565884

research-article2015

CPJXXX10.1177/0009922814565884Clinical PediatricsNguyen et al

Article

Pediatric Patient and Hospital Characteristics Associated With Treatment of Peritonsillar Abscess and Peritonsillar Cellulitis

Clinical Pediatrics 2015, Vol. 54(13) 1240­–1246 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814565884 cpj.sagepub.com

Thuy Nguyen, BS1, Corinna Anke Haberland, MD, MS1, and Tina Hernandez-Boussard, PhD, MPH, MS1

Abstract Objective. To identify patient and hospital characteristics associated with the choice of treatment for pediatric patients who present in the acute setting with peritonsillar abscess/cellulitis (PTA/PTC). Study Design. A retrospective cohort study was performed using Healthcare Cost and Utilization Project emergency department, ambulatory, and inpatient state databases for the years 2010 and 2011. Children aged 0 to 17 years were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for PTA/ PTC. The main outcome of interest was treatment received, which included medical therapy alone, incision and drainage (IND) or tonsillectomy. Multiple logistic regression analyses were conducted to model non-clinical factors associated with treatment received after adjusting for age, hospital state, race, primary expected payer, existing chronic condition(s), and type of hospital. Results. We identified 2994 patients who presented with PTA/PTC. The most common treatment choice was medical therapy alone (30.8%), followed by IND (30.5%) and tonsillectomy (9.4%). There were significant associations between treatment choice and race, primary payer status, and type of hospital (P < .05). We found that Hispanic patients, those with Medicaid as their primary expected payer, and those treated at a designated children’s hospital were 3 nonclinical factors independently associated with an increase in likelihood of receiving tonsillectomy as treatment. Conclusion. There are important nonclinical factors associated with treatment of children who present in the acute setting with PTA/PTC. Additional research is recommended to understand these observed differences in care and how they may affect health outcomes. Keywords peritonsillar abscess/peritonsillar cellulitis (PTA/PTC), tonsillectomy Peritonsillar abscess/cellulitis (PTA/PTC) is one of the most common deep neck infections in children and adolescences.1,2 There is an estimation of 13 500 cases in the United States annually.1 The classical presentation for PTA/PTC includes severe sore throat, fever, and a “hot potato” or muffled voice. Although a sudden onset of severe respiratory distress is rare, delayed intervention of PTA/PTC can allow for disease progression to compromised airways and life-threatening situations.3 There are several treatment choices available for the pediatric patient diagnosed with PTA/PTC. Considerable evidence supports incision and drainage (IND) and/or antibiotics as appropriate treatment1-5; however, other authors advocate for immediate tonsillectomy.4,5 Although each treatment choice has its own supporting body of research, to our knowledge, demographic and socioeconomic factors associated with treatment choices

have not been well described. In our study, we sought to identify nonclinical factors associated with treatment choice for PTA/PTC.

Methods Data Source This study used 3 sets of data distributed by the Healthcare Cost and Utilization Project (HCUP), 1

Stanford University School of Medicine, Palo Alto, CA, USA

Corresponding Author: Tina Hernandez-Boussard, Department of Surgery, Stanford University School of Medicine, 1070 Arastradero #307, Palo Alto, CA 94306, USA. Email: [email protected]

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Nguyen et al Table 1.  Codes Identifying Patient Population. ICD-9-CM Diagnosis   Peritonsillar abscess, peritonsillar cellulitis Procedure code(s)a   Incision and drainage of tonsil and peritonsillar structures   Tonsillectomy with/without adenoidectomy   Medical therapy: Therapeutic, prophylactic, or diagnostic injection/intravenous (electrolytes, antibiotic, steroid, etc)

CPT

28.0

  n/a   42700

28.2, 28.3 99.18

42820-42821, 42825-42826 96360-96361, 96365-96368, 96372-96376

475

Abbreviations: ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification; CPT, Current Procedural Terminology; n/a, not available. a Since procedures were recorded using ICD-9-DM codes as well as CPT codes, all subjects included in the current study meet the criteria for inclusion using at least 1 of the 2 methods of coding.

sponsored by the Agency for Healthcare Research and Quality (AHRQ) from 2010 to 2011 from California, Florida, and New York: (1) State Inpatient Database (SID),6 (2) State Ambulatory Surgery Database (SASD),7 and (3) State Emergency Department Database (SEDD),8 The SID captures all hospital discharges, the SEDD captures all emergency department discharges, and the SASD captures all outpatient discharges involving surgeries performed on the same day in which patients are admitted and released in a given state. All data sets represent a population-based sample and capture patient characteristics, diagnoses, and procedures performed, discharge disposition, and a linkage variable to track patients’ health care utilization across encounters. Hospital-level data were obtained through the linkage with the 2011 American Hospital Association survey database.9

Study Population and Design Hospital discharges for pediatric patients aged 0 to 17 years were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for peritonsillar abscess and peritonsillar cellulitis (475). Each discharge file contains an encrypted variable created by HCUP to represent a unique patient, allowing us to identify multiple records in the SID, SASD, and SEDD that belong to the same person. Additional variables within each discharge file, such as admission source and discharge disposition, also allow us to identify special scenarios such as transfer records or duplicate records. Specifically in the SID, there will be 2 different records if a patient is transferred from one hospital to another. However, since the coding of admission source and discharge

disposition is not always consistent, we counted each unique patient only once based on treatment received.

Study Outcomes Our primary outcome of interest was treatment received for PTA/PTC. Treatment choices were categorized as follows: medical therapy alone, IND, and tonsillectomy. Medical therapy alone is defined as general administration of IV fluids, antibiotics and/or steroids without any surgical procedures. Under this definition, medical therapy is often a part of standard care for patients who present with an acute infection. We differentiate patients who receive medical therapy alone from patients who receive surgical therapy in addition to medical therapy using ICD-9-CM and Current Procedural Terminology (CPT)10 codes specific to those procedures (Table 1). Hence, patients who received IND were likely to have also received medical therapy. However, since we also sought to identify any differences in care between surgical choices, we differentiated those patients who received IND from those who received tonsillectomy. During our data analysis, we found a number of patients who received a diagnosis for peritonsillar abscess/cellulitis but had no recorded procedure for their discharge. They were labeled as “no code” Demographic variables included the following: age, gender, race, primary expected payer, existing chronic condition(s),11 discharge status, and length of stay if the patient was hospitalized. Race was categorized as follows: white, Hispanic, Black, and other, which include subjects with missing race; primary expected payer was categorized as follows: private insurance, Medicaid and self-pay. In our current study, less than 20 patients were identified with Medicare as their primary expected payer and were thus excluded from analysis based on data use agreement.

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Clinical Pediatrics 54(13)

Statistical Analysis

Table 2.  Study Population.

Initial analyses were performed with χ2 test to assess differences in categorical demographic variables. After identifying clinically relevant variables and significant differences from univariate analysis, multiple logistic regression models were developed to identify independent predictors of treatment. The following variables were included in the model: age, hospital state, race, primary expected payer, existing chronic condition(s), and type of hospital. Adjusted odds ratios are reported with 95% confidence intervals. Results were considered statistically significant for P values 1 Discharge status, n (%)b   Routine discharge   Transfer to short-term hospital Treatment source, n (%)   Ambulatory surgery   Emergency department  Inpatient Type of hospital, n (%)a   General hospital   Children’s hospital Treatment, n (%)  Tonsillectomy   Incision and drainage   Medical therapy alone   No code

  13.3 (4.3) 15 247 (8.3) 725 (24.2) 2 022 (67.5) 1 517 (50.6) 1 340 (44.8) 1 278 (42.7) 906 (30.3) 810 (27.0) 1 025 (34.2) 575 (19.2) 876 (29.0) 527 (17.6) 1 429 (47.7) 1 291 (43.1) 274 (9.2) 2 839 (94.8) 155 (5.2) 2 857 (95.4) 119 (4.0) 220 (7.4) 1 491 (49.8) 1 283 (42.8) 2 633 (87.9) 252 (8.4) 280 (9.4) 912 (30.5) 922 (30.8) 880 (29.3)

a

These variables have missing values and percentages do not sum up to 100% for several factors. b Discharges to other locations (n < 20) not shown.

The majority of patients in our study were seen at a general hospital (87.9%) compared with a children’s hospital (8.4%). The tonsillectomy group had a larger proportion of patients seen at a children’s hospital compared with other treatment groups (12.1% vs 10.9% IND, and 11.8% no code, with the medical therapy group having too small a sample size to report). Alternatively, the medical therapy

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Nguyen et al Table 3.  Characteristics Stratified By Treatment. Characteristic Age, mean (SD), y Age, median, y Age, n (%), y  0-5  6-12  13-17 Gender, n (%)a  Female  Male Race, n (%)  White  Black  Hispanic  Other Payer, n (%)b  Private  Medicaid  Self-pay Chronic condition >1, n (%)b Discharge status, n (%)b   Routine discharge   Transfer to short-term hospital Treatment source, n (%)b   Ambulatory surgery   Emergency department  Inpatient Type of hospital, n (%)a,b   General hospital   Children’s hospital

Tonsillectomy (n = 280)

Incision and Drainage (n = 912)

Medical Therapy Alone (n = 922)

No Code (n = 880)

P Value    

12.9 (4.7) 15

13.5 (4.1) 15

14.2 (3.6) 15.5

12.3 (4.9) 14

32 (11.4) 74 (26.4) 174 (62.2)

51 (5.6) 254 (27.8) 607 (66.6)

41 (4.5) 162 (17.6) 719 (77.9)

123 (14.0) 235 (26.7) 522 (59.3)

135 (48.2) 105 (37.5)

445 (48.8) 409 (44.9)

485 (52.6) 430 (46.6)

452 (51.4) 396 (45.0)

112 (40.0) 37 (13.2) 51 (18.2) 80 (28.6)

272 (29.9) 180 (19.7) 245 (26.9) 214 (23.5)

336 (36.4) 196 (21.3) 276 (29.9) 114 (12.4)

304 (34.6) 162 (18.4) 295 (33.5) 119 (13.5)

104 (37.1) 168 (60.0)

405 (43.9) 403 (43.7) 114 (12.4)

46 (16.4)

465 (51.0) 366 (40.1) 81 (8.9) 46 (5.0)

455 (51.7) 354 (40.2) 71 (8.1) 48 (5.5)

280 (100)

906 (99.3)

791 (85.8) 116 (12.6)

880 (100)

179 (63.9)

913 (99.0)

101 (36.1)

41 (4.5) 291 (31.9) 580 (63.6)

287 (32.6) 593 (67.4)

222 (79.3) 34 (12.1)

781 (85.6) 99 (10.9)

880 (95.4)

750 (85.2) 104 (11.8)