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Effect of a health system payment and quality improvement programme for tonsillectomy in Ontario, Canada: an
Sanjay Mahant1,2,3, Jun Guan4, Jessie Zhang5
1Department of Paediatrics, University of Toronto Termerty Faculty of Medicine, Toronto, Ontario, Canada sanjay.mahant@sickkids.ca.
Insights
The Quality-Based Procedures (QBP) programme in Ontario reduced tonsillectomy revisits and inpatient admissions. This quality improvement initiative demonstrated positive impacts on pediatric surgical care.
Area of Science:
- Pediatric Surgery
- Health Services Research
- Quality Improvement
Background:
- Tonsillectomy is a common and costly pediatric surgical procedure with variable quality.
- Limited evidence exists on health system interventions to enhance tonsillectomy care quality.
- The Quality-Based Procedures (QBP) programme in Ontario introduced fixed payments and a perioperative pathway for tonsillectomy.
Purpose of the Study:
- To determine the association between the QBP programme and the quality of care for pediatric tonsillectomy.
- To evaluate the impact of a bundled payment and quality improvement initiative on surgical outcomes.
Main Methods:
- An interrupted time series analysis was conducted using health administrative data.
- The study included 111,411 children undergoing elective tonsillectomy in Ontario between January 2009 and December 2018.
- Key outcome measures included 30-day revisits, opioid prescription fills, and index inpatient admissions.
Main Results:
- Following QBP implementation, all-cause tonsillectomy-related revisits significantly decreased.
- The rate of inpatient admissions for index tonsillectomy also showed a significant reduction.
- While codeine prescription rates continued to decline, the rate of decrease slowed post-QBP implementation.
Conclusions:
- The QBP programme was associated with measurable improvements in the quality of pediatric tonsillectomy care.
- These findings suggest that payment reform and quality improvement initiatives can positively impact surgical care.
- The study provides valuable insights for other jurisdictions considering similar health system interventions for pediatric procedures.
Background:
Tonsillectomy is among the most common and cumulatively expensive surgical procedures in children, with known variations in quality of care. However, evidence on health system interventions to improve quality of care is limited. The Quality-Based Procedures (QBP) programme in Ontario, Canada, introduced fixed episode hospital payment per tonsillectomy and disseminated a perioperative care pathway. We determined the association of this payment and quality improvement programme with tonsillectomy quality of care.
Methods:
Interrupted time series analysis of children undergoing elective tonsillectomy at community and children's hospitals in Ontario in the QBP period (1 April 2014 to 31 December 2018) and the pre-QBP period (1 January 2009 to 31 January 2014) using health administrative data. We compared the age-standardised and sex-standardised rates for all-cause tonsillectomy-related revisits within 30 days, opioid prescription fills within 30 days and index tonsillectomy inpatient admission.
Results:
111 411 children underwent tonsillectomy: 51 967 in the QBP period and 59 444 in the pre-QBP period (annual median number of hospitals, 86 (range 77-93)). Following QBP programme implementation, revisit rates decreased for all-cause tonsillectomy-related revisits (0.48 to -0.18 revisits per 1000 tonsillectomies per month; difference -0.66 revisits per 1000 tonsillectomies per month (95% CI -0.97 to -0.34); p<0.0001). Codeine prescription fill rate continued to decrease but at a slower rate (-4.81 to -0.11 prescriptions per 1000 tonsillectomies per month; difference 4.69 (95% CI 3.60 to 5.79) prescriptions per 1000 tonsillectomies per month; p<0.0001). The index tonsillectomy inpatient admission rate decreased (1.12 to 0.23 admissions per 1000 tonsillectomies per month; difference -0.89 (95% CI -1.33 to -0.44) admissions per 1000 tonsillectomies per month; p<0.0001).
Conclusions:
The payment and quality improvement programme was associated with several improvements in quality of care. These findings may inform jurisdictions planning health system interventions to improve quality of care for tonsillectomy and other paediatric procedures.
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