NHS Wasting Millions on Child Tonsillectomies

Peter Russell

November 06, 2018

Seven out of eight children in the UK who undergo tonsillectomy are unlikely to benefit from the surgery, a study found.

However, many children who could benefit from having their tonsils removed are not having the surgical procedure, said researchers from the University of Birmingham.

Recurrent or chronic sore throat is the most common indication for tonsillectomy in the UK. There is evidence to show that surgery results in modest, short-term reductions in recurrent sore throats in severely affected children aged 3 to 15 but not in those with milder symptoms.

UK guidelines suggest offering tonsillectomy for children in line with the Paradise criteria: seven or more documented sore throats in a year, or five or more such episodes in each of the preceding 2 years, or three or more such episodes in each of the preceding 3 years.

Furthermore, sore throats should be characterised by at least one of the following: lymphadenopathy, tonsillar pus, fever, or evidence of streptococcal infection.

The NHS carried out approximately 37,000 tonsillectomies on children from April 2016 to March 2017, at a cost of £42 million.

Study of UK Medical Records

The researchers conducted a retrospective cohort study of more than 1.6 million electronic medical records of children aged up to 15 years who were registered with 739 UK general practices.

They found that out of 18,281 children who had their tonsils removed between 2005 and 2016, only 2144 (11.7%) had evidence-based indications to justify surgery.

They said most childhood tonsillectomies were performed after non-evidence-based symptoms. Of these 12.4% had only five to six sore throats in a year; 44.7% reported two to four sore throats in a year; and 9.9% had experienced only one sore throat in a year. Other reasons for surgery were sleep disordered breathing (12.3%), or obstructive sleep apnoea (3.9%).

The findings of the study, published in the British Journal of General Practice , suggested that 32,500 children undergo needless tonsillectomies at a cost to the NHS of £36.9 million.

Children Who Might Benefit 'Missing Out'

The data also suggested that many children who might benefit from tonsillectomy were not undergoing the procedure. The researchers found that out of 15,760 children who had records showing symptoms matching the Paradise criteria, only 2144 (13.6%) went on to have a tonsillectomy.

The study authors said their findings have some implications for UK clinical practice. They said doctors should already be informing parents of the likely effectiveness of tonsillectomy, "and should now also inform them that most children with either recurrent sore throats or sleep apnoea do not undergo tonsillectomy and have no need to".

Co-author Tom Marshall, professor or public health and primary care at the University of Birmingham, said: "Our research showed that most children who had their tonsils removed weren't severely enough affected to justify treatment, while on the other hand, most children who were severely enough affected with frequent sore throats did not have their tonsils removed.

"The pattern changed little over the 12 year period.

"Children may be more harmed than helped by a tonsillectomy. We found that even among severely affected children, only a tiny minority ever have their tonsils out. It makes you wonder if tonsillectomy [is] ever really essential in any child."

Reaction to the Study

Commenting on the research, UK ENT said surgeons use evidence from a number of sources including the referral letter from the child’s general practitioner and a careful history obtained from the child’s parents when making a decision whether a child should be offered surgery.

The statement also said: "However, it is the experience of many UK ENT surgeons that parents of children with recurrent tonsillitis are often unable to access care from their own GP when their child has acute tonsillitis – they may seek medical attention from other sources such as hospital emergency departments, walk-in primary care facilities, or may decide not to take the child to see a doctor but self-manage with simple analgesia.

"As a result it is unlikely that a paper based on GP attendances as a measure of whether guidelines are being followed is an accurate reflection of the reality of clinical practice."

NHS England already announced plans to reduce the number of tonsillectomies, along with other "ineffective or risky" treatments. It said the procedure carried a significant risk of bleeding that could require emergency surgery, while pain control could lead to rehospitalisation.

An NHS England spokesperson said: "This study shows why the NHS, the medical profession and patients are working together to phase out operations that don’t work or are inappropriate, which means better patient care and a more efficient use of taxpayer funding."

Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic records, Šumilo et al, Br J Gen Pract 5 November 2018. Abstract.

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