What Should an Aerodigestive Program Look Like

A recent “consensus statement” publication (Boesch RP, et al. Pediatrics 2018; 141: e20171701) discusses the structure and functions of an aerodigestive program. Congratulations to Dr. Ben Gold –one of my partners and a coauthor.

Overall this is a useful document and a good starting point to establish what an aerodigestive program should look like.

  • Table 1 lists common conditions addressed by aerodigestive programs like chronic cough, Gtube dependence, failure to thrive, TEF/esophageal atresia, recurrent infections, craniofacial anomalices, tracheostomy dependence, vocal cord dysfunction, stridor and wheezing.
  • Table 2 lists important team members.
  • Table 3 establishes important functions like care coordination, combined endoscopy, and summary of recommendations.
  • Table 4, 5, and 6 summarizes procedural skills needed by pulmonology, gastroenterology, and ENT respectively.

The accepted definition of an aerodigestive disorder: “A pediatric aerodigestive patient is a child with a combination of multiple and interrelated congenital and/or acquired conditions affecting airway, breathing, feeding, swallowing, or growth that require a coordinated interdisciplinary diagnostic and therapeutic approach to achieve optimal outcomes.”

  • The authors were split on whether the care needs to be provided by all providers in the same space or whether coordination can occur with separate physician locations.
  • The authors argue that coordinated care is valuable, citing care in children with cystic fibrosis and inflammatory bowel disease (via ImproveCareNow).
  • They note the major limitation is that their recommendations are based on expert opinion.

My take: My main concerns with multidisciplinary care, having participated in a number of multidisciplinary teams, are the following:

  1. There is a lot of redundancy in care with these clinics.  Often, these clinics result in a patient having two GIs, two pulmonologists, and two ENTs. If the aerodigestive team is useful, the aerodigestive expertise needs to be substantially greater than the expertise of their colleagues.  If it is simply a matter of care coordination, this is a deficiency that could be corrected in the absence of a multidisciplinary team.
  2. Many patients do not need all of the multidisciplinary team members. This increases costs unnecessarily.
  3. The potential promise of care coordination is sometimes offset by the extremely lengthy visits at multidisciplinary visits.

So in my view, the key for aerodigestive clinic success is to identify a narrow population of children with high-complexity problems and to identify subspecialists with exceptional abilities.  As an aside, the study states that Cincinnati was the first location to establish a pediatric aerodigestive clinic.  The success there was in large part due to Dr. Colin Rudolph (GI) and Dr. Robin Cotton (ENT), both recognized leaders and innovators in their fields.

Tunnels and hallways inside Hoover Dam

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