Surgical Variation in Tonsillectomy and Adenoidectomy Procedures

Abstract

Objectives: Identify potential sources of variation in tonsillectomy/ tonsillotomy and adenoidectomy procedures that may impact operating room (OR) efficiency and cost. Background: Surgeons display substantial variability in use of equipment and technique for same procedure. Examination of process variability may lead to valuable insights about potential improvements in efficiency and cost. Methods: Observational quality improvement initiative conducted at an academic inpatient children’s hospital and a satellite site in 2012. One author (RS) observed 65 procedures consisting of tonsillectomy/tonsillotomy with or without adenoidectomy; an additional 50 cases were included by review of patient records. Over 100 variables were measured for each case, including patient demographics, indication, and technique used. Univariate and multivariate analysis was used to determine predictors of OR times and total charges. Results: Multivariate analysis showed: Significantly lower charges at satellite location compared to main campus (34.1% reduction, P < 0.0001). Longer total OR time is associated with higher total charges. Anesthesia time did not vary between the two sites. Individual surgeons’ operating time varies up to two-fold. Factors with a statistically significant association with shorter total OR time are location (satellite vs. main campus, P = 0.0233), deep vs. awake extubation ( P < 0.0001), and identity of surgeon ( P = 0.0016). Conclusions: Results of this study suggest substantial opportunities for increased efficiency by identification of those process steps associated with shorter OR time and lower total charges, including satellite location, deep extubation, and possibly by using the more efficient surgeons as exemplars of most efficient techniques.