Original Research—Pediatric Otolaryngology
Associations between Socioeconomic Status and Race with Complications after Tonsillectomy in Children
Otolaryngology– Head and Neck Surgery 2014, Vol. 151(6) 1055–1060 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814552647 http://otojournal.org
Neil Bhattacharyya, MD1, and Nina L. Shapiro, MD2
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
burden of increased revisits and acute pain diagnoses after tonsillectomy deserve further attention.
Abstract Objective. To determine if disparities exist for revisits and complications after pediatric tonsillectomy.
Keywords
Study Design. Cross-sectional analysis of multistate databases. Setting. Ambulatory surgery. Methods. Cases of pediatric tonsillectomy with or without adenoidectomy were extracted from state ambulatory surgery databases and linked to state emergency department databases and inpatient databases for California, Iowa, Florida, and New York for 2010 and 2011. Revisit rates and diagnoses within 14 days were analyzed for potential associations of these complications with sex, race, and median household income quartile. Results. There were 79,520 cases of pediatric tonsillectomy that were extracted (50.3% male; mean age, 7.5 years). Overall, 6419 patients (8.1%) incurred a revisit after the procedure. Revisit rates for posttonsillectomy bleeding, acute pain, and fever/dehydration were 2.1%, 1.5%, and 2.2%, respectively. On multivariate analysis, increasing household income quartile was significantly associated with a decreasing rate of all complications: revisits (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.84-0.89), posttonsillectomy bleeding (OR, 0.91; 95% CI, 0.86-0.96), acute pain (OR, 0.79; 95% CI, 0.740.84), and fever/dehydration (OR, 0.93; 95% CI, 0.890.98). Female sex was associated with a decreased rate of posttonsillectomy hemorrhaging (OR, 0.81; 95% CI, 0.73-0.91). Black and Hispanic children had an increased risk for a revisit after tonsillectomy (OR, 1.11; 95% CI, 1.01-1.22; and OR, 1.17; 95% CI, 1.09-1.26, respectively) and increased odds for acute pain at the revisit (OR, 1.36; 95% CI, 1.10-1.67; and OR, 1.34; 95% CI, 1.141.57, respectively) relative to white children. Race was not associated with the rate of hemorrhage posttonsillectomy. Conclusion. Significant disparities, particularly with respect to household income, exist in the incidence of revisits and complications after pediatric tonsillectomy. The disparate
tonsillectomy, children, disparities, complications, bleeding, readmission, revisits, household income, race Received May 28, 2014; revised August 5, 2014; accepted September 3, 2014.
D
isparities in health care have long been the subject of continued investigation, analysis, and controversy over the past several decades. Such investigations seek to identify disparities in the access to and the provision of health care to identify disadvantaged populations that may be targeted for improvements in the delivery of care. For example, we recently demonstrated that a family income below the federal poverty level predicted increased odds for frequent ear infections among children in the United States but that significant disparities according to race or insurance did not exist with respect to antibiotic prescribing for acute otitis media at the point of care.1,2 In a recent systematic review, Boss and associates3 found racial/ ethnic and socioeconomic disparities in the access to care including adenotonsillectomy for children with sleep disordered breathing. Although some issues related to disparities in the access to care in the pediatric otolaryngology arena have been probed, relatively little data are available concerning disparities in outcomes after otolaryngologic care and treatment. Pediatric adenotonsillectomy is one of the most commonly performed pediatric surgical procedures in the United States, with close to 500,000 ambulatory procedures
1 Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA 2 Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Corresponding Author: Neil Bhattacharyya, MD, Division of Otolaryngology, Harvard Medical School, 45 Francis Street, Boston, MA 02115, USA Email: [email protected]
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performed in children annually.4,5 Unfortunately, pediatric adenotonsillectomy is also subject to a significant complication rate after the procedure, with our group and others reporting revisit rates approaching 7.8% and a reported posttonsillectomy bleeding rate of 0.05% to 2.0%.6-8 While many studies have focused on procedural components (eg, surgical technique) that may be related to posttonsillectomy complications in bleeding rates, there are little data regarding patient factors that may be associated with these complications, including demographic risk factors.7 We sought to determine if disparities in postoperative outcomes after pediatric tonsillectomy with or without adenoidectomy that might pertain to racial, ethnic, and/or socioeconomic factors exist among children undergoing these procedures.
Methods Cases of ambulatory pediatric (age \18.0 years) tonsillectomy or adenotonsillectomy were extracted from the state ambulatory surgery databases for New York, Florida, Iowa, and California for calendar years 2010 and 2011. These cases were linked to the corresponding state emergency department databases and state inpatient databases for visit encounters occurring after tonsillectomy but within a 14-day postoperative window.9 Tonsillectomy cases performed for malignancy as the primary diagnosis were explicitly excluded. These databases are part of the Healthcare Cost and Utilization Project maintained by the Agency for Healthcare Research and Quality.10 This study was reviewed by our hospital’s committee on clinical investigations and deemed exempt from review as the data are de-identified and are available to the public. Data extraction was conducted by the first author (N.B.), who has significant prior experience working with and publishing on national health care data. Standard demographic information was extracted and tabulated for the cases of pediatric tonsillectomy/adenotonsillectomy. Race/ethnicity was categorized as white, black, Hispanic, or other (including Asian/Pacific Islander and Native American) as reported by the patient/caregiver. Household income was assigned to 1 of the 4 state’s median household income quartiles to represent socioeconomic status. The presence or absence of asthma as a primary childhood comorbidity was also determined if any one of the diagnosis codes available in the state ambulatory surgery database at the time of the procedure coded for asthma. Next, for each case, whether a revisit occurred (including readmission) was determined; the timing (postoperative day from tonsillectomy) of the revisit was also tabulated. The primary revisit diagnoses (based on the primary or first diagnosis code listed) were codified as the following: posttonsillectomy bleeding, acute pain, or fever/nausea/vomiting/dehydration (FNVD). All diagnoses at the time of the revisit were examined to determine if any of the diagnoses encompassed posttonsillectomy bleeding. After univariate analysis, multivariate analysis was conducted with logistic regression to determine the associations between sex, race, and household income; age and asthma (as a comorbidity factor) with the occurrence of a revisit (or readmission); and
Figure 1. Race/ethnicity distribution of children undergoing tonsillectomy.
revisit diagnoses for posttonsillectomy bleeding, acute pain, or FNVD.
Results A total of 79,520 cases of pediatric tonsillectomy with or without adenotonsillectomy were examined across 4 states. There was an equal sex distribution (50.3% male), with a mean age of 7.45 years. Figure 1 depicts the relative racial/ethnic distribution of the patients. A comorbid asthma diagnosis was present in 9.6% of children undergoing tonsillectomy. Overall, 6419 patients or 8.1% had a revisit (to the emergency department, inpatient admission, or the ambulatory surgery center) within 14 days after their tonsillectomy procedure. The rate of any diagnosis of posttonsillectomy bleeding at the revisit was 2.1% (1652 cases). The rates of acute pain as a primary revisit diagnosis and FNVD as a primary revisit diagnosis were 1.5% (1180 cases) and 2.2% (1765 cases), respectively. The most common primary revisit diagnoses not captured among the categories above were the following: pneumonia (62 cases; 0.08% among all adenotonsillectomy cases), constipation (36 cases; 0.05%), viral infection (31 cases; 0.04%), urinary tract infection (31 cases; 0.04%), abdominal pain (31 cases; 0.04%), and asthma (31 cases; 0.04%). Table 1 presents the univariate analysis for the associations between sex, race, and household income with the revisit rate, rate of posttonsillectomy bleeding, primary diagnosis of acute pain at revisit, and primary diagnosis of FNVD at revisit. Table 2 presents the multivariate analysis for the relationships between the revisit rate and patient age, sex, race, and household income. Increasing household income quartile was strongly associated with a decreased likelihood of a posttonsillectomy revisit, as was increasing age (although the latter had a relatively small odds ratio). Both black and Hispanic patients had increased odds for a revisit relative to white patients, whereas ‘‘other’’ race/
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Table 1. Univariate Analysis of Factors Associated with Revisits after Pediatric Tonsillectomy. Variable
Revisit Rate, %
Sex Male Female Race White Black Hispanic Other Household income First quartilea Second quartile Third quartile Fourth quartile Asthma No Yes
P Value
Bleeding, %
P Value
Acute Pain, %
P Value
FNVD, %
P Value
7.97 8.12
.435
2.10 2.01
.392
1.34 1.59
.004
2.24 2.22
.850
7.57 9.10 9.38 7.01
\.001
2.09 1.77 2.17 1.79
.103
1.22 1.93 1.87 1.17
\.001
2.14 2.63 2.62 1.83
\.001
9.17 8.36 7.65 5.73
\.001
2.13 2.09 2.00 1.71
.031
1.78 1.59 1.26 0.77
\.001
2.45 2.30 2.19 1.80
.001
7.78 10.80
\.001
2.04 2.42
.027
1.40 2.32
\.001
2.15 2.91
\.001
Abbreviation: FNVD, fever/nausea/vomiting/dehydration. a The first quartile represents the poorest quartile.
Table 2. Multivariate Analysis for Revisit Rate with Age, Sex, Race, and Household Income after Pediatric Tonsillectomy. Variable
Wald
Significance
Odds Ratio
95% Confidence Interval
Female sex Household income quartile Race White Black Hispanic Other Age Asthma Constant
0.1 105.6
.769 \.001
1.01 0.87
0.95-1.07 0.84-0.89
Reference 4.6 19.5 2.3 51.2 51.2 2468.3
.032 \.001 .130 \.001 \.001 \.001
1.11 1.17 0.92 1.03 1.38
1.01-1.22 1.09-1.26 0.82-1.03 1.02-1.03 1.26-1.51
ethnicities did not. Finally, sex was not associated with the likelihood of a revisit. Similarly, Tables 3 to 5 present the multivariate analysis for the relationships among posttonsillectomy bleeding rate, primary diagnosis of acute pain at revisit, and primary diagnosis of FNVD at revisit and age, sex, race, and income. In all instances, increasing median household income quartile was associated with a lower rate of revisits for these diagnoses.
Discussion In this large-scale, multistate, multivariate analysis of revisits and complications after pediatric tonsillectomy, we found that significant disparities in complication rates exist among children undergoing tonsillectomy. We found a strong association between median household income and complication rates: In all instances, an increasing family
household income was associated with a significantly decreased odds ratio for revisits and complications. For example, with respect to revisits after pediatric tonsillectomy, a child in the lowest (poorest) quartile for household income had increased odds of 1.53 for a revisit and increased odds of 1.33 for posttonsillectomy hemorrhaging as compared to a child in the highest household income quartile. Although the absolute difference in percentages for complications between groups was relatively small, given that approximately 480,000 tonsillectomy procedures are performed in children each year in the United States, this small difference in percentages related to the disparity results is a significant difference in absolute numbers of children with complications.5 For example, based on current census data, Hispanic patients would be expected to suffer more than 1700 additional disparity-related revisits, and
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Table 3. Multivariate Analysis for Bleeding with Age, Sex, Race, and Household Income after Pediatric Tonsillectomy. Variable Female sex Household income quartile Race White Black Hispanic Other Age Asthma Constant
Wald
Significance
Odds Ratio
95% Confidence Interval
12.7 12.5
\.001 \.001
0.81 0.91
0.73-0.91 0.86-0.96
Reference 2.3 0.4 1.3 329.0 2.7 2216.7
.131 .509 .250 \.001 .103 \.001
0.85 1.05 0.88 1.12 1.16
0.70-1.05 0.91-1.21 0.70-1.10 1.10-1.13 0.97-1.39
Table 4. Multivariate Analysis for Acute Pain Revisits with Age, Sex, Race, and Household Income after Pediatric Tonsillectomy. Variable Female sex Household income quartile Race White Black Hispanic Other Age Asthma Constant
Wald 3.3 50.4 Reference 8.4 12.2 0.0 59.6 27.1 1536.9
Significance
Odds Ratio
95% Confidence Interval
.070 \.001
1.13 0.79
0.99-1.30 0.74-0.84
.004 \.001 .994 \.001 \.001 \.001
1.36 1.34 1.00 1.06 1.64
1.10-1.67 1.14-1.57 0.77-1.30 1.05-1.08 1.36-1.97
Table 5. Multivariate Analysis for FNVD Revisits with Age, Sex, Race, and Household Income after Pediatric Tonsillectomy. Variable Female sex Household income quartile Race White Black Hispanic Other Age Asthma Constant
Wald
Significance
Odds Ratio
95% Confidence Interval
.241 .005
1.06 0.93
0.96-1.18 0.89-0.98
.231 .004 .072 \.001 .015 \.001
1.11 1.21 0.82 0.93 1.23
0.94-1.32 1.06-1.37 0.66-1.02 0.91-0.94 1.04-1.45
1.4 8.0 Reference 1.4 8.3 3.2 103.0 5.9 1342.8
Abbreviation: FNVD, fever/nausea/vomiting/dehydration.
patients in the lowest income quartile would be expected to have more than 3000 additional revisits compared to children in the highest income quartile each year.11 The overall revisit rates following outpatient pediatric adenotonsillectomy have recently been reviewed. Mahant et al6 found that 7.8% of children revisited the emergency room,
ambulatory care center, or physician’s office following adenotonsillectomy. Notably, that study included only those children having undergone surgery at freestanding children’s hospitals. Our study builds on our previous report by adding a full additional year of data, which allows for a more robust analysis of a relatively overall low complication rate with
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respect to demographic disparities and includes children having undergone surgeries at both specialty and nonspecialty ambulatory care centers in 4 states across the United States.8 We found an overall posttonsillectomy revisit rate of 8.1%, which is similar to the rate found by Mahant et al.6 The present study found an association between family income quartile and pediatric posttonsillectomy complications while controlling for age, sex, race, and asthma. Income disparity has been used as a marker for socioeconomic, educational, and insurance status and has been correlated to both higher risk-adjusted morbidity as well as mortality. As in prior studies, we were not able to completely adjust for preoperative risk status, but we did adjust for the most common childhood ailment likely to be present in the outpatient setting: asthma. All patients in our cohort underwent one type of surgery (adenotonsillectomy) specifically in an ambulatory surgery setting, which would assume relatively low perioperative risks across all demographics. We also found a slightly lower risk of posttonsillectomy hemorrhaging in females as compared to males (odds ratio, 0.77; P \ .001). Stone et al12 also found a similar difference in postoperative morbidity outcomes in females compared to males (odds ratio, 0.87; P \ .001). Their database included 101,083 children undergoing several types of pediatric surgical procedures, including appendectomy, pyloromyotomy, and several other abdominal procedures. Despite this wide range of surgical procedures, the odds ratio for postoperative morbidity for females compared to males was strikingly similar to ours. Other investigators have also found a lower rate of posttonsillectomy hemorrhaging in female versus male patients.13 We also found a higher incidence of posttonsillectomy revisits in black and Hispanic children, specifically related to postoperative pain. The issue of postoperative pain with respect to race has been evaluated in the adult population and more recently in the pediatric population. In an adult Medicaid population, Baugh et al14 reviewed indications for postoperative revisits following surgical correction of obstructive sleep apnea. The majority of surgical procedures (n = 404) were performed in the ambulatory setting, and the most common adverse outcome requiring a postoperative emergency room visit was a pain-related diagnosis (51% of all revisits). Sadhasivam et al15 performed a prospective analysis of 194 healthy children undergoing tonsillectomy. An assessment of postoperative recovery room analgesia was conducted after all patients received the same weight-dependent dose of intraoperative morphine (0.2 mg/kg). Black children experienced significantly more postoperative recovery room pain than white children. Pain parameters included postoperative opioid requirements (P = .0011), maximum postoperative pain scores (P \ .0001), and analgesic interventions (P \ .0001). Conversely, while white children received overall lower perioperative doses of morphine, they incurred more adverse effects related to opioid analgesics. These data, taken with our study, suggest that further inquiry into the interactions between posttonsillectomy pain and race is warranted. Pediatric surgical outcomes have been evaluated with a focus on primary payer status, used as a marker for
socioeconomic and/or income status.16 The national Kids’ Inpatient Database (KIDS) from 2003 and 2006 evaluated the outcomes of 153,333 pediatric surgical patients. Adjusting for medically related perioperative risk factors, they found that uninsured patients were at an increased risk of in-hospital death (P \ .0001) and postoperative complications (P \ .02). This same group assessed the effect of race and sex on pediatric surgical outcomes in a separate study.12 Using a similar dataset from KIDS 2003 and 2006, they found that black children had a higher risk of postoperative in-hospital death than white children (P \ .02) after adjusting for perioperative medical risk factors. Black and Hispanic race/ethnicity also conferred a higher risk of postoperative morbidity (P = .01) and hospital length of stay (P \ .001) than white children. In a study evaluating pediatric intensive care outcomes by race and insurance status, Lopez et al17 found that uninsured children had a significantly greater likelihood of mortality (8.1%; 95% confidence interval [CI], 6.2-10.0) than did publicly insured (3.6%; 95% CI, 3.2-4.0) and commercially insured (3.7%; 95% CI, 3.3-4.1) children. There are many potential reasons as to why income and/or insurance status incurs differing risks of postoperative events. Prior studies have suggested that a lower income quartile and/or lack of health insurance may lead to a lack of access to primary care. Inadequate access to care may, in turn, lead to a higher likelihood of nonelective or urgent surgical interventions, with their associated higher morbidity and mortality risks than elective procedures.18 Andersen et al19 evaluated patients undergoing thoracic aortic operations and found that uninsured patients had a higher percentage of nonelective operations (71.7%) compared to privately insured patients (36.6%). The issue of poor access to pediatric subspecialty surgical care has been evaluated in the uninsured population, confirming this notion.20 However, in our study, as well as Stone et al’s,12 perioperative risks related to previous inequities in access to care were accounted for in the uniform preoperative status of the various patient cohorts. The implementation of the Affordable Care Act in 2013 to 2014 may, in time, shift the issue of perioperative risk profiles in relation to insurance status. There were several limitations to this study. First, we were not able to assess the incidence of other means of communication with physicians or other health care providers prior to patient revisits. It is possible that some families may have had easier access to communicate by telephone or email with providers, minimizing their need for postoperative revisits. Second, while we can assume that all children undergoing surgery at ambulatory surgery centers present with similarly low perioperative risk profiles, it is possible that those children in lower income quartiles had a higher incidence of low-grade chronic illnesses (although we did control for the presence of asthma as a comorbidity), putting them at a slightly higher risk of postoperative complications. Nonetheless, these findings should prompt clinicians to look for additional comorbidities in lower income children undergoing adenotonsillectomy. Third, we do not have access to preoperative laboratory testing, which may indicate increased risk factors for postoperative bleeding. Many
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surgeons do not routinely perform coagulation studies preoperatively; however, this is certainly not a standardized parameter. Last, educational level, which may be somewhat related to income quartile, may have also played a role in recovery outcomes. While the use of nonsteroidal antiinflammatory agents is now considered not to increase the risk of postoperative hemorrhaging, in the years of this dataset, it was not recommended that they be used following adenotonsillectomy. Had there been educational or language barriers regarding postoperative instructions, it is feasible that misunderstandings in pain control medications occurred. The identification of such disparity data is only the first step. Interventions to correct such disparities should then be considered, especially in light of the number of pediatric adenotonsillectomy procedures performed each year. For example, further study into income-related disparities with respect to tonsillectomy might possibly reveal issues surrounding miscommunications and misunderstandings regarding postoperative expectations and postoperative contingencies for pain and bleeding, among others. This may be an area for improvement in perioperative education. Second, these data may prove useful in the circumstance of physician performance metrics. If otolaryngologists who perform a large volume of pediatric adenotonsillectomy procedures also have a large proportion of low-income or racially skewed patients, this could influence such performance metrics and would therefore need adjustment.
Conclusion Adenotonsillectomy remains one of the most common outpatient surgical procedures in the pediatric population. We found that in a large multistate group of children undergoing outpatient tonsillectomy, there are significant disparities in postoperative outcomes. Further study in insurance-based and income-based outcomes should be carried out as the impact of the Affordable Care Act becomes measurable. Author Contributions Neil Bhattacharyya, study concept, data collection, data analysis, drafting of article, review of article for publication; Nina L. Shapiro, data analysis and verification, drafting of article, literature review, critical review of article for publication.
Disclosures Competing interests: Neil Bhattacharyya is a consultant for Intersect ENT Inc and Entellus Inc. Sponsorships: None. Funding source: None.
References 1. Bhattacharyya N, Shapiro NL, Vakharia KT. Influence of race and ethnicity on access to care among children with frequent ear infections. Otolaryngol Head Neck Surg. 2010;143:691-696. 2. Sidell D, Shapiro NL, Bhattacharyya N. Demographic influences on antibiotic prescribing for pediatric acute otitis media. Otolaryngol Head Neck Surg. 2012;146:653-658.
3. Boss EF, Marsteller JA, Simon AE. Outpatient tonsillectomy in children: demographic and geographic variation in the United States, 2006. J Pediatr. 2012;160:814-819. 4. Bhattacharyya N, Lin HW. Changes and consistencies in the epidemiology of pediatric adenotonsillar surgery, 1996-2006. Otolaryngol Head Neck Surg. 2010;143:680-684. 5. Bhattacharyya N. Ambulatory pediatric otolaryngologic procedures in the United States: characteristics and perioperative safety. Laryngoscope. 2010;120:821-825. 6. Mahant S, Keren R, Localio R, et al. Variation in quality of tonsillectomy perioperative care and revisit rates in children’s hospitals. Pediatrics. 2014;133:280-288. 7. Schmidt R, Herzog A, Cook S, O’Reilly R, Deutsch E, Reilly J. Complications of tonsillectomy: a comparison of techniques. Arch Otolaryngol Head Neck Surg. 2007;133:925-928. 8. Shay S, Shapiro NL, Bhattacharyya N. Revisit rates and diagnoses following pediatric tonsillectomy in a large, multistate population. Laryngoscope. Epub 2014 Jun 17. 9. Bhattacharyya N, Kepnes LJ. Revisits and postoperative hemorrhage after adult tonsillectomy. Laryngoscope. 2014; 124:1554-1556. 10. Healthcare Cost and Utilization Project (HCUP). HCUP databases: 2006-2009. Agency for Healthcare Research and Quality. Available at: www.hcup-us.ahrq.gov/databases.jsp. Accessed May 1, 2014. 11. United States Census Bureau. Population. http://www.census. gov/topics/population.html#. Acccessed August 5, 2014. 12. Stone ML, Lapar DJ, Kane BJ, Rasmussen SK, McGahren ED, Rodgers BM. The effect of race and gender on pediatric surgical outcomes within the United States. J Pediatr Surg. 2013; 48:1650-1656. 13. Windfuhr JP, Verspohl BC, Chen YS, Dahm JD, Werner JA. Post-tonsillectomy hemorrhage: some facts will never change. Eur Arch Otorhinolaryngol. Epub 2014 Apr 16. 14. Baugh R, Burke B, Fink B, Garcia R, Kominsky A, Yaremchuk K. Safety of outpatient surgery for obstructive sleep apnea. Otolaryngol Head Neck Surg. 2013;148:867-872. 15. Sadhasivam S, Chidambaran V, Ngamprasertwong P, et al. Race and unequal burden of perioperative pain and opioid related adverse effects in children. Pediatrics. 2012;129:832-838. 16. Stone ML, LaPar DJ, Mulloy DP, et al. Primary payer status is significantly associated with postoperative mortality, morbidity, and hospital resource utilization in pediatric surgical patients within the United States. J Pediatr Surg. 2013;48:81-87. 17. Lopez AM, Tilford JM, Anand KJ, et al. Variation in pediatric intensive care therapies and outcomes by race, gender, and insurance status. Pediatr Crit Care Med. 2006;7:2-6. 18. LaPar DJ, Bhamidipati CM, Mery CM, et al. Primary payer status affects mortality for major surgical operations. Ann Surg. 2010;252:544-550, discussion 550-551. 19. Andersen ND, Brennan JM, Zhao Y, et al. Insurance status is associated with acuity of presentation and outcomes for thoracic aortic operations. Circ Cardiovasc Qual Outcomes. 2014;7:398-406. 20. Wang EC, Choe MC, Meara JG, Koempel JA. Inequality of access to surgical specialty health care: why children with governmentfunded insurance have less access than those with private insurance in Southern California. Pediatrics. 2004;114:e584-e590.
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Associations between Socioeconomic Status and Race with Complications after Tonsillectomy in Children
Otolaryngology– Head and Neck Surgery 2014, Vol. 151(6) 1055–1060 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814552647 http://otojournal.org
Neil Bhattacharyya, MD1, and Nina L. Shapiro, MD2
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
burden of increased revisits and acute pain diagnoses after tonsillectomy deserve further attention.
Abstract Objective. To determine if disparities exist for revisits and complications after pediatric tonsillectomy.
Keywords
Study Design. Cross-sectional analysis of multistate databases. Setting. Ambulatory surgery. Methods. Cases of pediatric tonsillectomy with or without adenoidectomy were extracted from state ambulatory surgery databases and linked to state emergency department databases and inpatient databases for California, Iowa, Florida, and New York for 2010 and 2011. Revisit rates and diagnoses within 14 days were analyzed for potential associations of these complications with sex, race, and median household income quartile. Results. There were 79,520 cases of pediatric tonsillectomy that were extracted (50.3% male; mean age, 7.5 years). Overall, 6419 patients (8.1%) incurred a revisit after the procedure. Revisit rates for posttonsillectomy bleeding, acute pain, and fever/dehydration were 2.1%, 1.5%, and 2.2%, respectively. On multivariate analysis, increasing household income quartile was significantly associated with a decreasing rate of all complications: revisits (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.84-0.89), posttonsillectomy bleeding (OR, 0.91; 95% CI, 0.86-0.96), acute pain (OR, 0.79; 95% CI, 0.740.84), and fever/dehydration (OR, 0.93; 95% CI, 0.890.98). Female sex was associated with a decreased rate of posttonsillectomy hemorrhaging (OR, 0.81; 95% CI, 0.73-0.91). Black and Hispanic children had an increased risk for a revisit after tonsillectomy (OR, 1.11; 95% CI, 1.01-1.22; and OR, 1.17; 95% CI, 1.09-1.26, respectively) and increased odds for acute pain at the revisit (OR, 1.36; 95% CI, 1.10-1.67; and OR, 1.34; 95% CI, 1.141.57, respectively) relative to white children. Race was not associated with the rate of hemorrhage posttonsillectomy. Conclusion. Significant disparities, particularly with respect to household income, exist in the incidence of revisits and complications after pediatric tonsillectomy. The disparate
tonsillectomy, children, disparities, complications, bleeding, readmission, revisits, household income, race Received May 28, 2014; revised August 5, 2014; accepted September 3, 2014.
D
isparities in health care have long been the subject of continued investigation, analysis, and controversy over the past several decades. Such investigations seek to identify disparities in the access to and the provision of health care to identify disadvantaged populations that may be targeted for improvements in the delivery of care. For example, we recently demonstrated that a family income below the federal poverty level predicted increased odds for frequent ear infections among children in the United States but that significant disparities according to race or insurance did not exist with respect to antibiotic prescribing for acute otitis media at the point of care.1,2 In a recent systematic review, Boss and associates3 found racial/ ethnic and socioeconomic disparities in the access to care including adenotonsillectomy for children with sleep disordered breathing. Although some issues related to disparities in the access to care in the pediatric otolaryngology arena have been probed, relatively little data are available concerning disparities in outcomes after otolaryngologic care and treatment. Pediatric adenotonsillectomy is one of the most commonly performed pediatric surgical procedures in the United States, with close to 500,000 ambulatory procedures
1 Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA 2 Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Corresponding Author: Neil Bhattacharyya, MD, Division of Otolaryngology, Harvard Medical School, 45 Francis Street, Boston, MA 02115, USA Email: [email protected]
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performed in children annually.4,5 Unfortunately, pediatric adenotonsillectomy is also subject to a significant complication rate after the procedure, with our group and others reporting revisit rates approaching 7.8% and a reported posttonsillectomy bleeding rate of 0.05% to 2.0%.6-8 While many studies have focused on procedural components (eg, surgical technique) that may be related to posttonsillectomy complications in bleeding rates, there are little data regarding patient factors that may be associated with these complications, including demographic risk factors.7 We sought to determine if disparities in postoperative outcomes after pediatric tonsillectomy with or without adenoidectomy that might pertain to racial, ethnic, and/or socioeconomic factors exist among children undergoing these procedures.
Methods Cases of ambulatory pediatric (age \18.0 years) tonsillectomy or adenotonsillectomy were extracted from the state ambulatory surgery databases for New York, Florida, Iowa, and California for calendar years 2010 and 2011. These cases were linked to the corresponding state emergency department databases and state inpatient databases for visit encounters occurring after tonsillectomy but within a 14-day postoperative window.9 Tonsillectomy cases performed for malignancy as the primary diagnosis were explicitly excluded. These databases are part of the Healthcare Cost and Utilization Project maintained by the Agency for Healthcare Research and Quality.10 This study was reviewed by our hospital’s committee on clinical investigations and deemed exempt from review as the data are de-identified and are available to the public. Data extraction was conducted by the first author (N.B.), who has significant prior experience working with and publishing on national health care data. Standard demographic information was extracted and tabulated for the cases of pediatric tonsillectomy/adenotonsillectomy. Race/ethnicity was categorized as white, black, Hispanic, or other (including Asian/Pacific Islander and Native American) as reported by the patient/caregiver. Household income was assigned to 1 of the 4 state’s median household income quartiles to represent socioeconomic status. The presence or absence of asthma as a primary childhood comorbidity was also determined if any one of the diagnosis codes available in the state ambulatory surgery database at the time of the procedure coded for asthma. Next, for each case, whether a revisit occurred (including readmission) was determined; the timing (postoperative day from tonsillectomy) of the revisit was also tabulated. The primary revisit diagnoses (based on the primary or first diagnosis code listed) were codified as the following: posttonsillectomy bleeding, acute pain, or fever/nausea/vomiting/dehydration (FNVD). All diagnoses at the time of the revisit were examined to determine if any of the diagnoses encompassed posttonsillectomy bleeding. After univariate analysis, multivariate analysis was conducted with logistic regression to determine the associations between sex, race, and household income; age and asthma (as a comorbidity factor) with the occurrence of a revisit (or readmission); and
Figure 1. Race/ethnicity distribution of children undergoing tonsillectomy.
revisit diagnoses for posttonsillectomy bleeding, acute pain, or FNVD.
Results A total of 79,520 cases of pediatric tonsillectomy with or without adenotonsillectomy were examined across 4 states. There was an equal sex distribution (50.3% male), with a mean age of 7.45 years. Figure 1 depicts the relative racial/ethnic distribution of the patients. A comorbid asthma diagnosis was present in 9.6% of children undergoing tonsillectomy. Overall, 6419 patients or 8.1% had a revisit (to the emergency department, inpatient admission, or the ambulatory surgery center) within 14 days after their tonsillectomy procedure. The rate of any diagnosis of posttonsillectomy bleeding at the revisit was 2.1% (1652 cases). The rates of acute pain as a primary revisit diagnosis and FNVD as a primary revisit diagnosis were 1.5% (1180 cases) and 2.2% (1765 cases), respectively. The most common primary revisit diagnoses not captured among the categories above were the following: pneumonia (62 cases; 0.08% among all adenotonsillectomy cases), constipation (36 cases; 0.05%), viral infection (31 cases; 0.04%), urinary tract infection (31 cases; 0.04%), abdominal pain (31 cases; 0.04%), and asthma (31 cases; 0.04%). Table 1 presents the univariate analysis for the associations between sex, race, and household income with the revisit rate, rate of posttonsillectomy bleeding, primary diagnosis of acute pain at revisit, and primary diagnosis of FNVD at revisit. Table 2 presents the multivariate analysis for the relationships between the revisit rate and patient age, sex, race, and household income. Increasing household income quartile was strongly associated with a decreased likelihood of a posttonsillectomy revisit, as was increasing age (although the latter had a relatively small odds ratio). Both black and Hispanic patients had increased odds for a revisit relative to white patients, whereas ‘‘other’’ race/
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Table 1. Univariate Analysis of Factors Associated with Revisits after Pediatric Tonsillectomy. Variable
Revisit Rate, %
Sex Male Female Race White Black Hispanic Other Household income First quartilea Second quartile Third quartile Fourth quartile Asthma No Yes
P Value
Bleeding, %
P Value
Acute Pain, %
P Value
FNVD, %
P Value
7.97 8.12
.435
2.10 2.01
.392
1.34 1.59
.004
2.24 2.22
.850
7.57 9.10 9.38 7.01
\.001
2.09 1.77 2.17 1.79
.103
1.22 1.93 1.87 1.17
\.001
2.14 2.63 2.62 1.83
\.001
9.17 8.36 7.65 5.73
\.001
2.13 2.09 2.00 1.71
.031
1.78 1.59 1.26 0.77
\.001
2.45 2.30 2.19 1.80
.001
7.78 10.80
\.001
2.04 2.42
.027
1.40 2.32
\.001
2.15 2.91
\.001
Abbreviation: FNVD, fever/nausea/vomiting/dehydration. a The first quartile represents the poorest quartile.
Table 2. Multivariate Analysis for Revisit Rate with Age, Sex, Race, and Household Income after Pediatric Tonsillectomy. Variable
Wald
Significance
Odds Ratio
95% Confidence Interval
Female sex Household income quartile Race White Black Hispanic Other Age Asthma Constant
0.1 105.6
.769 \.001
1.01 0.87
0.95-1.07 0.84-0.89
Reference 4.6 19.5 2.3 51.2 51.2 2468.3
.032 \.001 .130 \.001 \.001 \.001
1.11 1.17 0.92 1.03 1.38
1.01-1.22 1.09-1.26 0.82-1.03 1.02-1.03 1.26-1.51
ethnicities did not. Finally, sex was not associated with the likelihood of a revisit. Similarly, Tables 3 to 5 present the multivariate analysis for the relationships among posttonsillectomy bleeding rate, primary diagnosis of acute pain at revisit, and primary diagnosis of FNVD at revisit and age, sex, race, and income. In all instances, increasing median household income quartile was associated with a lower rate of revisits for these diagnoses.
Discussion In this large-scale, multistate, multivariate analysis of revisits and complications after pediatric tonsillectomy, we found that significant disparities in complication rates exist among children undergoing tonsillectomy. We found a strong association between median household income and complication rates: In all instances, an increasing family
household income was associated with a significantly decreased odds ratio for revisits and complications. For example, with respect to revisits after pediatric tonsillectomy, a child in the lowest (poorest) quartile for household income had increased odds of 1.53 for a revisit and increased odds of 1.33 for posttonsillectomy hemorrhaging as compared to a child in the highest household income quartile. Although the absolute difference in percentages for complications between groups was relatively small, given that approximately 480,000 tonsillectomy procedures are performed in children each year in the United States, this small difference in percentages related to the disparity results is a significant difference in absolute numbers of children with complications.5 For example, based on current census data, Hispanic patients would be expected to suffer more than 1700 additional disparity-related revisits, and
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Table 3. Multivariate Analysis for Bleeding with Age, Sex, Race, and Household Income after Pediatric Tonsillectomy. Variable Female sex Household income quartile Race White Black Hispanic Other Age Asthma Constant
Wald
Significance
Odds Ratio
95% Confidence Interval
12.7 12.5
\.001 \.001
0.81 0.91
0.73-0.91 0.86-0.96
Reference 2.3 0.4 1.3 329.0 2.7 2216.7
.131 .509 .250 \.001 .103 \.001
0.85 1.05 0.88 1.12 1.16
0.70-1.05 0.91-1.21 0.70-1.10 1.10-1.13 0.97-1.39
Table 4. Multivariate Analysis for Acute Pain Revisits with Age, Sex, Race, and Household Income after Pediatric Tonsillectomy. Variable Female sex Household income quartile Race White Black Hispanic Other Age Asthma Constant
Wald 3.3 50.4 Reference 8.4 12.2 0.0 59.6 27.1 1536.9
Significance
Odds Ratio
95% Confidence Interval
.070 \.001
1.13 0.79
0.99-1.30 0.74-0.84
.004 \.001 .994 \.001 \.001 \.001
1.36 1.34 1.00 1.06 1.64
1.10-1.67 1.14-1.57 0.77-1.30 1.05-1.08 1.36-1.97
Table 5. Multivariate Analysis for FNVD Revisits with Age, Sex, Race, and Household Income after Pediatric Tonsillectomy. Variable Female sex Household income quartile Race White Black Hispanic Other Age Asthma Constant
Wald
Significance
Odds Ratio
95% Confidence Interval
.241 .005
1.06 0.93
0.96-1.18 0.89-0.98
.231 .004 .072 \.001 .015 \.001
1.11 1.21 0.82 0.93 1.23
0.94-1.32 1.06-1.37 0.66-1.02 0.91-0.94 1.04-1.45
1.4 8.0 Reference 1.4 8.3 3.2 103.0 5.9 1342.8
Abbreviation: FNVD, fever/nausea/vomiting/dehydration.
patients in the lowest income quartile would be expected to have more than 3000 additional revisits compared to children in the highest income quartile each year.11 The overall revisit rates following outpatient pediatric adenotonsillectomy have recently been reviewed. Mahant et al6 found that 7.8% of children revisited the emergency room,
ambulatory care center, or physician’s office following adenotonsillectomy. Notably, that study included only those children having undergone surgery at freestanding children’s hospitals. Our study builds on our previous report by adding a full additional year of data, which allows for a more robust analysis of a relatively overall low complication rate with
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respect to demographic disparities and includes children having undergone surgeries at both specialty and nonspecialty ambulatory care centers in 4 states across the United States.8 We found an overall posttonsillectomy revisit rate of 8.1%, which is similar to the rate found by Mahant et al.6 The present study found an association between family income quartile and pediatric posttonsillectomy complications while controlling for age, sex, race, and asthma. Income disparity has been used as a marker for socioeconomic, educational, and insurance status and has been correlated to both higher risk-adjusted morbidity as well as mortality. As in prior studies, we were not able to completely adjust for preoperative risk status, but we did adjust for the most common childhood ailment likely to be present in the outpatient setting: asthma. All patients in our cohort underwent one type of surgery (adenotonsillectomy) specifically in an ambulatory surgery setting, which would assume relatively low perioperative risks across all demographics. We also found a slightly lower risk of posttonsillectomy hemorrhaging in females as compared to males (odds ratio, 0.77; P \ .001). Stone et al12 also found a similar difference in postoperative morbidity outcomes in females compared to males (odds ratio, 0.87; P \ .001). Their database included 101,083 children undergoing several types of pediatric surgical procedures, including appendectomy, pyloromyotomy, and several other abdominal procedures. Despite this wide range of surgical procedures, the odds ratio for postoperative morbidity for females compared to males was strikingly similar to ours. Other investigators have also found a lower rate of posttonsillectomy hemorrhaging in female versus male patients.13 We also found a higher incidence of posttonsillectomy revisits in black and Hispanic children, specifically related to postoperative pain. The issue of postoperative pain with respect to race has been evaluated in the adult population and more recently in the pediatric population. In an adult Medicaid population, Baugh et al14 reviewed indications for postoperative revisits following surgical correction of obstructive sleep apnea. The majority of surgical procedures (n = 404) were performed in the ambulatory setting, and the most common adverse outcome requiring a postoperative emergency room visit was a pain-related diagnosis (51% of all revisits). Sadhasivam et al15 performed a prospective analysis of 194 healthy children undergoing tonsillectomy. An assessment of postoperative recovery room analgesia was conducted after all patients received the same weight-dependent dose of intraoperative morphine (0.2 mg/kg). Black children experienced significantly more postoperative recovery room pain than white children. Pain parameters included postoperative opioid requirements (P = .0011), maximum postoperative pain scores (P \ .0001), and analgesic interventions (P \ .0001). Conversely, while white children received overall lower perioperative doses of morphine, they incurred more adverse effects related to opioid analgesics. These data, taken with our study, suggest that further inquiry into the interactions between posttonsillectomy pain and race is warranted. Pediatric surgical outcomes have been evaluated with a focus on primary payer status, used as a marker for
socioeconomic and/or income status.16 The national Kids’ Inpatient Database (KIDS) from 2003 and 2006 evaluated the outcomes of 153,333 pediatric surgical patients. Adjusting for medically related perioperative risk factors, they found that uninsured patients were at an increased risk of in-hospital death (P \ .0001) and postoperative complications (P \ .02). This same group assessed the effect of race and sex on pediatric surgical outcomes in a separate study.12 Using a similar dataset from KIDS 2003 and 2006, they found that black children had a higher risk of postoperative in-hospital death than white children (P \ .02) after adjusting for perioperative medical risk factors. Black and Hispanic race/ethnicity also conferred a higher risk of postoperative morbidity (P = .01) and hospital length of stay (P \ .001) than white children. In a study evaluating pediatric intensive care outcomes by race and insurance status, Lopez et al17 found that uninsured children had a significantly greater likelihood of mortality (8.1%; 95% confidence interval [CI], 6.2-10.0) than did publicly insured (3.6%; 95% CI, 3.2-4.0) and commercially insured (3.7%; 95% CI, 3.3-4.1) children. There are many potential reasons as to why income and/or insurance status incurs differing risks of postoperative events. Prior studies have suggested that a lower income quartile and/or lack of health insurance may lead to a lack of access to primary care. Inadequate access to care may, in turn, lead to a higher likelihood of nonelective or urgent surgical interventions, with their associated higher morbidity and mortality risks than elective procedures.18 Andersen et al19 evaluated patients undergoing thoracic aortic operations and found that uninsured patients had a higher percentage of nonelective operations (71.7%) compared to privately insured patients (36.6%). The issue of poor access to pediatric subspecialty surgical care has been evaluated in the uninsured population, confirming this notion.20 However, in our study, as well as Stone et al’s,12 perioperative risks related to previous inequities in access to care were accounted for in the uniform preoperative status of the various patient cohorts. The implementation of the Affordable Care Act in 2013 to 2014 may, in time, shift the issue of perioperative risk profiles in relation to insurance status. There were several limitations to this study. First, we were not able to assess the incidence of other means of communication with physicians or other health care providers prior to patient revisits. It is possible that some families may have had easier access to communicate by telephone or email with providers, minimizing their need for postoperative revisits. Second, while we can assume that all children undergoing surgery at ambulatory surgery centers present with similarly low perioperative risk profiles, it is possible that those children in lower income quartiles had a higher incidence of low-grade chronic illnesses (although we did control for the presence of asthma as a comorbidity), putting them at a slightly higher risk of postoperative complications. Nonetheless, these findings should prompt clinicians to look for additional comorbidities in lower income children undergoing adenotonsillectomy. Third, we do not have access to preoperative laboratory testing, which may indicate increased risk factors for postoperative bleeding. Many
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surgeons do not routinely perform coagulation studies preoperatively; however, this is certainly not a standardized parameter. Last, educational level, which may be somewhat related to income quartile, may have also played a role in recovery outcomes. While the use of nonsteroidal antiinflammatory agents is now considered not to increase the risk of postoperative hemorrhaging, in the years of this dataset, it was not recommended that they be used following adenotonsillectomy. Had there been educational or language barriers regarding postoperative instructions, it is feasible that misunderstandings in pain control medications occurred. The identification of such disparity data is only the first step. Interventions to correct such disparities should then be considered, especially in light of the number of pediatric adenotonsillectomy procedures performed each year. For example, further study into income-related disparities with respect to tonsillectomy might possibly reveal issues surrounding miscommunications and misunderstandings regarding postoperative expectations and postoperative contingencies for pain and bleeding, among others. This may be an area for improvement in perioperative education. Second, these data may prove useful in the circumstance of physician performance metrics. If otolaryngologists who perform a large volume of pediatric adenotonsillectomy procedures also have a large proportion of low-income or racially skewed patients, this could influence such performance metrics and would therefore need adjustment.
Conclusion Adenotonsillectomy remains one of the most common outpatient surgical procedures in the pediatric population. We found that in a large multistate group of children undergoing outpatient tonsillectomy, there are significant disparities in postoperative outcomes. Further study in insurance-based and income-based outcomes should be carried out as the impact of the Affordable Care Act becomes measurable. Author Contributions Neil Bhattacharyya, study concept, data collection, data analysis, drafting of article, review of article for publication; Nina L. Shapiro, data analysis and verification, drafting of article, literature review, critical review of article for publication.
Disclosures Competing interests: Neil Bhattacharyya is a consultant for Intersect ENT Inc and Entellus Inc. Sponsorships: None. Funding source: None.
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