Admission Criteria for Children With Obstructive Sleep Apnea After Adenotonsillectomy: Considerations for Cost

David F Smith, Charlene P Spiceland, Stacey L Ishman, Branden M Engorn, Christopher Donohue, Paul S Park, James R Benke, Tiffany Frazee, Robert H Brown, Nicholas M Dalesio, David F Smith, Charlene P Spiceland, Stacey L Ishman, Branden M Engorn, Christopher Donohue, Paul S Park, James R Benke, Tiffany Frazee, Robert H Brown, Nicholas M Dalesio

Abstract

Study objectives: Postoperative respiratory complications (PRCs) are common among children with obstructive sleep apnea (OSA) after adenotonsillectomy. We analyzed postoperative admission guidelines to determine which optimally balanced patient safety and cost.

Methods: Retrospective study of children aged 12 years or younger undergoing adenotonsillectomy for OSA after polysomnography at a tertiary academic care center over 2 years. Demographics, medical History, and hospital course were collected. Advanced Excel modeling was used to assess the number of children with PRCs identified with guideline admission criteria and to validate the significance of these findings in our patient population with logistic regression.

Results: Six hundred thirty children were included; 116 had documented PRCs. Children with PRCs were younger (P = .024) and more frequently male (P = .012). There were no significant differences in race (P = .411) or obesity (P = .265). More children with PRCs had an apnea-hypopnea index (AHI) > 24 events/h (P < .001). Following guidelines from the American Academy of Pediatrics, American Academy of Otolaryngology - Head and Neck Surgery, and Nationwide Children's Hospital, 82%, 87%, and 99% of children with PRCs would be identified, costing $535,962, $647,165, and $1,053,694 for admission, respectively. Using a non-validated, forced model to refine predictors described in published guidelines, our model would have identified 95% of children with one or more PRCs, with a moderate cost.

Conclusions: Current admission guidelines attempt to identify children with OSA at high risk for PRCs after adenotonsillectomy; however, none consider the economic cost to the health care system. We present a comparison of the number of patients identified with PRCs after adenotonsillectomy and the cost of expected admissions using currently published guidelines.

Commentary: A commentary on this article appears in this issue on page 1371.

Keywords: adenotonsillectomy; obstructive sleep apnea; pediatric OSA; postoperative respiratory complications; safety; sleep apnea.

© 2017 American Academy of Sleep Medicine

References

    1. Ali NJ, Pitson DJ, Stradling JR. Snoring, sleep disturbance, and behavior in 4-5 year-olds. Arch Dis Child. 1993;68:360–366.
    1. Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Resp Crit Care Med. 1999;159(5 Pt 1):1527–1532.
    1. Farber JM. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;110(6):1255–1257.
    1. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3 Pt 1):616–620.
    1. Weissbluth M, Davis AT, Poncher J, Reiff J. Signs of airway obstruction during sleep and behavioral, developmental, and academic problems. J Dev Behav Pediatr. 1983;4(2):119–121.
    1. Gozal D, Capdevila OS, Kheirandish-Gozal L. Metabolic alterations and systemic inflammation in obstructive sleep apnea among non-obese and obese prepubertal children. Am J Respir Crit Care Med. 2008;177:1142–1149.
    1. de la Eva RC, Baur LA, Donaghue KC, Waters KA. Metabolic correlates with obstructive sleep apnea in obese subjects. J Pediatr. 2002;140(6):654–659.
    1. Amin RS, Carroll JL, Jeffries JL, et al. Twenty-four ambulatory blood pressure in children with sleep-disordered breathing. Am J Respir Crit Care Med. 2004;169(8):950–956.
    1. Enright PL, Goodwin JL, Sherrill DL, Quan JR, Quan SF Tucson Children's Assessment of Sleep Apnea Study. Blood pressure elevation associated with sleep-related breathing disorder in a community sample of white and Hispanic children: the Tucson Children's Assessment of Sleep Apnea Study. Arch Pediatr Adoles Med. 2003;157(9):901–904.
    1. Marcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med. 1998;157(4 Pt 1):1098–1103.
    1. Quan SF, Gersh BJ National Center on Sleep Disorders Research, National Heart, Lung, and Blood Institute. Cardiovascular consequences of sleep-disordered breathing: past, present and future: report of a workshop from the National Center on Sleep Disorders Research and the National Heart, Lung, and Blood Institute. Circulation. 2004;109(8):951–957.
    1. Singer LP, Saenger P. Complications of pediatric obstructive sleep apnea. Otolaryngol Clin North Am. 1990;23(4):665–676.
    1. Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(1 Suppl):S1–S30.
    1. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714–e755.
    1. Mitchell RB, Pereira KD, Friedman NR. Sleep-disordered breathing in children: survey of current practice. Laryngoscope. 2006;116(6):956–958.
    1. De Luca Canto G, Pacheco-Pereira C, Aydinoz S, et al. Adenotonsillectomy complications: a meta-analysis. Pediatrics. 2015;136(4):702–718.
    1. Ye J, Liu H, Zhang G, Huang Z, Huang P, Li Y. Postoperative respiratory complications of adenotonsillectomy for obstructive sleep apnea syndrome in older children: prevalence, risk factors, and impact on clinical outcome. J Otolaryngol Head Neck Surg. 2009;38(1):49–58.
    1. Nixon GM, Kermack AS, Davis GM, Manoukian JJ, Brown KA, Brouillette RT. Planning adenotonsillectomy in children with obstructive sleep apnea: the role of overnight oximetry. Pediatrics. 2004;113(1 Pt 1):e19–e25.
    1. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical practice guideline: polysonmography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1 Suppl):S1–S15.
    1. Raman VT, Jatana KR, Elmaraghy CA, Tobias JD. Guidelines to decrease unanticipated hospital admission following adenotonsillectomy in the pediatric population. Int J Pediatr Otorhinolaryngol. 2014;78(1):19–22.
    1. Schwengel DA, Sterni LM, Tunkel DE, Heitmiller ES. Perioperative management of children with obstructive sleep apnea. Anesth Analg. 2009;109(1):60–75.
    1. McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM. Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 1992;118(9):940–943.
    1. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can assessment for obstructive sleep apnea help predict postadenotonsillectomy respiratory complications. Anesthesiology. 2002;96(2):313–322.
    1. About Child & Teen BMI. Centers for Disease Control and Prevention website. [Accessed November 17, 2015]. . Published May 15, 2015.
    1. Harrell FE., Jr . Regression Modeling Strategies. 2nd ed. New York, NY: Springer International Publishing; 2015. Binary logistic regression; pp. 219–274.
    1. Burnham KP, Anderson DR. Multimodel inference: understanding AIC and BIC in model selection. Sociolog Methods Res. 2004;33:261–304.
    1. Thongyam A, Marcus CL, Lockman JL, et al. Predictors of perioperative complications in higher risk children after adenotonsillectomy for obstructive sleep apnea: a prospective study. Otolaryngol Head Neck Surg. 2014;151(6):1046–1054.
    1. Lower Costs, Better Care: Reforming Our Health Care Delivery System. [Accessed November 21, 2015]. Centers for Medicare and Medicaide Services website. . Published February 28, 2013.
    1. Sanders GD, Neumann PJ, Basu A, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA. 2016;316(10):1093–1103.
    1. Rajkumar R, Patel A, Murphy K, et al. Maryland's all-payer approach to delivery-system reform. N Engl J Med. 2014;370(6):493–495.
    1. Gleich SJ, Olson MD, Sprung J, et al. Perioperative outcomes of severely obese children undergoing tonsillectomy. Paediatr Anaesth. 2012;22(12):1171–1178.
    1. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39(11):1105–1111.

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