McCormick ME, Fissenden TM, Chun RH, Lander L, Shah RK. Resource Utilization and National Demographics of Laryngotracheal Trauma in Children. JAMA Otolaryngol Head Neck Surg. 2014;140(9):829-832. doi:10.1001/jamaoto.2014.1410
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Pediatric laryngotracheal trauma is rare but can carry considerable morbidity and health care resource expenditure. However, the true cost of these injuries has not been thoroughly investigated.
To use a national administrative pediatric database to identify normative data on pediatric laryngotracheal trauma, specifically with regard to cost and resource utilization.
Design and Participants
Retrospective medical record review using the Kids’ Inpatient Database (KID) 2009. Inclusion criteria were admissions with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for fractures or open wounds of the larynx and trachea.
Main Outcomes and Measures
Among many data analyzed were demographic information and admission characteristics, including length of stay, diagnoses, procedures performed, and total charges.
There were 106 admissions that met inclusion criteria. Patient mean (SE) age was 15.9 (0.45) years, and 79% were males. The mean (SE) length of stay (LOS) was 8.4 (1.1) days; more than 50% of patients had a LOS longer than 4 days. The mean number of diagnoses per patient was 6.9 (0.6); other traumatic injuries included pneumothorax (n = 18). More than 75% of patients underwent more than 2 procedures during their admission; 60.2% underwent a major operative procedure. The most common procedures performed were laryngoscopy (n = 54) and operative repair of the larynx and/or trachea (n = 32). Tracheostomy was performed in only 30 patients. The mean (SE) total charge was $90 879 ($11 419), and one-third of patients had total charges more than $100 000.
Conclusions and Relevance
Pediatric laryngotracheal trauma remains a relatively rare clinical entity. These injuries primarily affect older children and are associated with long hospitalizations, multiple procedures, and high resource utilization.
Anterior cervical trauma, specifically laryngotracheal injury, is a rare occurrence in the pediatric population.1,2 An analysis of pediatric laryngeal trauma utilizing the National Trauma Data Bank (NTDB) cited 633 laryngeal injuries from 2002 through 2006; of these, only 69 were in pediatric patients.2 The relative infrequency of pediatric neck trauma is attributed mainly to differences in anatomy between the adult and pediatric airway. Specifically, the pediatric larynx is relatively protected by its anterior-superior position, the greater elasticity of its cartilaginous structures, as well as a shorter neck.3
Despite its infrequency, pediatric anterior neck trauma poses considerable clinical challenges and can have clinically significant morbidity. Patients may sustain concurrent injuries to the head or thorax or other structures in the neck, such as the cervical spine, cranial nerves, or major blood vessels. From an otolaryngologic perspective, these patients demand immediate evaluation with appropriate diagnostic imaging and endoscopy. Patients may require nonsurgical or surgical treatment and many patients must be monitored in a critical care setting for intensive airway observation and/or postoperative care.
Administrative databases are valuable in their ability to rapidly analyze broad ranges of data on a macrolevel. This allows the researcher to both identify normative data for a specific disease state and describe national trends in patient demographics, health care costs and utilization, and outcomes.4 Because of the rarity of pediatric laryngotracheal trauma, macroanalysis using a large national database can provide insight into the impact of these injuries and may demonstrate trends that are otherwise not obvious.
The current study did not require institutional review board approval because a publicly available database was used. All data were accessed through the Kids’ Inpatient Database (KID) 2009. The KID 2009 was constructed by the Agency for Healthcare Research and Quality as a component of the Healthcare Resource Utilization Project (HCUP). The KID 2009 is the only all-payer data set to look exclusively at children’s (patients <21 years) utilization of hospital resources. This is accomplished by analyzing inpatient records and hospital information to identify data that can be used to demonstrate national trends in health care utilization and outcomes. The KID 2009 contains data on more than 3.4 million discharges from 4121 community nonrehabilitation hospitals in 44 states.5
The KID 2009 uses International Classifications of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis and procedure codes to track admissions, procedures, and resource utilization. A search was carried out within the database for ICD-9-CM codes listing for fractures and/or open wounds of the larynx and trachea with and without complications. Primary queried diagnoses included closed fracture of larynx and trachea (ICD-9-CM code 807.5), open wound of larynx with and without complications (codes 874.11, 874.01), open wound of the larynx and trachea with and without complications (codes 874.10, 874.00), and open fracture of the larynx and trachea (code 807.6).
Demographic data, hospital data, and admissions data were collected and analyzed, including procedures and total charges. Data were also collected on concurrent diagnoses and procedures performed during admission. Weighted data were analyzed and reported in accordance with the KID 2009 Data Use Agreement, which forbids reporting of data with numbers of less than 10.5
There were 106 patients admitted in 2009 with the selected codes for laryngotracheal trauma. The demographics and admission data can be found in Table 1 and Table 2. The mean age was 15.9 years, and 79% were male. The most common race was white (47 patients [44.3%]). Forty-seven patients (44.3%) were from the lowest socioeconomic quartile according to median household income by zip code. Most admissions were at large teaching hospitals (80.6%), and most hospitals (55.4%) were primarily nonpediatric when considering the percentage of pediatric discharges.
The mean (SE) total charges per admission were $90 879 ($11 419), with one-third of the cohort having charges totaling greater than $100 000. The average length of stay (LOS) was 8.4 (1.1) days. Medicaid was the payer for 37 patients (35.3%), although the most common payer was private insurance, including health maintenance organizations at 47 (44.3%).
The mean (SE) number of diagnoses per patient was 6.9 (0.6). Table 3 details the breakdown of primary and associated diagnoses. The most common primary diagnoses were closed fracture of larynx and trachea (53 [49.8%]) and open wound of larynx without complication (23 [22.1%]). The most common secondary diagnosis was “Other diseases of respiratory system” (36 [34.0%]), which included diagnoses such as pulmonary collapse, interstitial emphysema, pulmonary insufficiency following trauma and surgery, and acute respiratory failure. Eighteen patients had a diagnosis of pneumothorax.
The mean (SE) number of procedures per patient was 4.8 (0.5), and 64 patients (60.2%) underwent a major operative procedure during their hospitalization. Table 4 shows the most common procedures performed in these patients: laryngoscopy and other tracheoscopy (54 [50.9%]), operative repair of the larynx and/or trachea (32 [30.2%]), and tracheostomy (30 [28.3%]). Thirty-seven patients required mechanical ventilation, 16 of which for more than 96 hours. Notably, more than 75% of patients had at least 2 procedures performed during their hospitalization.
The KID has been used to study national trends in various otolaryngologic disease states, such as subglottic stenosis and methicillin-resistant Staphylococcus aureus cervical infections.6,7 With regard to pediatric laryngeal trauma, to our knowledge, there has been only 1 prior study that utilized an administrative database for the purposes of analyzing trends on a national level.2 That study examined demographic and hospital data of all-cause pediatric laryngeal trauma utilizing the National Trauma Data Bank. The purpose of their analysis was to investigate the surgical treatment and outcomes related to laryngeal trauma in children. To our knowledge, the present study is the first to specifically examine the impact that pediatric laryngotracheal trauma has on health care resource utilization.
The relative scarcity of pediatric laryngotracheal trauma is one characteristic that has remained constant over the past several decades.8- 12 However, the mechanism of injury has been changing over this period. While older studies have identified bicycles8 and minibikes13 as major causes of laryngotracheal trauma, a recent study12 has found that motor vehicles are responsible for most of these injuries in today’s society. Interestingly, the present study identified transportation-related mechanisms (motor vehicle accidents, bicycles) as the etiology for only 18.7% of the injuries in this national data set.
It has been demonstrated before that, while rare, laryngotracheal injuries can require considerable hospital and operative resources.2,10,11 One study from the Children’s Hospital of Pittsburgh found that either tracheostomy or open repair was needed in 4 of 6 major laryngotracheal injuries. All major injuries in that series required at least operative endoscopy.10 Another case series described the evaluation and management of 5 children who sustained laryngeal trauma. They also demonstrated that most patients required more than 1 procedure: 5 of 5 underwent direct laryngoscopy, 4 of 5 required open repair, and 3 of 5 needed tracheostomy tube placement. The average hospitalization in that study was more than 12 days, and only the patient who did not require open repair was discharged in less than a week.11 Analysis of the NTDB showed both a high percentage of multiorgan system involvement in patients with laryngeal injuries and also an increase in the LOS for those patients who underwent repair of laryngeal fractures.2
The present study also demonstrates significant comorbidity and resource utilization in pediatric laryngotracheal trauma, with a mean diagnoses of 6.9 and a mean LOS of 8.4 days. Sixty percent of patients required a major operative procedure, and the mean number of procedures was 4.8. Thirty percent of the study population underwent operative repair of their laryngeal injuries, including repair of laryngeal fractures and suturing of lacerations. Unfortunately, our KID 2009 data set did not allow us to analyze the impact of operative repair on LOS.
Because airway is typically the first priority in any patient with a laryngotracheal injury, especially in children, there is usually a low threshold to secure an airway at initial presentation. With clinically significant trauma to the airway, tracheostomy can sometimes be the safest and quickest option. Analysis of the KID 2009 suggests that this is necessary in less than a third of children with these injuries.
Limitations of the current study include those inherent to any large database study. The information held within any database is dependent on its own criteria for data acquisition, the sources of that data, as well as the data user agreements that it has with its users. Individual admission records cannot be reviewed and compared, and some data sets had numbers of less than 10 and were unsuitable for analysis.
Pediatric laryngotracheal trauma remains a rare problem encountered in our nation’s hospitals. This fact has led to a paucity of quality studies on the topic in the existing literature, and there are no guidelines or standards for evaluation and management as yet. These injuries can indeed be life threatening, and they still carry potential for serious morbidity. As a result, they can bring considerable burden to our health care system. Interestingly, tracheostomy is needed in less than a third of these patients. Future investigation into identifying effective and efficient triage and treatment algorithms, therefore, may help to decrease mounting expenditures in the system through the appropriate allocation of valuable hospital resources.
Submitted for Publication: April 15, 2014; final revision received June 2, 2014; accepted June 17, 2014.
Corresponding Author: Michael E. McCormick, MD, Division of Pediatric Otolaryngology, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin and Children’s Hospital of Wisconsin, 9000 W Wisconsin Ave, Ste 540, Milwaukee, WI 53226 (firstname.lastname@example.org).
Published Online: August 7, 2014. doi:10.1001/jamaoto.2014.1410.
Author Contributions: Dr McCormick had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: McCormick, Chun, Shah.
Acquisition, analysis, or interpretation of data: McCormick, Fissenden, Lander.
Drafting of the manuscript: McCormick, Fissenden, Chun, Shah.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: McCormick, Fissenden, Lander.
Administrative, technical, or material support: Shah.
Study supervision: Chun, Shah.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This study was presented at the Society for Ear, Nose, & Throat Advances in Children Annual Meeting; December 7, 2013; Long Beach, California.