2015 HSC Section 1 Book of Articles

Otolaryngology–Head and Neck Surgery 151(5)

patients in the Trach 1 MD group also had a lower median number of operations, fewer ER visits, and higher decannula- tion rates, resulting in lesser total costs compared to those in the Trach group. These differences weren’t statistically signifi- cant, so we cannot conclude that the addition of MD to tra- cheostomy provides a cost savings; however, we posit that there are no increased costs when both operations are per- formed versus tracheostomy alone. Costs associated with home tracheostomy care can be substantial and should be considered in any rigorous cost analysis for treatment of PRS. Although actual billed charges weren’t available for each patient, we generated an informed estimate based on an individual’s requirement for ventilatory support, local equipment rental rates, recom- mended level of home nursing care and rates, and age at decannulation. Inclusion of home care to the Trach group over the first 3 years increased the total cost to $358,395, a 7.3-fold increase over the MD group. The Trach 1 MD group also had increased charges due to home care, however remained lower than the Trach group each year, albeit not significantly. We did not consider the added costs of home tube feeding due to inability to obtain precise data on timing of cessation of enteral feeds. Were home feeds included, this would likely further increase charges to patients treated with tracheostomy, the majority of whom had gastrostomies, whereas most receiving MD weaned off of nasogastric tube feeds within a short time of discharge. Our study has a number of limitations. First, our patient population may not reflect that of patients with PRS nation- ally. As an airway referral center we are biased toward those with severe airway obstruction. We do successfully manage patients with mild to moderate PRS conservatively, however those patients were not included in this study as our purpose was to compare surgical interventions for moderate to severe PRS. Next, with a 3-year follow-up period we are not evalu- ating the contribution of long-term sequelae to patient costs, which may change the disparity between MD and tracheost- omy. These may include possible need for dental work or orthognathic surgery in patients receiving distraction and additional airway procedures in patients not decannulated within 3 years. Lastly, we cannot rule out the possibility that our data are skewed by a lower percentage of syndromic patients in the MD group (15% vs 42% for Trach group). Patients with syndromic PRS have been reported to have a greater severity of respiratory problems compared to nonsyn- dromic PRS, and they frequently require treatment for other congenital anomalies. We addressed this by excluding surgi- cal fees, studies, and clinic visits associated with non-airway diagnoses. However, the length of their ICU stay or acuity may have some influence on the financial charges. However, statistical analysis of the 3 groups did not demonstrate signif- icance in their different percentages of syndromic patients. Additionally, a direct comparison of nonsyndromic with syn- dromic patients showed higher charges for the latter, but which were significant only during year 2 (see Figure 4 ). We believe these findings may have important implica- tions for the treatment of neonatal PRS. With an incidence of

study examined the contribution of syndromic status or home care charges. Consistent with these reports, our study found a 2.6-fold higher cost for patients receiving tracheostomy compared to MD over a 3-year period. These figures are based on actual patients’ charges and thus factor in individuals’ variations in ER and clinic visits, imaging studies, and level of hospital acuity. In contrast to the other cost analyses, we found no significantly different lengths of hospital stay between the MD and Trach groups. However, the Trach group had nearly 3-fold higher hospital-related charges compared to the MD group. In our institution, patients receiving MD are extubated within a few days, typically fed by NG-tube without requir- ing gastrostomy, and require no or minimal oxygen support, often allowing for discharge home during active distraction. Those receiving tracheostomy more frequently require gastro- stomy feeding and ventilatory support. Once stable, they are transferred to a (stepdown) complex airway unit with decreased acuity of care under management of the ENT or pulmonary services with appropriate consultants (eg, speech therapy, genetics, plastics) but without ICU team involve- ment. Patients receiving tracheostomy also had increased OR-related charges. MD group patients typically received 3 operations: distractor application and removal, with simulta- neous microlaryngscopy/bronchoscopy, with a few requiring a distractor adjustment operation. Trach and Trach 1 MD group patients required their initial tracheostomy, often a gas- trostomy with Nissen fundoplication, and serial ML&B pro- cedures for airway maintenance and evaluation in preparation for decannulation, with a net greater cost to the patient over the MD group. We also observed increased clinic and ER visits for respiratory disease in Trach patients, as reported. 27 In years 2 and 3 following intervention, patients in the MD group averaged only $1000 per year in charges, which largely came from 2 patients who had persistent airway obstruction despite MD, necessitating tracheostomy. Our study is the first cost analysis to examine patients treated with tracheostomy and subsequent MD. Early in our study, MD was performed for some patients with severe PRS initially treated with tracheostomy, anticipating difficulty in decannulation due to severity of their micrognathia. As reported, 29 we observed a higher decannulation rate in patients receiving subsequent MD. Given this, our airway team now often recommends MD for neonates with PRS treated initially with tracheostomy, including those transferred from other hos- pitals or those receiving ex utero intrapartum (EXIT to airway) treatment. When considering a Trach 1 MD approach, it is important to consider possible additional costs. Not surpris- ingly, we found that Trach 1 MD patients had greater lengths of hospital stay and OR charges. However, these patients had lower costs compared to the Trach only group within the first year largely because of lower hospital-related charges. As shown in Table 2 , the median age at first surgery in the tra- cheostomy only patients is 16 days, whereas those in the Trach 1 MD group had a median age of 3 days at time of tra- cheostomy. This translates into a nearly 2-week longer stay in the ICU for the Trach only group. Over a 3-year period,

67