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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,
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
Otolaryngology–Head and Neck Surgery 151(5)
67