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Purpose: This study investigates the impact of patient characteristics and demographics on hospital charges for tonsillectomy as a treatment for pediatric obstructive sleep apnea (OSA). The aim is to identify potential disparities in hospital charges and contribute to efforts for equitable access to care., Methods: Data from the 2016 Healthcare Cost and Utilization Project (HCUP) Kid Inpatient Database (KID) was analyzed. The sample included 3,304 pediatric patients undergoing tonsillectomy ± adenoidectomy for OSA. Variables such as age, race, length of stay, hospital region, residential location, payer information, and median household income were collected. The primary outcome variable was hospital charge. Statistical analyses, including t-tests, ANOVA, and multiple linear regression, were conducted., Results: Among 3,304 pediatric patients undergoing tonsillectomy for OSA. The average total charges for tonsillectomy were $26,400, with a mean length of stay of 1.70 days. Significant differences in charges were observed based on patient race, hospital region, and payer information. No significant differences were found based on gender, discharge quarter, residential location, or median household income. Multiple linear regression showed race, hospital region, and residential location were significant predictors of total hospital charges., Conclusion: This study highlights the influence of patient demographics and regional factors on hospital charges for pediatric tonsillectomy in OSA cases. These findings underscore the importance of addressing potential disparities in healthcare access and resource allocation to ensure equitable care for children with OSA. Efforts should be made to promote fair and affordable treatment for all pediatric OSA patients, regardless of their demographic backgrounds., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Introduction: Coblation and electrocautery are two common techniques used for adenotonsillectomy (T&A). Numerous studies have assessed surgical outcomes of coblation versus electrocautery and overall, postoperative complications are similar with the exception of a decrease in patient reported postoperative pain for coblation. Instrumentation required for coblation is significantly more expensive than that required for electrocautery. With minimal outcome differences, justification for the additional instrumentation costs is difficult. We performed this study to assess if there is a difference between operative & postoperative costs of electrocautery and coblation., Methods: 300 patient medical records were reviewed from 2015 to 2017 with equal numbers of electrocautery and coblation surgeries. Outcome measures included finance information, duration and cost of OR and Phase I and Phase II post-anesthesia care unit (PACU), in-hospital pharmacy costs, and postoperative complications. Logistic regression was used for analysis., Results: The median patient age for each surgical technique was 6 years old. Electrocautery resulted in more time in the OR compared to coblation, (OR:1.11,95%CI:1.07-1.15, p < .001), with greater associated costs, p < .001. Electrocautery patients were under anesthesia longer and had a longer surgical duration, p < .001. These same patients had longer duration in Phase II PACU, p = .028, and were given pain medications an increased number of times, p < .001. Total costs including operative expense, physician charges, OR and anesthesia times, pharmacy, and instrument were significantly higher for electrocautery patients, p = .003. There were no differences in ED visits, post-tonsillectomy bleed, or additional surgery between techniques, p > .05., Conclusion: T&A electrocautery technique was found to have increased overall indirect costs. Costs of instrumentation in addition to increased operative time, use of analgesics and post-operative care contribute to costs associated with electrocautery and coblation should be used when assessing surgical costs., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: Analyze the differences in length of stay, cost, disposition, and demographics between syndromic and non-syndromic children undergoing multi-level sleep surgery., Methods: Children with sleep disordered breathing or obstructive sleep apnea that had undergone sleep surgeries were isolated from the 1997 to 2012 editions of the Kids' Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Children were then classified as syndromic or non-syndromic and stratified by level of sleep surgery (tonsillectomy & adenoidectomy, tonsillectomy & adenoidectomy plus other site surgery, other site surgery). Length of stay and cost were reported with Kruskal-Wallis one-way analysis of variance, disposition with binomial logistic regression, and demographics with chi-square., Results: Syndromic children compared to non-syndromic children were more likely to have surgery beyond just tonsillectomy & adenoidectomy and also had a longer length of stay, higher total cost and non-routine disposition (all P  < .001). Syndromic children undergoing tonsillectomy and adenoidectomy plus other site surgery had a longer length of stay compared to syndromic children undergoing tonsillectomy & adenoidectomy (6.00 days vs 3.63 days, P  < .001). However, no similar statistically significant difference in length of stay was found in non-syndromic children (2.01 days vs 2.87 days, P  > .05)., Conclusion: The potential risks/benefits need to be weighed carefully before undertaking sleep surgery in syndromic children. They experience a longer length of stay, higher cost, and non-routine disposition when compared to non-syndromic children. This is especially true when considering the transition from tonsillectomy & adenoidectomy to tonsillectomy & adenoidectomy plus other site surgery, as syndromic children experience a longer length of stay and non-syndromic children do not.

Objectives: At our institution, younger children require polysomnography (PSG) testing to confirm obstructive sleep apnea (OSA hereafter) before surgical intervention by adenotonsillectomy (T&A). Given that sleep studies can be costly, we investigated the cost-effectiveness of PSG as well as the possible role for symptom documentation in evaluation for T&A., Methods: Pediatric patients age 1-3 years who received PSG testing between Jan. 2015 and Jan. 2016 who had not previously had T&A were identified for retrospective cost analysis. Cost data were obtained from institutional accountants. We defined a positive PSG as obstructive apnea-hypopnea index ≥1. Logistic regression analysis was used, and statistical significance was set a priori at p < 0.05. Sensitivities and specificities of symptom documentation screen for OSA were compared to gold standard, or PSG testing., Results: Of the 176 children who received polysomnography testing, 140 (80%) had a positive PSG indicative of OSA. Seventy-one (51%) children with OSA underwent T&A within 1 year of PSG, and 10 (7%) eventually received T&A after 1 year from PSG date. Of the children whose PSG results were negative (n = 36), 14 (39%) still underwent T&A within 1 year (n = 7, 19%) or later (n = 7, 19%). Children with positive sleep studies were significantly more likely to receive T&A within one year of PSG (p = 0.0006) and at any time after PSG (p = 0.04). Hospital costs for T&A varied widely while PSG costs were fairly consistent. Using average institutional costs of T&A and PSG, the total cost of a T&A was 17.7× the cost of PSG testing. Using number of recorded symptoms to diagnose OSA instead of PSG testing yielded low specificities., Conclusion: Fifty-eight percent of patients with OSA and 39% of patients without OSA had a T&A within 1 year or later, although positive PSG was significantly associated with a higher likelihood of receiving T&A. Given costs at this institution and current decision-making practices, 147 PSGs would need to be done to account for the cost of one T&A, which in our cohort would occur after approximately 305 days., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: This study aims to measure the costs of treating obstructive sleep apnea (OSA) in children with an adenotonsillectomy using time-driven activity-based costing (TDABC) and explore how this differs from cost estimates using traditional forms of hospital accounting., Study Design: Prospective observational study., Methods: A total of 53 pediatric patients with symptoms of OSA or sleep-related breathing disorder were followed from their initial appointment through surgery to their postoperative visit at an academic medical center. Personnel timing and overhead costs were calculated for TDABC analysis., Results: Treating OSA with an adenotonsillectomy in a pediatric patient costs $1,192.61. On average, outpatient adenotonsillectomy costs $957.74 (80.31%); $412.18 of this cost ($4.89 per minute) was attributed to the overhead cost of the operating room. Traditional hospital accounting estimates outpatient adenotonsillectomy costs $2,987, with overhead attributing $11.27 per minute or $949.23 per case. 57% ($6.38 per minute) of the hospital's estimate for overhead was actually for equipment and implants used by different hospital services and not for equipment used in adenotonsillectomies., Conclusion: Through TDABC, we were able to highlight how traditional RVU-based hospital accounting systems apportion all overhead costs, including items such as orthopedic implants, evenly across specialties, thus increasing the perceived cost of equipment-light procedures such as adenotonsillectomies. We suspect that providers who perform a TDABC analysis at their home institution or practice will find their own unique insights, which will help them understand and control the different components of healthcare costs., Level of Evidence: 2 Laryngoscope, 129:1347-1353, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 established value-based reimbursement as the new norm in health care. As part of this shift, public and private insurers have adopted bundled payments in an effort to improve quality and control cost. Arkansas recently implemented an otolaryngology-specific bundled payment, which reimburses episodes of care involving adenoidectomy and/or tonsillectomy. In this mandatory model, otolaryngologists have the potential for shared savings or losses based on spending relative to risk-adjusted historical benchmarks and performance on quality metrics. The initiative has resulted in reduced health care costs and rates of postoperative antibiotic prescription and secondary bleeding. However, this experiment also illustrates potential pitfalls with bundled payments, such as emphasis of quality metrics lacking clinical relevance and incentive for increased service volume. The Arkansas initiative offers important lessons for otolaryngologists as ongoing reform under MACRA brings episode-based care to the forefront of our field.

Purpose: Though growth in children's surgical expenditures has been documented, procedure-specific differences in volume and costs at children's hospitals (CH) and non-hildren's hospitals (NCH) have not been explored. Our purpose was to compare trends in volume and costs of common pediatric surgical procedures between CH and NCH., Methods: We performed a review of the 2000-2009 Kids' Inpatient Database identifying all cases of appendectomy for uncomplicated appendicitis (AP), tonsillectomy and adenoidectomy (TA), fundoplication (FP), humeral fracture repair (HFR), pyloromyotomy (PYL), and cholecystectomy (CHOLE). Trends in case volume and costs were examined at CH versus NCH., Results: The proportion of surgical care at CH increased for all procedures from 2000 to 2009. TA and CHOLE demonstrated higher costs per case at CH. Positive growth over time in cost per case at CH was seen for AP and FP, with the cost per case of FP increasing by 21% between 2006 and 2009., Conclusions: The proportion of surgeries performed at CH is continuing to grow alongside proportionate increases in costs, however costs for certain procedures are higher at CH than NCH. Further investigation is needed to explore cost containment at CH while still maintaining specialized, high quality surgical care., Level of Evidence: Level III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The treatment of pediatric sinusitis continues to be a controversial topic. It has been recommended to treat pediatric chronic rhinosinusitis (CRS) with adenoidectomy before proceeding to more invasive techniques. There are concerns regarding side effects of endoscopic sinus surgery in pediatric patients. With the advent of balloon catheter dilation (BCD) as a minimally invasive technique, some authors are recommending up front adenoidectomy with BCD in order to maximize disease resolution while minimizing risk., Purpose: Our study examines the cost effectiveness of adenoidectomy alone versus adenoidectomy and upfront BCD for the management of pediatric CRS., Methods: A decision tree analysis was created to determine the cost effectiveness of treating a pediatric patient who has failed medical management, using adenoidectomy versus adenoidectomy with up-front BCD. Three separate decision trees were made. The incremental cost effectiveness ratio (ICER) was calculated for each scenario and a sensitivity analysis was done to determine how different values impacted our results., Results: Adenoidectomy as the sole first procedure was found to be more cost effective in all three decision trees. For tree 1, the adenoidectomy plus BCD arm was 0.03% more effective in the end, but with an $81, 431 incremental cost., Conclusions: Costs in addition to outcomes must be considered when comparing treatment modalities in our current health care environment. This study found that adenoidectomy as a first intervention before proceeding to more advanced techniques is nearly as effective and is a much more cost-effective algorithm for the treatment of pediatric CRS. However, the physician must advocate the best treatment for his or her own patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To report outcomes with regard to clinical aspects and medical costs of adenotonsillectomy and tonsillectomy at a single institution before and after implementation of the Diagnosis-Related Groups (DRG) payment system in Korea., Methods: We retrospectively reviewed the records of patients treated with adenotonsillectomy or tonsillectomy between July 2012 and June 2014. The Korean DRG payment system was applied to seven groups of specific diseases and surgeries including adenotonsillectomy and tonsillectomy from July 2013 at all hospitals in Korea. We divided patients into four groups according whether the fee-for-service (FFS) or DRG payment system was implemented and operation type (FFS-adenotonsillectomy (AT), DRG-AT, FFS-tonsillectomy (T), and DRG-T)., Results: A total of 1402 patients were included (485 FFS-AT, 490 DRG-AT, 203 FFS-T, and 223 DRG-T). The total medical cost of the DRG-AT group was significantly lower than that of the FFS-AT group (1191±404 vs. 1110±279 USD, P<0.05). There were no significant differences in length of hospital stay or postoperative complications among groups., Conclusion: The Korean DRG system for adenotonsillectomy and tonsillectomy reduced medical costs and clinical outcomes were not significantly altered by the adoption of the DRG system., Level of Evidence: 4., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: Evaluate the effects of electrocautery, microdebrider, and coblation techniques on outpatient pediatric adenoidectomy costs and complications., Study Design: Observational retrospective cohort study., Methods: An observational cohort study was performed in a multihospital network using a standardized accounting system. Children < 18 years of age who underwent outpatient adenoidectomy were included from January 2008 to September 2015. Cases with additional procedures were excluded. The cohorts were divided into children who underwent electrocautery, microdebrider, or coblator adenoidectomy. Data regarding costs, postoperative complications, and revision surgeries were analyzed., Results: A total of 1,065 cases of adenoidectomy were performed with electrocautery (34.9%), microdebrider (26.1%), and coblation (39.0%). There was an increased after direct cost associated with the microdebrider, $833 (standard deviation [SD] $363) and the coblator, $797 (SD $262) compared to the electrocautery, $597 (SD $361) (P < 0.0001). There was a greater overall operating room (OR) time associated with use of the microdebrider (mean 28.7, SD 11.0 minutes) compared with both the electrocautery (mean 24.7, SD 8.1 minutes) and coblator (mean 26.2, SD 9.8 minutes) (P < 0.0001). No significant difference was found with regard to complication rates. The incidence of repeat adenoidectomies was significantly greater for microdebrider (9.7%) compared to electrocautery (2.7%; P = 0.0002) and coblator (5.3%; P = 0.0336) techniques., Conclusion: These results suggest that adenoidectomy with electrocautery is significantly less expensive than microdebrider and coblator, with no differences in complication rates or surgical times among the techniques. Microdebrider adenoidectomy was associated with a longer overall OR time and a higher rate of adenoid regrowth, requiring revision surgery., Level of Evidence: 4. Laryngoscope, 128:745-749, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To review the causes, costs, and risk factors for unplanned return visits and readmissions after pediatric adenotonsillectomy (T&A)., Methods: Review of administrative database of outpatient adenotonsillectomy performed at any facility within a vertically integrated health care system in the Intermountain West on children age 1-18 years old between 1998 and 2012. Data reviewed included demographic variables, diagnosis associated with return visit and costs associated with return visits., Results: Data from 39,906 children aged 1-18 years old were reviewed. A total of 2499 (6.3%) children had unplanned return visits. The most common reasons for return visits were bleeding (2.3%), dehydration, (2.3%) and throat pain (1.2%). After multivariate analysis, the main risk factors for any type of return visits were Medicaid insurance (OR=1.64 95% CI 1.47-1.84), Hispanic race (OR=1.36 95% CI 1.13-1.64), and increased severity of illness (SOI) (OR=11.29 95% CI 2.69-47.4 for SOI=3). The only factor associated with increased odds of requiring an inpatient admission on return visit was length of time spent in PACU (p<0.001). A linear relationship was also observed between the child's age and the risk of post-tonsillectomy hemorrhage., Conclusion: Children with increased severity of illness, those insured with Medicaid, and children of Hispanic ethnicity should be targeted with increased education and interventions in order to reduce unplanned visits after T&A. Further studies on post-tonsillectomy complications should include evaluating the effect of surgical technique and post-operative pain management on all complications and not solely post-tonsillectomy hemorrhage., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives/hypothesis: Identify hospital costs for same-day pediatric adenotonsillectomy (T&A) surgery, and evaluate surgeon, hospital, and patient factors influencing variation in costs, and compare relationship of costs to complications for T&A., Study Design: Observational retrospective cohort study., Methods: A multihospital network's standardized activity-based accounting system was used to determine hospital costs per T&A from 1998 to 2012. Children 1 to 18 years old who underwent same-day T&A surgery were included. Subjects with additional procedures were excluded. Mixed effects analyses were performed to identify variation in mean costs due to surgeon, hospital, and patient factors. Surgeons' mean cost/case was related to subsequent complications, defined as any unplanned visit within 21 days in the healthcare system., Results: The study cohort included 26,626 T&As performed by 66 surgeons at 18 hospitals. Mean cost per T&A was $1,355 ± $505. Mixed effects analysis using patient factors as fixed effects and surgeon and hospital as a random effect identified significant variation in mean costs per surgeon, with 95% of surgeons having a mean cost/case between 67% and 150% of the overall mean (range, $874-$2,232/case). Similar variability was found among hospitals, with 95% of the facilities having mean costs between 64% to 156% of the mean (range, $1,029-$2,385/case). Severity of illness and several other patient factors exhibited small but statistically significant associations with cost. Surgeons' mean cost/case was moderately associated with an increased complication rate., Conclusions: Significant variation in same-day pediatric T&A surgery costs exists among different surgeons and hospitals within a multihospital network. Reducing variation in costs while maintaining outcomes may improve healthcare value and eliminate waste., Level of Evidence: 4., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: (1) Review the reasons, timing, and costs for children presenting to the emergency department (ED) after adenotonsillectomy (T&A)., Study Design: Case series with chart review., Setting: Tertiary care children's hospital., Subjects and Methods: A standardized activity-based hospital accounting system was used to identify 437 children from an academic pediatric otolaryngology practice presenting to the ED after T&A from 2009 to 2012. The reason for presentation, timing after surgery, and facility costs were recorded., Results: The study cohort represented 13.3% of the 3198 patients who underwent T&A during that time period. Overall, 133 (4.2%) presented for dehydration, 106 (3.3%) presented for post-tonsillectomy hemorrhage, 65 (2.0%) for poorly controlled pain, 42 (1.3%) for fever, 29 (1.0%) for vomiting/nausea/GI discomfort, 22 (0.7%) for respiratory complications, and 12 (0.4%) for miscellaneous reasons related to the operation; 28 (0.8%) were unrelated to the T&A and excluded. Mean postoperative day at the time of ED presentation was 4.4 (95% CI, 4.1-4.7). The mean cost per patient presenting to the ED was $1420 (95% CI, $1104-$1737), the most costly subgroups being those presenting with respiratory complications ($2855; 95% CI, $1434-$4277), hemorrhage ($1502; 95% CI, $1216-$1787), and dehydration ($1372; 95% CI, $995-$1750). The least costly subgroup was acute postoperative pain ($781; 95% CI, $282-$1200)., Conclusion: A significant portion of children present to the ED after T&A for poorly controlled pain, dehydration, or fever. The costs from these visits are significant. Accounting for these costs in the global care for pediatric T&A could assist in calculating appropriate reimbursement for bundled payments in this climate of health care reform., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Objectives: (1) To describe the application of a detailed cost-accounting method (time-driven activity-cased costing) to operating room personnel costs, avoiding the proxy use of hospital and provider charges. (2) To model potential cost efficiencies using different staffing models with the case study of outpatient adenotonsillectomy., Study Design: Prospective cost analysis case study., Setting: Tertiary pediatric hospital., Subject and Methods: All otolaryngology providers and otolaryngology operating room staff at our institution., Results: Time-driven activity-based costing demonstrated precise per-case and per-minute calculation of personnel costs. We identified several areas of unused personnel capacity in a basic staffing model. Per-case personnel costs decreased by 23.2% by allowing a surgeon to run 2 operating rooms, despite doubling all other staff. Further cost reductions up to a total of 26.4% were predicted with additional staffing rearrangements., Conclusion: Time-driven activity-based costing allows detailed understanding of not only personnel costs but also how personnel time is used. This in turn allows testing of alternative staffing models to decrease unused personnel capacity and increase efficiency., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

In Korea, the proportion of the pediatric population is decreasing due to low fertility rates and aging of the society. It is hypothesized that this change in population structure and medical insurance status may affect rates of elective surgeries more significantly than clinical factors. An observational study conducted using data from the Health Insurance Review and Assessment Service for tonsillectomy and adenoidectomy, with 403,924 registered patients from 2007 through 2011. We analyzed longitudinal changes in crude and age-adjusted surgery rates of three surgeries-tonsillectomy without adenoidectomy (T), adenoidectomy without tonsillectomy (A), and tonsillectomy with adenoidectomy (T&A)-according to medical insurance status: health insurance (HI) group (better economic status) versus health aid (HA) group (poorer economic status). Most of the surgeries (51.8 % of T, 93.7 % of A, and 95.1 % of T&A) were performed in patients younger than 15. Over 5 years, the proportion of the child population numbers decreased, from 17.43 to 15.41 % in the HI group and from 21.20 to 13.15 % in the HA group. Thus, crude surgery rates for T, A, and T&A decreased more rapidly in the HA group (7.50, 14.79, and 15.55 %) than the HI group (1.69, 1.49, and 0.90 %) each year. Adjusted surgery rates for T, A, and T&A increased in the HI group (1.01, 2.64, and 3.36 %) and decreased in the HA group (1.39, 2.86, and 2.76 %) each year. These adjusted surgery rates partially explains the sharper decrease in crude surgery rates in the HA group than the HI group. The crude and adjusted rates of surgeries were usually higher in lower economic status groups. In conclusion, surgery rates were affected by changes in the population structure, but by other factors as well. Predictable socioeconomic factors could be used to calculate and predict the rates for other well-established surgeries.

Objective: To evaluate the cost-effectiveness of adenotonsillectomy (T&A) for adenotonsillar hypertrophy and recurrent tonsillitis through the use of Missouri Medicaid data., Study Design: Children ages 2-16 years who had a diagnosis of adenotonsillar hypertrophy (based on medical claim codes) in 2006 (n = 4276) were included in this population-based study. The main outcome was direct total costs paid by Medicaid. Costs 2 years before and after T&A were compared in children who underwent surgical intervention with those who did not as well as costs comparison pre- and post-T&A. Wilcoxon rank-sum or Wilcoxon Signed-rank test was used for costs comparisons., Results: Children with adenotonsillar hypertrophy who underwent T&A were significantly less likely to be African American. They had more adenotonsillar infections before undergoing T&A and greater total costs (median costs $2313 vs. $1945; P = .009). The median costs were $1228 pre-T&A, compared with $823 post-T&A (P < .0001). This reduction in costs of $405 (33%) compares with a median cost of the procedure of $1088. The reduction in costs was mostly because of less antibiotic use and outpatient visits., Conclusions: African American children have fewer T&A procedures for adenotonsillar hypertrophy than white children, which represents an unexplained racial disparity. Children with adenotonsillar hypertrophy who underwent T&A compared with those who did not had more adenotonsillar infections and greater health care costs. T&A leads to a reduction in costs that, after 2 years, is 37% of the costs of the procedure. Future studies should examine the effects of demographics, obesity, and disease severity on health care costs in children with adenotonsillar hypertrophy., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: To (1) identify the major expenses for same-day adenotonsillectomy (T&A) and the costs for postoperative complication encounters in a children's hospital and (2) compare differences for variations in costs by surgeon., Study Design: Observational cohort study., Setting: Tertiary children's hospital., Subjects and Methods: A standardized activity-based hospital accounting system was used to determine total hospital costs per encounter (not including professional fees for surgeons or anesthetists) for T&A cases at a tertiary children's hospital from 2007 to 2012. Hospital costs were subdivided into categories, including operating room (OR), OR supplies, postanesthesia care unit (PACU), same-day services (SDS), anesthesia, pharmacy, and other. Costs for postoperative complication encounters were included to identify a mean total cost per case per surgeon., Results: The study cohort included 4824 T&As performed by 14 different surgeons. The mean cost per T&A was $1506 (95% confidence interval, $1492-$1519, with a range of $1156-$1828 for the lowest and highest cost per case per surgeon; P < .01). Including the cost for postoperative complications, the mean cost increased to $1599 ($1570-$1629). The largest cost categories included OR (31.9%), SDS (28.1%), and OR supplies (15.6%)., Conclusion: A large portion of T&A expenses are due to OR and supply costs. Significant differences in costs between surgeons for outpatient T&A were identified. Studies to understand the reasons for this variation and the impact on outcomes are needed. If this variation does not affect patient outcomes, then reducing this variation may improve health care value by limiting waste.

Objectives/hypothesis: To analyze variables that affect time and cost parameters of pediatric adenotonsillectomy., Study Design: Longitudinal 7-month retrospective review of sequential tonsil and adenoid surgery at a university pediatric tertiary care hospital., Methods: All children aged 2 to 12 years who underwent adenotonsillectomy from May 2008 to October 2008 had charts and billing records analyzed for variations in charges and times of adenotonsillectomy according to patient age, body mass index for age (BMIFA), American Society of Anesthesiologists (ASA) status, surgical indication, technology used, and teaching status of case. A total of 214 children had records reviewed., Results: Statistically significant variations were observed for all measured parameters except for indications for surgery. Children 3 years and younger had shorter procedures (P = .005) and total operating room times (P = .037). Charges for supplies were lower for ASA 1 patients than for ASA 2 patients (P = .010). Obese children with elevated BMIFA required longer procedures (P = .039) and more expensive surgery (P = .003). Procedure times were shorter for Coblation (ArthroCare, Austin, TX) compared with electrocautery (P = .27) and for microdebrider compared with electrocautery (P < .001). Charges for Coblation were substantially higher (P < .001). Teaching cases took longer (P < .001)., Conclusions: Charges and times for adenotonsillectomy surgery varied by patient age, BMIFA, ASA status, tonsillectomy technique, and teaching case status. Clinically salient differences were noted for ASA status, BMIFA, and surgical technique. This method of cost analysis provides useful information for resource management in tonsillectomy., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The tonsillectomy is realized inpatient and outpatient in different countries. Caused by the pressure of reduction of expenses there is the question of the economic benefit if done outpatient in Germany., Material and Methods: A comparison of the inpatient and outpatient gratification will be done., Results: There is a yearly potential of cost reduction of 213.5 million euro, if the operation would be done as an outpatient procedure. From the hospital view there is no economical recommendation doing an outpatient tonsillectomy., Conclusion: With simultaneous consideration of economical reasons, the medical quality and macroeconomic reasons there is no recommendation doing the tonsillectomy as an outpatient operation in Germany., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To compare the costs associated with 2 clinical strategies in children with recurrent upper respiratory tract infections (URTIs): immediate adenoidectomy vs an initial watchful waiting strategy., Design: A cost-minimization analysis from a societal perspective including both direct and indirect costs, alongside an open randomized controlled trial with a 2-year follow-up., Setting: Multicenter study, including 11 general and 2 university hospitals in the Netherlands., Patients: The study population comprised 111 children aged 1 through 6 years, selected for adenoidectomy for recurrent URTIs according to current clinical practice., Intervention: A strategy of immediate adenoidectomy with or without myringotomy or a strategy of initial watchful waiting., Main Outcomes Measures: Difference in median costs during the 2-year follow-up., Results: The median total of direct and indirect costs in the adenoidectomy and watchful waiting group were €1385 (US $1995) and €844 (US $1216) per patient, respectively. The extra costs in the adenoidectomy group are primarily attributable to surgery and visits to the otorhinolaryngologist. Other costs did not differ significantly between the groups., Conclusions: In children selected for adenoidectomy for recurrent URTIs, immediate adenoidectomy results in an increase in costs, whereas it confers no clinical benefit over an initial watchful waiting strategy., Trial Registration: trialregister.nl Identifier:NTR968; isrctn.org Identifier:ISRCTN03720485.

Large amounts of waste in hospitals are generated in the operating rooms from disposable surgical supplies. Tonsillectomy/adenotonsillectomy (T&A) cases use many disposable supplies that are not recyclable. It is critical to reduce disposable waste, as such waste directly affects the environment and increases health care costs. The authors noticed a difference between the number of disposable items prepared, available, but almost never used, for each tonsillectomy case between a children's hospital setting and a university ambulatory surgery center setting. The aims were the following: (1) identify what disposable medical supplies were unnecessarily opened for each case, (2) eliminate all disposable medical waste that was not critical to the case in both settings, and (3) determine the cost reduction at both hospital and surgery center facilities by revising the current disposable instruments/supplies pulled for tonsillectomy cases. The authors report projected cost savings and reduction in waste for one children's hospital and nationally based on their waste reduction.

Objectives: Adenoidectomy is one of the oldest and most frequent ENT procedures. This study aimed to compare adenoidectomy using suction-cautery adenoidectomy (SCA) to curettage with respect to operative time, postoperative complications, and cost-effectiveness., Methods: The data for this retrospective case control study were retrieved from the Medical Records Department at one of the few medical centers that perform this technique in the Kingdom of Saudi Arabia. The data for each case included the following: patient demographic features, type of procedure, time of operation, occurrence of any postoperative complications, length of hospital stay and cost of the procedure. To minimize the sources of variance in our data, all adenoidectomies were performed by the same consultant otolaryngologist, using either SCA or curettage., Result: Of the 86 patients who underwent adenoidectomy in this study, SCA was performed in half of them (43) and curettage in the other half. The two groups were well matched with no significant group differences in either age or gender (p=0.2 and p=0.19, respectively). There was a significant reduction in operative time (p<0.001) in the SCA group. There were no cases of postoperative hemorrhage after SCA, but there was one case of hemorrhage in the curette group that required a 2nd surgery to control the bleeding. Regarding cost, there were additional profits of more than 700,000 SR (US$180,000) each month with SCA as compared to curettage., Conclusions: The suction cautery technique was superior at reducing operative time, increasing cost-effectiveness and decreasing the risk of postoperative complications. Therefore, we suggest suction cautery as the most appropriate method for adenoidectomy., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

In children with sickle cell disease (SCD), adenotonsillar hypertrophy or recurrent tonsillitis are frequently linked with an increased risk of obstructive sleep apnea, cerebrovascular ischemia, or frequent pain episodes and often require an adenoidectomy and/or tonsillectomy. Interventions designed to prevent these complications, control vaso-occlusive pain episodes, and avoid hospitalizations may reduce the significant personal and economic burden of SCD. This study compares episode recurrence and treatment costs for cerebrovascular ischemia, vaso-occlusive pain, acute chest syndrome (ACS), and obstructive sleep apnea in children who had an adenotonsillectomy (A/T surgery, N = 256; 11.7%) and a matched cohort of those who did not (N = 512; 23.3%) from a cohort of 2,194 children and adolescents with SCD from South Carolina's Medicaid system. A/T surgery was associated with a significantly reduced rate of visits over time for obstructive sleep apnea and cerebrovascular ischemia (e.g., stroke, transient ischemic attacks), but not with any change in the rate of visits for vaso-occlusive pain or ACS/pneumonia visits. The rate of mean acute (emergency and inpatient) service costs was significantly decreasing over time after an increase about the time the A/T surgery was performed. The cost-effectiveness of adenoidectomy and/or tonsillectomy for treating obstructive sleep apnea and preventing cerebrovascular ischemia without increasing vaso-occlusive pain episodes or long-term acute service costs in routine clinical practice settings was demonstrated. The matched control group of SCD patients without A/T surgery contained more patients with severe vaso-occlusive pain episodes, ACS visits, and higher mean total costs over time and appears to represent a different phenotype of children with SCD.

Background: The American Society of Pediatric Otolaryngology recommends pre-operative coagulation testing only when indicated by history or physical exam. Nevertheless, many surgeons test all children scheduled for tonsillectomy and/or adenoidectomy (T&A). Studies of pre-operative screening have had conflicting results. A decision analysis model was constructed to address the costs and health outcome states of pre-operative screening strategies in children., Procedure: A 14-day Markov model evaluated three strategies: (1) test all children for coagulation disorders; (2) test only those children with a pertinent history; and (3) perform no pre-operative testing. A literature search and a review of national databases estimated probabilities, costs, and utility data. Parameters then were varied widely in sensitivity analyses. Using a societal perspective and a cycle length of 1 day, we compared the strategies based on total costs and quality-adjusted life years (QALYs)., Results: Total costs for the strategies were $3,200 for testing all children, $3,083 for testing only those with a history finding, and $3,077 for not testing. Total utilities were 0.02579, 0.02654, and 0.02659 QALYs, respectively. Cost-effectiveness ratios were most sensitive to variation in the cost of post-operative care and the probability of post-operative bleeding. The strategy of not testing was dominant in all sensitivity analyses., Conclusions: Our results demonstrate that not performing preoperative testing is the most cost-effective strategy. This was persistent in sensitivity analyses, indicating that the model was robust. These data may be helpful to institutions and organizations to formulate policies regarding pre-operative coagulation for children without previous diagnoses of bleeding disorders.

Objective/hypothesis: To compare cold and mixed (electrocautery tonsillectomy with curettage adenoidectomy) adenotonsillectomies in children in terms of hospital medications' and materials' costs, surgical time, aspirated blood volume, and postoperative pain., Study Design: Randomized clinical trial in community hospitals., Methods: Seventy-two patients aged 3 to 12 years, undergoing adenotonsillectomy, were randomized in two groups through sealed envelopes that were opened just prior to the procedure. Surgical time and aspirated blood volume were measured by a staff nurse. Hospital medication and material costs were supplied by the hospital's accounting department. A validated facial pain scale was used from the day of surgery to the 10th postoperative day to quantify pain., Results: Bicaudal t test showed that materials' cost was lower in the mixed technique. Surgical time and aspirated blood volume were also lower with the mixed technique. The postoperative pain was more intense in the cold technique on the day of surgery, but was more intense in the mixed technique from the 4th day to the 6th day. Linear regression showed a weak association between materials' cost and aspirated blood volume., Conclusions: Mixed technique reduces the costs of materials while offering the patient and the surgeon a safer and faster method to perform adenotonsillectomy, although it is slightly more painful than the cold technique in the latter part of the postoperative period.

Objective: We aimed to determine the incidence of abnormal pathological findings in the tonsils and/or adenoids of children undergoing tonsillectomy and/or adenoidectomy, and the incidence of tuberculosis of the tonsils and adenoids; suggest criteria to identify children at risk for adenotonsillar tuberculosis; and investigate the association between HIV and adenotonsillar abnormality, the cost-effectiveness of routine pathological examination of adenotonsillectomy specimens, and criteria to decide which specimens to send for histological examination., Methods: We undertook an 8-month prospective study on all children (< or =12 years) undergoing consecutive tonsillectomy or adenotonsillectomy (T&A) at Red Cross War Memorial Children's Hospital. Patients were assessed pre-operatively and tonsil sizes graded pre- and intra-operatively. Blood was taken for HIV testing, and all tonsils and adenoids were examined histologically. A cost-benefit analysis was done to determine the cost-effectiveness of adenotonsillectomy routine pathology., Results: A total of 344 tonsils were analysed from 172 children (102 boys, 70 girls); 1 patient had nasopharyngeal tuberculosis, and 1 lymphoma of the tonsils; 13 (7.6%) patients had clinically asymmetrically enlarged tonsils but no significant abnormal pathological finding. The average cost of detecting a clinically significant abnormality was R22 744 (R45 488 + 2 abnormalities)., Conclusions: The following criteria could improve cost-effectiveness of pathological examination of adenotonsillectomy specimens: positive tuberculosis contact at home, systemic symptoms of fever and weight loss, cervical lymphadenopathy >3 cm, suspicious nasopharyngeal appearance, HIV-positive patient, rapid tonsillar enlargement or significant tonsillar asymmetry. On our evidence, routine pathological investigation for South African children does not seem to be justified.

Objective: To evaluate the incidence of unexpected histologic findings in routine tonsillectomy and adenoidectomy specimens., Methods: A retrospective medical record review was performed at a tertiary care children's hospital. The pathology records of 2062 children who underwent tonsil or adenoid surgery were analyzed and the final histologic diagnosis was recorded., Results: Four unexpected histologic findings were found on routine tonsil and adenoid specimens. None were clinically significant. A review of the literature shows a very low rate (0.015%) of unexpected clinically significant diagnoses in pediatric adenotonsillectomy specimens., Conclusions: Given rarity of unexpected clinically significant diagnoses in pediatric adenotonsillectomy specimens, the cost and effort of analyzing each specimen histologically is difficult to justify.

Unlabelled: Managed care decreases reimbursement for surgical referral care and may decrease access for elective procedures. This study seeks to determine the impact of Medicaid managed competition on elective pediatric otolaryngology surgery., Design and Setting: Payer mix was analyzed for tonsillectomy and adenoidectomy (T&A) and bilateral myringotomy with ventilation tube insertion (BM&VT) charges for an eight-year period surrounding TennCare implementation. The payer mix for hospital gross charges was analyzed for the same period as a control., Results: After TennCare implementation, hospital gross charges shifted toward increased TennCare/Medicaid and decreased commercial insurance, whereas charges for the two elective procedures shifted toward increased commercial insurance and decreased TennCare/Medicaid., Conclusion: Otolaryngologists avoided impending losses under TennCare through indirect cost shifting. Numbers of T&A and BM&VT procedures performed on Tenncare/Medicaid patients remained constant, while numbers of these procedures performed on commercially-insured patients increased.

Background: Obesity is a highly prevalent chronic problem with health and fiscal consequences. Data from adults and nonsurgical pediatric patients suggest that obesity has serious implications for the US economy., Objective: Our goal was to describe the impact of BMI on hospital charges in children undergoing adenotonsillectomy (AT)., Methods and Procedures: We carried out a retrospective comparative analysis of the electronic anesthesia record and the charges from billing data from a large tertiary institution on children aged 3-18 years who had AT during the year 2005-2007. The main outcome measures were mean total hospital charges, likelihood of admission, and length of hospital stay (LOS)., Results: Of 1,643 children, 68.9% were aged <10 years, 76% were whites, and 74.1% had private commercial insurance. Most (75.3%) children were discharged on the day of surgery. Obese and overweight children were more likely to be admitted than their normal-weight peers (X(2)=26.3, P<0.001). Among those admitted, BMI showed a positive correlation with LOS (r=0.20, P<0.001). Obese and overweight patients had significantly higher total hospital charges than their healthy-weight counterparts (P=0.001). Anesthesia, postanesthesia care unit (PACU), and pharmacy and laboratory charges were also higher for obese than normal-weight children (P<0.05)., Discussion: Overweight and obese children undergoing AT accrued higher hospital charges and had longer postoperative LOS than their healthy-weight peers. If these findings are extendable to other surgical procedures, they could have far-reaching implications for the US economy.

Objective: To evaluate the cost-effectiveness of adenotonsillectomy compared with watchful waiting in Dutch children., Design: Economic evaluation along with an open, randomized, controlled trial., Setting: Multicenter, including 21 general and 3 university hospitals in the Netherlands., Participants: Three hundred children aged 2 to 8 years were selected for adenotonsillectomy according to routine medical practice. Excluded were children who had frequent throat infections and those with suspected obstructive sleep apnea., Main Outcome Measures: Incremental cost-effectiveness in terms of costs per episode of fever, throat infection, and upper respiratory tract infection avoided., Results: Annual costs incurred in the adenotonsillectomy group were euro803 (the average exchange rate for the US dollar in 2002 was $1.00 = euro1.1, except toward the end of 2002 when $0.95 = euro100) and euro551 in the watchful waiting group (46% increase). During a median follow-up of 22 months, surgery compared with watchful waiting reduced the number of episodes of fever and throat infections by 0.21 per person-year (95% confidence interval, -0.12 to 0.54 and 0.06 to 0.36, respectively) and upper respiratory tract infections by 0.53 (95% confidence interval, 0.08 to 0.97) episodes. The incremental costs per episode avoided were euro1136, euro1187, and euro465, respectively., Conclusions: In children undergoing adenotonsillectomy because of mild to moderate symptoms of throat infections or adenotonsillar hypertrophy, surgery resulted in a significant increase in costs without realizing relevant clinical benefit. Subgroups of children in whom surgery would be cost-effective may be identified in further research. .

Objective: To determine whether the current practice and incurred cost of histologic examination of tonsillectomy and adenoidectomy specimens is warranted., Study Design: Review article based on medical literature., Subjects and Methods: A retrospective PubMed review of all pertinent literature regarding tonsillectomy, adenoidectomy, and related surgical pathology was conducted. References of the articles obtained were reviewed for additional sources., Results: Twenty studies report 54,901 patients and found 54 malignancies (0.087% prevalence). Of these, 48 (88% of the patients) had suspicious features such as tonsillar asymmetry, cervical lymphadenopathy, or abnormal tonsil appearance, preoperatively. The remaining six patients without any suspicious features (better representing true occult malignancy) were 0.011% of the total cases., Conclusion: Submission of tonsillectomy, adenoidectomy, or both specimens is warranted only when patients demonstrate findings associated with malignancy: tonsillar asymmetry, history of cancer, neck mass, tonsil firmness or lesion, weight loss, and constitutional symptoms.

Background: The aim of this study was an improvement in patient comfort, reduction of anaesthesia costs and room contamination by the use of propofol for adenoidectomy., Methods: A total of 103 infants (aged 1-5 years) undergoing elective adenoidectomy were randomized for anaesthesia with sevoflurane-nitrous oxide/oxygen (group 1), sevoflurane-air/alfentanil (group 2), alfentanil-propofol under induction with sevoflurane (group 3) or alfentanil-propofol (group 4)., Results: Using propofol, postoperative agitation and emesis were significantly less and the anaesthesia costs as well as the need for analgesics was reduced compared to inhalative anaesthesia., Conclusions: The use of propofol for preschool children undergoing ear, nose and throat (ENT) surgery seems to be advantageous because of less postoperative agitation, emesis and costs.

Objective: Much has been written about the merits of various techniques of adenotonsillectomy. Proponents of each technique tout many virtues over one another. However, cost remains one variable that has not been thoroughly addressed. In this study, we compared the surgery time, anesthesia time, bleeding, and cost between 2 well-established techniques. Electrocautery tonsillectomy/adenoid ablation was compared against traditional cold knife dissection with adenoid curette., Study Design and Setting: A retrospective chart review of 275 patients in a large tertiary teaching hospital., Results: The electrocautery group had overall savings of 8, 8, and 9 minutes in surgery, anesthesia, and operating room times, respectively. In terms of cost, the variable cost of the electrocautery group was 19% less than the cold knife dissection group., Conclusion/significance: This study demonstrated that cautery ablation of adenoids, when employed as part of adenotonsillectomy, enables the surgical team to save significant amount of time, and substantial cost for patients., Ebm Rating: B-3.

Problem Addressed: Floseal is a novel matrix hemostatic sealant composed of collagen-derived particles and topical bovine-derived thrombin. It is applied as a high-viscosity gel for hemostasis and has been clinically proven to control bleeding. This study is a prospective, randomized, controlled clinical trial of Floseal sealant compared to traditional suction cautery hemostasis in children undergoing adenoidectomy., Methods and Measures: Seventy patients (mean age 7.0 yrs, 45.7% male) with obstructive sleep apnea underwent traditional cold steel adenoidectomy with an adenoid curette and were then randomized to receive the hemostatic sealant (Floseal) or cautery to obtain hemostasis. Patients were crossed over to the other hemostatic technique if hemostasis was not achieved after more than 100 mL of blood loss or 15 minutes elapsed time. Objective data collected included time to hemostasis and blood loss during hemostasis. Visual analog scales (VAS) were used to record subjective data by the operating surgeon including bleeding following adenoid pack removal (0 = none, 3 = brisk) and ease of operation (1 = extremely easy, 6 = extremely difficult). Parents recorded diet on a journal and were contacted by phone at postoperative day 7 and questioned with regard to return to regular diet and use of narcotics., Results: Compared to patients in the cautery group (n = 35), Floseal patients (n = 35) had significantly shorter times to hemostasis (0.6 +/- 1.3 minutes vs 9.5 +/- 5.4 minutes [mean +/- SD], P < 0.001), less blood loss (2.5 +/- 9.2 mL vs 29.4 +/- 27.1 mL, P < 0.001), less subjective bleeding (0.0 +/- 0.6 vs 2.0 +/- 0.7, [median 4-point VAS +/- SD], P < 0.001), and subjectively easier operations (2.6 +/- 1.0 vs 5.2 +/- 1.0 [mean 6-point VAS +/- SD], P < 0.001). Furthermore, Floseal patients returned to regular diet earlier (2.7 +/- 0.7 vs 4.1 +/- 0.5 days [mean +/- SD], P < 0.001) and had less use of narcotics at 7 days postoperatively (40% vs 69%, P < 0.05). Lastly, three patients in the cautery group were crossed over to the Floseal group, but no Floseal subjects were crossed over to the cautery group. The retail cost of Floseal is US 85 dollars. Operating room costs are estimated at US 12 dollars/minute. Reducing the operative length by 8.9 minutes on average produces a cost savings of US 106.80 dollars per operation. There were no complications in either experimental group including postoperative hemorrhage, hospitalization, blood transfusion, or aspiration., Conclusions: Floseal matrix hemostatic sealant is a safe, efficacious, easy, and cost-effective technique for obtaining hemostasis in children undergoing adenoidectomy. Limitations of the study include the fact that it is nonblinded, which does allow for some bias in the subjective data recorded. However, utilizing 4 different operating surgeons, 3 of whom were not affiliated with the study, minimized this. CLINICAL SIGNIFICANCE OF STUDY: This study demonstrates the safety and efficacy of a novel hemostatic sealant in children undergoing adenoidectomy. Floseal matrix hemostatic sealant can be used as a first-line hemostatic agent, and it is a good tool in the armamentarium of otolaryngologists who encounter significant bleeding following adenoidectomy.

Objective: To investigate health care utilization of children with obstructive sleep apnea syndrome (OSAS) 1 year after adenotonsillectomy (T&A)., Methods: A longitudinal, case-controlled, prospective study was conducted at Clalit Health Care Services (CHS), a health maintenance organization in the southern region of Israel. We defined 3 groups of children: 1) children who had OSAS and were treated with T&A (n = 130); 2) children who had OSAS and did not undergo surgery (n = 90); and 3) control subjects who were matched by age, sex, and area of residency (n = 520) and randomly selected from the CHS database. OSAS was verified with polysomnography studies in all patients. Indices of health care utilization were analyzed 1 year before and 1 year after T&A. Medical records in the emergency department and during hospitalization were reviewed for diagnosis before the polysomnography diagnosis., Results: Mean age of all children with OSAS was 5.6 +/- 3.6 years. Total annual health care costs were reduced by one third in children who underwent T&A, whereas there was no change in the control and untreated OSAS groups. T&A was associated with a 60% reduction in the number of new admissions, 39% reduction in emergency department visits, 47% reduction in the number of consultations, and 22% reduction in costs for prescribed drugs. In group 2, the total costs were similar in years 1 and 2., Conclusions: T&A significantly reduces health care utilization in children with OSAS. Untreated children with moderate and severe OSAS will continue to consume high levels of health care resources. Increased morbidity among children with OSAS is mainly related to upper respiratory tract infections.

A recognized disadvantage of power-assisted adenoidectomy (PAA) is the increased patient charge associated with the disposable instrumentation. The elimination of pathological review of routine adenoid specimens may provide a means of offsetting the increased charge, as 1) unsuspected findings are rare, and 2) PAA specimens are too traumatized to provide the microscopic detail necessary to make an unsuspected diagnosis. The pathology reports of all adenoidectomy specimens removed over a 10-year period were reviewed and combined with previously published reviews in order to estimate the prevalence of unsuspected disease. The estimated prevalence of unsuspected diagnoses found by routine pathological review of adenoid specimens is 37 per 100,000 cases (95% confidence interval, 26-51). In a separate analysis, a pathologist blinded to the technique of adenoid removal assessed the tissue effects of curette adenoidectomy versus PAA. Significant tissue damage at the microscopic level was identified in 6 of 11 specimens removed with the power-assisted technique as compared to 0 of 11 specimens removed by curette (p = .03). Eliminating histopathologic review of routine adenoidectomy specimens can potentially offset the increased patient charge of PAA by 62%. Power-assisted adenoidectomy, however, should be avoided in nonroutine cases in which the potential for occult disease exists.

Otitis media with effusion is a common disorder in children, associated to hearing loss and recurrent acute otitis media. It has three basic treatments: Spontaneous resolution, oral antibiotics and surgery including adenoidectomy and/or grommets insertion. Through a sensibility analysis on a theoretical group of 1000 patients our aim is to study the cost-effectiveness of the different therapeutic options, evaluating direct and indirect costs, and identifying the most efficient option (cost-effective). We analysed effectiveness and variable costs of each arm of the decision tree, considering initial and rescue treatments. As expected, effectiveness grows up to the most through treatment, including adenoidectomy and grommets insertion, from 92% to 98% of children treated. Nevertheless, unitary cost of each child treated also increases, from 302 to 401 euros; that is, choosing the most cost-effective treatment enables to save approximately 100 euros per child. But, fixed costs, which are much higher (600 euros per child), will not change, limiting our management resources.

Objectives: To evaluate the use and necessity of obtaining histopathology on patients undergoing tonsillectomy, and to provide indications and guidelines for requesting histopathology on tonsillectomy patients., Study Design: At the University of Mississippi Medical Center, we have been routinely obtaining histopathologic diagnoses on every patient undergoing tonsillectomy or tonsillectomy and adenoidectomy. Specimens are separated into left and right tonsils and adenoids. This study was designed at our tertiary care academic center to evaluate the necessity for obtaining histopathologic diagnosis on each of these patients., Methods: A retrospective review of histopathologic reports on all patients in both pediatric and adult age groups undergoing tonsillectomy or tonsillectomy and adenoidectomy between January 1994 and December 1999 was performed., Results: A total of 2438 reports were reviewed. There were 2099 in the pediatric age group and 339 were adults. None of the children had an unusual histopathology finding other than lymphoid hyperplasia. Of the 339 adults, 34 had squamous cell carcinoma and 6 had lymphoma; however, these findings were suspected preoperatively by history and clinical manifestations., Conclusions: The general practice guidelines mandate obtaining histopathologic diagnoses on most of the tissues received. Based on our review, histopathology of tonsillectomy and/or adenoidectomy may not be necessary, especially in children. In this era of cutting excess costs of health care dollars, waving histopathology in these cases may have major implications without compromising delivery of quality care.

Background: The issues of whether minor surgery should be performed in private or public clinics and/or be funded by the national health service are under continuous debate in Norway., Material and Methods: A prospective study of the benefit of (adeno)tonsillectomies in 120 children is presented. Surgery included in the study was performed on an inpatient as well as an outpatient basis and in public as well as private clinics., Results: There was no difference in patient satisfaction or in the quality of surgery depending on the type of organisation. Relief of symptoms associated with (adeno)tonsillar infections and obstruction following surgery was consistent. Less euresis was found in the study population following surgery. Increased haemoglobin concentration and less protoporfyrin IX in erythrocytes indicate an improved erythropoiesis following (adeno)tonsillectomy. Less manpower was needed to perform (adeno)tonsillectomies in private compared to public clinics., Interpretation: We suggest that the Norwegian national health system opens up for funding surgery of established quality irrespective of whether it is performed in a public or a private clinic.

Postoperative management of the patient younger than 36 months undergoing adenotonsillectomy has been the subject of many debates. Concerns for early postoperative complications such as airway obstruction, emesis, dehydration, and hemorrhage have led many physicians to consider overnight hospitalization following adenotonsillectomy in very young children. Trends in health care management have had increasing focus on cost effective means of treating patients to limit unnecessary expenditure on the part of the patient, physician, and hospital facility. The purpose of this retrospective review was to analyze two methods of early postoperative management in children less than 36 months old undergoing adenotonsillectomy at the Children's Hospital, San Diego from 1992 to 1997. Three hundred and seven cases were reviewed. Same-day discharge was compared with overnight inpatient observation based on the cost analysis of these two methods of postoperative care. Postoperative care was based on length of stay in the recovery room and as an inpatient. Expense of postoperative care was based on cost calculation for the recovery room and overnight hospitalization. Of the 307 patients, 194 went home the day of surgery and 113 were observed overnight in the hospital. Average hospital cost was higher in the outpatient group than in the inpatient group (P < 0.001). This difference reflects longer recovery room stay (350 min) in the outpatient group compared to the inpatient group (108 min) (P < 0.001). Outpatient adenotonsillectomy in the patient under 36 months may be safe; however, prolonged recovery room stays may actually make outpatient surgery less cost-effective than overnight admission. Recovery room costs are significantly higher per unit time than costs of inpatient hospitalization. Further investigation of cost-effective outpatient observation units may improve cost containment in the outpatient surgical setting.

Purpose: The purpose of this study is to examine two different dimensions of an outpatient pediatric tonsillectomy and adenoidectomy (T&A) clinical pathway at a tertiary care children's hospital. First, the analysis investigates whether the T&A clinical pathway effectively aids in the decision to discharge a pediatric patient as a day surgery (DS) (less than 12 hours) rather than as an outpatient observation surgery (OPO) (12 to 23 hours). Second, the pathway's impact on quality and financial outcomes is explored., Patients and Methods: Forty prepathway pediatric T&A patients were randomly selected and matched to 40 pathway pediatric T&A patients by age, gender, medical history, and surgeon to form a retrospective cohort. Using chi-square and analysis of variance, the two groups were compared by type of discharge (DS or OPO), length of stay, readmission rates, and costs., Results: The results show that patients on a pathway were more likely to be discharged as a DS. The shift toward DS discharges effected significant reduction in average length of stay and overall direct costs. Furthermore, there was no difference in readmission rates., Conclusion: These results indicate that the development and implementation of a pathway is an effective method in reducing length of stay and overall direct costs while maintaining quality outcomes.

To study the cost-effectiveness of the histologic examination of tonsil and adenoid specimens, the histologic diagnoses for all routine (2,700) and nonroutine (71) tonsil and adenoid specimens during a 10-year period were reviewed. There were 27 routine cases (1%) and 56 nonroutine cases (79%) with a diagnosis other than normal, tonsillitis, or hyperplasia. Twelve of the 27 routine cases did not have a significant clinical history, and a potentially significant pathologic diagnosis was made in only 6 cases; in none of these cases did the pathologic diagnosis affect patient care. In all nonroutine cases, the pathologic diagnosis affected patient care. The average charge per case to detect potentially significant disease in routine and nonroutine cases was $64,718 and $525, respectively. We conclude that histologic examination of nonroutine cases is cost-effective, whereas in most routine cases with adequate clinical history, histologic examination is not cost-effective.