Candidate's Thesis: Laryngotracheal separation in neurologically impaired children: long-term results
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1Division of Pediatric Otolaryngology, Alfred I duPont Hospital for Children, Nemours Children's Clinic, Wilmington, DE 19803, USA. scook@nemours.org
Insights
Laryngotracheal separation (LTS) effectively controls aspiration in neurologically impaired children, improving survival and reducing hospitalizations. This procedure also lowers healthcare costs by decreasing Diagnosis Related Groups (DRGs) and work relative value units (wRVUs).
Area of Science:
- Pediatric Surgery
- Otolaryngology
- Pediatric Pulmonology
Background:
- Recurrent aspiration in neurologically impaired children poses significant health risks, including frequent pneumonias and hospitalizations.
- Laryngotracheal separation (LTS) is a surgical intervention considered for managing intractable aspiration in this vulnerable population.
- Evaluating the efficacy, complications, and healthcare economic impact of LTS is crucial for informed clinical decision-making.
Purpose of the Study:
- To review patient demographics, surgical indications, and comorbidities in pediatric patients undergoing LTS for aspiration.
- To report on the early and late complications, survivorship, and hospital admission rates for pneumonia post-LTS.
- To assess the potential healthcare economic benefits by measuring Diagnosis Related Groups (DRGs) and work relative value units (wRVUs) before and after LTS.
Main Methods:
- Retrospective chart review of 56 neurologically impaired pediatric patients who underwent LTS over an 18-year period.
- Data collection included patient demographics, indications, comorbidities, complications, survival data, and hospitalization metrics.
- Analysis involved chi-square tests, two-tailed t-tests, and Fisher's Exact tests to evaluate statistical significance.
Main Results:
- Laryngotracheal separation (LTS) completely controlled aspiration in all 56 pediatric patients.
- A significant reduction in hospital admissions for pneumonia was observed post-surgery.
- Post-LTS, there was a statistically significant decrease in average monthly DRGs and wRVUs, indicating reduced healthcare utilization and costs. Transient fistula formation (11%) was the most common complication, with no reversals reported.
Conclusions:
- Laryngotracheal separation (LTS) is a highly effective procedure (100% efficacy) for managing intractable aspiration in neurologically impaired children, prolonging life.
- LTS leads to a significant reduction in healthcare costs, evidenced by decreased DRGs and wRVUs.
- Thorough discussion of all medical and surgical options, considering the child's neurological status and prognosis, is essential before considering LTS.
Objectives:
Fifty-six consecutive neurologically impaired pediatric children underwent laryngotracheal separation (LTS) for acute recurrent and chronic aspiration in the last 18 years. The population demographics, indications for surgery, and comorbidities are reviewed. This study reports early and late complications and survivorship including admissions for pneumonia/aspiration. Diagnosis related group (DRGs) and work relative value units (wRVUs) were measured to document the potential benefits before and after LTS.
Study Design:
Retrospective review of patient charts and records in an electronic medical record during an 18 year period.
Methods:
Information was obtained by a chart review and utilization of the electronic medical record. Patient specific DRG and wRVU data on their hospitalizations and outpatient encounters at the Alfred I. duPont Hospital for Children of the Nemours Foundation and survival data were recorded. Data was analyzed using chi-square analysis, a two-tailed t test, and a Fisher's Exact test.
Results:
Laryngotracheal separation achieved complete control of aspiration in all the children. A significant reduction in the number of hospital admissions for pneumonias after surgery was noted. After LTS there was a reduced average number of DRGs per month (p < .001) as well as wRVUs. Transient fistula formation (11%) was the most common complication. No patient had his or her procedure reversed to date.
Conclusion:
Laryngotracheal separation is 100% effective in controlling aspiration in all of neurologically impaired children in this study, It is a valuable procedure to prolong the life of children who have intractable aspiration. After LTS, a decrease in DRGs and wRVUs reduces health care costs for these patients. Prior to LTS, all medical and surgical treatment options for aspiration should be discussed and considered, based on the extent of the child's underlying neurologic status, ability to verbally communicate, degree of upper airway obstruction, and hope of recovery of neurologic function.
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