dhave setabutr, m.d., eelam adil, m.d., tabrez adil, b.s., michele … · 2013-07-12 · title:...
TRANSCRIPT
Abstract
Objective To evaluate the effect of the recently published pediatric tonsillectomy and polysomnography clinical guidelines on current practice patterns Design Survey of members of the American Academy of Otolaryngology ndash Head amp Neck Surgery Setting Tertiary medical center Results 93 of respondents read the Guidelines Most respondents had completed a Pediatric Otolaryngology fellowship (84) A small majority of physicians (54) continue to prescribe antibiotics within 24 hours after surgery One-third of respondents stopped prescribing antibiotics because of the new guidelines Discord between severity of symptoms and tonsil size was the most common reason cited for ordering a polysomnogram prior to tonsillectomy (76) in concordance with the Guidelinersquos recommendations The most common reason cited for admission post-tonsillectomy was age less than three (40) Less than half of physicians prescribe NSAIDrsquos for pain control (45) despite its safety profile and only 23 reported that the Guidelines influenced their use of NSAIDrsquos postoperatively Most respondents use intra-operative steroids (90) as recommended Conclusion The Guidelines are intended to provide evidence based direction in tonsillectomy practices and improve referral patterns for polysomnography prior to tonsillectomy A majority of the surveyed Otolaryngologists reviewed these guidelines There is some evidence practice has changed secondary to the Guidelinesthose using bronchodilators or anti-reflux medication
Introduction
Clinical Practice Guidelines are commonly published with the intent to provide a consensus on management of patients as directed by evidence based medicine The American Academy of Otolaryngology ndash Head amp Neck Surgery has recently published two sets of guidelines regarding the second most common procedure performed by practicing Otolaryngologists tonsillectomy1 The impact of these guidelines however may not be as great as intended
Results
Survey
Discussion
Most Otolaryngologists read the Clinical Practice Guidelines In situations where physicians were not in concordance with guidelines 23-30 changed their practice Depending on the category up to half of Otolaryngologists do not change their practice A Dutch survey completed in 2012 found that non adherence to Otolaryngology guidelines was 455 Younger physicians were found to be more compliant according to previous reports5 As has been previously published the practice of physicians is largely anecdotal and based upon prior experiences and training The Clinical Practice Guidelines impact patient care but to a less extent than most might assume
Conclusion
This study was completed to evaluate whether practicing Otolaryngologists and specifically those dealing with the pediatric patient change their practice based upon the published Clinical Practice Guidelines Compliance rates were similar to adherence rates published previously among Otolaryngologists4-6 Overall physicians report that the Clinical Practice Guidelines affect their practice in some categories however not in others
References
1 Setabutr D Adil EA Adil TK Carr MM Emerging trends in tonsillectomy Otolaryngol Head Neck Surg 2011 Aug145(2)223-9
2 Baugh RF Archer SM Mitchell RB et al Clinical Practice Guideline Tonsillectomy in Children Otolaryngol Head Neck Surg Dec 31 2010 vol 144 no 1 suppl S1-S30
3 Roland PS Rosenfeld RM Brooks LJ Friedman NR Jones J Kim TW Kuhar S Mitchell RB Seidman MD Sheldon SH Jones S Robertson P American Academy of OtolaryngologymdashHead and Neck Surgery Foundation Clinical practice guideline Polysomnography for sleep-disordered breathing prior to tonsillectomy in children Otolaryngol Head Neck Surg 2011 Jul145(1 Suppl)S1-15 Epub 2011 Jun 15
4 Farias M Friedman KG Powell AJ de Ferranti SD Marshall AC Brown DW Kulik TJ Dynamic Evolution of Practice Guidelines Analysis of Deviations From Assessment and Management Plans Pediatrics 2012 Jun 4 [Epub ahead of print]
5 Aarts MC van der Heijden GJ Siegers C Grolman W Rovers MM Awareness of opinions about and adherence to evidence-based guidelines in otorhinolaryngology Arch Otolaryngol Head Neck Surg 2012 Feb138(2)148-52
6 Reuveni H Asher E Greenberg D Press J Bilenko N Leibovitz E Adherence to therapeutic guidelines for acute otitis media in children younger than 2 years Int J Pediatr Otorhinolaryngol 2006 Feb70(2)267-73 Epub 2005 Aug 15
No
Antibiotics
54
Administer
Antibiotics
46
Antibiotic Use
Is this a change since the guidelines
Yes 31
No 69
Yes
44
No
56
Do you recommend NSAIDs for post-operative pain control
Is this a change since the guidelines
Yes 23
No 77
0 10 20 30 40 50 60 70 80 90
Yes all the time
No
Sometimes
Is this a change since the guidelines
Yes 25
No 975 0 10 20 30 40 50 60 70 80
Age lt 3
Age lt 2
Age lt 1
Obesity
Trisomy 21
Mucopolysacharidosis
Sickle cell anemia
Craniofacial abnormalities
Patients with small tonsils and SDB sx
Unclear sx
I do not order PSG
Percent
Which category of patients do you order polysomnograms for Do you administer intraoperative steroids
34
21
36
16
46 40
8
16
0
10
20
30
40
50
60
R
outi
ne
adm
issio
ns
n = 278
n = 278
Reason for admitting patients post-tonsillectomy
Guidelines Reviewed
Clinicians should not routinely administer or prescribe peri-operative antibiotics to children undergoing tonsillectomy NSAIDs did not significantly increase the rate of bleeding following tonsillectomy Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy Before performing tonsillectomy the clinician should refer children with sleep-disordered breathing (SDB) for polysomnography (PSG) if they exhibit any of the following obesity Down syndrome craniofacial abnormalities neuromuscular disorders sickle cell disease or mucopolysaccharidoses The clinician should advocate for PSG prior to tonsillectomy for SDB in children without any of the comorbidities listed in prior statement for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of SDB Clinicians should admit children with OSA documented in results of PSG for inpatient overnight monitoring after tonsillectomy if they are under age 3 years or have severe OSA (apnea-hypopnea index of 10 or more obstructive eventshour oxygen saturation nadir less than 80 or both)
Methods
A 15-question survey was distributed to members of the American Academy of Otolaryngology-Head and Neck Surgery