Predictive factors for prolonged hospital stay in pediatric tonsillectomy patients

Incidence and predictors of readmission following tonsillectomy in pediatric population

BACKGROUND

Tonsillectomy is one of the most common surgical procedures performed in the pediatric population. This study aims to estimate the incidence rate of readmission post tonsillectomy in pediatrics and identify the causes and predictors contributing to the readmission post-surgery.

METHODS

A retrospective cohort study included 1280 pediatric patients (18 years or younger) who underwent tonsillectomy at a tertiary hospital in 2019 and 2020. The study sample was divided into two groups based on readmission and were compared using the appropriate statistical tests. Significant variables (p-value≤0.05) were included in the logistic regression model to determine the predictors of readmission following tonsillectomy in these patients.

RESULTS

The readmission rate following tonsillectomy was 6.3 % (95 % confidence interval 5.1-7.9). The causes of readmission included poor oral intake followed by bleeding and vomiting, 55.6 %,49.4 %, and 13.6 %, respectively. In the multivariable logistic regression model, the only significant predictor of post-tonsillectomy readmission was the use of a single postoperative analgesia (OR: 57.27, P = 0.000).

CONCLUSION

The readmission rate following tonsillectomy in this study was relatively high. The most common causes contributing to readmission post tonsillectomy were poor oral intake and hemorrhage. The study also revealed a significant association between the utilization of single postoperative analgesia and an increased likelihood of readmission.

Cost and economic determinants of paediatric tonsillectomy

Objective Hospital utilisation research is important in pursuing cost-saving healthcare models. Tonsillectomy is one of the most common paediatric surgeries and the most frequent reason for paediatric hospital readmission. This study aimed to report the government-funded costs of paediatric tonsillectomy in the state of Victoria, Australia, extrapolate costs across Australia, and identify the cost determinants. Methods A population-based longitudinal study was conducted with a bottom-up costing approach using linked datasets containing all paediatric tonsillectomy and tonsillectomy with adenoidectomy surgeries performed in the state of Victoria between 2010 and 2015. Results The total average annual cost of tonsillectomy hospitalisation in Victoria was A$21 937 155 with a median admission cost of A$2224 (interquartile range (IQR) 1826-2560). Inflation-adjusted annual tonsillectomy costs increased during 2010-2015 (P < 0.001), not explained by the rising number of surgeries. Hospital readmissions resulted in a total average annual cost of A$1 427 716, with each readmission costing approximately A$2411 (IQR 1936-2732). The most common reason for readmission was haemorrhage, which was associated with the highest total cost. The estimated total annual expenditure of both tonsillectomy and resulting readmissions across Australia was A$126 705 989. Surgical cost in the upper quartile was associated with younger age, male sex, lower socioeconomic status, surgery for reasons other than infection alone, overnight vs day case surgery, public hospitals and metropolitan hospitals. Surgery for obstructed breathing during sleep had the strongest association to high surgical cost. Conclusions This study highlights the cost of paediatric tonsillectomy and associated hospital readmissions. The study findings will inform healthcare reform and serve as a basis for strategies to optimise patient outcomes while reducing both postoperative complications and costs.

Unplanned Postoperative Reintubation in Children with Bronchial Asthma

Unplanned postoperative reintubation is a serious complication that may increase postsurgical hospital length of stay and mortality. Although asthma is a risk factor for perioperative adverse respiratory events, its association with unplanned postoperative reintubation in children has not been comprehensively examined. Our aim was to determine the association between a preoperative comorbid asthma diagnosis and the incidence of unplanned postoperative reintubation in children. This was a retrospective cohort study comprising of 194,470 children who underwent inpatient surgery at institutions participating in the National Surgical Quality Improvement Program–Pediatric. The primary outcome was the association of preoperative asthma diagnosis with early, unplanned postoperative reintubation (within the first 72 hours following surgery). We also evaluated the association between bronchial asthma and prolonged hospital length of stay (longer than the 75th percentile for the cohort). The incidence of unplanned postoperative reintubation in the study cohort was 0.5% in patients with a history of asthma compared with 0.2% in patients without the diagnosis (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.71–2.89). This association remained significant after controlling for several clinical characteristics (OR: 1.54, 95% CI: 1.17–2.20). Additionally, asthmatic children were more likely to require a hospital length of stay longer than the 75th percentile for the study cohort (adjusted OR: 1.05, 95% CI: 1.01–1.10). Children with preoperative comorbid asthma diagnosis have an increased incidence of early, unplanned postoperative reintubation and prolonged postoperative hospitalization following inpatient surgery. By identifying these patients as having higher perioperative risks, it may be possible to institute strategies to improve their outcomes.

Reflux as a Risk Factor for Morbidity after Pediatric Tonsillectomy: A National Cohort of Inpatients

OBJECTIVE

Gastroesophageal reflux (GER) has been identified as a risk factor for complications following pediatric tonsillectomy. The primary objective of this study was to examine outcomes after tonsillectomy among children with GER using a nationwide database. Secondary objectives included analyzing duration of hospitalization and total charges after admission.

METHODS

A cross-sectional review of the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Databases (KID) from 2012 and 2016.

RESULTS

A total of 21,232 children had a tonsillectomy with or without adenoidectomy, with 1683 (7.9%) diagnosed with GER. Average age for patients with reflux was 4.4 years and for those without was 5.6 years (P < .001). The rate of primary hemorrhage was not statistically different between groups (P = .87). Patients with reflux were more likely to have respiratory complications (P = .03), aspiration pneumonitis (P < .001), and hypoxemia (P < .001) during their hospital course. Noninvasive ventilation and reintubation also occurred more frequently in this population (P < .001). Children with reflux had a longer duration of postoperative admission (3.8 vs. 2.3 days, P < .001) and higher total hospital charges ($47,129 vs. $27,584, P < .001). Multivariable regression analysis determined that reflux remained a statistically significant indicator of aspiration pneumonitis, hypoxemia, invasive and non-invasive ventilation, as well as length of admission.

CONCLUSION

Children with GER were significantly more likely to experience inpatient complications following tonsillectomy. Further, length of admission was higher compared to children without reflux. These results suggest that children with GER experience poorer outcomes after tonsillectomy and highlight the role for appropriate preoperative counseling and planning in this patient population. Laryngoscope, 131:907-910, 2021.

Postoperative respiratory complications and racial disparities following inpatient pediatric tonsillectomy: A cross-sectional study

OBJECTIVES/HYPOTHESIS

To study rates of respiratory complications/interventions among inpatient tonsillectomy patients in the United States and identify risk factors for these events.

STUDY DESIGN

Retrospective database review.

METHODS

Children (age < 18 years) undergoing tonsillectomy with or without adenoidectomy in 2006, 2009, and 2012 were studied using the Kids Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Outcomes were analyzed for respiratory events (complications/interventions) and racial disparities. Pearson χ test was used to analyze categorical data and regression analysis was used for continuous variables. Respiratory events were analyzed by racial identity using logistic regression analysis. A P < .05 was considered significant.

RESULTS

The study included 30,617 patients (41% female, 51% white, 24% African American, 23% Hispanic, 3.0% Asian). The mean age was 5.2 years, and mean length of stay 2.3 days. The overall complication rate was 6.0%, and overall intervention rate was 3.6%. Respiratory events were more common among African American children (odds ratio [OR]: 1.5, 95% confidence interval [CI]: 1.3-1.6) and less common among white children (OR: 0.8, 95% CI: 0.8-0.9). These differences were significant after controlling for age, gender, obesity, obstructive sleep apnea, and asthma. The mortality rate was 0.05% with no ethnic predilection.

CONCLUSIONS

Respiratory events after inpatient tonsillectomy included laryngo/bronchospasm, pneumonia, pulmonary edema, intubation, prolonged intubation, and ventilation. Although uncommon, these were more common among African American children. Further research is needed to understand the etiology of this disparity.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:995-1000, 2019.

Tonsillectomy in Children with Down Syndrome: A National Cohort of Inpatients

Objective To describe the cost, length of stay, and incidence of postoperative hemorrhage associated with Down syndrome (DS) patients undergoing tonsillectomy in a national sample of inpatient children. Study Design This study uses a national cross-sectional cohort to analyze children with and without DS undergoing tonsillectomy with or without adenoidectomy. Setting 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database. Subjects and Methods The database was analyzed for postoperative hemorrhage and respiratory compromise, length of stay, and total charges of hospital stay. These outcomes were compared between patients with DS vs patients without DS. Results In total, 7512 patients were identified who underwent tonsillectomy: 7159 patients without DS and 353 patients with DS. The non-DS group was younger with a median age of 3 years (range, 0-18) compared with a DS median age of 4 years (range, 0-20), P = .004. The DS group had a significant increase in postoperative hemorrhage compared with non-DS (10 [2.8%] vs 87 [1.2%], respectively), P = .024. However, the DS and non-DS groups were comparable for respiratory complications (5 [1.4%] vs 106 [1.5%], respectively), P = .922. Median length of stay was significantly increased in the DS group (1 [interquartile range (IQR), 1-3]) compared with the non-DS group (1 [IQR, 1-2]), P < .001. Median charges for hospital stay totaled $17,451 (IQR, $11,901-$24,949) for the DS group compared with $14,395 (IQR, $9739-$21,890) for the non-DS group, P < .001. Conclusion Across the United States, children with DS hospitalized for tonsillectomy have an increased length of stay and cost of care. These data also suggest an increased risk of postoperative hemorrhage during the initial admission without an increased risk of respiratory complications.

The effect of perioperative dexamethasone dosing on post-tonsillectomy hemorrhage risk

OBJECTIVES

Dexamethasone is currently recommended for routine prophylaxis against postoperative nausea and vomiting after tonsillectomy procedures. However, some studies have raised concern that dexamethasone use may lead to higher rates of post-tonsillectomy hemorrhage. Our objective was to determine whether higher doses of dexamethasone administered perioperatively during tonsillectomy procedures are associated with an increased risk of secondary post-tonsillectomy hemorrhage.

METHODS

We conducted a retrospective review of 9843 patients who underwent tonsillectomy and received dexamethasone at our institution from January 2010 to October 2014. We compared the dose of dexamethasone administered to patients who did and did not develop secondary post-tonsillectomy hemorrhage using Mann Whitney U tests. Multivariable logistic regression models were used to evaluate the association between dexamethasone dose and post-tonsillectomy hemorrhage after adjustment for demographic and clinical characteristics.

RESULTS

A total of 280 (2.8%) patients developed secondary post-tonsillectomy hemorrhage. Patients who developed hemorrhage tended to be older (median (interquartile range) 7 (4-11) vs. 5 (3-8) years), p < 0.001) and had undergone tonsillectomy more often for chronic tonsillitis but less often for tonsillar or adenotonsillar hypertrophy or sleep disturbances. Dexamethasone dose was significantly lower on average in patients who experienced secondary post-tonsillectomy hemorrhage (median (interquartile range) 0.19 (0.14, 0.23) mg/kg vs. 0.21 (0.17, 0.30), p < 0.001). Multivariable modeling demonstrated that the dose of dexamethasone was not significantly associated with post-tonsillectomy hemorrhage after adjustment for age.

CONCLUSIONS

There does not appear to be a dose-related increase in the risk of post-tonsillectomy hemorrhage for patients receiving dexamethasone during tonsillectomy procedures.

Pediatric adenotonsillectomy and postoperative hemorrhage: Demographic and geographic variation in the US

OBJECTIVE

To examine demographic and regional variations in pediatric tonsillectomy, with or without adenoidectomy, and post-tonsillectomy hemorrhage on a national level.

METHODS

The MarketScan(®) database was analyzed for claims made between 2008-2012 for the 30 days following tonsillectomy/adenotonsillectomy in privately insured children 1-17 years of age.

RESULTS

We analyzed 305,860 patients with 98.6% of these tonsillectomies occurring in an ambulatory setting. Children between 3-6 years old comprised our largest group of tonsillectomies (45.1%). More tonsillectomies were done in the South (42.1%) than any other region in our sample. Patients between 11 and17 years old had the highest percentage of bleeding (4.8%). Patients between 1 and 3 years old had the lowest values. Of the 8,518 children who presented with post-operative hemorrhage, 71.7% had only one hemorrhagic event, 28.3% had at least a second one, 6.0% had at least 3 events, and 1.3% had at least 4 events. Post-operative dehydration had a similar pattern. The South had the lowest percentage of post-tonsillectomy bleeds (2.5%) and overall ER visits (7.1%), both of which were most common in the Midwest. Gender had no significant association with incidence of tonsillectomy procedures or post-op complications.

CONCLUSION

There are geographic and demographic variations in adenotonsillectomy and in post-operative complications for children nationally.

Role of Laryngopharyngeal Reflux in Complications of Tonsillectomy in Pediatric Patients

Tonsillectomy and tonsillectomy with adenoidectomy are among the most common surgical procedures in otolaryngology practice. Gastroesophageal reflux was identified as a risk factor for complications in tonsillectomy. This prospective study was designed to assess the role of reflux in the development of complications following tonsillectomy in pediatric patients. Children (n = 60) who underwent tonsillectomy with adenoidectomy were divided into two groups, i.e., the laryngopharyngeal reflux (LPR) group and control group. Patients with LPR were identified by reflux symptom index and reflux finding score. Pain, hemorrhage, fever, nausea, vomiting, fever, dehydration, infection, and pulmonary problems were evaluated post operatively. The mean lengths of hospital stay were 2.11 days in the reflux group and 1.05 days in the control group. The difference was statistically significant. Visual analogue scores of both groups were similar on day 1 but it was significantly higher on day 7 and 14 in LPR group. Nausea and vomiting rates were 11.1 and 9.5 % for the patients in the LPR group and the controls, respectively. The difference between the two groups was not significant. The mean fever was 37.6 °C in the reflux group and 37.3 °C in the controls, which were not significantly different. 19 % of the controls and 22 % of the LPR group patients were readmitted. This difference was not statistically significant. There were two cases of bleeding in the reflux group, while no bleeding occurred in the control group. This difference was significant statistically. LPR is a risk factor for complications following tonsillectomy.