group (IRR, 1.10; 95% CI, 1.01-1.20; P = .03), with an estimated reduction of $266 709. Extrapolation to 3167 patients treated according to protocol since the end of the study (up to April 2024) reveals an estimated reduction of $2 236 583 and 1584 hospital days. Conclusions and Relevance: In this study, the MViPS initiative was associated with reduced THC and LOS while maintaining outcomes. These findings support the value of standardized protocols in improving pediatric surgical outcomes and efficiency across institutions.