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Association of National Guidelines With Tonsillectomy Perioperative Care and Outcomes
Sanjay Mahant1, Matt Hall2, Stacey L Ishman3
1Division of Pediatric Medicine, Pediatric Outcomes Research Team (PORT), Department of Pediatrics, Institute of Health Policy, Management and Evaluation, University of Toronto, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada; sanjay.mahant@sickkids.ca.
Insights
The 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines improved tonsillectomy care processes, increasing dexamethasone use and decreasing antibiotic use. However, complication-related revisits, mainly for pain, slightly increased post-tonsillectomy.
Area of Science:
- Otolaryngology
- Pediatric Surgery
- Health Services Research
Background:
- Tonsillectomy is a common pediatric surgical procedure.
- The 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines aimed to standardize perioperative care.
- Evidence-based processes include perioperative dexamethasone and judicious antibiotic use.
Purpose of the Study:
- To evaluate the impact of the 2011 guidelines on perioperative care processes for pediatric tonsillectomy.
- To assess the association of the guidelines with 30-day complication-related revisits after tonsillectomy.
- To analyze trends in guideline adherence and outcomes over time.
Main Methods:
- Retrospective cohort study of 111,813 otherwise healthy children undergoing tonsillectomy.
- Data collected from 29 US children's hospitals between January 2009 and January 2013.
- Interrupted time series analysis used to assess changes in care processes and outcomes before and after guideline implementation.
Main Results:
- Perioperative dexamethasone use increased from 74.6% to 77.4% (P < .001).
- Antibiotic use significantly decreased from 34.7% to 21.8% (P < .001).
- Total complication-related revisits increased from 8.2% to 9.0% (P < .001), primarily due to pain-related visits; bleeding revisits remained stable.
Conclusions:
- The guidelines were associated with improved adherence to evidence-based processes, specifically reduced antibiotic use.
- No significant improvement in overall tonsillectomy outcomes was observed.
- An increase in pain-related revisits suggests a need for better post-tonsillectomy pain management strategies.
Objective:
To investigate the association of the 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines with perioperative care processes and outcomes in children undergoing tonsillectomy.
Methods:
We conducted a retrospective cohort study of otherwise healthy children undergoing tonsillectomy between January 2009 and January 2013 at 29 US children's hospitals participating in the Pediatric Health Information System. We measured evidence-based processes suggested by the guidelines (perioperative dexamethasone and no antibiotic use) and outcomes (30-day tonsillectomy complication-related revisits). We analyzed rates aggregated over the preguideline and postguideline periods and then by month over time by using interrupted time series.
Results:
Of 111,813 children who underwent tonsillectomy, 54,043 and 57,770 did so in the preguideline and postguideline periods, respectively. Dexamethasone use increased from 74.6% to 77.4% (P < .001) in the preguideline to postguideline period, as did its rate of change in use (percentage change per month, -0.02% to 0.29%; P < .001). Antibiotic use decreased from 34.7% to 21.8% (P < .001), as did its rate of change in use (percentage change per month, -0.17% to -0.56%; P < .001). Revisits for bleeding remained stable; however, total revisits to the hospital for tonsillectomy complications increased from 8.2% to 9.0% (P < .001) because of an increase in revisits for pain. Hospital-level results were similar.
Conclusions:
The guidelines were associated with some improvement in evidence-based perioperative care processes but no improvement in outcomes. Dexamethasone use increased slightly, and antibiotic use decreased substantially. Revisits for tonsillectomy-related complications increased modestly over time because of revisits for pain.
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