2015 HSC Section 1 Book of Articles

Otolaryngology–Head and Neck Surgery 151(5)

controversy in the suitability of TLA for more severely affected infants 6,7 along with the interference of tongue mobility and the possibility of tongue dehiscence, 8 this pro- cedure is not used at our institution. Tracheostomy is effec- tive at bypassing the obstruction but doesn’t address the cause of the airway obstruction and requires extensive main- tenance. Until recently, this has been the standard treatment of moderate to severe PRS. 9 Mandibular distraction (MD) consists of performing an osteotomy on the ramus of the mandible and gradually pulling it forward, correcting the micrognathia and tongue-based airway obstruction by pro- viding more space for the tongue and oropharyngeal airway. An important consideration with these surgical interven- tions is the associated cost for patients’ families and the health care system. In our institution, patients with PRS receiving MD seemed to have shorter hospital stays and fewer subsequent interventions than those receiving tra- cheostomy. We therefore hypothesized that MD would be associated with significantly lower costs than tracheostomy. To test this we performed a retrospective cohort study com- paring the costs associated with MD and tracheostomy for infants with PRS, both isolated and syndromic. Additionally, costs for neonates with PRS who underwent tracheostomy and secondarily underwent MD within the first year of life were compared. A retrospective chart review was performed on neonates with PRS whose treatment at Cincinnati Children’s Hospital Medical Center (CCHMC) began between 2001 and 2009. This study was approved by the Institutional Review Board (IRB) at CCHMC (#2009-0162). A multidisciplinary airway team including neonatologists, geneticists, otolaryngologists, pulmonologists, speech therapists, and plastic surgeons eval- uated patients identified with PRS in the neonatal ICU. Workup typically included bedside nasopharyngoscopy, cephalogram, pulse oximetry monitoring, feeding assess- ment, and a sleep study. Mildly abnormal sleep studies despite repositioning lead to discharge with supplemental oxygen as appropriate and close follow-up. Moderately/ severely abnormal sleep studies are followed by further ima- ging including microlaryngoscopy, bronchoscopy, and/or CINE MRI to evaluate for multilevel obstruction. Patients with moderate-severe sleep studies and additional risk fac- tors (eg, multilevel obstruction, neurologic delay) or those requiring early intervention (eg, ex utero intrapartum [EXIT] to airway) are often referred for tracheostomy. Others receive tracheostomy or MD based on team recom- mendations. Seventy neonates (defined as infants less than 1 year old) were identified with PRS who underwent MD or tracheostomy. These included a subset of patients for whom our group recently published separate outcomes data. 10 Patients with incomplete billing records or incomplete follow-up charges ( \ 3 years) were excluded (n = 23). One syndromic patient who received both tracheostomy and Methods Data Collection

subsequent MD was excluded due to lengthy cardiac ICU stay unrelated to PRS. The CCHMC billing department provided records of all charges to patients over a 3-year period. These included daily inpatient fees (for all admissions over 3 years includ- ing patient-specific nursing care, mechanical ventilation, enteral feeding, radiologic studies, medications, and labora- tory tests), surgical fees (gastrostomy, microlaryngoscopy and bronchoscopy [ML&B], tracheostomy, mandibular osteotomies and distractor placement/adjustment/removal including distractor hardware costs), anesthesia fees, inpati- ent consultation fees, outpatient clinic fees, emergency room visits, and radiologic and sleep studies. Operations, imaging studies, and emergency room and clinic visits unre- lated to the PRS diagnosis were excluded. Charges prior to 2009 were adjusted for inflation using an annual rate of 3%. All patients discharged with a tracheostomy received home tracheostomy care. The monthly cost for home tra- cheostomy care was estimated based on a patient’s level of respiratory support (CPAP vs ventilator), the number of months with tracheostomy before decannulation, estimated equipment rental and tracheostomy supply costs, and indivi- dualized home nursing care recommendations. A common recommendation provided 8 hours of home nursing care per night for 8 weeks. A list of the home nursing care and tra- cheostomy rental and supply rates used may be found in Supplemental Table S1 at www.otojournal.org. Data Analysis Data distributions for continuous data were assessed using means with standard deviations and medians with ranges (minimum and maximum) and interquartile ranges. Categorical data were reported as frequencies and percen- tages. Comparisons of median costs (adjusted for inflation) across the 3 groups (mandibular distraction only, tracheost- omy only [Trach], and tracheostomy with subsequent man- dibular distraction [Trach 1 MD]) were made using the Kruskal-Wallis test. Post hoc pairwise comparisons between groups were conducted using a Wilcoxon rank sum test with a Bonferonni adjustment. Total costs for year 1 were also adjusted for the number of days in the ICU using a general linear model (with least square means reported as the adjusted means). The data did not follow a Gaussian distri- bution, and therefore a log transformation was conducted on total costs for year 1 in order to control for number of days in the ICU, and the results were back transformed into whole dollar amounts for the purpose of interpretation. Adjusted mean total costs were reported with 95% confi- dence intervals. Results Forty-seven patients with PRS were identified who were treated with mandibular distraction (MD, n = 26), tracheost- omy (Trach, n = 12), or tracheostomy with subsequent MD (Trach 1 MD, n = 9) and who met inclusion criteria ( Table 1 ). The MD group had a higher percentage of patients with non- syndromic PRS (82%) compared to the Trach (58%) and

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