Substantial variation in quality of pediatric tonsillectomy perioperative care

Image: PD 

1. There was significant variation in perioperative care for tonsillectomies among pediatric hospitals, as measured by rates of dexamethasone and antibiotic use. 

2. Across US children’s hospitals, re-admission rates for bleeding, vomiting and dehydration after tonsillectomy varied significantly. 

Evidence Rating Level: 2 (Good) 

Study Rundown: This trial evaluated the perioperative care and outcomes of routine, low risk tonsillectomies at children’s hospitals in the United States. Tonsillectomies are common same-day procedures that are most often performed for recurrent throat infections and sleep disordered breathing. The American Academy of Otolaryngology-Head and Neck Surgery published explicit practice guidelines for pediatric tonsillectomy perioperative care in 2011 recommending dexamethasone administration perioperiatvely and recommending against antibiotic administration. The present study retrospectively evaluated a cohort of low-risk patients who underwent same-day tonsillectomies in US children’s hospitals. Considerable variation in administration of perioperative dexamethasone was noted across hospitals evaluated (0.3-98.8%,), as well as variation in antibiotic administration (2.7-92.6%). Readmission rates post-operatively varied four-fold across hospitals (p<0.001), with an aggregate readmission rate of 7.8% within 30 days of surgery. These data suggest that variation in care for routine tonsillectomy is accompanied by considerable variation in outcomes across US children’s hospitals. Improvement efforts should be made to standardize routine tonsillectomies to provide quality care and avoid revisits.

Click to read the study, published today in Pediatrics

Relevant Reading: Clinical practice guidelines: Tonsillectomy in Children

In-Depth [retrospective cohort]: This study evaluated the quality of care for tonsillectomy in 38 US children’s hospitals, focusing on low-risk children who underwent same-day procedures. Authors evaluated 139,715 who underwent tonsillectomy between 2004 and 2010. The median percentage of patients who were administered pre-operative dexamethasone was 76.2% with a range of 0.3-98.8%, and antibiotics were administered to a median of 16.3% patients, with a range of 2.7-92.6%. There was significant variation in the rates of revisits to the hospital for tonsillectomy-related complications, with a median of 7.8%, and a range of 3.0-12.6% (p < 0.001). Most revisits were due to bleeding (3.0%), followed by vomiting and dehydration (2.2%), pain (0.8%), and infection (0.5%). Older children aged 10-18 had an increased risk of revisits for bleeding (OR 2.74, 95% CI 2.08-3.60). Most revisits occurred within 15 days of surgery (93.8%).

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