Indirect costs related to caregivers' absence from work after paediatric tonsil surgery

Posterior crossbite corrections in the early mixed dentition with quad helix or rapid maxillary expander: a cost-effectiveness analysis of a randomized controlled trial

BACKGROUND

Unilateral posterior crossbite is a common malocclusion, and early treatment is recommended to enable normal growth. There are several possibilities regarding choice of appliances used for correcting this malocclusion; however, when treatment is financed by public funds the decision needs to be based not only on the effects but also on the effect in relation to the costs.

OBJECTIVES

The aim was to perform a cost-effectiveness analysis comparing quad helix (QH) and rapid maxillary expanders (RME; hyrax-type) in children in the early mixed dentition.

MATERIAL AND METHODS

Seventy-two patients were randomized to treatment with either QH or RME, at two different centres. Data were collected from the patient's medical records regarding success rate, number of visits, total treatment time, emergency visits, and so forth, together with answers from patient questionnaires concerning absence from school and use of analgesics. A cost-effectiveness analysis with both an intention-to-treat (ITT) and a per-protocol approach was performed, as well as a deterministic sensitivity analysis.

RESULTS

The success rate, one year after the completion of the expansion, was equal between groups according to the ITT approach. From a healthcare perspective, the mean cost difference between RME and QH was €32.05 in favour of QH (P = 0.583; NS). From a societal perspective, the mean cost difference was €32.61 in favour of QH (P = 0.742; NS). The total appliance cost alone was higher in the RME group €202.67 resp. €155.58 in the QH group (P = 0.001). The probability of RME having a higher cost was 71% from a healthcare perspective and 62.7% from a societal perspective. The total treatment time was 97 days longer in the QH group. In the deterministic sensitivity analysis, when using a higher valuation of the children's educational loss, the QH becomes €58 more costly than the RME. There was a statistically significant difference in chair time and visits between centres (P < 0.001).

CONCLUSION

The difference in costs between RME and QH is not statistically significant, however, there is a slightly higher probability that RME is more expensive than QH with a mean cost of an additional €32 per patient from a healthcare perspective. Different work procedures at different centres indicate that logistics around the patient's treatment is a more important aspect than appliance used to decrease the number of visits and save chair time and thereby also costs.

Pain management after tonsil surgery in children and adults-A national survey related to pain outcome measures from the Swedish Quality Register for tonsil surgery

OBJECTIVE

The primary aim of this study was to describe the current practice regarding pain management in relation to tonsil surgery among Ear Nose and Throat (ENT) clinics in Sweden. The secondary aim was to determine the impact of the provider's regime of rescue analgesics on the pain related Patient Reported Outcome Measures (pain-PROMs) from the Swedish Quality Register for Tonsil Surgery (SQTS).

MATERIALS & METHODS

A descriptive cross-sectional study originating from a validated web-based questionnaire. The survey enrolled one respondent from each ENT clinic (47/48 participated) nationally. Pain-PROMs from the SQTS, recorded from October 2019 to October 2022, were included (8163 tonsil surgeries).

RESULTS

Paracetamol was used by all enrolled ENT clinics as preemptive analgesia. The addition of COX inhibitors was used in 40% of the clinics. Betamethasone was usually administered, to prevent pain and nausea (92%). All clinics gave postdischarge instructions on multimodal analgesia with COX inhibitors and paracetamol. Rescue analgesics were prescribed after tonsillectomy for 77% of adults, 62% of older children, 43% of young children and less often after tonsillotomy. The most frequently prescribed rescue analgesic was clonidine in children (55%) and oxycodone in adults (72%). A high proportion of patients reported contact with health care services due to postoperative pain (pain-PROMs/ SQTS). Tonsillectomy procedures were associated with the highest rates of contacts (children/adolescents 13-15%; adults 26%), while tonsillotomy were associated with lower rates, (5-7% of children/adolescents). There was no significant difference in the frequency of health care contacts due to pain regarding whether clinics routinely prescribed rescue analgesics or not after tonsillectomy.

CONCLUSION

The Swedish analgesic regimen after tonsil surgery is good overall. Nevertheless, there is a need for increased awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the call for improvement in pain management after tonsil surgery.

Adenotonsillotomy versus adenotonsillectomy in pediatric obstructive sleep apnea: A 5-year RCT

Objectives

Adenotonsillectomy (ATE) is a common treatment for pediatric obstructive sleep apnea (OSA). Intracapsular adenotonsillotomy (ATT) is associated with less postoperative morbidity. Our previous randomized controlled trial (RCT) compared ATE and ATT in otherwise healthy children with moderate to severe OSA. No differences in polysomnographic (PSG) and OSA-18 were found between the groups at one-year follow-up. This study presents the long-term results of the RCT.

Methods

Non-obese children (n = 79, 2–6 years) who had undergone either ATE (n = 40) or ATT (n = 39) were offered PSG and OSA-18 questionnaire five-years after surgery. Primary outcome was the group difference in postoperative Obstructive Apnea/Hypopnea Index (OAHI). ATE was recommended to the ATT group if they had a relapse of OSA.

Results

The follow-up was completed by 45 of 79 (57%) children; 28 (35%) drop-outs, and six of 39(15%) in the ATT group were excluded after ATE. After ATE(n = 17), OAHI decreased from mean 12.3(SD 8.0) to 0.6(0.7), and after ATT(n = 28) from 12.6(7.4) to 0.5(0.6), a mean difference in postoperative OAHI of 0.1(95% CI -0.3 – 0.5). Sensitivity analyses did not change the results. The median OSA-18 decreased in the ATE group from 57(interquartile range 47–79) to 27(22–36), and in the ATT group from 67(53–79) to 32(25–44), without group differences for postoperative values.

Conclusion

The results of this five-year follow-up of otherwise healthy OSA-children showed a high drop-out rate, but indicates that ATT could be an effective treatment for pediatric OSA. However, ATT warrants follow-up due to the risk of recurrence, and further studies are needed.

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Adenotonsillotomy is an effective treatment for Obstructive sleep apnea in otherwise healthy children.

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Six children out of 39 were reoperated with adenotonsillectomy within three years.

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Follow-up after adenotonsillotomy is recommended.

Impact of tonsillotomy versus tonsillectomy on health-related quality of life and healthcare costs in children with sleep-disordered breathing

Objective

This study aimed to explore health-related quality of life and use of healthcare services and ensuing costs before and after tonsillotomy in children with sleep-disordered breathing and to compare the results to an earlier cohort of children who had undergone tonsillectomy.

Method

Children undergoing tonsillotomy answered the 17-dimensional, standardised health-related quality of life instrument questionnaire and a questionnaire on use of healthcare services and sick leave before and after surgery. Costs of specialist care were obtained pre- and post-operatively. The data were compared with similar data collected previously from children with tonsillectomy.

Results

Tonsillotomy improved mean total health-related quality of life score significantly at 6 and 12 months. Healthcare costs and number of sick-leave days diminished significantly from 3 months pre-operatively to 12 months after surgery. Tonsillotomy had similar positive effects compared with tonsillectomy regarding health-related quality of life and healthcare costs.

Conclusion

Tonsillotomy improves health-related quality of life in children with sleep-disordered breathing and reduces healthcare service needs and sick leave similarly to tonsillectomy.

Open and closed surgical exposure of palatally displaced canines: a cost-minimization analysis of a multicentre, randomized controlled trial

OBJECTIVE

To evaluate the costs of open and closed surgical exposure and subsequent orthodontic treatment for the correction of palatally displaced canines (PDCs).

TRIAL DESIGN

A multicentre, two-arm parallel group randomized controlled trial.

METHODS

One hundred twenty adolescents between 9 and 16 years of age, from three orthodontic specialist centres, were randomized to one of the two surgical exposure interventions. The randomization was conducted according to a two-arm parallel group 1:1 allocation ratio, using computerized lists with block randomization. In both the surgical techniques, whole mucoperiosteal flaps were raised, and bone covering the PDCs was removed. In the open technique, glass ionomer was built up on the PDC crown - reaching above the mucosa through a hole punched in the flap - to allow the canine to erupt autonomously. After eruption, the canine was orthodontically moved above the mucosa. In the closed technique, an eyelet was bonded onto the PDC, the flap was repositioned and the canine was orthodontically moved beyond the mucosa. The trial ended when the PDC was successfully aligned in the dental arch.Cost analysis was performed including costs for surgery, orthodontic treatment, emergency visits, and material, as well as costs for transports and time spent in connection with every appointment.

BLINDING

Patients and caregivers could not be blinded due to obvious limitations of the clinical setting, while outcome assessors and data analysts were blinded.

RESULTS

A cost-minimization analysis was performed since both exposure groups succeeded equally well in terms of treatment effects. The two different surgical exposures and following orthodontic treatments did not differ significantly in terms of costs.

GENERALIZABILITY AND LIMITATIONS

Costs are estimated in the Swedish setting, which needs to be considered if applying the results in other settings. Calculations of total cost do not include finishing, debonding, retention, and follow-up.

CONCLUSION

There is no significant difference in costs between closed and open surgical exposure with following orthodontic treatments in PDCs.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02186548.

Monopolar tonsillotomy versus cold dissection tonsillectomy in children: Prospective study on postoperative recovery

OBJECTIVES

To compare postoperative self-reported recovery results with monopolar tonsillotomy and cold dissection tonsillectomy in children. To evaluate the feasibility of the monopolar technique in tonsillotomy.

METHODS

Children <12 years undergoing tonsillotomy or tonsillectomy between April 2018 and March 2020 who (with a caregiver) were willing to participate in a two-week follow-up formed the study group. They filled in a questionnaire about pain-related outcomes, return to normal activities, weight changes, complications, and length of home care.

RESULTS

Altogether 166 patients were recruited; 103 (62%) returned the questionnaire. The first pain-free day with tonsillotomy was day 5 and with tonsillectomy day 11. After tonsillotomy, patients returned to normal activities faster, e.g. they were able to eat normally 6.5 days earlier than tonsillectomy patients. During the first postoperative week weight dropped after tonsillectomy, but not after tonsillotomy. The length of home care was 6 days with tonsillotomy and 10 days with tonsillectomy. The incidence of postoperative hemorrhage (including minor bleedings at home) was 14% after tonsillotomy and 32% after tonsillectomy. Hemorrhages needing interventions were 0% with tonsillotomy and 2% with tonsillectomy.

CONCLUSION

Children operated on with monopolar tonsillotomy recovered faster and had less postoperative hemorrhage than those undergoing tonsillectomy. They were able to return earlier to daycare/school and their caregivers back to work. Recovery results with monopolar tonsillotomy were equal to other tonsillotomy techniques reported in the literature, hence the monopolar technique can be considered an alternative method to perform tonsillotomy.

Randomised trial showed no difference in behavioural symptoms between surgical methods treating paediatric obstructive sleep apnoea

AIM

Our previous randomised controlled trial of children with obstructive sleep apnoea (OSA) showed no significant differences between adenotonsillectomy (ATE) and adenotonsillotomy (ATT) in improving nocturnal respiration and quality of life after 1 year. The aim of this report was to evaluate the effects on behavioural symptoms using the Strengths and Difficulties Questionnaire (SDQ).

METHODS

Children between 2 and 6 years with OSA were randomised to ATT or ATE. Parents, blinded to method, answered the SDQ while their child underwent polysomnography before and 1 year after surgery. Differences between the total SDQ scores were analysed between the treatment groups.

RESULTS

The SDQ was filled out in 87% of the cases preoperatively, and in 86% postoperatively. At follow-up, the mean total SDQ score was 9.6 SD ± 5.1 in the ATE group (n = 31), and 8.2 ± 6.7 in the ATT group (n = 37), P = .09. The mean total SDQ score for all was preoperatively 10.6 ± 5.0, and postoperatively 8.8 ± 6.0, P = .0002.

CONCLUSION

There were no significant differences in SDQ scores between the groups at follow-up, indicating that the more conservative ATT is a treatment option in paediatric OSA. The whole group of patients showed a significant improvement after surgery.

Caregivers' absence from work before and after tonsil surgery in children with sleep-disordered breathing

Purpose

Sleep-disordered breathing, SDB, in children is associated with morbidity that can result in caregivers having to stay at home from work. The aim of this study was to investigate whether the number of days when caregivers are reimbursed, temporary parental benefit (TPB) to stay at home from work to care for their sick child is increased among children with SDB before and after tonsil surgery.

Methods

This is a retrospective, cross-sectional study of children (n = 440), aged 2–11 years, that underwent tonsil surgery for SDB in day surgery at Sahlgrenska University Hospital in 2014 and 2015. TPB, was provided by the Swedish Social Insurance Agency. The expected days of TPB in the general population of the region were calculated. The number of days with TPB was compared 2 years before and 2 years after surgery and compared with the expected days of TPB.

Results

Two years before surgery, the children had no more days of TPB than expected. Two years after surgery, the children with SDB had 4.8 more days with TPB (p < 0.001) than expected, but, when the 1st month after surgery was excluded from the analysis, there was no difference in days of TPB compared with the general population.

Conclusion

Children with SDB who had tonsil surgery had no more days of parental benefits 2 years before and 2 years after surgery than expected. SDB is associated with increased morbidity, but it does not appear to cause caregivers to stay at home in the majority of children.

Impact of adenotonsillectomy on the evolution of inflammatory markers

BACKGROUND

Tonsils are first-line host defence organs against pathogenic agents and participate in local and systemic immunity. Persistent increases in systemic inflammatory responses may contribute to associated morbidity. The aim of this study was to verify the short- and long-term impact of adenotonsillectomy on the evolution of inflammatory markers in 3- to 9-year-old children.

METHODS

A prospective and longitudinal study was conducted over 1 year in 29 children who underwent tonsillectomy due to either chronic tonsillitis or adenotonsillar hypertrophy. Measurements of high-sensitivity C-reactive protein (hs-CRP) levels were taken. Levels of Th1-type cytokines [interleukin-1, interferon-γ, and tumor necrosis factor-α (TNF-α)] and anti-inflammatory Th2-type cytokines [interleukin-4, -5, -6, -10 and -13] were measured. Levels of transforming growth factor-beta (TGF-β) and intercellular adhesion molecule-1 (ICAM-1) were also determined. The results were compared to those of 29 control children.

RESULTS

At baseline, children with surgery indications presented with higher levels of hs-CRP, interleukin-1 and -10, interferon-γ, TNF-α and ICAM-1, whereas values of interleukin-4 were significantly lower than in control children. Children with severe tonsillar obstruction had higher values of interleukin-1, -4, and -5 and lower values of interleukin-10 compared with children with recurrent tonsillitis. One year after surgery, the levels except IL-4 did not show a significant difference from those obtained in the control group. The levels of hs-CRP and TNF-α decreased significantly in the first month.

CONCLUSION

Children with chronic tonsillitis and/or adenotonsillar hypertrophy have significantly elevated levels of proinflammatory cytokines. Adenotonsillectomy restores the normal values of these parameters 1 year after surgery.

Indirect costs and incidence of caregivers' short-term absenteeism in Poland, 2006-2016

BACKGROUND

There is a growing interest in the costs of informal care; however, the results of previous studies mostly rely on self-reported data, which is subject to numerous biases. The aim of this study is to contribute to the topic by estimating the indirect costs of short-term absenteeism associated with informal caregiving in Poland with the use of social insurance data on care absence incidence.

METHODS

The human capital method was used to estimate the indirect costs of caregiving from a societal perspective. The incidence of caregiving was identified based on the Social Insurance Institution's data on absence days attributable to care provided to children and other family members. Gross domestic product (GDP) per worker was used as a proxy of labour productivity. Deterministic one-way sensitivity analysis was performed.

RESULTS

The indirect costs of short-term caregivers' absenteeism in Poland was €306.2 million (0.116% of GDP) in 2006 and increased to €824.0 million in 2016 (0.180% of GDP). The number of care absence days grew from 5.9 million (0.45 days per worker) in 2006 to 10.6 million (0.70 days per worker) in 2016. Approximately 85% of the total costs were attributable to child care. The results of the sensitivity analysis show that the indirect costs varied from the base scenario by - 30.8 to + 15.8%.

CONCLUSION

Informal short-term caregiving leads to substantial productivity losses in the Polish economy, and the dynamic upward trend of care absence incidence suggests that the costs of caregiving are expected to rise in the future.

Adherence to Swedish guidelines for pain treatment in relation to pediatric tonsil surgery: A survey of the multidisciplinary team

BACKGROUND

Pain management in children after tonsil surgery is essential, and optimal pain treatment has been discussed for many years. Data from the National Tonsil Register in Sweden (NTRS) and a national mapping have demonstrated the need for national pain treatment guidelines for pediatric tonsil surgery. As a result, Swedish national guidelines, together with updated patient information on the website tonsilloperation.se, were developed and implemented in 2013.

OBJECTIVES

The objective of this study was to evaluate the professionals' opinions of and adherence to pain treatment guidelines for pediatric tonsil surgery patients in a two-year follow-up.

METHOD

This descriptive cross-sectional study was based on data from an inter-professional questionnaire, which was validated by an expert group using a content validity index (S-CVI 0.93). The questionnaire was sent to all Swedish ear, nose and throat (ENT) departments (n = 49) that the NTRS identified as performing tonsil surgery on children younger than 18 years of age. In each clinic, we asked for responses from staff in each of the following professions: ENT physicians, anesthesia physicians, registered nurse anesthetists, and registered nurses in the ENT departments.

RESULTS

Respondents from 48 ENT departments participated, and 139/163 (85%) completed questionnaires were returned. The guidelines were reported as being clear, ensuring patient safety and providing optimal pharmacological treatment. Treatment was given according to the guidelines: Half of the departments gave pre- or intraoperative treatment with clonidine, betamethasone and high-dose paracetamol (acetaminophen). A multimodal pain approach (paracetamol and COX-inhibitors) after hospital discharge was prescribed by all departments after tonsillectomy and, extensively, after tonsillotomy. One-third of the departments prescribed paracetamol with a higher normal dose for the first three postoperative days. Half of the departments prescribed rescue analgesics, clonidine or opioids after tonsillectomy. None of the departments prescribed codeine or tramadol, drugs that are discouraged in the guidelines. The majority of the departments used the website tonsilloperation.se to provide information to the patients and their caregivers.

CONCLUSION

The respondents' opinions of and the ENT departments adherence to the Swedish national guidelines were considered to be good. The national implementation process in Sweden has impacted the manner in which ENT departments treat pain after tonsil surgery.

Patient reported pain-related outcome measures after tonsil surgery: an analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009-2016

The objective of this study was to describe factors affecting pain after pediatric tonsil surgery, using patient reported pain-related outcome measures (pain-PROMs) from the National Tonsil Surgery Register in Sweden. In total, 32,225 tonsil surgeries on children (1 to <18 years) during 2009-2016 were included; 13,904 tonsillectomies with or without adenoidectomy (TE ± A), and 18,321 tonsillotomies with or without adenoidectomy (TT ± A). Adjustments were made for variables included in the register to compensate for contributable factors in the analysis. When compared to TE ± A for surgical indication obstruction, TT ± A resulted in lower pain-PROMs, shorter use of postoperative analgesics, earlier return to regular food intake, and lower risk for contact with health care services due to pain. Children who underwent TE ± A because of obstruction problems stopped taking painkillers and returned to normal eating habits sooner, compared to children who underwent TE ± A for infectious indications. In both indication groups, TE ± A performed with hot rather than cold technique (dissection and haemostasis) generally resulted in higher pain-PROMs. Older children reported more days on analgesics and a later return to regular food intake after TE ± A than younger ones. No clinically relevant difference between sexes was found. Between 2012 and 2016 (pre-and post-implementation of Swedish national guidelines for pain treatment), the mean duration of postoperative analgesic use had increased. In conclusion, TE ± A caused considerably higher ratings of pain-related outcome measures, compared to TT ± A. For TE ± A, cold surgical techniques (dissection and haemostasis) were superior to hot techniques in terms of pain-PROMs. Older children reported higher pain-PROMs after TE ± A than younger ones.