Perioperative Steroid Use for Tonsillectomy and Its Association With Reoperation for Posttonsillectomy Hemorrhage

Clinical epidemiology and pharmacoepidemiology studies with real-world databases

Hospital-based registry data, including patients' information collected by academic societies or government based research groups, were previously used for clinical research in Japan. Now, real-world data routinely obtained in healthcare settings are being used in clinical epidemiology and pharmacoepidemiology. Real-world data include a database of claims originating from health insurance associations for reimbursement of medical fees, diagnosis procedure combinations databases for acute inpatient care in hospitals, a drug prescription database, and electronic medical records, including patients' medical information obtained by doctors, derived from electronic records of hospitals. In the past ten years, much evidence of clinical epidemiology and pharmacoepidemiology studies using real-world data has been accumulated. The purpose of this review was to introduce clinical epidemiology and pharmacoepidemiology approaches and studies using real-world data in Japan.

Risk of peri-operative complications in children receiving preoperative steroids

BACKGROUND

Steroid use predisposes adult patients to increased perioperative complications including wound dehiscence and delayed wound healing. A similar large study investigating the perioperative impact of steroid use in pediatric patients has not been performed.

METHODS

The National Surgical Quality Improvement Project Pediatric Database was queried from 2012-2017 to identify patients who received steroid preoperatively. Patient demographics, comorbidities, surgical variables, and outcomes were compared between cohorts. Patients were propensity score matched and thirty-day adverse events were compared.

RESULTS

Of 425,251 pediatric surgery patients, 9716 (2.3%) received preoperative steroids. Pediatric patients treated with steroids were older and had more comorbidities. After propensity score matching, the steroid population had a significantly higher rate of adverse events, including prolonged hospital stay (15.3% vs. 9.1%, p < 0.001), seizure (0.9% vs. 0.4%, p < 0.001), readmission (14.4% vs. 9.2%, p < 0.001), and death (2.2% vs. 1.1%, p < 0.001).

CONCLUSION

Preoperative steroid use is independently associated with increased 30-day postoperative adverse events among pediatric patients. Given the significant impact of steroid use on surgical outcomes, the risks and benefits of steroid treatment in children receiving surgery should be carefully evaluated.

Use of preoperative haemostasis and ABO blood typing tests in children: a retrospective observational study using a nationwide claims database in Japan

OBJECTIVES

To describe the prevalence and factors associated with preoperative haemostasis and ABO blood typing tests for children because these tests might represent low-value care.

DESIGN

A retrospective observational study.

SETTING

Nationwide insurance claims database in Japan.

PARTICIPANTS

Patients aged 1-17 years who underwent common non-cardiac surgeries between April 2012 and March 2018 were included. Patients with high-risk comorbidities for bleeding (n=175) and those with multiple eligible surgeries were excluded (n=2121).

MAIN OUTCOME MEASURES

We described the proportions of each preoperative test performed within 60 days before an index surgery, including platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT) and ABO blood typing tests. We also explored the associations between patient-level and institutional-level factors and any preoperative tests, using multilevel logistic regression analysis.

RESULTS

We included 13 018 patients (median (IQR) age, 5.2 (2.9-7.7) years; 8276 (63.6%) boys) from 1499 institutions. The overall proportion of each test was as follows: platelet count, 78.6%; PT, 54.4%; aPTT, 56.4% and ABO blood typing tests, 50.4%. The proportion of patients undergoing any preoperative tests in the overall sample was 79.3%. Multilevel logistic regression analysis indicated that preoperative tests were associated with type of anaesthesia (general anaesthesia: adjusted OR 7.06; 95% CI 4.94 to 10.11), type of surgery (tonsillectomy: adjusted OR 3.45; 95% CI 2.75 to 4.33) and surgical setting (inpatient procedure: adjusted OR 5.41; 95% CI 3.83 to 7.66). There was one postoperative transfusion event (0.008%) in the entire cohort and 37 postoperative reoperation events for surgical bleeding after tonsillectomy (0.90%).

CONCLUSIONS

In the largest Japanese cohort reported to date, preoperative haemostasis and ABO blood typing tests were performed in a majority of children prior to common paediatric surgeries. Preoperative tests were associated with anaesthesia, surgical type and surgical setting.