Variability of adenoidectomy/tonsillectomy rates among children of the Veneto Region, Italy

Revisiting systematic geographical variations in tonsils surgery in children in the Spanish National Health System: spatiotemporal ecological study on hospital administrative data

OBJECTIVE

To provide new evidence on how tonsils surgery in children has geographically varied over time in the context of the Spanish National Health System.

DESIGN

Observational ecological spatiotemporal study on geographical variations in medical practice, using linked administrative datasets, including virtually all surgeries performed from 2003 to 2015.

SETTING

The Spanish National Health System, a quasi-federal structure with 17 autonomous communities (ACs), and 203 healthcare areas (HCAs).

PARTICIPANTS

Patients aged 19 and younger residing in the HCAs and ACs.

INTERVENTIONS

Tonsillectomy with adenoidectomy (T&A); and tonsillectomies alone (T). MAIN ENDPOINTS: (1) Evolution of T&A and T rates; (2) spatiotemporal variation in the risk of receiving T&A or T surgery at regional level (ACs) and HCAs; and (3) the fraction of the variation (FV) attributed to each of the components of variation-ACs, HCAs, year and interaction ACs year.

RESULTS

T&A age-sex standardised rates increased over the period of analysis from 15.2 to 20.9 (5.7 points per 10 000 inhabitants). T alone remained relatively lower than T&A rates, evolving from 3.6 in 2003 to 3.9 in 2015 (0.3 points per 10 000 inhabitants). Most of the risk variation was captured at the HCAs level in both procedures (FV: 55.3% in T&A and 72.5% in T). The ACs level explained 27.6% of the FV in the risk in T&A versus 8% in T. The interaction ACs year was similar in both procedures (FV: 15.5% in T&A and 17.5% in T). The average trend hardly explained 1.46% and 1.83% of the variation, respectively.

CONCLUSION

Our study showed wide persistent variations with a steady increase in rates and risk of T&A and a stagnation of T alone, where most of the variation risk was explained at HCA level.

The impact of new evidence on regional variation in paediatric tonsillectomy and adenoidectomy: a historical review

BACKGROUND

Tonsillectomy and adenoidectomy have been among the most commonly performed procedures in children for approximately 100 years. These procedures were the first for which unwarranted regional variation was discovered, in 1938. Indications for these procedures have become stricter over time, which might have reduced regional practice variation.

METHODS

This paper presents a historical review on practice variation in paediatric tonsillectomy and adenoidectomy rates. Data on publication year, region, level of variation, methodology and outcomes were collected.

RESULTS

Twenty-one articles on practice variation in paediatric tonsil surgery were included, with data from 12 different countries. Significant variation was found throughout the years, although a greater than 10-fold variation was observed only in the earliest publications.

CONCLUSION

No evidence has yet been found that better indications for tonsillectomy and adenoidectomy have reduced practice variation. International efforts are needed to reconsider why we are still unable to tackle this variation.

[Is the number of tonsillectomies and tonsillotomies a relevant issue? German version]

BACKGROUND

A second-opinion procedure was introduced for (adeno)tonsillectomy and tonsillotomy in 2018 by the Federal Joint Committee, due to the assumed high prevalence of both procedures. This study was conducted to quantify and analyze both types of tonsil surgery in Germany.

METHODS

Data from the Federal Office of Statistics on the number of procedures and population size were used to calculate annual intervention rates between 2005 and 2017. Percentual changes in intervention rates compared to the previous year were calculated for Germany, for the total number of ENT specialists, for the ENT specialists of the federal states, and for four age groups (≤10; ≤20; ≤40; >40 years).

RESULTS

Regression analysis revealed a significant decrease in (adeno)tonsillectomy and a significant increase in tonsillotomy in each investigated year (p < 0.001; exception: 2006 for adenotonsillectomy). Surgical rates of tonsillectomy and tonsillotomy decreased significantly with age (p < 0.001). There was no clear relationship between the density of ENT specialists in the different federal states and the number of surgical procedures.

CONCLUSION

There was no clear association between the surgical prevalence and the density of ENT specialists. The significant decrease in rates of (adeno)tonsillectomy began in 2005 and the tonsillotomy rates have been increasing since 2007, albeit without a compensatory effect. Both procedures are on the list of the 50 most frequently performed operations. The decreasing total number of both surgical procedures questions the value of a second-opinion procedure as suggested by the Federal Joint Committee. Tonsil surgery is significantly associated with young age (<10 years) and discussions on surgery rates must consider the age structure of the investigated population, since this is the most important influencing factor in tonsil surgery.

Regional variability of hemorrhage following tonsil surgery in 1,520,234 cases

PURPOSE

To evaluate, whether the regional variability of tonsil surgery in terms of the 16 Federal States of Germany was mirrored by a comparable variability of bleeding complications in male and female patients.

METHODS

A longitudinal population-based inpatient cohort study was performed including all patients who had undergone tonsil surgery between 2005 and 2018. The database was provided by the Federal Statistical Office of Germany and included all inpatient cases after tonsillectomy (with or without adenoidectomy), tonsillotomy, abscess-tonsillectomy and secondary tonsillectomy. The population was stratified by region (16 Federal States) and gender. Operation rates were calculated in relation to the end-year population number of each region. Bleeding percentages were calculated for each calendar year and region as the number of procedures to achieve hemostasis divided by the total number of operations.

RESULTS

The surgical rates varied significantly between the 16 Federal States in male, female and all patients (p = 0.001). Revision surgery to achieve hemostasis was predominantly performed in male patients (5.2-11.4% male vs. 3.7-7.6% female patients). Bleeding percentages did not differ significantly from national values in male and female patients in 5 Federal States, but were significantly higher than the national average in 3 Federal States and significantly lower in 7 Federal States for both genders (p < 0.05), while in 1 Federal State it was significantly lower only for the male patients. Pearson's correlation coefficient for surgical and bleeding rates was positive and statistically significant (p < 0.05) for all Federal States, except for two. This phenomenon was emphasized by female gender.

CONCLUSIONS

Gender had an impact not only on surgical rates but also on bleeding percentages and this was independent from the decrease in the total number of operations. Surprisingly, there was a clear correlation between the rates of both variables in the majority of the Federal States of Germany. It needs further studies to clarify, why a higher prevalence of surgical practice, thus surgical experience, was not followed by lower bleeding complications.

Is the number of tonsillectomies and tonsillotomies a relevant issue?

BACKGROUND

A second-opinion procedure was introduced for (adeno)tonsillectomy and tonsillotomy in 2018 by the Federal Joint Committee, due to the assumed high prevalence of both procedures. This study was conducted to quantify and analyze both types of tonsil surgery in Germany.

METHODS

Data from the Federal Office of Statistics on the number of procedures and population size were used to calculate annual intervention rates between 2005 and 2017. Percentual changes in intervention rates compared to the previous year were calculated for Germany, for the total number of ENT specialists, for the ENT specialists of the federal states, and for four age groups (≤10; ≤20; ≤40; >40 years).

RESULTS

Regression analysis revealed a significant decrease in (adeno)tonsillectomy and a significant increase in tonsillotomy in each investigated year (p < 0.001; exception: 2006 for adenotonsillectomy). Surgical rates of tonsillectomy and tonsillotomy decreased significantly with age (p < 0.001). There was no clear relationship between the density of ENT specialists in the different federal states and the number of surgical procedures.

CONCLUSION

There was no clear association between the surgical prevalence and the density of ENT specialists. The significant decrease in rates of (adeno)tonsillectomy began in 2005 and the tonsillotomy rates have been increasing since 2007, albeit without a compensatory effect. Both procedures are on the list of the 50 most frequently performed operations. The decreasing total number of both surgical procedures questions the value of a second-opinion procedure as suggested by the Federal Joint Committee. Tonsil surgery is significantly associated with young age (<10 years) and discussions on surgery rates must consider the age structure of the investigated population, since this is the most important influencing factor in tonsil surgery.

Tonsil surgery in the federal states of Germany: similarities and differences

BACKGROUND

Tonsillectomy remains a common procedure in Germany. However, demographic changes, the advent of tonsillotomy, and current guidelines may have an impact on the overall incidence.

OBJECTIVE

To longitudinally evaluate the number of tonsillectomies, with (ATE) or without adenoidectomy (TE), and tonsillotomies (TT) performed annually in Germany.

MATERIALS AND METHODS

Based on comprehensive data from the Federal Office for Statistics, the number of patients undergoing the above-stated surgical procedures on an inpatient basis was retrospectively assessed in terms of year and federal state, without restriction by age or gender. Annual rates of ATE, TE, and TT were calculated based on population statistics. Regression analysis was performed to compare different federal states, years, and age groups. The variables were compared using the Pearson correlation coefficient.

RESULTS

Between 2005 and 2017, 1,313,449 tonsil surgeries were registered. There was a considerable decrease in the overall incidence rate (per 100,000) of TE (92 to 43), which was even more pronounced for ATE (51 to 15). In contrast, an increased TT rate (6 to 22) was observed. Correlation analysis revealed a strong positive correlation (r = 0.986).

CONCLUSION

The change of trends in tonsil surgery started long before relevant national guidelines were published. The national trend was associated with considerably less surgical activity overall, a significant decrease in ATE/TE, and a significant increase in TT. Regional differences to the national trend were identified and found to be significant in at least in 7 of 16 federal states.

[Tonsil surgery in the federal states of Germany: similarities and differences. German version]

BACKGROUND

Tonsillectomy remains a common procedure in Germany. However, demographic changes, the advent of tonsillotomy, and current guidelines may have an impact on the overall incidence.

OBJECTIVE

To longitudinally evaluate the number of tonsillectomies, with (ATE) or without adenoidectomy (TE), and tonsillotomies (TT) performed annually in Germany.

MATERIALS AND METHODS

Based on comprehensive data from the Federal Office for Statistics, the number of patients undergoing the above-stated surgical procedures on an inpatient basis was retrospectively assessed in terms of year and federal state, without restriction by age or gender. Annual rates of ATE, TE, and TT were calculated based on population statistics. Regression analysis was performed to compare different federal states, years, and age groups. The variables were compared using the Pearson correlation coefficient.

RESULTS

Between 2005 and 2017, 1,313,449 tonsil surgeries were registered. There was a considerable decrease in the overall incidence rate (per 100,000) of TE (92 to 43), which was even more pronounced for ATE (51 to 15). In contrast, an increased TT rate (6 to 22) was observed. Correlation analysis revealed a strong positive correlation (r = 0.986).

CONCLUSION

The change of trends in tonsil surgery started long before relevant national guidelines were published. The national trend was associated with considerably less surgical activity overall, a significant decrease in ATE/TE, and a significant increase in TT. Regional differences to the national trend were identified and found to be significant in at least in 7 of 16 federal states.

Factors associated with changing indications for adenotonsillectomy: A population-based longitudinal study

OBJECTIVE

Adenotonsillectomy (AT) is one of the most common surgical procedures performed in children and adults. We aim to assess the factors associated with changes in the incidence of and indications for AT using population-level data.

STUDY DESIGN

This retrospective cohort study investigated patients who underwent AT between 1997 and 2010 by using data from the Taiwan National Health Insurance Research Database. We examined surgical rates and indications by the calendar year as well as age, sex, hospital level, and insured residence areas for the correlating factors.

RESULTS

The average annual incidence rate of AT was 14.7 per 100,000 individuals during 1997-2010. Pediatric (<18 years) patients represented 48.2% of the total AT population. More than 99% of the patients underwent the AT procedures as an inpatient intervention. Longitudinal data demonstrated an increasing trend in the pediatric AT rates from 1997 (4.3/100,000) to 2010 (5.7/100,000) (p = 0.029). In the adult subgroup, a decreasing prevalence of infectious indications (p = 0.014) coincided with an increasing neoplastic indications (p = 0.001). In the pediatric subgroup, the prevalence of obstructive indications increased (p = 0.002). The logistic regression analyses indicated that the significant factors associated with the changing surgical indications for AT were the age in the adult subgroup and hospital level in the pediatric subgroup.

CONCLUSIONS

This study revealed a low AT rate in Taiwan than that in other countries. Pediatric AT incidence increased during 1997-2010. Although a rising prevalence of obstructive and neoplastic indications was noted, infection remained the most common indications for AT. Age in the adult subgroup and hospital level in the pediatric subgroup were factors associated with the changing indications for AT.

Variation in tonsillectomy rates by health care system type

OBJECTIVE

To analyze variation in tonsillectomy procedure rates between health care system types around the world.

STUDY DESIGN

International database analysis.

METHODS

The 2015 Organization for Economic Co-operation and Development (OECD) Health Statistics surgical procedures database was used to ascertain tonsillectomy procedure volumes for 31 countries. Each country's health system type and structure were classified by overall system type, and by health care regulation, financing, and provision methods. Each system type and structure variable were compared using the rate of tonsillectomy procedures per 100,000 citizens.

RESULTS

10.5 million tonsillectomy procedures completed between 1993 and 2014 were analyzed. Overall, social health insurance system types had higher total tonsillectomy rates versus other health care system types (p < 0.05 for each comparison). Health systems with private care provision had a higher procedure rate versus state provided care (159.1 vs. 131.1 per 100,000 citizens; p = 0.002). Health care systems with societal regulation and financing had a higher procedure count versus state regulated or financed care (regulation 193.3 vs. 139.7 per 100,000 citizens, p < 0.0001; financing 168.2 vs. 135.0 per 100,000 citizens, p = 0.0004).

CONCLUSIONS

The volume of tonsillectomy procedures is associated with a health care system's overall structure, regulation, financing, and provision methods. International health care systems with state mediated provision, regulation, and financing had lower tonsillectomy rates versus systems with private provision, and societal regulation or financing. Further study is needed to determine differences in indications for tonsillectomy between countries, but these results underscore potential variation in health care delivery in different systems.

Tonsillectomy, adenoidectomy and adenotonsillectomy rates in school-aged children: Relative contributions of socio-demographic and clinical features

OBJECTIVES

The present study sought to investigate the frequencies of tonsillectomy, adenoidectomy and both adenotonsillectomy (T&A) among 6-12 years old children. In addition, we tried to find out the predictors associated with these previous upper respiratory tract (URT) surgeries.

METHODS

This cross-sectional study consisted of 1900 children educated in 3 different elementary schools in Ankara, Turkey. Data about demographics and health conditions were obtained from survey questionnaires completed by parents.

RESULTS

Of the 1900 children, 15 children (0.8%) previously underwent tonsillectomy, 43 children (2.3%) had adenoidectomy and 80 children (4.2%) had T&A surgical histories. Multiple logistic regression analysis revealed that older students compared to younger ones [odds ratio (OR) = 1.15, p = 0.011], and those who had parent-reported apnea compared to subjects without apnea were more likely to have URT surgery histories [OR = 2.34, p = 0.001]. Those children with surgery histories were more likely to have fathers with a higher educational level [medium level: OR = 2.07, p = 0.012; high level: OR = 2.79, p = 0.001 vs. low level) and the subjects had greater BMI percentiles [overweight: OR = 1.71, p = 0.036; obesity: OR = 2.32, p = 0.003 vs. healthy weight]. Children who had 1-2 URT infections per year [OR = 0.47, p = 0.019] had less probability of URT surgery histories, whereas those children with AOM ≥ 3 times per year [OR = 2.52, p = 0.003] had more probability of URT surgery history.

CONCLUSIONS

We conclude that a reasonable explanation for higher rates of URT surgery among children with a high level of paternal education may originate from their awareness about URT associated diseases and possibly due to the ease of access to health care services.

Influences of demographic changes and medical insurance status on tonsillectomy and adenoidectomy rates in Korea

In Korea, the proportion of the pediatric population is decreasing due to low fertility rates and aging of the society. It is hypothesized that this change in population structure and medical insurance status may affect rates of elective surgeries more significantly than clinical factors. An observational study conducted using data from the Health Insurance Review and Assessment Service for tonsillectomy and adenoidectomy, with 403,924 registered patients from 2007 through 2011. We analyzed longitudinal changes in crude and age-adjusted surgery rates of three surgeries-tonsillectomy without adenoidectomy (T), adenoidectomy without tonsillectomy (A), and tonsillectomy with adenoidectomy (T&A)-according to medical insurance status: health insurance (HI) group (better economic status) versus health aid (HA) group (poorer economic status). Most of the surgeries (51.8 % of T, 93.7 % of A, and 95.1 % of T&A) were performed in patients younger than 15. Over 5 years, the proportion of the child population numbers decreased, from 17.43 to 15.41 % in the HI group and from 21.20 to 13.15 % in the HA group. Thus, crude surgery rates for T, A, and T&A decreased more rapidly in the HA group (7.50, 14.79, and 15.55 %) than the HI group (1.69, 1.49, and 0.90 %) each year. Adjusted surgery rates for T, A, and T&A increased in the HI group (1.01, 2.64, and 3.36 %) and decreased in the HA group (1.39, 2.86, and 2.76 %) each year. These adjusted surgery rates partially explains the sharper decrease in crude surgery rates in the HA group than the HI group. The crude and adjusted rates of surgeries were usually higher in lower economic status groups. In conclusion, surgery rates were affected by changes in the population structure, but by other factors as well. Predictable socioeconomic factors could be used to calculate and predict the rates for other well-established surgeries.

Pediatric adenoidectomy: a population-based regional study on epidemiology and outcome

OBJECTIVES

To evaluate population-based data on incidence of pediatric adenoidectomy and rate of revision surgery.

METHODS

A retrospective study of all adenoidectomies in children was performed in the year 2009 in all otolaryngology departments in one federal state, Thuringia, in Germany. Patients' characteristics, preoperative diagnostics and postoperative complications were analyzed. The association between baseline characteristics and the risk of re-adenoidectomy was examined using Kaplan-Meier method with univariate log-rank test, and with a multivariate Cox regression model. Population data were used to calculate age-related annual rates of adenoidectomies.

RESULTS

1939 adenoidectomies were performed in 2009 in Thuringia. 89% were primary cases and 11% of the children already had an adenoidectomy prior to 2009. Immediate re-surgery because of primary hemorrhage was necessary in 0.8% of the cases. Re-adenoidectomy because of recurrent symptoms was needed in 9% of patients after a median interval of 16 months. The univariate analysis showed that the factors age ≤3 years and primary surgery were significantly associated to a higher risk of surgery because of recurrent symptoms The multivariate analysis showed that primary surgery was independently associated with the risk of re-surgery (hazard ratio 1.66; 95% confidence interval 1.01-2.74). The annual adenoidectomy rate was 678/100,000 underage habitants. The incidence was highest between 2 and 4 years of age.

CONCLUSIONS

This population based analysis is showing that adenoidectomy is performed country-wide with good results and low risk on important scale in daily routine by otorhinolaryngologists. The risk of re-adenoidectomy seems to be higher than hitherto reported by hospital-based studies.

How to make tonsillectomy a safer procedure: the anaesthetist's view

Anaesthetists use specific drugs peri-operatively to try to decrease the incidence and severity of postoperative pain and of postoperative nausea and vomiting. These drugs are usually administered pre-operatively with the premedication, or intra-operatively when the patient is still anaesthetised. The aim of this approach is to prevent the occurrence of intolerable pain or to avoid any nausea or vomiting symptoms which may be clearly unpleasant for the patient and which interfere with the patient's well-being, recovery and satisfaction. However, since most of these drugs are given prophylactically, and since not all patients will actually be suffering from intolerable pain or severe nausea and vomiting symptoms postoperatively, many patients will receive these drugs unnecessarily. Thus, for the individual patient, the risk of suffering from drug-related adverse reactions without profiting from any benefit may be relevant. Perhaps a 'wait-and-see' approach should be considered; especially non-steroidal anti-inflammatory drugs or dexamethasone should not be given pre-operatively to all patients but should be provided exclusively to those in whom alternative analgesics (for instance, paracetamol combined with a weak opioid) or alternative anti-emetics (for instance, a setron or droperidol) have failed or are associated with unacceptable adverse effects. There is no evidence that prophylactic administration of an analgesic or an anti-emetic is more efficacious than the therapeutic administration. An interesting alternative to achieve satisfactory posttonsillectomy analgesia may be with local anaesthesia swabs that are applied onto the wound.

Is variation management included in regional healthcare governance systems? Some proposals from Italy

The Italian National Health System, which follows a Beveridge model, provides universal healthcare coverage through general taxation. Universal coverage provides uniform healthcare access to citizens and is the characteristic usually considered the added value of a welfare system financed by tax revenues. Nonetheless, wide differences in practice patterns, health outcomes and regional usages of resources that cannot be justified by differences in patient needs have been demonstrated to exist. Beginning with the experience of the health care system of the Tuscany region (Italy), this study describes the first steps of a long-term approach to proactively address the issue of geographic variation in healthcare. In particular, the study highlights how the unwarranted variation management has been addressed in a region with a high degree of managerial control over the delivery of health care and a consolidated performance evaluation system, by first, considering it a high priority objective and then by actively integrating it into the regional planning and control mechanism. The implications of this study can be useful to policy makers, professionals and managers, and will contribute to the understanding of how the management of variation can be implemented with performance measurements and financial incentives.

Does Adenotonsillectomy really reduced clinic visits for pediatric upper respiratory tract infections? A national database study in Taiwan

OBJECTIVE

To investigate whether adenotonsillectomy reduces upper respiratory tract infections (URIs) in the pediatric population.

METHODS AND SUBJECTS

We identified 415 children, aged ≤18 years who had undergone adenoidectomy and/or tonsillectomy during the period from 1999 to 2006, from the Taiwan National Health Insurance Research Database. The comparison group consisted of 1630 children without the surgery randomly selected from the same database frequency matched with sex, age and the surgery date (index date). Changes in physician visits for URIs 2-year period before and 2-year period after the index date were compared between the two groups of children.

RESULTS

The number of outpatient visits for URIs decreased with time, children with tonsillectomy and/or adenoidectomy had a greater reduction than comparison children (mean changes, -14 times and -6 times, respectively) in the 2-year period after the index date. Multivariate analyses using generalized estimated equation revealed a significant effect in reducing URIs visits from the surgery (relative ratio=0.85, p<0.0001), strongest for children undergoing both tonsillectomy and adenoidectomy (relative ratio=0.76, p<0.0001). The association between surgery and the decrease in URIs was more pronounced for children aged 12 years and less.

CONCLUSION

This population-based study suggests that tonsillectomy and/or adenoidectomy is associated with fewer physician visits for URIs. The association is weakened in old children.

Effects of guidelines on adeno-tonsillar surgery on the clinical behaviour of otorhinolaryngologists in Italy

Background

Several guidelines on adeno-tonsillar disease have been proposed in recent years and some discrepancies in relation both to clinical manifestations and indications for surgical treatment have emerged. The aim of the study was to verify what influence (adeno)-tonsillectomy guidelines have had on the clinical behaviour of ENT specialists in Italy. Our study is a retrospective and multi-centre case series with chart review.

Methods

The survey involved 14,770 children, aged between the ages of 2 and 11, who had undergone adeno-tonsillar surgery between 2002 and 2008 in fourteen Italian tertiary and secondary referral centres. Anova test was used for the statistical analysis, assuming p < 0.05 as the minimum statistical significance value.

Results

The frequency of adeno-tonsillar surgeries did not change significantly (p>0.05) during the study period and following the Italian policy document publication. Overall, adeno-tonsillectomy was the most frequent intervention (64.1%), followed by adenoidectomy (31.1%) and tonsillectomy (4.8%). The indications for surgery did not change significantly for each of the operations (p>0.05), with the exception of adeno-tonsillectomy in case of feverish episodes due to acute recurrent tonsillitis ≥ 5 without nasal obstruction (decreased p= 0.010) , even when the feverish episodes due to acute recurrent tonsillitis were < 5 over the last year. Nasal obstruction was associated with feverish episodes due to acute recurrent tonsillitis in 65.2% of operated cases, while otitis media had been diagnosed in 43.3% of the patients studied.

Conclusions

The recommendations first developed in Italy in a 2003 policy document and then resumed in guidelines in 2008, were not implemented by ENT units involved in the survey. The study highlights the fact that the indications for adeno-tonsillar operations are based on the overall clinical presentation (comorbidity) rather than on a single symptom. Guidelines are necessary to give coherent recommendations based on both the findings obtained through randomized controlled trials and the data collected from observational studies.