From the Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois.
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland.
Anesth Analg. 2018 Aug;127(2):478-484. doi: 10.1213/ANE.0000000000003540.
Pediatric adenotonsillectomies are common and carry known risks of potentially severe complications. Complications that require a revisit, to either the emergency department or hospital readmission, increase costs and may be tied to lower reimbursements by federal programs. In 2011 and 2012, recommendations by pediatric and surgical organizations regarding selection of candidates for ambulatory procedures were issued. We hypothesized that guideline-associated changes in practice patterns would lower the odds of revisits. The primary objective of this study was to assess whether the odds of a complication-related revisit decreased after publication of guidelines after accounting for preintervention temporal trends and levels. The secondary objective was to determine whether temporal associations existed between guideline publication and characteristics of the ambulatory surgical population.
This study employs an interrupted time series design to evaluate the longitudinal effects of clinical guidelines on revisits. The outcome was defined as revisits after ambulatory tonsillectomy for privately insured patients. Data were sourced from the Truven Health Analytics MarketScan database, 2008-2015. Revisits were defined by the most prevalent complication types: hemorrhage, dehydration, pain, nausea, respiratory problem, infection, and fever. Time periods were defined by surgeries before, between, and after guidelines publication. Unadjusted odds ratios estimated associations between revisits and clinical covariates. Multivariable logistic regression was used to estimate the impact of guidelines on revisits. Differences in revisit trends among pre-, peri-, and postguideline periods were tested using the Wald test. Results were statistically significant at P < .005.
A total of 326,993 surgeries met study criteria. The absolute revisit rate increased over time, from 5.9% (95% confidence interval [CI], 5.8-6.0) to 6.7% (95% CI, 6.6-6.9). The proportion of young children declined slightly, from 6.4% to 5.9% (P < .001). The proportion of patients having a tonsillectomy in an ambulatory surgery center increased (16.5%-31%; P < .001), as did the prevalence of obstructive sleep apnea (7.0%-14.0%; P < .001) and sleep-disordered breathing (20.6%-35.0%; P < .001). In a multivariable logistic regression model adjusted for age, sex, comorbidities, and surgical location, odds of a revisit increased during the preguideline period (0.4% increase per month; 95% CI, 0.24%-0.54%; P < .001). This monthly increase did not continue after guidelines (P = .002).
While odds of a postoperative revisit did not decline after guideline publication, there was a significant difference in trend between the pre- and postguideline periods. Changes in the ambulatory surgery population also suggest at least partial adherence to guidelines.
小儿腺样体扁桃体切除术很常见，且存在潜在严重并发症的已知风险。需要再次就诊的并发症，无论是去急诊还是再次住院，都会增加成本，并且可能会导致联邦项目的报销金额降低。2011 年和 2012 年，儿科和外科组织发布了有关选择门诊手术候选人的建议。我们假设，指南相关实践模式的改变会降低再次就诊的几率。本研究的主要目的是评估在指南发布后，是否在考虑干预前的时间趋势和水平的情况下，与并发症相关的再次就诊的几率会降低。次要目标是确定指南发布与门诊手术人群特征之间是否存在时间关联。
本研究采用中断时间序列设计来评估临床指南对再次就诊的纵向影响。该研究的结果定义为接受门诊扁桃体切除术的私人保险患者的再次就诊。数据来源于 2008 年至 2015 年的 Truven Health Analytics MarketScan 数据库。再次就诊的定义是由最常见的并发症类型：出血、脱水、疼痛、恶心、呼吸问题、感染和发热引起的。时间段定义为手术前、手术中和手术后的指南发布时间。未调整的优势比估计了再次就诊与临床变量之间的关联。多变量逻辑回归用于估计指南对再次就诊的影响。使用 Wald 检验测试了指南前后期间再次就诊趋势的差异。结果在 P<.005 时具有统计学意义。
共有 326993 例手术符合研究标准。绝对再次就诊率随时间增加，从 5.9%（95%置信区间 [CI]，5.8-6.0）增加到 6.7%（95% CI，6.6-6.9）。年幼儿童的比例略有下降，从 6.4%降至 5.9%（P<.001）。在门诊手术中心进行扁桃体切除术的患者比例增加（16.5%-31%；P<.001），阻塞性睡眠呼吸暂停（7.0%-14.0%；P<.001）和睡眠呼吸障碍（20.6%-35.0%；P<.001）的患病率也增加。在调整年龄、性别、合并症和手术部位的多变量逻辑回归模型中，与术前相比，再次就诊的几率在术前期间增加（每月增加 0.4%；95% CI，0.24%-0.54%；P<.001）。该月的增加在指南发布后并未持续（P=.002）。
尽管术后再次就诊的几率在指南发布后并未下降，但在指南前后期间趋势存在显著差异。门诊手术人群的变化也表明至少部分遵守了指南。
