Healthcare disparities in revisits for complications after adult tonsillectomy

Healthcare Disparities in Otolaryngology

Purpose of Review

The purpose of this review is to summarize some of the recent research studies on healthcare disparities across various subspecialties within otolaryngology. This review also highlights the impact of COVID-19 pandemic on disparities and proposes potential interventions to mitigate disparities.

Recent Findings

Significant healthcare disparities in care and treatment outcomes have been reported across all areas of otolaryngology. Notable differences in survival, disease recurrence, and overall mortality have been noted based on race, ethnicity, socioeconomic status (SES), insurance status, etc. This is most well-researched in head and neck cancer (HNC) within otolaryngology.

Summary

Healthcare disparities have been identified by numerous research studies within otolaryngology for many vulnerable groups that include racial and ethnic minority groups, low-income populations, and individuals from rural areas among many others. These populations continue to experience suboptimal access to timely, quality otolaryngologic care that exacerbate disparities in health outcomes.

Complications of canine tonsillectomy by clamping technique combined with monopolar electrosurgery - a retrospective study of 39 cases

Background

Canine tonsillectomy is performed due to acute or chronic tonsillitis, neoplasia, trauma or occasionally brachycephalic obstructive airway syndrome. Several tonsillectomy techniques are used but information about surgical complications is scarce. This retrospective study of patient records at the University Animal Hospital aimed to investigate complications related to canine tonsillectomy performed by 20-min clamping combined with monopolar electrosurgery.

Inclusion criteria were bilateral tonsillectomy performed with “20-min clamping technique combined with monopolar electrosurgery without suture or ligation”. Exclusion criteria were unilateral tonsillectomy, tonsillar neoplasia, additional surgical procedures other than tonsillectomy, cases where sutures were used initially, and cases where unspecified or other methods of tonsillectomy were used. The search of the patient records of the University Animal Hospital included a 10-year period. Complications that required additional anaesthesia were defined as major complications. Minor complications were handled during surgery or after surgery without surgical intervention.

Results

Of 39 dogs that fulfilled the inclusion criteria, 11 dogs had complications and out of those 1 dog had two complications. Altogether, of the 12 complications, 2 were classified as major complications and 10 as minor.

The most frequent complication was bleeding from the surgical site, in total 11 incidences; 10 dogs had an incidence of bleeding and out of those, 1 dog bled twice, both during and after surgery. Of these 10 dogs that bled, seven incidences of bleeding occurred during surgery and four incidences occurred after surgery. The two dogs with major complications were re-anaesthetized due to bleeding after surgery. No lethal complications occurred and all dogs survived to discharge.

Conclusions

Bleeding during and after surgery was a common complication in dogs after bilateral tonsillectomy using “20-min clamping technique combined with monopolar electrocautery”. Revision intervention was often needed, sometimes urgently. Although no comparison was made with another technique, the studied technique should be used with caution.

Adult tonsillectomy: An evaluation of indications and complications

OBJECTIVE

This study aimed to evaluate current adult tonsillectomy indications along with risk factors associated with postoperative complications.

METHODS

In this retrospective chart review, demographic, clinical, and surgical data were collected from 2004 to 2020 of adult patients who underwent tonsillectomy. Indications for surgery were categorized as infectious etiology, biopsy, obstructive sleep apnea (OSA), and tonsillar stones. Data regarding postoperative hemorrhage, emergency department (ED) visits, and readmissions were collected. Multivariable logistic regression models were used to evaluate factors associated with postoperative complications.

RESULTS

574 adults (mean age 32 years, 69.9% F vs. 30.1% M) were included. The most common indication was infections (62.2%), followed by biopsy (26.5%), tonsillar stones (6.8%), and OSA (4.5%). The highest frequency of postoperative bleeds (17.9%) occurred in the tonsillar stones cohort; however, the indication for surgery was not a significant predictor on multivariate analysis. Male sex and younger age were independent predictors of postoperative bleeding, while younger age was a significant predictor of postoperative ED visits. There was a significant linear trend of an increasing proportion of tonsillectomies performed for tonsillar stones compared to other indications for 2011-2019.

CONCLUSION

Infectious etiology was the most common indication for tonsillectomy. Indication for surgery was not a significant predictor of postoperative bleeding; however, male sex and younger age had higher odds of postoperative bleeding. The proportion of tonsillectomies performed for tonsillar stones was steadily increasing.

The Value of Diversity, Equity, and Inclusion in Otolaryngology

Diversity impacts performance of our teams, fosters innovation, and improves outcomes of our patients in otolaryngology head and neck surgery. In addition to the moral imperative, increasing the otolaryngology diversity workforce will decrease health care disparities while equity and justice can increase the culture humility to take care of an increasingly diverse patient population. To move toward justice, otolaryngology departments need to end biases in faculty hiring, development, research evaluations, and publication practices. The more intentional our efforts, the more benefit to our patients, providers, staff, learners, and society.

Demographic Characteristics of Children Diagnosed with Bacterial Tracheitis

OBJECTIVES

Examine the presentation and clinical course of patients with bacterial tracheitis (BT). Identify if socioeconomic differences exist among children who present with BT.

METHODS

This was a retrospective case series from a tertiary care pediatric medical center. The study group included patients less than 18 years old who were diagnosed with BT from January 2011 to March 2019. Patients with a tracheostomy and those who developed BT after prolonged hospitalization were excluded. Patient demographics were compared with the demographics of the counties surrounding the hospital.

RESULTS

33 patients with BT met inclusion criteria. The most common presenting symptoms were difficulty breathing, stridor, and sore throat (81.8% each), followed by cough (78.8%). Median length of stay was 3 days [interquartile range (IQR):2-4]. 19 patients (57.5%) were admitted to the intensive care unit. Intubation was required for 13 patients (39.4%), for a median length of 2 days [IQR:2-2]. Methicillin sensitive staphylococcus aureus was the most common bacterial etiology (33%). Mean presenting age was 8.58 years [95% confidence interval:7.3-9.9] and 14 patients were female (42.4%). 31 patients were white (93.9%), 1 was black (3%), and 1 was Hispanic (3%). BT patients were more likely to have private insurance compared to comparison (81.8% vs 63.4%, P < .001).

CONCLUSION

Children who presented with BT were more likely to be privately insured than a comparison population.

Postoperative hemorrhage following coblation tonsillectomy with and without suture: A randomized study in Chinese adults

PURPOSE

Coblation tonsillectomy (TE) increases gradually in China. Hemorrhage is the main complication after tonsillectomy. The conclusions of the studies about suture after tonsillectomy are conflicting. To compare the post-tonsillectomy hemorrhage (PTH) rates in patients who underwent coblation with vs. without suture.

MATERIALS AND METHODS

This was a randomized controlled study of adult patients who underwent coblation TE at our hospital between 01/2017 and 08/2019. The patients were randomized to TE with or without suture. The primary endpoint was the secondary PTH. The secondary endpoints included the primary PTH, grade of PTH, and incidence of PTH within 4 weeks post-TE.

RESULTS

There were no differences between the two groups regarding sex, age, disease course, and BMI (all P > 0.05). The occurrence of secondary PTH was lower in the suture group compared with the non-suture group (2.8% vs. 7.7%, P = 0.016). Compared with non-suture group, the incidence of PTH within 4 weeks (2.8% vs. 10.6%, P = 0.009) and the PTH degree (P = 0.02) were all significantly lower in the suture group.

CONCLUSION

Intraoperative suture reduces the secondary PTH in adult patients who underwent coblation tonsillectomy. The incidence of PTH within 4 weeks, PTH degree and pain might all improved for intraoperative suture.

Self-Reported Complications after Tonsillectomy: Comparison of Responders and Nonresponders to a Mailed Questionnaire

Some studies of tonsillectomy outcomes have low response rates to mailed quality control questionnaires. This study evaluated the effect of nonresponders to mailed questionnaires about posttonsillectomy complications by determining whether mail responders and nonresponders differ. Questionnaires were mailed to patients 3-6 weeks after tonsillectomy to assess postoperative complications, defined as contact with a private practitioner and/or hospital readmission related to postsurgical bleeding, pain, or infection. Nonresponders to the mailed questionnaire were interviewed by telephone 7-11 weeks postoperatively, and responses of mail and telephone responders were compared. Of 818 patients undergoing tonsillectomy during the study period, 66.3% responded by mail, and 29.5% were interviewed by telephone, for a total response rate of 95.7%. The mail response rate was significantly higher among parents of pediatric patients than among adult patients (71.4% versus 58.7%, p < 0.001). In the pediatric group, overall complication rates were 65% higher among mail responders than telephone responders (20.9% versus 12.7%, p=0.049), likely due to their higher rates of both visits to private practitioners and infection, as there were no differences in rates of pediatric readmission, bleeding, or pain between the responder groups. Among adult patients, mail and telephone responders did not differ with respect to their overall complication rate (40.9% versus 34.1%, p=0.226) or their rates of readmission or bleeding. However, similar to the pediatric group, visits to a private practitioner were slightly more common among adult mail responders than telephone responders (30.6% versus 21.1%, p=0.065), as were reports of pain (p=0.001) and infection (p=0.006). Studies relying on mailed questionnaires with low response rates likely overestimate the rate of minor complications handled outside the hospital, but rates of major complications involving readmission are unlikely to be seriously biased by low response rates. Supplementing mailed questionnaires with telephone interviews may increase the validity of surgical outcome studies.

Revisit Rates for Pediatric Tonsillectomy: An Analysis of Admit and Discharge Times

Objective:

To determine the association between intraday timing of outpatient pediatric tonsillectomy and revisit outcomes and complications.

Study Design:

Cross-sectional analysis of New York databases.

Setting:

Ambulatory surgery, emergency department and inpatient hospital settings.

Subjects and Methods:

The State Ambulatory Surgery, State Emergency Department and State Inpatient Databases for 2010-2011 were analyzed for revisits. Outcomes assessed were revisits for any reason, bleeding, acute pain or fever, nausea, vomiting and dehydration. The relationships between the hour of admission for surgery, the hour of discharge and the revisit outcomes were analyzed.

Results:

The study included 33,611 children (mean age, 6.62 years; 45.7% female) and 62.0% were admitted in the early morning. Discharges were most common in the early afternoon (28.3%). Revisit rates were significantly higher for the early evening discharges (6.0%) versus late morning discharges (3.1%) ( P < .001). Revisits for bleeding were 1.8% for discharge in the early evening versus 0.6% in the late morning ( P < .001). Revisits for fever, nausea, vomiting or dehydration were 1.8% for discharge in the early evening versus 0.9% in the late morning ( P = .002). Late afternoon admission was significantly associated with higher revisit rates (10.9%, P < .001). Bleeding revisits were highest for late afternoon admit hour (1.5%, P = .001). Revisits for acute pain were also highest for late afternoon admit hour (2.3%, P = .005).

Conclusion:

Revisit are significantly higher when the patient is discharged late. Late afternoon surgery is also significantly associated with higher revisit rates. Surgeons may wish to consider these findings when a late tonsillectomy or late discharge is anticipated post-tonsillectomy.

Postoperative hemorrhage following tonsillectomy in adults: Analysis of population-based inpatient cohort in Taiwan

OBJECTIVE

Because of the lack of population-based analyses, this study elucidated the epidemiology and 30-day postoperative complications of inpatient adult tonsillectomies in Taiwan.

METHODS

Using the Taiwan National Health Insurance Research Database, we identified all inpatient adult tonsillectomies (age>20years) in Taiwan during 1997-2012 through International Codes of Diseases, 9th Revision. Trend of the inpatient tonsillectomy in adult during the study period was explored. Major complications of readmission, reoperation, and mortality within 30days after tonsillectomies were identified. Factors associated with major complications were analyzed using multivariate logistic model.

RESULTS

In total, 27,365 adults received inpatient tonsillectomies (mean age, 38.4±13.0years; 57.2% male). The overall incidence was 10.2 per 100,000 population per year among adults. Incidence rates increased from 1997 (8.2/100,000 adults) to 2012 (11.2/100,000 adults) (P trend<0.001). The rate of readmission for any reason, readmission for bleeding, reoperation for bleeding, and mortality were 4.9%, 2.2%, 1%, and 0.1%, respectively. Young age increased the risk of bleeding-related readmission and reoperation, whereas old age increased the risk of readmission for any reason and mortality. Male gender increased the risk of all major complications. Hypertension was associated with an increased risk of bleeding-related readmission (odds ratio [OR]=2.21; 95% confidence interval [CI] 1.68-2.92) and reoperation (OR=2.17; 95% CI 1.44-3.27). Existing catastrophic illness increased the risk of readmission (OR=4.28; 95% CI 3.60-5.08) for any reason and mortality (OR=3.24; 95% CI 1.37-7.65). Nonsteroidal anti-inflammatory drugs and steroids were associated with an increased risk of readmission or reoperation for bleeding.

CONCLUSION

Incidence rates of inpatient adult tonsillectomy increased during 1997-2012 in Taiwan. Age, gender, comorbidity, and drug administration characteristics were associated with major complications of adult tonsillectomies in this cohort.

Reoperation following Adult Tonsillectomy

Objective

Tonsillectomy remains a common procedure in adults; however, there are few population-level data evaluating risk factors for reoperation.

Study Design

Retrospective review of national database.

Setting

American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2005-2013.

Subjects and Methods

The ACS-NSQIP was queried for patients undergoing tonsillectomy ± adenoidectomy as their primary procedure ( CPT 42821 or 42826). Demographic information and indications were reviewed along with complications and reoperation rates.

Results

In total, 12,542 cases met inclusion criteria. Patients were predominantly female (66.4%) and white (70.8%), with mean age of 30 ± 12 years (range: 16-90+). Thirty-day mortality was 0.03%, and 4.8% of patients experienced at least 1 complication, including reoperation (3.6%). Risk of complications was associated with male sex ( P < .0001; odds ratio [OR], 1.7), diabetes ( P = .0002; OR, 2.1), and presence of a bleeding disorder ( P = .002; OR, 3.2). Risk factors for reoperation were similar, in addition to older age ( P = .002; OR, 0.986). Complications other than reoperation were correlated with older age ( P = .001; OR, 1.02) and diabetes ( P = .001; OR, 2.59). Procedures were done mostly for infectious/inflammatory (70.4%) versus hypertrophic (16.4%) indications. Indication had no significant effect on the rate of reoperation. Most reoperations occurred after postoperative day 1 (86%; mean, 6.4 ± 4.2 days).

Conclusion

This review of a large validated surgical database provides an overview of the rates of, and risk factors for, complications and reoperations following tonsillectomy in the adult population.