Tonsillectomy Guidelines Improve Processes but Not Outcomes

Susan London

June 24, 2015

In the 2 years after publication of national guidelines on tonsillectomy quality of care, there were favorable changes in medication use among children undergoing this operation, according to a retrospective cohort study published online June 22 in Pediatrics. However, the proportion of children returning to the hospital because of complications increased.

Investigators assessed the effect of the 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines among otherwise healthy children undergoing tonsillectomy between 2009 and 2013 at 29 US children's hospitals participating in the Pediatric Health Information System.

The guidelines recommend using perioperative dexamethasone to prevent postoperative nausea and vomiting and avoiding perioperative prophylactic antibiotics, given their lack of benefit in reducing infections or bleeding. They also recommend that hospitals implement effective pain management strategies, with discharge education for caregivers, as well as monitoring of postoperative hemorrhage rates.

Using administrative data and diagnosis codes, the investigators compared medication use and outcomes among 54,043 children operated on during the preguideline period and 57,770 children operated on during the postguideline period. The team was led by Sanjay Mahant, MD, FRCPC, from the Division of Pediatric Medicine, Pediatric Outcomes Research Team, Department of Pediatrics, Institute of Health Policy, Management and Evaluation, University of Toronto, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.

Results showed small but significant increases in dexamethasone use, going from 74.6% to 77.4% (P < .001), and the rate of change in use, with the percentage change per month rising from −0.02% to 0.29% (P < .001).

"There are many reasons why physicians may not adhere to clinical practice guideline recommendations," the investigators note.

"Uncertainty about the safety of dexamethasone and disagreement with guideline recommendations may explain the lack of greater adoption," they add.

At the same time, there were significant marked decreases in antibiotic use, going from 34.7% to 21.8% (P < .001), and the rate of change in use, with the percentage change per month continuing to decline from −0.17% to −0.56% (P < .001).

"This reduction in unnecessary antibiotic use minimizes the potential for antibiotic adverse events and emergence of antimicrobial resistance, and it contributes to antibiotic stewardship efforts," the investigators maintain.

Total revisits to the hospital for tonsillectomy complications within 30 days increased significantly, from 8.2% to 9.0%. This was driven by an increase in revisits for pain, as revisits for bleeding remained constant.

The overall revisit finding "is not surprising because there is a lack of evidence on the most important factors or bundle of care necessary to reduce tonsillectomy-related revisits," the investigators write.

During the study, the US Food and Drug Administration began requiring a boxed warning on codeine-containing products pertaining to risks associated with their use after tonsillectomy in children and a contraindication to their use in this population; the American Academy of Otolaryngology Head and Neck Surgery endorsed these requirements.

"With this practice shift in pain management, it is possible that a lack of comfort with alternatives, such as ibuprofen or selective use of morphine, resulted in undertreatment of pain and an increase in revisits. Our observation of increased revisits due to pain warrants additional exploration to understand the actual practice of tonsillectomy pain medication prescription and management as an area for improvement," they recommend.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online June 22, 2015. Abstract


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