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Published on: November 6, 2019
Variation in post-adenotonsillectomy admission practices in 24 pediatric hospitals
Samita S Goyal1, Rahul Shah, David W Roberson
1Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
Insights
Post-adenotonsillectomy (T&A) admission rates vary widely in children. Younger children, those with obstructive sleep apnea (OSA), and complex conditions have higher admission rates, highlighting a need for standardized T&A care guidelines.
Area of Science:
- Pediatric Surgery
- Healthcare Policy
- Clinical Outcomes Research
Background:
- Practice variations exist in pediatric adenotonsillectomy (T&A) postoperative admissions.
- Current T&A admission decisions lack robust clinical evidence, relying on anecdotal data.
- Identifying patterns in T&A admissions is crucial for optimizing pediatric surgical care.
Purpose of the Study:
- To investigate variations in postoperative admission rates following T&A in pediatric hospitals.
- To analyze factors influencing T&A admission decisions, including patient age, obstructive sleep apnea (OSA), and comorbidities.
- To highlight the need for evidence-based guidelines for T&A postoperative care.
Main Methods:
- Retrospective analysis of administrative data from the Pediatric Health Information System (PHIS) database.
- Inclusion of 29,920 T&A procedures across 24 tertiary care pediatric hospitals (July 2009-June 2010).
- Stratification of T&A admission rates by patient age, presence of OSA, and complex chronic conditions.
Main Results:
- Younger age, OSA, and complex chronic conditions were significantly associated with increased T&A admissions.
- Admission rates varied dramatically, from over 94% for high-risk infants to 14% for older, healthier children.
- Extreme between-hospital variability in T&A admission rates persisted even after adjusting for patient factors.
Conclusions:
- Significant disparities in T&A postoperative admission rates exist among pediatric hospitals.
- A clearer understanding of first-night postoperative complication risks is essential for T&A care.
- Standardized criteria are needed to guide monitored admissions after T&A in children.
Objectives/Hypothesis:
There is controversy about which children should be admitted after adenotonsillectomy (T&A) and limited clinical evidence to help with this decision. Current practice has evolved based on empirical or anecdotal evidence. We sought to identify practice variations in postoperative admission after T&A in tertiary care pediatric hospitals.
Study Design:
Retrospective database study using administrative information stored in the Pediatric Health Information System (PHIS) database.
Methods:
There were 29,920 T&As performed in 24 pediatric hospitals included in the PHIS database between July 1, 2009 and June 30, 2010. Patients were identified as outpatient (discharged the same day) or inpatient (not discharged on the day of surgery). We examined admission rates across different hospitals stratified by age, obstructive sleep apnea (OSA), and other complex chronic conditions.
Results:
Younger age, the existence of a complex chronic condition, and OSA were all associated with higher post-T&A admission rates. Admission rates ranged from >94% for children under 2 years of age, with OSA and at least one medical comorbidity, to 14% for children older than 5 years, without OSA and without any medical comorbidities. Between-hospital variability was extreme; for example, for 3 to 5 year olds, the admission rate varied from 5% to 90% between hospitals. Very significant variation remained even after controlling for age, comorbidities, and OSA.
Conclusions:
Post T&A admission rates vary tremendously across comparable tertiary-care pediatric hospitals. There is a crucial need for a better understanding of the risk of complications on the first postoperative night, and the appropriate indications for monitored admission on that night.
Level Of Evidence:
4.
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