“Readmission rates are greatest for tonsillectomy compared with any other type of surgery in children or adults, higher than hip replacement or cataract extraction,” explains Gillian M. Nixon, MD. “Of great concern is that there is wide variability in readmission between health centers, raising issues related to the quality of care. This variation in care highlights considerable opportunities for enhanced patient safety and quality outcomes, with potential impact on many families and healthcare services.”
In addition, these factors—how common it is, the variation in admission rates between centers, and the financial and social impact—make better understanding the issue an important goal, according to Dr. Nixon.
For a study published in Journal of Otolaryngology-Head & Neck Surgery, Dr. Nixon and colleagues sought to describe the incidence and timing of surgery-related hospital revisits, including emergency presentations as well as readmissions, after pediatric tonsillectomy and adenotonsillectomy. “We used a large statewide cohort, with data from the government that is collected from all hospitals across the state of Victoria, Australia,” Dr. Nixon notes. “Statewide linked data is crucial to understand this issue, as many children present to a hospital other than the one at which their surgery was performed, meaning that single-center studies may be less representative of the cohort undergoing tonsillectomy as a whole.”
Reasons for Revisits & Impact of Age
From 2010 to 2015 there were 47,054 surgeries, with 4,758 ED presentations (10.1% of all surgeries) and 2,750 readmissions (5.8% of all surgeries). Hemorrhage was the most common issue for both types of revisits, accounting for 33% of ED presentations (3.3% of all surgeries) and 68% of readmissions (4.0% of all surgeries).
“Although hemorrhage is a well-recognized and, in some cases, unavoidable complication, two-thirds of visits to the ED and one-third of readmissions were for reasons other than hemorrhage, including dehydration, pain, nausea, and infection (Table),” says Dr. Nixon. “Peak presentation for dehydration and nausea occurred on the day after surgery, whereas the peak for infection, hemorrhage, upper respiratory complications, and pain occurred at days 4 and 5, coinciding with the well-described surge in pain at this time after tonsillectomy. Recognizing this pattern of post-operative pain as a normal phenomenon and helping parents to manage pain relief and therefore oral intake at home is a critical contribution that physicians can make to post-operative care.”
The researchers also found that older age (15-19 years) was the greatest predictor of both ED presentation (adjusted OR 2.30) and hospital readmission (adjusted OR 3.20). These results point to an area of focus for clinical care and future research, Dr. Nixon explains. While the reason for this increased rate of revisits among adolescents has not been reported in the literature, she notes that a significant reason could be limited understanding and compliance with post-operative diet, activity, and pain management guidelines in older children, as they are not as closely overseen by adults. As a result, she says, healthcare workers should ensure teenagers as well as parents are educated regarding post-operative care guidelines.
Improving Post-Operative Care
Targeted interventions should focus on improving post-operative education for both patients and caregivers, the researchers recommend. “Increased education for parents in managing pain, what to expect in the post-operative period, and access to support and advice as needed without having to present to the hospital, especially before the peak in revisits 4-5 days after surgery, would be expected to reduce the need for hospital revisits,” says Dr. Nixon. “This can be challenging, particularly in large public hospital settings, but simple improvements in post-operative care has the potential to reduce costs as well as morbidity.”
Future studies will help to determine “the extent to which the level of patient understanding of post-operative care and outside-of-hospital factors impact on the risk of readmission,” Dr. Nixon notes. “Research focused on healthcare improvement could help determine what interventions are the most effective to reduce revisit rates. Development of patient education resources that can be shared between health services, including smaller hospitals, would also help optimize care.”