Readmission after Adult Uvulopalatopharyngoplasty: A Population-Based Inpatient Cohort Study in Taiwan

Epidemiology of pediatric tracheotomy: A population-based study using National Health Insurance Research Database in Taiwan

OBJECTIVE

Tracheostomy in children is a surgical procedure with considerable morbidity and mortality. However, there is still a lack of population-based survey in pediatric tracheostomy. This study analyses population-based data in pediatric tracheostomy among different ages in Taiwan.

METHODS

This study used National Health Insurance Research Database in Taiwan. All children (aged <18 years) who underwent tracheostomy during 1997-2016 were identified. We retrieved data regarding baseline characteristics, perioperative care, and mortality associated with pediatric tracheostomy, and compared differences in variables between different age groups.

RESULTS

We observed that 2300 children received tracheostomy (mean age, 8.7 years; 64% boys). Regarding the age group distribution of the patients, 585 (25.4%) were infants (<1 year), 227 (9.9%) were toddlers (1-3 years), 175 (7.6%) were preschool-aged children (3-6 years), 317 (13.8%) were school-aged children (6-12 years), and 996 (43.3%) were adolescents (12-18 years). Surgical indications included pulmonary disorders (64.9%), neurological disorders (38.4%), trauma (32.3%), head injury (25.2%), and congenital anomalies (21.5%). Of these patients, 94.9% required intensive care unit (ICU) care, with the mean length of ICU stay being 63.8 days. The mean length of hospital stay was 74.5 days. The overall mortality at the last follow-up was 43.96% (1011/2300), and the tracheostomy related mortality at the last follow-up was 1.43% (33/2300). Compared with adolescents, infants more commonly underwent tracheostomy in the northern area (66.7% vs 37.2%, P < .001), more commonly received tracheostomy indicated by congenital anomalies (53.7 vs 4.6%, P < .001), had longer ICU stays, had longer hospital stays (100.7 vs 57.5 days, P < .001), and had a higher 5-year mortality rate (42.4 vs 29.6%, P < .001). Multivariable logistic and Cox regression models revealed that young age was associated with an increased risk of prolonged hospital stay and long-term mortality, respectively.

CONCLUSIONS

This study elaborates the epidemiology of pediatric tracheostomy in different age groups.

Screening of obstructive sleep apnea in patients who snore using a patch-type device with electrocardiogram and 3-axis accelerometer

STUDY OBJECTIVES

People with obstructive sleep apnea (OSA) remain undiagnosed because of the lack of easy and comfortable screening tools. Through this study, we aimed to compare the diagnostic accuracy of chest wall motion and cyclic variation of heart rate (CVHR) in detecting OSA by using a single-lead electrocardiogram (ECG) patch with a 3-axis accelerometer.

METHODS

In total, 119 patients who snore simultaneously underwent polysomnography with a single-lead ECG patch. Signals of chest wall motion and CVHR from the single-lead ECG patch were collected. The chest effort index (CEI) was calculated using the chest wall motion recorded by a 3-axis accelerometer in the device. The ability of CEI and CVHR indices in diagnosing moderate-to-severe OSA (apnea-hypopnea index ≥ 15) was compared using the area under the curve (AUC) by using the DeLong test.

RESULTS

CVHR detected moderate-to-severe OSA with 52.9% sensitivity and 94.1% specificity (AUC: 0.76, 95% confidence interval: 0.67-0.84, optimal cutoff: 21.2 events/h). By contrast, CEI identified moderate-to-severe OSA with 80% sensitivity and 79.4% specificity (AUC: 0.87, 95% confidence interval: 0.80-0.94, optimal cutoff: 7.1 events/h). CEI significantly outperformed CVHR regarding the discrimination ability for moderate-to-severe OSA (ΔAUC: 0.11, 95% confidence interval: 0.009-0.21, P = .032). For determining severe OSA, the performance of discrimination ability was greater (AUC = 0.90, 95% confidence interval: 0.85-0.95) when combining these two signals.

CONCLUSIONS

Both CEI and CVHR recorded from a patch-type device with ECG and a 3-axis accelerometer can be used to detect moderate-to-severe OSA. Thus, incorporation of CEI is helpful in the detection of sleep apnea by using a single-lead ECG with a 3-axis accelerometer.

Effect of adenotonsillectomy on blood pressure in children with obstructive sleep apnea: a meta-analysis

BACKGROUND

While adenotonsillectomy (T&A) is widely recognized as the first-line therapy for pediatric obstructive sleep apnea (OSA), effects of T&A on blood pressure (BP) remain unclear. This meta-analysis evaluates the associations between T&A and BP in children with OSA.

METHODS

The study protocol was registered on PROSPERO (CRD42020154425). Two authors independently searched the PubMed, Medline, EMBASE, and Cochrane databases. The keywords used were "sleep apnea syndromes," "adenotonsillectomy," and "child." A random-effects model was applied to determine office systolic BP (SBP), diastolic BP (DBP), and ambulatory BP changes.

RESULT

Twelve studies with 1193 children were analyzed (mean age: 7.6 y; 54% boys). The apnea-hypopnea index significantly reduced of 9.4 events/h (95% CI, -12.0 to -6.8) after T&A. Office SBP (-0.24 mmHg; 95% CI, -1.64 to 1.16) and DBP (-1.65 mmHg; 95% CI, -3.47 to 0.17) did not decrease significantly after surgery. No significant decreases were observed in 24-h ambulatory BP after T&A. Subgroup analysis showed a significant postoperative decrease in office SBP (-6.23 mmHg; 95% CI, -7.78 to -4.67) and DBP (-7.93 mmHg; 95% CI, -10.37 to -5.48) among children with hypertension but a slight increase in office SBP (2.50 mmHg; 95% CI, 1.14 to 3.86) and DBP (1.98 mmHg; 95% CI, -0.02 to 3.98) in those without (P for heterogeneity < 0.001).

CONCLUSION

This meta-analysis suggests the office and ambulatory BP changes after T&A in children with OSA are trivial. Moreover, children with hypertension experience a significantly greater decrease in office BP than children without hypertension.

Post-Operative Sleep Endoscopy with Target-Controlled Infusion After Palatopharyngoplasty for Obstructive Sleep Apnea: Anatomical and Polysomnographic Outcomes

INTRODUCTION

The findings of drug-induced sleep endoscopy (DISE) are not always correlated with the outcome of upper airway surgery for obstructive sleep apnea (OSA), and whether multilevel surgery is truly required in treating multilevel obstruction identified in preoperative DISE remains an issue. We attempted to compare DISE findings before and after palatopharyngoplasty in patients with OSA because changes in DISE may be beneficial to better understand polysomnographic and anatomical outcomes.

METHODS

This was a prospective cohort study for 34 patients with moderate to severe OSA who underwent palatopharyngoplasty at a tertiary care center from 2016 to 2018. We recorded the patients' demographic characteristics, procedures, and surgical outcomes and compared the preoperative and postoperative DISE staging patterns.

RESULTS

The apnea-hypopnea index (AHI) values of 34 adults improved significantly after surgery (40.6 ± 23.3 versus 25.6 ± 20.6, P < 0.001). The majority of patients, 26/34, had preoperative complete concentric collapse at the velum, and for most (20/26, 77%) there was a change of the collapse pattern into anteroposterior collapse postoperatively. Patients with postoperative velar collapse had higher follow-up AHI values than those who without (27.8 ± 21.9 versus 15.2 ± 7.7, P = 0.023). Patients with preoperative complete tongue base collapse had higher follow-up AHI values than did those with no or partial collapse (40.6 ± 21.0 versus 21.0 ± 18.6, P = 0.017). Patients with postoperative complete tongue base collapse also had higher follow-up AHI values than the others (42.7 ± 22.1 versus 18.5 ± 15.4, P = 0.001).

CONCLUSION

Palatopharyngoplasty could change the collapse pattern at the velum in most patients. Preoperative and postoperative complete tongue base collapse and postoperative velar collapse identified in TCI-DISE were associated with relatively poor outcomes.

Bariatric surgery may provide better protection than uvulopalatopharyngoplasty against major adverse cardiovascular events in obese patients with obstructive sleep apnea

BACKGROUND

The major adverse cardiovascular events (MACE) risk is unclear among Asian obese patients with obstructive sleep apnea (OSA) who undergo bariatric surgery (BS) or uvulopalatopharyngoplasty (UPPP).

OBJECTIVES

We aimed to evaluate differences between Asian obese patients with OSA who underwent BS or UPPP regarding MACE.

SETTING

The Longitudinal Health Insurance Database, a subset of the NHI Research Database (NHIRD) originated from the National Health Insurance (NHI) program in Taiwan, which comprises information from 2 million randomly sampled individuals between 2000 and 2015.

METHODS

Participants aged 18-55 years whose diagnoses corresponded with codes in the International Classification of Diseases, Ninth Revision, Clinical Modification for BS, UPPP, obesity, and OSA were included in this population-based, matched cohort study of Taiwan's insurance claims data gathered between 2000 and 2015. Obese patients with OSA who underwent BS or UPPP were propensity score matched; the study's outcome was MACE.

RESULTS

A total of 1336 patients, comprising 668 in each of the BS and UPPP cohorts, were enrolled. After a mean follow-up period of 8.51 years, 166 patients, comprising 52 in the BS cohort and 114 in the UPPP cohort, experienced MACE. The adjusted hazard ratio (aHR) for MACE was .592 (95% confidence interval [CI] = .324-.789; P < .001). The BS cohort had lower risks of stroke (aHR = .663; 95% CI = .312-.890; P < .001), myocardial infarction (aHR = .116; 95% CI = .052-.135; P < .001), and mortality (aHR = .779; 95% CI = .423-.948; P = .001) than the UPPP cohort.

CONCLUSION

BS may provide greater protection against MACE than UPPP in Asian obese patients with OSA. Additional mechanistic research is needed to clarify differences between BS and UPPP in these patients.

Effect of Sleep Surgery on C-Reactive Protein Levels in Adults With Obstructive Sleep Apnea: A Meta-Analysis

OBJECTIVES/HYPOTHESIS

To evaluate associations between sleep surgery and CRP (C-reactive protein) levels in adults with obstructive sleep apnea (OSA).

STUDY DESIGN

Meta-analysis.

METHODS

Two authors independently searched PubMed, Medline, EMBASE, and Cochrane review databases until July 2019. The keywords used were sleep apnea, OSA, sleep apnea syndromes, surgery, C-reactive protein (CRP), and inflammatory markers. The effects of sleep surgery on CRP levels were examined using a random-effects model.

RESULTS

Nine studies with 277 patients were analyzed (mean age: 46.5 years; 92% men; mean sample size: 30.8 patients). The mean change in the apnea-hypopnea index (AHI) after surgery was significantly reduced by -21.1 (95% confidence interval [CI], -28.4 to -13.7) events/hr. Overall, sleep surgery resulted in a significant reduction of CRP levels in patients with OSA (standardized mean difference [SMD] = -0.39, 95% CI, -0.67 to -0.11). Patients with postoperative AHI reduction >20 events/hr achieved a greater reduction in CRP than those with AHI reduction <20 events/hr (SMD: -0.72 vs. -0.14, P for heterogeneity = .007). According to subgroup analysis, differences in the CRP levels after surgery were nonsignificant in the different countries (i.e., United States vs. other countries), CRP types (i.e., CRP vs. high-sensitivity CRP), surgical procedures (i.e., pharyngeal surgery vs. other surgical procedures), and follow-up period (i.e., <6 vs. >6 months).

CONCLUSIONS

Sleep surgery for OSA resulted in a significant reduction of CRP levels in adults. The beneficial effect of surgery on CRP levels is greater in patients with large improvement in OSA (i.e., AHI reduction >20 events/hr) after sleep surgery. Laryngoscope, 131:1180-1187, 2021.

Association of cumulative surgeon volume and risk of complications in adult uvulopalatopharyngoplasty: a population-based study in Taiwan

STUDY OBJECTIVES

Patients with obstructive sleep apnea undergoing upper airway surgery are known to have an increased perioperative risk, however, the effect of surgeon volume on this risk is largely unknown. We compared the 30-day readmission, bleeding, and mortality rates in adult patients with obstructive sleep apnea undergoing uvulopalatopharyngoplasty by cumulative surgeon volume. The objective of this study is to compare the risks of complications among different cumulative surgeon volume groups in adult patients undergoing uvulopalatopharyngoplasty and multilevel surgery.

METHODS

In this retrospective study, data of all adult inpatients (aged older than 18 years) who underwent uvulopalatopharyngoplasty in Taiwan between 2000 and 2012 were identified from the National Health Insurance Research Database and then analyzed. Using mixed-effect logistic regression, we compared the risks of major complications in patients undergoing uvulopalatopharyngoplasty alone, uvulopalatopharyngoplasty with nasal surgery, and uvulopalatopharyngoplasty with tongue or hypopharyngeal surgery according to groups of cumulative surgeon volume (divided into four quartiles).

RESULTS

A total of 36,483 adults were identified (mean age, 38.6 years; 73.7% men). When quartile 4 was used as reference, very low surgeon volume (quartile 1) was associated with higher risks of readmission within 30 days (adjusted odds ratio [aOR] 1.35, 95% confidence interval [CI] 1.17-1.57, P < .001), in-hospital death (aOR, 6.14, 95% CI 1.33-28.27, P = .020), and 30-day mortality (aOR, 4.90, 95% CI 1.83-13.09, P = .002).

CONCLUSIONS

Higher complication rates in uvulopalatopharyngoplasty appear to be associated with very low cumulative surgeon volume.

Trends in the management of peritonsillar abscess in children: A nationwide population-based study in Taiwan

OBJECTIVE

Population-based studies analyzing peritonsillar abscess in children are lacking. In this study, a population-based survey of the epidemiology of pediatric peritonsillar abscess in Taiwan was conducted.

METHODS

This cross-sectional study was conducted using the Taiwan National Health Insurance Research Database. All cases of inpatient pediatric peritonsillar abscess (age < 18 years) in Taiwan between 2000 and 2012 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification. Incidence rates of inpatient peritonsillar abscess in children were calculated. Characteristics such as age, gender, hospital level, treatment modalities, imaging studies, drug administration, and length of hospital stays during the study period were analyzed.

RESULTS

A total of 12,965 children with peritonsillar abscess were included (mean age, 6.6 years [standard deviation, 4.8 years]; 56.5% boys). The overall incidence was 18 per 100,000 children. Incidence rates decreased from 2000 to 2012 (19.1/100,000 to 8.3/100,000 children) (p_trend < 0.001). During the study period, the proportion of peritonsillar abscess treatments at medical centers increased from 4.6% to 15.0%. The proportion of treatments involving incision and drainage or needle aspiration increased significantly (1.3%-4.1% and 49.4%-65.6%, respectively), whereas treatments with antibiotics only decreased significantly (48.9%-29.0%). The use of computed tomography (CT) increased (1.4%-12%, p_trend < 0.001). The use of nonsteroidal anti-inflammatory drugs, steroids, and penicillin increased during the study period. The mean length of hospital stays increased from 3.78 to 4.67 days.

CONCLUSIONS

The incidence of peritonsillar abscess in children decreased between 2000 and 2012 in Taiwan. Moreover, increasing trends were observed in the use of CT, the rates of incision and drainage and needle aspiration procedures, and the length of hospital stay in this study cohort.

Does Insurance Status Impact Delivery of Care with Upper Airway Stimulation for OSA?

OBJECTIVE

To understand differences in patient demographics, insurance-related treatment delays, and average waiting times for Medicare and private insurance patients undergoing upper airway stimulation (UAS) for treatment of obstructive sleep apnea (OSA).

METHODS

Retrospective chart review of all Medicare and private insurance patients undergoing upper airway stimulation (UAS) from 2015 to 2018 at a single academic center. Primary outcomes were insurance-related procedure cancellation rate and time from drug induced sleep endoscopy (DISE) and UAS treatment recommendation to UAS surgery in Medicare versus private insurance patients.

RESULTS

In our cohort 207 underwent DISE and were recommended treatment with UAS. Forty-four patients with Medicare and 30 patients with private insurance underwent UAS procedure. Patients with Medicare undergoing UAS were older (67.4 ± 11.1 years) than patients with private insurance (54.9 ± 8.1 years). Medicare patients had a shorter mean wait time of 121.9 ± 75.8 days (range, 15-331 days) from the time of UAS treatment recommendation to UAS surgery when compared to patients with private insurance (201.3 ± 102.2 days; range, 33-477 days). Three patients with Medicare (6.4%) and 8 patients with private insurance (21.1%) were ultimately denied UAS.

CONCLUSION

Medicare patients undergoing UAS have shorter waiting periods, fewer insurance-related treatment delays and may experience fewer procedure cancellations when compared to patients with private insurance. The investigational status of UAS by private insurance companies delays care for patients with OSA.

LEVEL OF EVIDENCE

4.

Incidence of Multilevel Surgical Procedures and Readmissions in Uvulopalatopharyngoplasty in Taiwan

Importance

Multilevel surgical procedures with uvulopalatopharyngoplasty (UPPP) appear to be associated with more complications than UPPP alone, but general and bleeding-related hospital readmissions have not been specifically investigated to date.

Objective

To compare the risk of 30-day general and bleeding-related readmissions in adult patients who underwent UPPP alone and those who received a multilevel surgical procedure.

Design, Setting, and Participants

This cross-sectional study retrospectively analyzed all cases of UPPP among adults (aged >20 years) in Taiwan from January 1, 2000, to December 31, 2012. Claims data in the Taiwan National Health Insurance Research Database were used. Participants were patients who underwent inpatient UPPP (n = 35 029), and their basic information was acquired from the database. Data analyses were conducted from June 22, 2018, to August 22, 2018.

Main Outcomes and Measures

The risks of major complications in patients who underwent UPPP alone, UPPP with nasal operation, and UPPP with tongue or hypopharyngeal operation were compared using a generalized linear mixed model.

Results

In total, 35 029 adults were identified (mean [SD] age of 39.2 [12.2] years, and 25 923 men [74.0%]). The proportion of UPPP concurrent with nasal operation increased from 2000 to 2012 (19.9% to 42.9%), as did that of UPPP with concurrent tongue or hypopharyngeal operation (2.7% to 5.2%). The rate of readmission for any reason after UPPP with nasal operation was higher than that for UPPP alone (4.7% vs 3.7%; adjusted odds ratio [aOR], 1.22; 95% CI, 1.09-1.37). The rate of readmission for any reason and readmission for bleeding for UPPP with tongue or hypopharyngeal operation (aOR, 1.68; 95% CI, 1.34-2.11) was also higher than that for UPPP alone (aOR, 2.34; 95% CI, 1.72-3.17). However, a multilevel surgical procedure was not associated with an increased risk of bleeding-related reoperation, regardless of the concurrent procedure.

Conclusions and Relevance

The incidence of multilevel UPPP in Taiwan increased from 2000 to 2012, and these surgeries appeared to be associated with a higher risk of complications; results of this study suggest that these findings should be considered during surgical decision-making.