Impact on Patient Care of a Multidisciplinary Center Specializing in Colorectal and Pelvic Reconstruction

Is Collaborative Care the Future of Medicine? Lessons Learned from the Care of Children with Colorectal Conditions

The treatment of patients with colorectal disorders requires care from a wide variety of medical and surgical specialties over the course of their lifetime. This is ideally handled by a collaborative center which facilitates the assessment and development of patient care among multiple specialties which can enhance the quality and implementation of treatment plans, improve communication among different specialties, decrease morbidity, and improve patient satisfaction and outcomes. This collaborative approach can serve as a model for other parts of medicine requiring a similar multi-disciplinary and integrated method of care delivery. We describe the process, as well as the lessons learned in developing such a program.

Pediatric Bowel Management Options and Organizational Aspects

A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.

Patient driven change: Is collaborative care the future of medicine? Lessons learned from the care of children with colorectal problems

A basic premise in the care of complex patients is that experience, increased volume of cases, and an integrated, multi-disciplinary approach yields improved outcomes. Is this true using the example of the care of children with colorectal and pelvic reconstructive needs? This review gives a brief historical context on how care for this patient group evolved, delineates the key elements to create a collaborative care model, and describes multiple advances that have been developed, based on the model, which have improved patient care and quality of life. LEVEL OF EVIDENCE: Review.

Hirschsprung disease outcomes

Hirschsprung disease (HD) is a complex surgical and medical problem that appears to have varied health and social outcomes with the age and neurodevelopmental state of patients. In general, long-term outcomes are thought to be good for the majority of patients despite recognized problems with constipation and/or fecal incontinence. However, there are no universally accepted pathways regarding post-operative bowel management programs nor clearly defined follow-up pathways making the current outcome measures difficult to interpret. Further, other factors that may influence outcome including age at the time of procedure and procedure type continue to lack consensus. Improved support of children in resource limited environments and during periods of transition into the adult medical care environment are needed to improve outcome.  Recent proliferation of multidisciplinary care teams and consortia may help to better understand outcomes and address current knowledge gaps. Continuing these collaborations will be imperative to continuing improvements in care which may ultimately impact outcome.

Healthcare Burden and Cost in Children with Anorectal Malformation During the First 5 Years of Life

OBJECTIVE

To identify cumulative 5-year healthcare costs and healthcare days in children with anorectal malformation (ARM) and to compare the cumulative 5-year healthcare costs and healthcare days in children with ARM with 3 control cohorts: healthy, premature, and congenital heart disease (CHD).

STUDY DESIGN

We performed a retrospective case-control study using the Truven MarketScan database of commercial claims encounters between 2008 and 2017. The ARM, CHD, and premature cohorts were identified using a targeted list of International Classification of Diseases 9th or 10th Revision diagnosis and Current Procedural Terminology codes. The healthy cohort included patients without ARM, preterm birth, or CHD.

RESULTS

We identified 664 children with ARM, 3356 children with heart disease, 63 190 children who were born preterm, and 2947 healthy patients. At 5 years, the total healthcare costs of children with ARM ($273K, 95% CI $168K-$378K) were similar to the premature cohort ($246K, 95% CI $237K-$255K) and lower than the CHD cohort ($466K, 95% CI $401K-$530K, P < .001). Total healthcare days were similar in children with ARM (158 days, 95% CI 117-198) and prematurity (141 days, 95% CI 137-144) but lower than CHD (223 days, 95% CI 197-250, P = .02). In ARM, outpatient care (126 days, 95% CI 93-159) represented the largest contribution to total healthcare days.

CONCLUSIONS

Children with ARM accumulate similar healthcare costs to children with prematurity and comparable healthcare days to children with CHD and prematurity in the first 5 years of life. Outpatient care represents the majority of healthcare days in children with ARM, identifying this as a target for quality improvement and demonstrating the long-term impact of this condition.

Outpatient Botulinum Injections for Early Obstructive Symptoms in Patients with Hirschsprung Disease

INTRODUCTION

Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC.

METHODS

A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 - July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections.

RESULTS

Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P < 0.001), with no patient developing more than one HAEC episode.

CONCLUSION

Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.

Leveraging Collaboration in Pediatric Multidisciplinary Colorectal Care Using a Telehealth Platform

PURPOSE

Pediatric colorectal problems often require complex multidisciplinary care (MDC), which has been affected by the SARS-CoV-2-2019 (COVID-19) pandemic. We describe our utilization and implementation of telehealth (TH) for pediatric colorectal surgery MDC visits and collate patient satisfaction using TH compared to in-person (IP) visits.

METHODS

Implementation of a single-institution MDC TH platform to perform patient visits on February 1, 2020 was studied. Following 6 months of implementation, TH visits' characteristics were compared with IP visits in the 3 months before implementation by patient volume, length of clinic visits, and patient satisfaction survey results.

RESULTS

Before implementation, 152 (100%) of clinic visits were IP. During the implementation, 87 (37.7%) were TH visits. Seventy-four (49%) were MDC visits, 17 (23%) of these using the TH platform. Each TH visit's median length was 25 minutes (IQR 15-30), while the median length of IP visits was 45 minutes (IQR 30-45). Pre-implementation satisfaction scores were 88.6% positive, while satisfaction scores after implementation were 96.8% positive. None of the patients who utilized the TH platform had an unplanned hospital admission within 24 hours of being seen.

CONCLUSION

Our experience demonstrates that the TH platform can provide an efficient avenue for established patients and families to receive highly complex multidisciplinary follow-up care. High levels of patient satisfaction indicated that TH should become part of the routine care plan for patients who require long-term or consistent follow-up.

Quality outcomes for pediatric colorectal surgery treated during short-term international medical service trips at a dedicated site in Honduras

INTRODUCTION

Short-term international medical service trips (MSTs) provide specialized care in resource-constrained countries. There are limited data on immediate and long-term reported outcomes following specialty MST. We hypothesized that dedicated collaborative MST team and host institution produce outcomes and results comparable to those of high-income settings. Our primary aim was to analyze the long-term surgical and functional outcomes of our specialty-specific MSTs following five years of annual MST in Honduras.

METHODS

We performed a single-institution retrospective analysis of 56 children who underwent colorectal and pelvic reconstructive operations between 2014 and 2018. Demographics, diagnosis, comorbidities, type of repair, long-term complications, and functional bowel and bladder results were recorded.

RESULTS

We included a total of 56 children, 47 with ARM and 9 with HD, with a median age of 43.5 months (17-355) at the time of surgery. 25% (22) of the patients were lost to follow-up. Fecal continence was achieved by 23 (60%) patients <5 years who reported toilet training (n = 39) and by 5 (45%) patients >5 years (n = 11). Complications included constipation in 18 (42.9%) children with ARM and in 1 (12.5%) with HD. Eleven (19.6%) patients required revisional surgery for skin level anal stricture. Seventy-five percent of the patients with pediatric colorectal disorders attending the MST were compliant with continued long-term follow-up.

CONCLUSION

We were able to demonstrate that with organized, dedicated site and surgeon, results achieved can be comparable to those in the high-income countries (HICs). We conclude that this type of specialized care is feasible and beneficial for affected pediatric colorectal patients in resource-limited settings, when a strong partnership with a system of preoperative assessments and peri- and postoperative care can be established.

LEVEL OF EVIDENCE

Level IV (retrospective cohort study).

The Growth of Integrated Care Models in Urology

With heightened awareness of health care outcomes and efficiencies and reimbursement-based metrics, it is ever more important that urologists consider the effects of integrated care models on physicians/staff/clinics fulfillment and patient outcomes, and whether and how to optimally implement these models within their unique practice settings. Despite growing evidence that integrating care improves outcomes, uncertainty persists regarding which approach is most efficient and achievable in terms of specialty considerations and financial resources. In this article, we discuss strategies for integrating urologic care and its impact on current and future health care delivery.

Long-term urologic and gynecologic follow-up and the importance of collaboration for patients with anorectal malformations

Anorectal malformations (ARM) are well recognized to be associated with anomalies in other organ systems. The introduction of screening protocols has increased the diagnosis of these anomalies and greater collaboration with other specialties has influenced the treatment and follow-up of patients with ARMs. Much of the medical literature regarding the treatment of anorectal malformations has focused on technical details of operations and early post-surgical outcomes. Recently, an increase in published data regarding the long-term sequelae of an ARM diagnosis has resulted in an emphasis extended follow up in this population. Patient support groups have highlighted complex issues in ARM patients persist into adulthood have advocated for improved transitional care. This article describes the benefits of long-term follow-up and identifies key issues in ARM patients with respect to urologic and gynecologic health. A collaborative model of care is outlined and suggested timings of screening for potential problems is described.

New and exciting advances in pediatric colorectal and pelvic reconstructive surgery - 2021 update

Caring for children with colorectal and pelvic reconstructive needs is complex and requires a lifelong commitment from clinicians devoted to the field. There has been a myriad of advances that have improved care and it has become clear that an integrated, multi-disciplinary approach maximizes the goal of improving the quality of life of children afflicted with these conditions. The purpose of this review is to briefly discuss the history of this field and to describe the key advances that have improved patients' lives.

Creating a collaborative program for the care of children with colorectal and pelvic problems

The treatment of patients with colorectal disorders and their associated urologic, gynecologic, gastrointestinal, spinal, and orthopedic anomalies requires care from various medical and surgical specialties over the course of their lifetime. This is ideally handled by a collaborative center which facilitates the assessment and development of a long-term patient care plan among multiple specialties which can enhance the quality of care, improve communication among different specialties, and improve patient satisfaction and outcomes. We describe the process, as well as lessons learned in developing such a center.

Development of a multidisciplinary colorectal and pelvic health program: Program implementation and clinical impact

INTRODUCTION

Pediatric patients with complex colorectal and genitourinary conditions often require coordinated multidisciplinary care; however, this coordinated care can be hard to structure and deliver. The purpose of this paper is to review the development and implementation of a multidisciplinary colorectal and pelvic health program, one year after the program's initiation.

METHODS

This is an observational retrospective 1-year study (10/1/2017 to 9/30/2018). In fiscal year (FY) 2018, a multidisciplinary colorectal and pelvic health program was initiated. The program development incorporated bimonthly team meetings, educational conferences, and initiation of three clinics: a complex colorectal and genitourinary reconstruction clinic, a bowel management clinic, and a colonic motility clinic. Conditions treated included complex anorectal and cloacal malformations, Hirschsprung disease, and idiopathic constipation. The fiscal year was selected to provide comparative administrative data after program implementation.

RESULTS

During the study period, 121 patients underwent comprehensive collaborative evaluation of which 58 (47%) were new to the institution compared to 12 (19%) new patients in the previous year (p < 0.001). In FY 2018, there were 130 procedures performed and 512 collaborative visits with an average of 47 visits per month. This was a 3.4-fold increase in visits compared to FY2017 (171 visits). Of the new patients, 60% (35/58), traveled a median of 181 miles, representing 33 statewide counties, and 4 states compared to a median of 93 miles in the previous fiscal year (p = 0.004).

CONCLUSION

The development of a colorectal and pelvic health program is feasible and requires a collaborative approach, necessitating multiple service lines within an institution. Program creation and implementation can result in rapid institutional clinical growth by filling a local and regional need through coordinated multidisciplinary care.

LEVEL OF EVIDENCE

IV.

Surgical Interventions for Functional Constipation: An Update

Chronic idiopathic constipation, also known as functional constipation, is defined as difficult and infrequent defecation without an identifiable organic cause. Medical management with laxatives is effective for the majority of constipated children. However there is a subset of patients who may need evaluation by a surgeon. As constipation progresses, it can lead to fecal retention and rectal and sigmoid distension, which impairs normal colorectal motility. Surgical interventions are influenced by the results of: a rectal biopsy, transit studies, the presence of megacolon/megarectum on contrast enema, the degree of soiling/incontinence, anorectal manometry findings, and colonic motility evaluation. In this review, we describe the different surgical options available (intestinal diversion, antegrade enemas, sacral nerve stimulation, colonic resections, and Botulinum toxin injection) and provide guidance on how to choose the best procedure for a given patient.

Overview of Anorectal Malformations in Africa

Anorectal malformation is one of the most common structural congenital malformations treated by pediatric surgeons globally. The outcome of care is largely dependent on the spectrum, clinical features, associated malformations, expertise of the surgeons, and available perioperative facilities. Africa has a large burden of unmet surgical needs in children, and as in other low resource settings, local pediatric surgeons are faced with different and challenging clinical scenarios, hence, adopt various measures to enable children with surgically correctable congenital malformations to survive. There are increasing collaborations between local surgeons and experts in other continents, which often involves surgeons traveling to Africa on missions or well-structured partnerships. It is highly beneficial for the physician who is interested in global-surgery to understand the terrain in low resource settings and prepare for possible changes in management plan. This review highlights the epidemiology, clinical presentation, treatment, and outcome of care of children with anorectal malformations in Africa and provides options adopted by pediatric surgeons working with limited resources.