title: Association of National Guidelines With Tonsillectomy Perioperative Care and Outcomes.
abstract: OBJECTIVE
  To investigate the association of the 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines with perioperative care processes and outcomes in children undergoing tonsillectomy.
  
  
  METHODS
  We conducted a retrospective cohort study of otherwise healthy children undergoing tonsillectomy between January 2009 and January 2013 at 29 US children's hospitals participating in the Pediatric Health Information System. We measured evidence-based processes suggested by the guidelines (perioperative dexamethasone and no antibiotic use) and outcomes (30-day tonsillectomy complication-related revisits). We analyzed rates aggregated over the preguideline and postguideline periods and then by month over time by using interrupted time series.
  
  
  RESULTS
  Of 111,813 children who underwent tonsillectomy, 54,043 and 57,770 did so in the preguideline and postguideline periods, respectively. Dexamethasone use increased from 74.6% to 77.4% (P < .001) in the preguideline to postguideline period, as did its rate of change in use (percentage change per month, -0.02% to 0.29%; P < .001). Antibiotic use decreased from 34.7% to 21.8% (P < .001), as did its rate of change in use (percentage change per month, -0.17% to -0.56%; P < .001). Revisits for bleeding remained stable; however, total revisits to the hospital for tonsillectomy complications increased from 8.2% to 9.0% (P < .001) because of an increase in revisits for pain. Hospital-level results were similar.
  
  
  CONCLUSIONS
  The guidelines were associated with some improvement in evidence-based perioperative care processes but no improvement in outcomes. Dexamethasone use increased slightly, and antibiotic use decreased substantially. Revisits for tonsillectomy-related complications increased modestly over time because of revisits for pain.
authors.affiliation: Division of Pediatric Medicine, Pediatric Outcomes Research Team (PORT), Department of Pediatrics, Institute of Health Policy, Management and Evaluation, University of Toronto, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada; sanjay.mahant@sickkids.ca.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Mahant
authors.affiliation: Children's Hospital Association, Overland Park, Kansas;
authors.forename: Matt
authors.initials: M
authors.lastname: Hall
authors.affiliation: Division of Otolaryngology, Head & Neck Surgery, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, and Department of Otolaryngology, Head & Neck Surgery, University of Cincinnati, Cincinnati, Ohio;
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Ishman
authors.affiliation: Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas;
authors.forename: Rustin
authors.initials: R
authors.lastname: Morse
authors.affiliation: Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas;
authors.forename: Vineeta
authors.initials: V
authors.lastname: Mittal
authors.affiliation: Division of Hospital Medicine and.
authors.forename: Grant M
authors.initials: GM
authors.lastname: Mussman
authors.affiliation: New York-Presbyterian Morgan Stanley Children's Hospital and Columbia University Medical Center, New York, New York;
authors.forename: Jessica
authors.initials: J
authors.lastname: Gold
authors.affiliation: Children's Mercy Hospitals and Clinics and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri;
authors.forename: Amanda
authors.initials: A
authors.lastname: Montalbano
authors.affiliation: Division of Inpatient Medicine, Department of Pediatrics, University of Utah Health Sciences Center, Institute for Healthcare Delivery Research, Intermountain Healthcare Inc., Salt Lake City, Utah; and.
authors.forename: Rajendu
authors.initials: R
authors.lastname: Srivastava
authors.affiliation: Section of Pediatric Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado.
authors.forename: Karen M
authors.initials: KM
authors.lastname: Wilson
authors.affiliation: Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
authors.forename: Samir S
authors.initials: SS
authors.lastname: Shah
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003907:Dexamethasone / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007223:Infant; D008137:Longitudinal Studies; D008297:Male; D019990:Perioperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000188:drug therapy; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D014068:Tonsillectomy / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents; D003907:Dexamethasone