Medications vary during and after tonsillectomy care

While same-day tonsillectomy may be one of the most common and cumulatively costly surgeries for children in the United States, there is substantial variability in the quality of care and outcomes, reports a study in Pediatrics.

In a large cohort of children undergoing same-day tonsillectomy between 2004 and 2010 at 36 children’s hospitals in the United States that submit data to the Pediatric Health Information System Database, study author Sanjay Mahant and colleagues assessed quality of care by measuring evidence-based processes suggested by national guidelines; perioperative dexamethasone and no antibiotic use; and outcomes, 30-day tonsillectomy-related revisits to hospital.

Research has shown that a single dose of the steroid dexamethasone during a tonsillectomy can control nausea and pain afterward, and guidelines issued in 2011 by the American Academy of Otolaryngology-Head and Neck Surgery recommend that most children receive the drug. Antibiotics reportedly have shown no benefit in previous tonsillectomy studies, and the guidelines advise against routinely giving them to patients.

Across the 36 US hospitals, children were given dexamethasone an average of three-quarters of the time, said Dr Mahant, a pediatrician at the Hospital for Sick Children in Toronto. But there was significant variation in use, with some hospitals almost never giving the drug and others almost always doing so.

For antibiotics, on average about 16% of children were given antibiotics. Again there was a wide discrepancy, with a few hospitals giving the drugs to almost every child.

“Efforts in quality improvement across and within hospitals are needed to implement best evidence into practice and to learn and disseminate practices from high-performing hospitals to improve the value of care provided for these children,” said Dr Mahant.

Of 139, 715 children who underwent same-day tonsillectomy, 10, 868 (7.8%) had a 30-day revisit to hospital. There was significant variability in the administration of dexamethasone (median 76.2%, range 0.3%–98.8%) and antibiotics (median 16.3%, range 2.7%–92.6%) across hospitals. Bleeding (3.0%) and vomiting and dehydration (2.2%) were the most common reasons for revisits. Older age (aged 10 to 18 years vs 1 to 3 years) was associated with a greater standardized risk of revisits for bleeding and a lower standardized risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, there was significant variability (P<.001) across hospitals in total revisits (median 7.8%, range 3.0%–12.6%), revisits for bleeding (median 3.0%, range 1.0%–8.8%), and revisits for vomiting and dehydration (median 1.9%, range 0.3%–4.4%).

More than 500,000 tonsillectomies are performed yearly in the ambulatory setting, which is comparable to adult knee arthroplasty and more than adult hip arthroplasty volumes, according to Dr Mahant.

Not only is tonsillectomy common in children, it is also a cumulatively costly condition for the healthcare system, he said. Across 36 children’s hospitals, it ranked as the ninth most cumulatively costly condition of all medical and surgical reasons for hospital care.

 “Given the changing environment of US healthcare reform, with new payment models such as bundled payments, where providers will be reimbursed for episodes of care, hospitals will be required to deliver high-quality care at low cost while avoiding revisits for complications,” Dr Mahant said. “For tonsillectomy, where reimbursements per procedure and profit margins are low, there is a further urgency around providing high-value care. Our study provides data showing substantial variability in quality of care, identifies where the opportunities for improvement exist, and analyzes quality measurement for this common and costly condition.”