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Tonsillectomy care varies widely among US children’s hospitals

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The tragic incident of brain death that occurred earlier this month brought to the forefront the fact that all surgical procedures come with a risk of serious consequences, including death. Thirteen year old Jahi McMath was declared brain dead following a routine tonsillectomy at Children’s Hospital Oakland. A new study, published online on January 20 in the journal Pediatrics found that the quality of care for routine tonsillectomy at US children’s hospitals varies widely.

The researchers conducted a retrospective (backward-looking) study of low-risk children undergoing same-day tonsillectomy between 2004 and 2010 at 36 children’s hospitals in the United States that provide information to the Pediatric Health Information System Database. They assessed quality of care by measuring evidence-based processes suggested by national guidelines: perioperative dexamethasone, no antibiotic use, outcomes, and 30-day tonsillectomy-related revisits to hospital. Dexamethasone (a steroid) is often given at the time of surgery to reduce postoperative nausea and vomiting.

The study group comprised 139,715 children who underwent same-day tonsillectomy. The researchers found that 10,868 (7.8%) had a 30-day revisit to hospital. Significant variability was found in regard to the administration of dexamethasone (average: 76.2%; range: 0.3-98.8%) and antibiotics (average: 16.3%; range: 2.7-92.6%) across hospitals. The most common reasons for revisits were bleeding (3.0%) and vomiting and dehydration (2.2%). Older age (10–18 vs. 1–3 years) was related to a greater risk of revisits for bleeding and a lower risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, the investigators found a significant variability across hospitals in regard to total revisits (average: 7.8%; range: 3.0-12.6%), revisits for bleeding (average: 3.0%; range 1.0-8.8%), and revisits for vomiting and dehydration (average: 1.9%; range 0.3-4.4%).

The study authors concluded that significant variation exists in the quality of care for routine tonsillectomy across US children’s hospitals as measured by perioperative dexamethasone, antibiotic use, and revisits to the hospital. They noted that their data on evidence-based processes and relevant patient outcomes should be useful for hospitals’ tonsillectomy quality improvement efforts.

Children's Hospital Oakland, this 191-bed facility, which has 166 hospital-based physicians in 30 pediatric subspecialties, from adolescent medicine to urology. Its affiliated research institute is involved in children's health issues such as pediatric obesity, cancers, sickle cell disease, HIV/AIDS, hemophilia, and cystic fibrosis. The hospital is one of only 45 freestanding children’s hospitals in the nation that are not connected to a university or other institution. In 2008, it ranked sixth in the nation for NIH awards to pediatric healthcare research programs.

Take home message:
This study points out a wide variability in the level of care provided by Children’s hospitals. Both Mattel Children's Hospital UCLA and Children’s Hospital of Orange County are ranked among the nation’s top pediatric hospitals in U.S. News & World Report's “America's Best Children's Hospitals.”

The study was conducted by researchers at the Hospital for Sick Children (Toronto, Canada), Children’s Hospital of Philadelphia (Philadelphia, Pennsylvania), Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania), Cincinnati Children’s Hospital Medical Center (Cincinnati, Ohio), University of Washington and Seattle Children’s Hospital (Seattle, Washington), Children’s Hospital Colorado (Aurora, Colorado), Children’s Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania), and University of Utah Health Sciences Center (Salt Lake City, Utah).