Aerodigestive clinic may curb hospital stays in kids with special healthcare needs

Last Updated: 2017-10-11

By David Douglas

NEW YORK (Reuters Health) - Enrolling children with aerodigestive disorders in a pediatric multidisciplinary clinic appears to shorten associated hospital stays by almost a week per year, according to a retrospective study.

In an October 5 online article in JAMA Otolaryngology - Head and Neck Surgery, Dr. Swathi Appachi and colleagues at the Cleveland Clinic, in Ohio, note that children with special healthcare needs may prompt expenditures up to threefold higher than those without such needs, with much of the cost attributable to acute inpatient care.

To study whether coordinated, multidisciplinary care helps to limit inpatient admissions and overall hospital stays in the needier population, the team reviewed aerodigestive clinic records for 113 patients up to 20 years old (52% age 5 or younger).

All of the patients had aerodigestive disorders, and during the study period more than half had a tracheostomy and more than 80% had a gastrostomy tube placed. The majority had multiple comorbidities, most often cerebral palsy (28%) and extreme prematurity (18%).

The aerodigestive clinic offered care by specialists in pediatric otolaryngology, gastroenterology, pulmonology, physical medicine, rehabilitation, and others. Individual health plans involving coordinated follow-up and procedures were developed and passed on to families and community-based primary care physicians.

Analysis of 967 hospital admissions, beginning in 1995 (before the clinic was established) and continuing through 2009 to 2014 (after it was opened), showed no significant difference in the total number of admissions between these periods.

However, after patients were being enrolled in the clinic, median inpatient days per year dropped significantly - by 4.1 days. For aerodigestive admissions alone, the corresponding reduction was 6.8 days, equivalent to a 70% cut in technical direct cost.

Using an average daily technical direct cost of $2,502 for a nonprofit hospital in Ohio, the researchers observed that the drop in aerodigestive admissions "equals an extrapolated reduction of $1.9 million per year in hospital costs."

The authors acknowledge that their study lacked a true control group and that "as children mature, they may experience natural improvement in their condition and recovery times." They also concede the "measurable start-up and maintenance costs of an ambulatory specialty clinic."

Nevertheless, they conclude that "once established, the reduction in hospital length of stay as seen with enrollment in our clinic leads to decreased system costs."

Pediatrician Dr. Eyal Cohen, of the University of Toronto, told Reuters Health by email, "Aerodigestive problems are very common in children with special healthcare needs like children with cerebral palsy, and efforts to better coordinate this challenging clinical issue across multiple subspecialists, such as those noted in this article, are promising."

However, Dr. Cohen whose professional interests include children with medical complexity - but who was not involved in the current study - also noted that given the lack of a comparison group, "it is impossible to determine if the changes described would have occurred without this model of care; additional information on other clinical outcomes beyond hospital use, including the experiences of the families themselves, would have been beneficial."

Dr. Ricardo. A. Mosquera, an associate professor of pediatrics affiliated with the University of Texas Health Science Center, Houston, agrees that a multidisciplinary aerodigestive clinic could improve outcomes. But he also noted, by email, that the comparisons in the study are "problematic." He asked, "How do we know that the intervention really decreases days, when other factors may have an impact (on) length of stay?" In addition, he highlighted that "primary care physicians were not involved in this aerodigestive clinic."

Dr. Appachi did not respond to requests for comment.

SOURCE: http://bit.ly/2fXRY9l

JAMA Otolaryngol Head Neck Surg 2017.