Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.

Racial Disparities in Pediatric Endoscopic Sinus Surgery.

OBJECTIVE: To determine the impact of race and ethnicity on 30-day complications following pediatric endoscopic sinus surgery (ESS). STUDY DESIGN: Cross-sectional cohort study. SUBJECTS AND METHODS: Patients ≤ 18 years of age undergoing ESS from 2015 to 2017 were identified in the Pediatric National Surgical Improvement Program-Pediatric database. Patient demographics, comorbidities, surgical indication, and postoperative complications were extracted. Patient race/ethnicity included non-Hispanic black, non-Hispanic white, Hispanic, and other. Multivariable logistic regression was performed to determine if race/ethnicity was a predictor of postoperative complications after ESS. RESULTS: A total of 4,337 patients were included in the study. The median age was 10.9 (interquartile range: 14.5-6.7) years. The cohort was comprised of 68.3% non-Hispanic white, 13.9% non-Hispanic black, 9.7% Hispanic, and 2.1% other. The 30-day complication rate was 3.2%, and the mortality rate was 0.3%. The rate of reoperation was 3.8%, and readmission was 4.1%. Black and Hispanic patients had higher rates of urgent operations (P = .003 and P < .001, respectively), and black patients had a higher incidence of emergent operations (P < .001) compared to their white peers. For elective ESS cases, multivariable analysis adjusting for sex, age, comorbidities, and surgical indication indicated that children of Hispanic ethnicity had increased postoperative complications (odds ratio: 1.57, 95% confidence interval: 1.04-2.37). CONCLUSION: This analysis demonstrated that black and Hispanic children disproportionately undergo more urgent and emergent ESS. Hispanic ethnicity was associated with increased 30-day complications following elective pediatric ESS. Further studies are needed to elucidate potential causes of these disparities and identify areas for improvement. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E1369-E1374, 2021.

Insurance type impacts bronchoscopy for foreign body aspiration: An analysis of the Kids' Inpatient Database.

OBJECTIVES: To ascertain whether insurance type is associated with postoperative adverse effects and hospital length of stay for inpatient airway foreign body removal. METHODS: Retrospective analysis of children <18 years of age that underwent inpatient bronchoscopy with removal of airway foreign body in the national Healthcare Cost and Utilization Project Kid's Inpatient Database (KID). Postoperative outcomes and length of stay were analyzed for racial disparities and insurance type using multivariable logistic regression and negative binomial regression. Models adjusted for race, insurance type, sex, age, and presence of pulmonary risk factors. RESULTS: A total of 5,850 children underwent bronchoscopy for foreign body removal. The median age was 2 (IQR: 4-1) years and 61.6% patients were male. Payer status included Medicaid (38.9%), private insurance (51.5%), self-pay (4.3%) and other (9.6%). The Medicaid cohort had a higher proportion of black (19.1%) and Hispanic patients (34.5%) (P < 0.001). Children covered under Medicaid had higher odds of postoperative complications (odds ratio [OR] 1.216; P = 0.031) and a greater length of stay (OR 1.533; P < 0.001) relative to the private insurance group when adjusting for sex, age, race and presence of pulmonary risk factors. The odds of having a greater length of stay was 33% higher for black (P < 0.001) and 37% higher for Hispanic (P < 0.001) children compared to white children. The average adjusted LOS under Medicaid was 8.37 days compared to 5.46 days for privately insured children. CONCLUSION: This study demonstrated that a difference in postoperative complications and LOS exist between public and privately insured children for foreign body removal via bronchoscopy. Further studies are warranted to investigate factors that drive these disparities.

Outcomes Assessment of Multi-Level Sleep Surgery in Syndromic Versus Non-Syndromic Children.

OBJECTIVES: Analyze the differences in length of stay, cost, disposition, and demographics between syndromic and non-syndromic children undergoing multi-level sleep surgery. METHODS: Children with sleep disordered breathing or obstructive sleep apnea that had undergone sleep surgeries were isolated from the 1997 to 2012 editions of the Kids' Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Children were then classified as syndromic or non-syndromic and stratified by level of sleep surgery (tonsillectomy & adenoidectomy, tonsillectomy & adenoidectomy plus other site surgery, other site surgery). Length of stay and cost were reported with Kruskal-Wallis one-way analysis of variance, disposition with binomial logistic regression, and demographics with chi-square. RESULTS: Syndromic children compared to non-syndromic children were more likely to have surgery beyond just tonsillectomy & adenoidectomy and also had a longer length of stay, higher total cost and non-routine disposition (all P < .001). Syndromic children undergoing tonsillectomy and adenoidectomy plus other site surgery had a longer length of stay compared to syndromic children undergoing tonsillectomy & adenoidectomy (6.00 days vs 3.63 days, P < .001). However, no similar statistically significant difference in length of stay was found in non-syndromic children (2.01 days vs 2.87 days, P > .05). CONCLUSION: The potential risks/benefits need to be weighed carefully before undertaking sleep surgery in syndromic children. They experience a longer length of stay, higher cost, and non-routine disposition when compared to non-syndromic children. This is especially true when considering the transition from tonsillectomy & adenoidectomy to tonsillectomy & adenoidectomy plus other site surgery, as syndromic children experience a longer length of stay and non-syndromic children do not.

Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric tracheotomy. STUDY DESIGN: Blinded, modified, Delphi consensus process. METHODS: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items. RESULTS: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus. CONCLUSIONS: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure. LEVEL OF EVIDENCE: 5 Laryngoscope, 130:2700-2707, 2020.

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

INTRODUCTION: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

Blood transfusion in children with sickle cell disease undergoing tonsillectomy.

INTRODUCTION: Tonsillectomy is the second most common surgery in children with sickle cell disease. These children are at an increased risk of perioperative complications due to vaso-occlusive events. Although controversial, preoperative blood transfusions are sometimes given in an effort to prevent such complications. The purpose of this study is to analyze trends in the use of blood transfusion for management of children with sickle cell disease (SCD) undergoing tonsillectomy in a national database. METHODS: Patients in the 1997-2012 KID with a primary procedure matching the ICD-9 procedure code for tonsillectomy (28.2-28.3) and diagnosis code for SCD (282.60-282.69) were examined. Patients were split into groups by blood transfusion status and compared across variables including complication rate, length of stay (LOS), and hospital charges. Statistical analysis included chi-square test for trend, Mann-Whitney U test, and independent t-test. RESULTS: 1133 patients with SCD underwent tonsillectomy. There was a strong positive correlation between increasing chronologic year and the proportion of patients receiving blood transfusions, 47 (30.1%) in 1997 to 78 (42.5%) in 2012 (r = 0.94, p = 0.005). During this period, there was no significant change in the rate of complications (r = -0.1, p = 0.87). Overall, patients receiving blood transfusion had a longer mean LOS (3.1 ± 2.4 days vs. 2.5 ± 2.2 days, p < 0.005) and higher mean charge ($17,318 ± 13,191 vs. $13,532 ± 12,124, p < 0.005) compared to patients who did not receive blood transfusion. The rate of complications in the transfusion group, 18 of 352(5.1%), was not significantly different (p = 0.48) from the group without transfusion, 40 of 626 (6.4%). CONCLUSIONS: From 1997 to 2012, there was a significant increase in the proportion of patients with SCD receiving perioperative blood transfusions for tonsillectomy. While the frequency of transfusion rose, those who received a transfusion had similar complication rates with increased charges and length of hospital stays compared to those who did not receive a transfusion.

Assessment of weight gain following adenotonsillectomy in children with Down syndrome.

INTRODUCTION: Adenotonsillectomy (T&A) has been associated with postoperative weight gain in children. The purpose of this study is to determine whether a similar association exists in children with Down syndrome (DS). METHODS: The medical records of 311 DS patients were reviewed. Subjects were classified into either a control group or surgical group based on whether they had undergone adenotonsillectomy (T&A). Subjects were excluded if they only had one recorded BMI. Cases were analyzed in a pairwise fashion to maximize available data. 113 total patients with DS were identified: 84 (74.3%) in the control group and 29 (25.7%) in the T&A group. Height, weight, BMI, and Z-score data were compared between the control and T&A groups at 6-month intervals over a 24-month period. RESULTS: Children with DS who underwent T&A were comparable by demographics to children with DS who did not undergo T&A. Mean weight gain at 24 months for the T&A group was 8.07 ± 5.66 kg compared with 5.76 ± 13.20 kg in controls. The median Z-score at 24 months for the T&A group was 1.11 (0.10-1.88) compared with 1.17 (0.80-1.75) in controls. Children undergoing T&A had a stable median Z-score change of 0.09 at 24 months (p = 0.861, compared to baseline) while children who did not undergo T&A had a significantly increased median Z-score of 0.52 (p = 0.035, compared to baseline). Despite this, there were no significant intergroup differences between weight change, BMI, nor Z-score at any interval (p > 0.05). CONCLUSIONS AND RELEVANCE: Children with DS did not have an increased rate of weight gain or increased BMI after T&A. BMI Z-scores were shown to stabilize over 24 months in the T&A group and increase in the control group. While this suggests that T&A provides an added benefit of weight control in patients with DS, the results should be interpreted with caution due to the small sample size and the fact that not all patients had complete follow up across a 24-month period.

Health Care Resource Use in Patients With and Without 22q11.2 Deletion Syndrome Undergoing Sphincter Pharyngoplasty for Velopharyngeal Insufficiency.

Importance: The use of health care resources in patients with velopharyngeal insufficiency undergoing sphincter pharyngoplasty is unknown. Objectives: To examine the use of health care resources by patients with velopharyngeal insufficiency who have undergone sphincter pharyngoplasty and investigate whether patients with 22q11.2 deletion syndrome (22qDS) had a longer length of stay, increased cost of admission, and higher number of complications. Design, Setting, and Participants: Using data from the Kids' Inpatient Database for January 1 to December 31, 2012, we retrospectively analyzed all patients undergoing pharyngoplasty for velopharyngeal insufficiency. In addition, patients were analyzed according to whether or not they had 22qDS. Data were analyzed from January 1 to December 31, 2012. Main Outcomes and Measures: Total cost of admission, length of stay, number of procedures, and number of complications. Results: There were 687 patients: 90 with 22qDS (mean [SD] age, 6.4 [2.7] years; 43 males and 47 females) and 597 without 22qDS (mean [SD] age, 7.5 [4.1] years; 326 males and 271 females). In both groups, patients were predominantly white, had private insurance, were treated in a children's hospital, and were from either the West or Midwest. The median length of stay (2.0 [interquartile range (IQR), 1.0-3.9] vs 1.0 [IQR, 1.0-2.0] days; 95% CI, 1.0-2.0) and total cost of admission ($9269.24 [IQR, $6800.65-$13 189.25] vs $6936.95 [IQR, $5036.71-$9054.98]; 95% CI, $6791.83-$7542.47) were higher for the group with 22qDS than those without 22qDS, while there was no significant difference in the number of procedures performed. In addition, the median number of diagnoses (5.0 [IQR, 3.0-9.0] vs 3.0 [IQR, 2.0-5.0]; 95% CI, 3.0-4.0) and number of chronic conditions (3.0 [IQR, 2.0-5.0] vs 2.0 [IQR, 1.0-2.0]; 95% CI, 2.0-2.0) were higher for the group with 22qDS than those without 22qDS. Furthermore, results of a multiple regression model showed that 22qDS was positively associated with both length of stay (B = 0.92; 95% CI, 0.59-1.24) and total cost (B = $3458.78; 95% CI, $2051.09-$4866.46). Conclusions and Relevance: This study demonstrates that patients with 22qDS undergoing sphincter pharyngoplasty for velopharyngeal insufficiency have more complex medical conditions and require more health care resources than patients without 22qDS.

Cost-effective airway cultures in the cystic fibrosis patient.

BACKGROUND: Cystic fibrosis (CF) patients have a high incidence of multidrug-resistant infections, rendering CF patients a treatment challenge. OBJECTIVE: To evaluate culture protocols for CF patients and develop a cost-effective culture regimen that identifies clinically relevant pathogens. STUDY DESIGN: Retrospective review. METHODS: At the time of endoscopic sinus surgery, CF patients underwent both sinus and bronchial lavage cultures. Medical records from 2002 to 2006 were reviewed. RESULTS: Twenty-four cases were identified; 12 had complete sets of cultures. Seven of 12 had sinus aerobic bacteria that were also present in bronchial culture. Anaerobic cultures from both sites were all negative (42%) or nondiagnostic (58%). Thirty-three percent of sinus fungal cultures and 91.6% of bronchial fungal cultures were positive. Sinus acid fast bacillus cultures were all negative. CONCLUSION: CF culture protocols may be streamlined by eliminating all anaerobic cultures, as well as sinus acid fast bacillus and fungal cultures for a 52% reduction in cost.