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Introduction In the past two decades, Enhanced Recovery After Surgery (ERAS) pathways for adults have improved efficiency of care and decreased length of stay (LOS) without increasing postoperative complications. The effects of enhanced recovery pathways for children are less well known. In this retrospective cohort study, we evaluated the effects of an enhanced recovery protocol (ERP) implementation in children undergoing colorectal surgery. Methods We introduced a colorectal ERP in 2017. Children and young adults (ages 2-22 years) were divided into pre-intervention (2014-2016) and post-intervention groups (2017-2019) for analysis. We abstracted data, including demographics, primary surgery, LOS, postoperative pain scores, and postoperative complications. Results A total of 432 patients were included. Of those,148 (34%) were pre-ERP implementation and 284 (66%) were post-ERP implementation. Post-ERP patients experienced significantly shorter LOS (5.7 vs. 8.3 days, p0.01); required less intraoperative local anesthetic (9.5% vs. 38.5%, p0.01) because 55% of patients received an epidural and 18% received an abdominal plane block; and used less postoperative opioid (62.5% vs. 98.7%, p0.01) than did pre-ERAS patients. After protocol implementation, average pain scores were lower on postoperative day 1 (3.6 vs. 4.5, p0.05) and across the hospitalization (3.0 vs. 4.0, p0.01). Conclusion Enhanced recovery pathways decrease LOS, opioid use, and postoperative pain scores for children undergoing colorectal surgery and should be considered for this patient population.

Physician-patient interactions influence the immediate encounter and leave lasting impressions for future health care encounters. We aimed to understand patient experiences and decision-making for considering sleep surgery, in terms of barriers and communication behaviors that facilitate or hinder referral for consideration of sleep surgery management of obstructive sleep apnea (OSA) when continuous positive airway pressure (CPAP) therapy has failed.We employed qualitative methods, using semistructured interviews of adults with OSA who presented for sleep surgery consultation after unsatisfactory therapy with CPAP. Open-ended questions traced symptoms and progression of sleep apnea burden, trials of noninvasive OSA therapies, outcomes, and patient expectations and concerns. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes.Ten adult patients with OSA were enrolled March through April 2021 and reached predominant thematic saturation. Barriers to sleep surgery consultation included: (1) delays in OSA diagnosis due to limited OSA awareness among patients or primary providers and patients' perceived inconvenience of sleep testing, (2) patients faulted for slow progress, (3) patient-reported lack of urgency by providers in troubleshooting noninvasive management options, (4) scheduling delays and waitlists, and (5) cost. Patients were receptive to noninvasive treatment options, but inadequate improvement led to frustration after multiple encounters. Patients appreciated empathetic providers who shared information through transparent and understandable explanations and who presented multiple treatment options.Experiences of patients with OSA highlight the need for shared decision-making through improved communication of unresolved concerns and alternative management options, including timely referral for sleep surgery consultation when indicated.Ikeda AK, McShay C, Marsh R, et al. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives.

We sought to evaluate the impact of thoracoscopic repair on perioperative outcomes in infants with esophageal atresia and tracheoesophageal fistula (EA/TEF).The American College of Surgeons National Surgical Quality Improvement Program pediatric database from 2014 to 2018 was queried for all neonates who underwent operative repair of EA/TEF. Operative approach based on intention to treat was correlated with perioperative outcomes, including 30-day postoperative adverse events, in logistic regression models.Among 855 neonates, initial thoracoscopic repair was performed in 133 (15.6%) cases. Seventy (53%) of these cases were converted to open. Those who underwent thoracoscopic repair were more likely to be full-term (p = 0.03) when compared to those in the open repair group. There were no significant differences in perioperative outcome measures based on surgical approach except for operative time (thoracoscopic: 217 min vs. open: 180 min, p0.001). A major cardiac comorbidity (OR 1.6, 95% CI 1.2-2.1; p = 0.003) and preoperative ventilator requirement (OR 1.4, 95% CI 1.0-1.9; p = 0.034) were the only risk factors associated with adverse events.Thoracoscopic neonatal repair of EA/TEF continues to be used sparingly, is associated with high conversion rates, and has similar perioperative outcomes when compared to open repair.III.

Perioperative dysglycemia is associated with adverse surgical outcomes in adults. We sought to determine the association between perioperative dysglycemia and 30-day adverse surgical events in pediatric patients undergoing non-cardiac surgery.We analyzed records from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) database from 2016 to 2021 at two academic tertiary care hospitals. The primary outcomes were individual 30-day adverse events, composite serious adverse events, composite hospital acquired infections and composite morbidity.A total of 5410 records were analyzed: the cohort was 52.6% male and 52.6% non-Hispanic White, and 1472 (27.2%) had dysglycemia. Children undergoing procedures in general surgery (48.4%), neurosurgery (25.4%), and orthopedic surgery (16.0%) had higher rates of dysglycemia compared to other surgical specialties. Patients with dysglycemia were more likely to have surgical site infection (4.3% dysglycemic vs. 3.1% normoglycemic, p = 0.028), cardiac arrest (2.6% vs. 0.1%, p 0.001), and sepsis (3.7% vs. 1.3%, p 0.001); more likely to undergo reoperation (11.3% vs. 5.8%, p 0.001); and more likely to remain hospitalized after 30 days (33.0% vs. 6.1%, p 0.001). After controlling for patient and case demographics, perioperative dysglycemia was associated with more composite serious adverse events (OR 1.85, 95% CI 1.49-2.29, p = 0.000), composite hospital acquired infections (OR 1.42, 95% CI 1.04-1.93, p = 0.026), and composite morbidity (OR 2.52, 95% CI 2.13-2.97, p = 0.000).Perioperative dysglycemia in children undergoing non-cardiac surgery is associated with increased risk of adverse events and outcomes. Interventions that screen and normalize blood glucose in the perioperative period may mitigate risk and improve quality of care.

There are several obstructive sleep apnea (OSA) treatment options available to patients, including surgery and less invasive therapies. Little is known about the factors that influence patient preferences for treatment. We aimed to understand factors influencing patient experience and decision making for undergoing sleep surgery.Retrospective qualitative study.Tertiary sleep surgery clinic.We conducted semistructured interviews with adults who previously underwent any nasal and/or pharyngeal sleep surgery. We asked open-ended questions about their decision-making process within a preconceived thematic framework of chief OSA symptoms, expectations for recovery, and sources of information. The interviews were audio recorded and transcribed, and content was analyzed for defined, emergent, and prevalent themes.Ten patients were interviewed from December 11, 2020 through January 29, 2021. Six patients underwent nasal surgery, 1 underwent pharyngeal surgery, and 3 underwent staged nasal and pharyngeal procedures. All patients were beyond the acute recovery phase. Reasons for pursuing surgical consultation varied from sleep apnea burden to external factors, such as recommendations from significant others. Duration of sleep surgery consideration varied from months to years. Major concerns about sleep surgery involved anesthesia and postoperative pain. External factors influencing patients' decisions to pursue sleep surgery included family and friend support. Postoperative outcomes of surgery included patient satisfaction with decision for surgery, given OSA improvements.Understanding patient factors that influence decision making for sleep surgery may guide clinicians in patient-centered counseling that engages patients in decision making, aligning with clinical symptoms and patient preferences.

Hearing loss is associated with higher health care spending and use, but little is known about the unmet health care needs of people with hearing loss or difficulty. Analysis of 2016 Medicare Current Beneficiary Survey data for beneficiaries ages sixty-five and older reveals that those who reported a lot of trouble hearing in the past year were 49 percent more likely than those who reported no trouble hearing to indicate not having a usual source of care. Compared with those who reported no trouble hearing, those who reported some trouble hearing were more likely to indicate not having obtained medical care in the past year when they thought it was needed, as well as not filling a prescription, with the risk for both behaviors being greater among those reporting a lot of trouble hearing versus a little. Interventions that improve access to hearing services and aid communication may help older Medicare beneficiaries meet their health care needs.

Anorectal malformations (ARMs) have a wide spectrum of presentation ranging from mild defects with perineal fistulas to more severe defects requiring complex management. A primary repair of ARMs with perineal or rectovestibular fistulas has been shown to have good outcomes. However, the timing of the reconstruction is still debated. The aim of this study is to investigate the safety of early versus delayed repair.This study was performed using data from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) from 2012 to 2017. Patients who underwent repair of anorectal malformation with perineal or vestibular fistula were included in the study. Patients with associated diagnosis for Hirschsprung disease, cloaca, rectal prolapse or stenosis, bladder exstrophy, and tracheoesophageal fistula were excluded. 30-day postoperative outcomes included wound and nonwound complications, readmissions, and reoperations. Outcomes were compared by early (≤7 days of age) versus delayed repair (6 weeks to 8 months).A total of 291 patients were included, with 66 in the early and 231 in the delayed group. Patients in the early group were more likely to be male (68.2% vs 31.8%; p 0.01) and have cardiac risk factors (71.2% vs 49.4%, p 0.01). The mean operative time was significantly shorter in the early group (90.1 vs 129.6 min; p 0.01). 30-day complications were not statistically significant between the two groups (p = 0.76). After multivariate analysis, timing of repair did not affect 30-day complications (p = 0.15).Our study shows that early repair of low anorectal malformations with a perineal or vestibular fistula appears to be associated with no increase in risk of postoperative complications as compared to delayed repair. At present, the decision remains dependent on the surgeon's experience and judgment.Level III. Retrospective comparative study.

OBJECTIVES Juvenile onset recurrent respiratory papillomatosis (JORRP) can cause severe or disseminated disease. Surgical treatment may be inadequate. Systemic bevacizumab has shown initial success for severe JORRP. The objective of this systematic review was to assess usage, effectiveness, and safety of this treatment. METHODS We searched PubMed, Embase, and Web of Science for studies of humans with JORRP treated with systemic bevacizumab. Two researchers independently reviewed the studies to determine inclusion and aggregate data on patient characteristics, dosing protocols, treatment response, adverse events, and level of evidence. RESULTS Of 80 identified articles, 12 studies were included detailing 20 distinct cases. At a mean age of 12.8 years (range = 1-43 years) patients received initial dosing of 5 to 10 mg/kg of bevacizumab followed by ongoing doses at a mean 3-week intervals (range = 2-5 weeks). All patients had clinically significant disease reduction with reduced need for surgery. Six patients (30%) had complete response in at least one involved anatomic site. Eleven (55%) required no surgery after initiating treatment. There was recurrence in all four patients whose treatment was stopped, but had rapid improvement with treatment resumption. Six (30%) experienced mild or moderate adverse events. CONCLUSIONS Marked improvement in severe JORRP has been reported from systemic bevacizumab. Treatment protocols vary, and treatment discontinuation was not feasible in any reported patient. Based on currently available data, systemic bevacizumab can be considered for severe JORRP as it appears to be well tolerated and effective. A clinical trial could enhance the understanding of its safety and efficacy for this indication. Laryngoscope, 131:1138-1146, 2021.

OBJECTIVES Prader-Willi syndrome (PWS) increases the risk of obstructive sleep apnea (OSA) due to obesity, hypotonia, and abnormal ventilatory responses. We evaluated post-adenotonsillectomy complications, polysomnography changes, and quality of life in children with OSA and PWS. STUDY DESIGN Systematic review and meta-analysis. METHODS We conducted a systematic review and meta-analysis by searching PubMed, Embase, Cochrane, Web of Science, and Scopus. Two researchers independently reviewed studies about adenotonsillectomy for OSA in patients

IMPORTANCE: Little is known about emotional communication between parents and surgeons. Understanding the patterns and correlates of emotional communication may foster collaboration during surgical consultations. OBJECTIVE: To describe the emotional expressions by parents when bringing their child for evaluation of obstructive sleep-disordered breathing (SDB) as well as surgeon responses to these emotional expressions and to evaluate the association between parental demographic characteristics and surgeon response types. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed the audio-recorded consultations between otolaryngologists and parents of children who underwent their initial otolaryngological examination for obstructive SDB at 1 of 3 outpatient clinical sites in Maryland from April 1, 2016, to May 31, 2017. Data analysis was performed from November 1 to December 31, 2019. MAIN OUTCOMES AND MEASURES: Emotional expressions by parents and surgeon responses were audio recorded, transcribed, and coded using the Verona Coding Definitions of Emotional Sequences. RESULTS: A total of 59 consultations, of which 40 (67.8%) contained at least 1 emotional expression, were included. Participants included 59 parents (53 women [89.8%]; mean [SD] age, 33.4 [6.4] years) and 7 surgeons (4 men [57.1%]; mean [SD] age, 42.8 [7.9] years). Parents made 123 distinct emotional expressions (mean [SD], 3.08 [2.29] expressions per visit), which were often expressed as subtle cues (n = 103 of 123 [83.7%]) vs explicit concerns (n = 20 [16.3%]). Most expressions (n = 98 [79.7%]) were related to medical issues experienced by the child (eg, symptoms and surgical risks). Most surgeon responses provided parents space for elaboration of emotional expressions (n = 86 [69.9%]) and were nonexplicit (n = 55 [44.7%]). Surgeons were less likely to explore the emotions of parents from racial and ethnic minority groups compared with White parents (OR, 0.47; 95% CI, 0.18-0.98). CONCLUSIONS AND RELEVANCE: This cross-sectional study found that emotional communication occurs between surgeons and parents of pediatric patients with obstructive SDB. However, surgeon responses varied according to parental race and ethnicity, suggesting the existence of implicit biases in surgeon-patient communication and calling for further research to inform efforts to promote family-centered, culturally competent communication in surgery.

Background: Caregiver values and preferences with regard to oral immunotherapy (OIT) for treatment of food allergies are not widely reported. Understanding caregiver perspectives is integral to establishing shared decision-making in the treatment of food allergy. Objective: We aimed to understand caregiver opinions that may influence caregivers in their decisions about OIT through social media. Methods: We searched a popular parenting web site for posts related to OIT from December 2008 to September 2019. We applied a Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework to review posts for inclusion, performed thematic content analysis to determine common themes, and calculated frequencies for each theme and subtheme. Posts and comments were included if they contained discussions about OIT for immunoglobulin E‐mediated food allergy and were excluded if they were duplicates, comments from an original post from the original user, or comments on a nonrelevant original post. Results: Of 1300 posts and comments retrieved, 174 were included (13%). Most were excluded because they did not directly address OIT for food allergy. Relevant posts could fall into multiple themes and were categorized under three main themes: attitudes (n = 128, “I am scared to do OIT but scared not to!”), logistics (n = 168, “We will be doing this once LO [little one] is a little older”), and questions (n = 32, “How does it work?”). Conclusion: Caregivers communicate with each other through social media, expressing attitudes, logistics, and questions about OIT. Understanding these lay perspectives may help guide clinicians in counseling and engage caregivers in decision-making.

Session Description: Themes of inequity, injustice, and health disparities are woven through the history of medicine. The national and specialty-wide conversation about these critical problems has evolved in the past year in parallel with major social movements around the world. In combination with the COVID-19 pandemic, these conversations have shed light on ways in which privilege, disadvantage, and systemic biases have contributed to diminished quality of medical care and exacerbated disparities in health outcomes. This panel, sponsored by the American Academy of Otolaryngology- Head and Neck Surgery Patient Safety and Quality Improvement Committee and featuring national experts in health care quality, value, and diversity, justice, and inclusion will complement other sessions at this meeting addressing inequities in health care. In this panel, we will focus specifically on how systemic bias and workforce inequity directly contributes to disparate, low-quality, and low-value health care. We will focus on racism, sexism, and anti-LGBTQ+ bias in both the workforce and in treatment of patients, providing a review of current knowledge on the effects of these biases on the quality of surgical care in the United States, including effects on provider-patient interaction, treatment recommendations, and adherence to these recommendations. We will then address ways in which inequities in the otolaryngology workforce further limit opportunities for patient-physician racial concordance and exacerbate disparities in patient outcomes and strategies to begin addressing workforce diversity and inclusion problems. These issues will be examined for both academic and nonacademic practice settings. We will connect quality to costs of care to discuss how systemic bias affects the value of surgical care delivered to patients of different privilege and how this difference in value perpetuates injustice in health care. Outcome Objectives: (1) Define privilege, bias, equality, equity, inclusion, and justice as individual constructs in the context of medical, and specifically otolaryngologic, care. (2) Summarize current knowledge of the effects of systemic racism, sexism, and anti-LGBTQ+ bias on workforce equity and quality of care in otolaryngology. Demonstrate specific examples in otolaryngology. (3) Relate the effects of these biases to the value of otolaryngologic care.

* Abbreviations: BIA — : Brief Intellectual Ability OSDB — : obstructive sleep-disordered breathing POSTA — : Preschool Obstructive Sleep Apnea Tonsillectomy Adenoidectomy Approximately 500 000 US children undergo tonsillectomy, with or without adenoidectomy, every year.1–2 Most adenotonsillectomies are performed for obstructive sleep-disordered breathing (OSDB), which encompasses a broad range of conditions from primary snoring to obstructive sleep apnea.3,4 OSDB is prevalent in children and more common in children who are overweight, Black, Hispanic, or economically disadvantaged.5–8 Children with OSDB experience neurobehavioral issues, including problems with attention, hyperactivity, and learning. These sequelae may be explained by disruptions in sleep and intermittent hypoxia. However, social and environmental factors also play a role as root causes of both OSDB and neurobehavioral concerns.9–11 Because of the high prevalence of OSDB in children, especially in vulnerable populations, and its impact on behavior and learning issues, for which vulnerable children are more at risk, optimizing appropriate, timely treatment of OSDB is a public health priority. In this issue of Pediatrics , Waters et al12 report on the cognitive, behavioral, and sleep effects of adenotonsillectomy in preschool-aged children … Address correspondence to Jennifer N. Cooper, PhD, Abigail Wexner Research Institute at Nationwide Children’s Hospital, 700 Children’s Dr, FB Suite 3A.3, Columbus OH 43205. E-mail: jennifer.cooper{at}nationwidechildrens.org

OBJECTIVE Balloon sinuplasty (BSP) is associated with varied practice patterns. This study sought to identify otolaryngologist characteristics associated with BSP utilization. STUDY DESIGN Retrospective analysis of Medicare claims data and the National Physician Compare database. METHODS Outlier otolaryngologists were compared to non-outliers. Otolaryngologist characteristics included sex, practice size, geographic setting, years of experience, procedure setting, 10 or fewer endoscopic sinus surgeries per year for 3 or more years, and high number of services per unique Medicare beneficiary. Outlier status was defined as performing an annual total of balloon procedures of 2 standard deviations (SDs) above the mean for all otolaryngologists in the same year. RESULTS Between January 2012 and December 2017, 1,408 otolaryngologists performed 101,662 endoscopic sinus surgeries and 97,680 BSP procedures. Sixty-six outlier otolaryngologists (4.7%) accounted for 44.3% of all BSP procedures. Outlier status was associated with practice size of 10 or fewer individual providers (OR, 5.15; 95% CI, 2.73-9.74; P

Objectives Postoperative hemorrhage is a serious complication of tonsillectomy, with secondary bleeding rates affecting up to 0.8% to 3% of patients. Although these bleeds are anecdotally perceived as occurring more frequently at night, the occurrence of hemorrhage relative to the time of day has not been investigated. We measured the frequency of post-tonsillectomy hemorrhage onset relative to the time of day. Methods We reviewed electronic medical records of all patients who experienced postprocedural hemorrhage (International Classification of Disease, Ninth Edition [ICD-9] 998.11, ICD-10 J95.830 at two hospitals within a tertiary academic health system in a 10-year period). Patient demographics, time of bleed onset, emergency room [ED] arrival time, and management (operating room vs. observation) were abstracted. Patients without a recorded bleeding time were excluded. Time of bleed onset was categorized as morning (6:01 am-12 pm), afternoon (12:01 pm-6 pm), evening (6:01 pm-12 am), or overnight (12:01 am-6 am). Chi-square goodness of fit test was used to assess the distribution of hemorrhage timing (P ≤ 0.05). Results A total of 7,396 patients underwent tonsillectomy May 2008 through May 2018, among whom 121 (2%) post-tonsillectomy hemorrhage patients were identified. Among the 104 patients with ED arrival times, 29 (28%) arrived in the morning; 15 (14%) arrived in the afternoon; 40 (38%) arrived in the evening; and 20 (19%) arrived overnight (P = 0.003). Sixty patients (mean age 17.1 years, standard deviation 16.6) had a recorded timing of bleed onset. Bleed onset occurred most commonly overnight (24, 40%), followed by evening (21, 35%), afternoon (11, 18%), and morning (4, 7%) (P = 0.0007). Conclusion In this cohort, post-tonsillectomy hemorrhage occurred most frequently between midnight and 6 am. Our findings confirm anecdotal experience and provide data in setting caregiver expectations. Level of evidence 4 Laryngoscope, 130:1823-1827, 2020.

OBJECTIVES Collaboration and diversity of expertise are increasingly emphasized in the production of successful research. However, the degree of cross-disciplinary collaboration in otolaryngology research is unknown. In this study, we quantify cross-disciplinary collaboration in otolaryngology publications. METHODS We retrospectively analyzed authorship and study characteristics for all original articles published from January 2014 to December 2016 in three key peer-reviewed otolaryngology journals: Laryngoscope, Otolaryngology-Head & Neck Surgery, and JAMA Otolaryngology-Head & Neck Surgery. Author affiliations and online searches were used to determine author's primary discipline. Subspecialty topic of article, study design, and funding sources were also recorded. Fisher exact test was used to compare characteristics of articles with and without cross-disciplinary authorship. RESULTS A total of 2,378 articles were reviewed, of which 1,312 (55%) articles had one or more cross-disciplinary collaborators. Among articles with cross-disciplinary collaboration, the greatest representation of disciplines was from other medical specialties (1,109, 50.9%), epidemiology/biostatistics (266, 12.2%), pathology/histology (175, 8.0%), biologic sciences (168, 7.7%), and radiology/imaging (144, 6.6%). Cross-disciplinary studies had a significantly greater proportion of articles on the topic of head and neck compared to studies without collaboration (P < 0.0001). The proportion of funded studies was significantly greater among articles with collaboration compared to articles without collaboration (P < 0.0001). CONCLUSION The majority of articles published during a 3-year period in three influential otolaryngology journals had cross-disciplinary collaboration. There is potential opportunity for further leveraging expertise, funding opportunities, and dissemination of key findings through collaborative research. LEVEL OF EVIDENCE NA Laryngoscope, 129:1800-1805, 2019.

Complete tumor resection of primary malignant liver tumors offers the best chance of survival. However, many of these children may experience anemia and failure to thrive. This study analyzes the association of preoperative anemia and nutritional support with outcomes in children undergoing major resection of primary malignant liver tumors.Using the National Surgical Quality Improvement Program Pediatric database from 2012 to 2015, children undergoing major liver resections for primary malignant hepatic tumors were selected. Patient demographics, comorbidities, and 30-d outcomes were compared with respect to the presence of preoperative anemia and the need for nutritional support. Outcomes included 30-d postoperative complications, perioperative blood transfusions, and hospital readmissions. Propensity score matching was performed to control for significant confounders.One hundred ten children were included, 76 (69.1%) with preoperative anemia, and 36 (32.7%) receiving nutritional support. Anemia was associated with preoperative chemotherapy (P = 0.02) and steroids (P = 0.03). Nutritional support was associated with cardiac (P = 0.01), respiratory (P 0.01), neurologic (P 0.01), and hematologic comorbidities (P = 0.02). There were 20 (18.2%) postoperative complications and 6 (5.5%) hospital readmissions. After propensity score matching, there was no difference in complications between anemic and nonanemic patients (P = 0.13). Preoperative nutritional support was associated with an increased rate of complications (P 0.01). Neither anemia (P = 1.00) nor nutritional support (P = 0.49) were associated with readmissions.The need for nutritional support is common in children undergoing resection of primary malignant hepatic tumors. Anemia was not significantly associated with postoperative complications. In this study, nutritional support was associated with an increased risk of postoperative complications. The need for nutritional support may warrant special attention to the patient's overall conditioning during operative planning.

Objectives/hypothesis Adenotonsillectomy is first-line treatment for pediatric obstructive sleep apnea syndrome (OSAS) when not otherwise contraindicated. There is concern severe OSAS increases risk of comorbid cardiopulmonary abnormalities, such as ventricular hypertrophy or pulmonary hypertension, which preoperative testing could detect. Our objective is to determine if there is a severity of pediatric OSAS where previously undetected cardiopulmonary comorbidities are likely. Study design Retrospective chart review. Methods We performed a retrospective review of 358 patients ≤21 years with severe OSAS who underwent adenotonsillectomy at a tertiary hospital June 1, 2016 to June 1, 2018. We extracted demographics, comorbidities, polysomnography, and preoperative tests. Wilcoxon rank-sum and logistic regression estimated associations of OSAS severity (based on obstructive apnea-hypopnea index [OAHI], hypoxia, hypercarbia) with preoperative echocardiograms and chest X-rays (CXRs). Results Mean age was 5.9 (±3.6) years and 52% were male. Mean OAHI and oxygen saturation nadir were 30.3 (±23.8) and 80.7% (±9.2), respectively. OAHI ≥60 was associated with having a preoperative echocardiogram (OR, 3.8; 95% CI, 1.7-8.5) or CXR (OR, 3.0; 95% CI, 1.4-6.8) compared to OAHI 10-59. There were no significant associations between OSAS severity and test abnormalities. The presence of previously diagnosed cardiopulmonary comorbidities was associated with abnormalities on echocardiogram (OR, 36; 95% CI, 4.1-320.1) and CXR (OR, 4.1; 95% CI, 1.2-14.4). Conclusions Although pediatric patients with very severe OSAS (OAHI ≥60) underwent more pre-adenotonsillectomy cardiopulmonary tests, OSAS severity did not predict abnormal findings. Known cardiopulmonary comorbidities may be a better indication for cardiopulmonary testing than polysomnographic parameters, which could streamline pre-adenotonsillectomy evaluation and reduce cost. Level of evidence 4 Laryngoscope, 131:2361-2368, 2021.

Objective: Effective delivery of discharge instructions and access to postoperative care play a critical role in outcomes after pediatric surgery. Previous studies in the pediatric emergency department suggest that caregivers with language barriers have less comprehension of discharge instructions despite use of interpretation services. However, the impact of language barriers during discharge on surgical outcomes in a pediatric surgical setting has not been studied. This study examined the effect of parental language during discharge on number and mode of healthcare contact following pediatric adenotonsillectomy. Methods: A retrospective cohort study was conducted on children who underwent adenotonsillectomy at a tertiary care pediatric academic medical center from July 1, 2016 to June 1, 2018. Data were collected on consecutive patients with non-English-speaking caregivers and a systematic sampling of patients with English-speaking caregiver. Surgery-related complications and healthcare contacts within 90 days after discharge were collected. Two-tailed t tests, χ2 tests, and logistic regression were performed to assess the association between parental primary language and incidence of healthcare contact after surgery. Results: A total of 136 patients were included: 85 English-speaking and 51 non-English-speaking. The groups were comparable in age, sex, and comorbidities. The non-English group had more patients with public insurance (86% vs. 56%; P Conclusion: Language barriers at discharge following pediatric otolaryngology surgery is associated with a meaningful difference in how patients utilized medical care. Interventions to improve comprehension and access may help reduce preventable emergency department visits and healthcare costs.

Objective Despite the implementation of advanced health care safety systems including checklists, preventable perioperative sentinel events continue to occur and cause patient harm, disability, and death. We report on findings relating to otolaryngology practices with surgical safety checklists, the scope of intraoperative sentinel events, and institutional and personal response to these events. Study Design Survey study. Setting Anonymous online survey of otolaryngologists. Methods Members of the American Academy of Otolaryngology–Head and Neck Surgery were asked about intraoperative sentinel events, surgical safety checklist practices, fire safety, and the response to patient safety events. Results In total, 543 otolaryngologists responded to the survey (response rate 4.9% = 543/11,188). The use of surgical safety checklists was reported by 511 (98.6%) respondents. At least 1 patient safety event in the past 10 years was reported by 131 (25.2%) respondents; medication errors were the most commonly reported (66 [12.7%] respondents). Wrong site/patient/procedure events were reported by 38 (7.3%) respondents, retained surgical items by 33 (6.4%), and operating room fire by 18 (3.5%). Although 414 (79.9%) respondents felt that time-outs before the case have been the single most impactful checklist component to prevent serious patient safety events, several respondents also voiced frustrations with the administrative burden. Conclusion Surgical safety checklists are widely used in otolaryngology and are generally acknowledged as the most effective intervention to reduce patient safety events; nonetheless, intraoperative sentinel events do continue to occur. Understanding the scope, causes, and response to these events may help to prioritize resources to guide quality improvement initiatives in surgical safety practices.

BACKGROUND Despite the ubiquity of social media, the utilization and audience reach of this communication method by otolaryngology-head and neck surgery (OHNS) residency programs has not been investigated. OBJECTIVE The purpose of this study was to evaluate the content posted to a popular social media platform (Twitter) by OHNS residency programs. METHODS In this cross-sectional study, we identified Twitter accounts for accredited academic OHNS residency programs. Tweets published over a 6-month period (March to August 2019) were extracted. Tweets were categorized and analyzed for source (original versus retweet) and target audience (medical versus layman). A random sample of 100 tweets was used to identify patterns of content, which were then used to categorize additional tweets. We quantified the total number of likes or retweets by health care professionals. RESULTS Of the 121 accredited programs, 35 (28.9%) had Twitter accounts. Of the 2526 tweets in the 6-month period, 1695 (67.10%) were original-content tweets. The majority of tweets (1283/1695, 75.69%) were targeted toward health care workers, most of which did not directly contain medical information (954/1283, 74.36%). These tweets contained information about the department’s trainees and education (349/954, 36.6%), participation at conferences (263/954, 27.6%), and research publications (112/954, 11.7%). Two-thirds of all tweets did not contain medical information. Medical professionals accounted for 1249/1362 (91.70%) of retweets and 5616/6372 (88.14%) of likes on original-content tweets. CONCLUSIONS The majority of Twitter usage by OHNS residency programs is for intra and interprofessional communication, and only a minority of tweets contain information geared toward the public. Communication and information sharing with patients is not the focus of OHNS departments on Twitter.

Background/objectives Nearly 38 million Americans have hearing loss. Understanding how sensory deficits such as hearing loss, which limit communication, impact satisfaction has implications for Medicare value-based reimbursement mechanisms. The aim of this study was to characterize the association of functional hearing loss and dissatisfaction with quality of health care over the past year among Medicare beneficiaries. Methods Cross-sectional study of satisfaction with quality of health care among Medicare beneficiaries with self-reported trouble hearing from the 2015 Medicare Current Beneficiaries Survey. There were 11,441 Medicare beneficiaries representing a 48.6 million total weighted nationally representative sample. Results Forty-eight percent of Medicare beneficiaries reported a little or a lot of trouble hearing. Medicare beneficiaries with a little trouble hearing (odds ratio=1.496; 95% confidence interval, 1.079-2.073; P=0.016) and a lot of trouble hearing (odds ratio=1.769; 95% confidence interval, 1.175-2.664; P=0.007) had 49.6% and 76.9% higher odds of being dissatisfied with the quality of their health care over the previous year, respectively. Conclusions Medicare beneficiaries with functional hearing loss had higher odds of dissatisfaction with health care over the past year compared to those without functional hearing loss. Given Medicare's reliance on patient satisfaction as a value-based measure for hospital reimbursement, interventions to address hearing loss in the health care system are needed.

Oropharyngeal squamous cell cancer (OPSCC) is now the most common site of head and neck squamous cell cancer. Despite the focus on treatment deintensification in clinical trials, little is known about the preferences, experiences and needs of patients with OPSCC when deciding between surgery and radiation therapy as primary treatment with curative intent. In this qualitative study, pre-treatment and post-treatment oropharyngeal cancer patients were recruited to take part in one-on-one interviews (n = 11 pre-treatment) and focus group discussions (n = 15 post-treatment) about treatment decision-making. Recordings were transcribed and assessed for emergent themes using framework analysis. From the one-on-one interviews and focus group discussions with OPSCC patients, fourteen themes were identified. Participants expressed alarm at diagnosis, decisional conflict, and a variety of roles in decision-making (physician-controlled, shared, and autonomous). Decisions were driven by the perceived recommendation of the treatment team, a desire for physical (surgical) tumor removal, fear of adverse effects of treatment, and patient-specific values. Although participants felt well-informed by their treating physicians, they identified a need for additional patient-centered information. Participants were critical of the poor quality of information available on the internet, and acknowledged the advantage of hearing the experiences of post-treatment patients. The experiences identified herein may be used to guide patient-centered communication during patient counseling and to inform interventions designed to support patients’ needs at diagnosis, ultimately helping to implement high-quality, patient-centered care.

Tonsillectomy is one of the most common pediatric surgical procedures. In previous decades, large geographic variation and racial disparities in its use have been reported. We aimed to compare contemporary rates of pediatric tonsillectomy utilization in the United States by child race/ethnicity, type of health insurance, and metropolitan/nonmetropolitan residence.We performed a cross-sectional study using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project State Ambulatory Surgery and Services Databases and State Inpatient Databases of 8 US states. We included all children aged15 years who underwent tonsillectomy in 2013 to 2017. Annual population-level tonsillectomy rates across states and sociodemographic groups overall and by surgical indication were calculated using US Census data. Negative binomial regression models were used to compare rates between groups.In all states evaluated, tonsillectomy utilization was higher in non-Hispanic white children than non-Hispanic black or Hispanic children, higher in publicly insured than privately insured children, and higher in children residing in nonmetropolitan areas as compared to metropolitan areas (all P.05). Tonsillectomy use was highest among white children from nonmetropolitan areas, both overall and for each indication (all P.05).Tonsillectomy utilization is higher in US children who are white, publicly insured, and who live in nonmetropolitan areas. Future research should identify multilevel factors, such as those at the patient, family, primary care provider, otolaryngologist, health care delivery system, interpersonal and community levels, that explain these differences in utilization in order to improve the appropriateness and equity of tonsillectomy use in children.

Introduction: Parent experience is a core component of the quality of pediatric care and an increasingly common focus of quality improvement initiatives. However, the parent experience of communication in the pediatric surgical setting remains unexplored. Methods: We conducted semi-structured interviews with 20 parents of children undergoing surgery. Interviews were analyzed using directed qualitative content analysis. Results: Content analysis revealed 3 overarching themes. The theme of “provider–parent communication” included interpersonal behaviors and communication-originating skills of the surgeon. Parents valued surgeons incorporating multimodal information-sharing techniques, recognizing children’s psychological needs, providing reassurance, engaging in teamwork, and including parents. The theme of “parental emotional experiences” included domains of parent worry, intimidation, offense, self-doubt, mistrust, and strength surrounding their child’s surgery. Parents felt simultaneously responsible for their child’s welfare and for understanding medical information. The theme of “process improvement” included preparation for surgery, efficiency, managing delays, anesthesia induction, emergence from anesthesia, privacy, and preparation for recovery. Conclusions: Themes identified through these parental narratives and proposed solutions inform quality improvement efforts related to surgeon communication strategies and facilitate family-centered surgical care for children. Parents often provided solutions after they described concerns, which attests to the utility of parent perspectives.

Clinical practice guidelines synthesize and disseminate the best available evidence to guide clinical decisions and increase high-quality care. Since 2004, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published 16 guidelines. The objective of this review was to evaluate clinicians' adherence to these guidelines' recommendations as measured in the literature.We searched PubMed, Embase, and Web of Science on August 29, 2019, for studies published after June 1, 2004.We systematically identified peer-reviewed studies in English that reported clinician adherence to AAO-HNSF guideline recommendations. Two authors independently reviewed and abstracted study characteristics, including publication date, population, sample size, guideline adherence, and risk of bias.The search yielded 385 studies. We excluded 331 studies during title/abstract screening and 32 more after full-text review. The remaining 22 studies evaluated recommendations from 8 of the 16 guidelines. The Otitis Media with Effusion, Polysomnography, Tonsillectomy, and Sinusitis guidelines were studied most. Study designs included retrospective chart reviews (7, 32%), clinician surveys (7, 32%), and health care database analyses (8, 36%). Studies reported adherence ranging from 0% to 99.8% with a mean of 56%. Adherence varied depending on the recommendation evaluated, type of recommendation, clinician type, and clinical setting. Adherence to the polysomnography recommendations was low (8%-65.3%). Adherence was higher for the otitis media with effusion (76%-90%) and tonsillectomy (43%-98.9%) recommendations.Adherence to recommendations in the AAO-HNSF guidelines varies widely. These findings highlight areas for further guideline dissemination, research about guideline adoption, and quality improvement.

Ankyloglossia, or "tongue-tie," refers to limited tongue mobility caused by a restrictive lingual frenulum. Previous studies have demonstrated rapid increases in diagnosis and treatment of ankyloglossia in the United States up to 2012. We performed an updated retrospective review of data from the National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (AHRQ) to evaluate trends in diagnosis of ankyloglossia and use of lingual frenotomy in the hospital setting. From 2012 to 2016, there was an 110.4% increase in reported diagnosis of ankyloglossia in the inpatient setting with similar increases in lingual frenotomy procedures. As seen previously, sex, type of insurance, median income ZIP code, and geographic region were associated with diagnosis of ankyloglossia. The observed trends from prior to 2012 have continued to increase, while unanswered questions about diagnostic criteria and about which infants should undergo frenotomy remain.

BACKGROUND/PURPOSE: The role of process measures used to predict quality in pediatric colorectal surgery enhanced recovery protocols has not been described. The purpose of this study was to demonstrate the feasibility of abstracting and monitoring process measures over protocol improvement iteration. METHODS: Patients enrolled in the Pediatric Colorectal Enhanced Recovery After Surgery pathway at our institution were grouped by stage of implementation. We used a quality improvement database to compare multi-stage enhanced recovery process measures and 30-day patient outcomes. RESULTS: We identified 58 surgical patients with 28(48%) cases enrolled in the pathway. There was increased use of regional anesthesia techniques in pathway patients (83% versus 20%, p

OBJECTIVES Rhinoplasty is commonly performed in children with congenital anomalies and resultant nasal deformity causing airway obstruction. Little is known regarding patient factors or perioperative sequelae. We define demographic characteristics and perioperative complications for children undergoing rhinoplasty within a large national cohort. STUDY DESIGN Retrospective cohort study of children aged ≤ 18 years undergoing rhinoplasty utilizing data from the 2012 to 2015 American College of Surgeons National Surgery Quality Improvement Program-Pediatric public use file. METHODS All children who underwent rhinoplasty were identified. Postoperative complications were defined as 30-day postoperative infection, unplanned readmission and reoperation, and death. Multivariate logistic regression was used to identify predictors of complications. Subgroup analysis was performed based on child age (age

Patient race/ethnicity affects health care utilization, provider trust, and treatment choice. It is uncertain how these influences affect pediatric care. We performed a systematic review (PubMed, Scopus, Web of Science, PsycINFO, Cochrane, and Embase) for articles examining race/ethnicity and parental treatment decision-making, adhering to PRISMA methodology. A total of 9200 studies were identified, and 17 met inclusion criteria. Studies focused on treatment decisions concerning end-of-life care, human papillomavirus vaccination, urological surgery, medication regimens, and dental care. Findings were not uniform between studies; however, pooled results showed (1) racial/ethnic minorities tended to prefer more aggressive end-of-life care; (2) familial tradition of neonatal circumcision influenced the decision to circumcise; and (3) non-Hispanic Whites were less likely to pursue human papillomavirus vaccination but more likely to complete the vaccine series if initiated. The paucity of studies precluded overarching findings regarding the influence of race/ethnicity on parental treatment decisions. Further investigation may improve family-centered communication, parent engagement, and shared decision-making.

Patient safety/quality improvement (PS/QI) is the cornerstone of 21st-century health care. Otolaryngology-Head and Neck Surgery is excited to provide a dedicated PS/QI primer. The overarching goal for this PS/QI series is to provide a comprehensive and practical resource that assists readers, authors, and peer reviewers in understanding PS/QI research, its unique methodology, and the associated reporting standards for trustworthy performance measures. The target audience includes resident and fellows, faculty from the private sector and academia, and allied health professionals. This inaugural primer reviews PS/QI background as it relates to otolaryngology practice. It explores the history, goals, and development of performance measurement. In addition, it highlights opportunities for integrating PS/QI into otolaryngology practice. Payers will drive patients to quality care based on outcomes. Otolaryngologists have a responsibility to embrace a culture of PS/QI. In doing so, we will define optimal, quality otolaryngology care through objective data and metrics.

To evaluate the perioperative risk factors for 30-day complications of the Kasai procedure in a large, cross-institutional, modern dataset. The 2012–2015 National Surgical Quality Improvement Program Pediatric database was used to identify patients undergoing the Kasai procedure. Patients’ characteristics were compared by perioperative blood transfusions and 30-day outcomes, including complications, reoperations, and readmissions. Multivariable logistic regression was used to identify risk factors predictive of outcomes. Propensity matching was performed for perioperative blood transfusions to evaluate its effect on outcomes. 190 children were included with average age of 62 days. Major cardiac risk factors were seen in 6.3%. Perioperative blood transfusions occurred in 32.1%. The 30-day post-operative complication rate was 15.8%, reoperation 6.8%, and readmission 15.3%. After multivariate analysis, perioperative blood transfusions (OR 3.94; p

Background Despite the ubiquity of social media, the utilization and audience reach of this communication method by otolaryngology-head and neck surgery (OHNS) residency programs has not been investigated. Objective The purpose of this study was to evaluate the content posted to a popular social media platform (Twitter) by OHNS residency programs. Methods In this cross-sectional study, we identified Twitter accounts for accredited academic OHNS residency programs. Tweets published over a 6-month period (March to August 2019) were extracted. Tweets were categorized and analyzed for source (original versus retweet) and target audience (medical versus layman). A random sample of 100 tweets was used to identify patterns of content, which were then used to categorize additional tweets. We quantified the total number of likes or retweets by health care professionals. Results Of the 121 accredited programs, 35 (28.9%) had Twitter accounts. Of the 2526 tweets in the 6-month period, 1695 (67.10%) were original-content tweets. The majority of tweets (1283/1695, 75.69%) were targeted toward health care workers, most of which did not directly contain medical information (954/1283, 74.36%). These tweets contained information about the department’s trainees and education (349/954, 36.6%), participation at conferences (263/954, 27.6%), and research publications (112/954, 11.7%). Two-thirds of all tweets did not contain medical information. Medical professionals accounted for 1249/1362 (91.70%) of retweets and 5616/6372 (88.14%) of likes on original-content tweets. Conclusions The majority of Twitter usage by OHNS residency programs is for intra and interprofessional communication, and only a minority of tweets contain information geared toward the public. Communication and information sharing with patients is not the focus of OHNS departments on Twitter.

Objective Tympanostomy tube (TT) placement is common in children; however, family-centeredness and utility of online information used for decision making and understanding is unknown. We evaluate the quality of leading Internet resources describing TT placement. Study design Cross-sectional descriptive design. Methods We performed a Google (Menlo Park, CA) search for terms related to TTs. We defined quality using scaled readability measures (Flesch Reading Ease and Flesch-Kincaid Grade-Level), understandability and actionability (Patient Education Materials Assessment Tool), shared decision-making centrality (Center for Medicare and Medicaid Services informed consent guidelines), and clinical practice guideline (CPG) compatibility. Three reviewers coded each measure. Fleiss κ interrater reliability analysis was performed. Results Ten most frequently encountered websites were analyzed. One of 10 met national health literacy standards (mean 10th-grade level reading, median 9th, range 6-15th). All sites were understandable (mean understandability 81.9%, range 73%-92%). Most had low actionability scores (7 of 10, median 47%, mean 44.6%, range 0-80). Shared decision-making centrality was high (mean 5, range 4-6), but most did not list alternative treatment options. Although CPG compatibility was high (mean 3.4, range 1-4), many websites contained inconsistent recommendations about tube duration, follow-up, and water precautions. There was inter-rater agreement for understandability scoring (κ = 0.20; P = 0.02). Conclusion Internet resources about TT placement vary in quality pertaining to health literacy, principles of shared decision making, and consistency with practice guidelines. With growing emphasis on patient-/family-centered engagement in healthcare decision making, standardization of content and improved usability of educational materials for common surgical procedures in children such as tympanostomy tube placement should be a public health priority. Level of evidence NA. Laryngoscope, 128:496-501, 2018.

Background Little is known about how hospitalized patients share decisions with physicians. Methods We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis. Results Most patients were white (61%) and half were female. Most physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed. Conclusions Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict. Practice implications Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy.

Introduction This study describes safety outcomes of pediatric endoscopic sinus surgery (ESS) to identify risk factors for 30-day postoperative adverse events using the National Surgical Quality Improvement Program–Pediatric (NSQIP-P) database. Methods We performed a retrospective cohort study involving patients in the 2012–2015 NSQIP-P database who underwent ESS. Predictors included demographics, comorbidities and surgical acuity. Outcomes included 30-day complications, reoperations, and readmissions. Results Among 2,061 ESS cases identified, 1,829 (88.7%) were elective and 232 (11.3%) were urgent/emergent. There were 92 (4.5%) readmissions, 54 (2.6%) unplanned reoperations, and 61 (3.0%) complications. On multivariate analysis, readmission was associated with urgent/emergent procedures (OR 2.31, CI 1.36-3.93, p

Objectives (1) Describe trends in the diagnosis of ankyloglossia and the use of lingual frenotomy and (2) analyze patient- and hospital-level factors as compared with the total pediatric discharge population. Study Design National database analysis. Methods We reviewed available data from 1997 to 2012 using the Kids' Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. All weighted pediatric discharges with ankyloglossia, newborn feeding difficulty, or lingual frenotomy were analyzed for variables of sex, payer, zip code median income, hospital ownership, location/teaching status, bed size, region, and children's hospital status. Chi-square analysis with 95% CIs and odds ratio were used to identify differences between the study group and the total database discharge population. Results Diagnosis of ankyloglossia increased each year of publication (every third year)-with 3934, 5430, 7785, 11,397, 19,459, and 32,837 children, respectively, from 1997 to 2012-with the largest increase in the last 6 years. Similarly, frenotomy increased with 1279, 1633, 2538, 3988, 6900, and 12,406 procedures. Compared with the total discharge population, children with ankyloglossia or frenotomy were more often male (63.6% ankyloglossia, 65.3% frenotomy vs 51.2%), privately insured (60.1%, 62.1% vs 43.6%), from a higher median-income zip code (78.1%, 78.2% vs 68.6%), and in Midwest region (29.3%, 32.3% vs 21.7%). Conclusion These pilot data show increases in diagnoses of ankyloglossia and use of frenotomy. There is a preponderance of children who are male, privately insured, or Midwest residents being diagnosed and treated for ankyloglossia. This broad variation may reflect local practice patterns or imply cultural and socioeconomic bias.

Pressure equalization tube (PET) placement (also referred to as tympanostomy tube placement) is among the most common ambulatory surgical procedures performed on US children. More than 20 years ago, differences according to race/ethnicity in the national prevalence of having had PETs placed were documented. Whether these differences persist is unknown.We used data from the 2014 National Health Interview Survey to examine the percentage of children 0 to 17 years of age who have ever undergone PET placement. Unadjusted logistic regression with predictive margins was used to assess the relationship between having received PETs and race/ethnicity, as well as other clinical, socioeconomic, and geographic factors. Multivariable logistic regression was used to determine whether other factors could account for any observed differences according to race/ethnicity.Overall, 8.9% of children 0 to 17 years of age had undergone PET surgery. By race/ethnicity, 12.6% of non-Hispanic white children received PETs, which was significantly greater than the 4.8% of non-Hispanic black, 4.4% of Hispanic, and 5.6% of non-Hispanic other/multiple race children who had this surgery (P .001 for all comparisons). In multivariable analysis, the adjusted prevalence for non-Hispanic white children (10.8%) was greater than for non-Hispanic black (5.4%) and Hispanic (5.8%) children (P .001 for both comparisons).Nearly 9% of US children have had PETs placed. Non-Hispanic white children still have a greater prevalence of PET placement compared with non-Hispanic black and Hispanic children. These differences could not be fully explained by other demographic, clinical, socioeconomic, or geographic differences between racial/ethnic groups.

To evaluate whether differences in pediatric tonsillectomy use by race/ethnicity and type of insurance were impacted by the American Academy of Otolaryngology-Head and Neck Surgery's 2011 tonsillectomy clinical practice guidelines.We included children aged15 years from Florida or South Carolina who underwent tonsillectomy in 2004-2017. Annual tonsillectomy rates within groups defined by race/ethnicity and type of health insurance were calculated using US Census data, and interrupted time series analyses were used to compare the guidelines' impact on utilization across groups.The average annual tonsillectomy rate was greater among non-Hispanic white children (66 procedures per 10 000 children) than non-Hispanic black (38 procedures per 10 000 children) or Hispanic children (41 procedures per 10 000 children) (P.001). From the year before to the year after the guidelines' release, tonsillectomy use decreased among non-Hispanic white children (-11.1 procedures per 10 000 children), but not among non-Hispanic black (-0.9 procedures per 10 000 children) or Hispanic children (+3.9 procedures per 10 000 children) (P.05). Use was greater among publicly than privately insured children (75 vs 52 procedures per 10 000 children, P.001). The guidelines were associated with a reversal of the upward trend in use seen in 2004-2010 among publicly insured children (-5.5 procedures per 10 000 children per year, P.001).Tonsillectomy use is greatest among white and publicly insured children. However, the American Academy of Otolaryngology-Head and Neck Surgery's 2011 clinical practice guideline statement was associated with an immediate decrease and change in use trends in these groups, narrowing differences in utilization by race/ethnicity and type of insurance.

Importance Despite various barriers identified to early pediatric access to cochlear implantation, barriers to timely access to pediatric hearing aids are not well characterized. Objective To identify socioeconomic, demographic, and clinical factors that may be associated with pediatric access to hearing aids. Design, Setting, and Participants This retrospective cohort study included 90 patients aged 1 to 15 years who were referred for auditory brainstem response (ABR) testing and evaluation for hearing aids at a single tertiary care academic medical center from March 2004 to July 2018. Children who did not receive both ABR testing and hearing aids at the same center were excluded from analysis. Main Outcomes and Measures Associations of insurance type (private vs public), race/ethnicity (white vs other), primary language (English vs other), cause of hearing loss (complex vs not complex), zip code, hearing aid manufacturer, and severity of hearing loss (in decibels) with the duration of intervals from newborn hearing screening to ABR testing, from ABR testing to ordering of hearing aids, and from ABR testing to dispensing of hearing aids. Results Of the 90 patients, mean (SD) age was 5.6 (3.7) years, 56% were female, and 77 (86%) were non-Hispanic. Results of χ2tests indicated significant assocations existed between public insurance and race/ethnicity and between public insurance and primary language other than English. Variables associated with the interval from newborn hearing screening to ABR testing included insurance type (mean difference, 7.4 months; 95% CI, 2.6-12.2 months) and race/ethnicity (mean difference, 6.9 months; 95% CI, 2.7-11.1 months). Increased delays between birth and a child’s first ABR test were associated with public insurance (mean difference, 6.0 months; 95% CI, 1.8-10.2 months) and race/ethnicity other than white (mean difference, 6.0 months; 95% CI, 2.3-9.7 months). The mean time from birth to initial ABR testing was a mean of 6 months longer for patients from non–English-speaking families than for those from English-speaking families (mean [SD] interval, 14.9 [16.3] months vs 9.0 [8.5] months), although the difference was not statistically significant. Severity of hearing loss was associated with a decrease in the interval from ABR testing to ordering of hearing aids after accounting for other potential barriers (odds ratio, 0.6; 95% CI, 0.4-0.9). Zip code and complexity of the child’s medical condition did not appear to be associated with timely access to pediatric hearing aids. Conclusions and Relevance This study’s findings suggest that insurance type, race/ethnicity, and primary language may be barriers associated with pediatric access to hearing aids, with the greatest difference observed in time to initial ABR testing. Clinical severity of hearing loss appeared to be associated with a significant decrease in time from ABR testing to ordering of hearing aids. Greater efforts to assist parents with ABR testing and coordination of follow-up may help improve access for other at-risk children.

Objective Parental role in decision-making has implications for quality of care. We describe roles of parent participation in decision-making for tonsillectomy. Methods Parents reported preferred role in decision-making before consultations for tonsillectomy and the role they experienced after their consult. Parents completed questionnaires, including items evaluating clinician/parent communication. Clinicians rated perception of parents’ preferred role in decision-making. Congruence between parent and clinician responses was evaluated via kappa analysis. Logistic regression identified associations between decision-making roles and socioemotional and communication factors. Results Consults between 63 parents and 8 otolaryngologists were analyzed.There was inadequate agreement between clinician and parent ratings of preferred roles (37%, p = 0.6, 95% CI [-0.09, 0.001]). Parents perceived greater involvement when clinicians discussed reasons to have (OR = 4.3, p = 0.03) or not have (OR = 4.1, p = 0.005) surgery. Parents perceived less involvement when clinicians used jargon (OR = 0.1, p = 0.03), and when parents trusted clinicians (OR = 0.4, p = 0.049), or experienced greater decisional conflict (OR = 0.9, p = 0.03). Conclusions Parents and clinicians perceived parental preference for decision-making involvement differently during consultations for tonsillectomy. Clinician information-sharing, jargon use, and parent trust in clinician predicted extent of perceived engagement. Practice implications Findings may enhance understanding of strategies to effectively communicate and engage parents in shared decision-making for pediatric surgical care.

Perioperative blood transfusions in children are associated with patient morbidity and are often overutilized. In this study, we identify procedures most commonly associated with the use of red blood cells (RBC) in childrens surgery and develop risk-adjusted models for benchmarking.Data from the 2012-2015 National Surgical Quality Improvement Program-Pediatric participant use data files were used. CPT (Current Procedural Terminology) codes were grouped to identify the procedures where transfusions were allocated and associated patient demographics and comorbidities. Patients were stratified in two age groups (0-3 mo and 3 mo to 18 y), and a logistic regression model was developed for each age group.Of 369,176 total cases, 21,410 (5.8%) were associated with a perioperative transfusion. 659 CPT codes were grouped in 207 clusters according to their similarities. The most common procedures associated with transfusion were arthrodesis for spinal deformity (n = 9533, 44.5%), followed by craniectomy for craniosynostosis (n = 1853, 8.7%). The logistic regression model for patients3 mo included 18 variables and had excellent discriminatory performance (area under the curve 0.866). The model for patients ≥3 mo to 18 y had 21 variables and an area under the curve of 0.911.The majority of transfusions used in children's surgery are concentrated within a relatively few procedural groups. These findings can help centers in focusing blood optimization efforts on common surgeries with high transfusion rates. In addition, multiple preoperative factors have been built into a risk-adjusted model that can be used for benchmarking blood transfusions among hospitals.

Objectives Pediatric otolaryngology bears the highest frequency of elective surgical cases in children, but little is known regarding the health literacy of these children's parents. In a questionnaire-based pilot study, we assessed parental health literacy in our pediatric otolaryngology clinic and evaluated its relation to personal demographics. We also evaluated postoperative and diagnosis-based leaflets for readability using validated measures. Methods Parents completed the Short Assessment of Health Literacy-English (SAHL-E) and were defined as low (0–14) or high (>14) literacy based on mean scores. Results Fifty parents participated (mean SAHL-E score, 17.6), and all scored >14, indicating proficient health literacy. No differences existed in mean or median scores based on demographics. Continued education after high school was associated with higher scores (P = 0.003) and was the only significant variable in multivariable linear regression. All leaflets were at or below the recommended reading level for public health information. Conclusions Parents generally had high health literacy.

Introduction Patients with obstructive sleep apnea (OSA) are offered many treatment options spanning the spectrum of lifestyle modification, device therapy, and surgery. Sleep surgery, while often effective, results in moderate morbidity and has variable effectiveness on OSA improvement. Little is known about what patients consider when choosing treatment. We aim to identify factors that influenced the decision for sleep surgery among adults with OSA. Methods We conducted semi-structured virtual interviews with patients (≥18 years) with OSA (apnea-hypopnea index ≥5 events per hour of sleep) who underwent sleep surgery at a tertiary academic center, querying patients about factors in their decision for OSA treatment. Interviews were audio-recorded, transcribed, and analyzed for thematic content. We anticipate enrolling 10–18 total participants based on previously reported sample size in specialty groups for thematic saturation in specialty groups (ie, when no new concepts or factors emerge from interviews). Here we report pilot qualitative analysis results. Results Of nine eligible patients, eight enrolled (mean +/- standard deviation age 45.8 +/- 13.4 years, 2 female/6 males). Four patients underwent nasal surgery only, two patients underwent staged procedures, one underwent pharyngeal surgery only, and the last underwent nasal surgery with tori removal. Patients reported decision making duration of days to years for scheduling surgery. Reasons for pursuing sleep surgery included fatigue, quality of life, work performance, and safety. Overarching thematic domains related to decision for surgery were (1) major concerns, (2) external factors influencing decision, and (3) retrospective satisfaction/regret with decision. Major concerns involved factors beyond surgeon’s control, such as anesthesia and postoperative pain management, not surgery itself. Family and friends were reported to be highly influential in the process, both in favor and against surgery. Social media features and celebrity patients with OSA heightened awareness of sleep surgery and set preconceived expectations. Patients were mostly satisfied with outcomes, despite unanticipated acute recovery challenges. Conclusion This pilot qualitative analysis identifies factors influencing patients’ OSA treatment decisions. Understanding patients’ major concerns and sources of information may help to guide physician counseling, set realistic expectations, offer peri-operative support, and better engage parents in shared decision-making for sleep surgery. Support (if any) None.

Importance The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child’s consultation is not known. Objective To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent–clinician communication. Design, Setting, and Participants Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist. Main Outcomes and Measures The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient’s treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents). Results A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as “Other.” Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34). Conclusions and Relevance In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.

Despite increased emphasis on patient satisfaction as a quality measure in health care, little is known about the influence of race in parent-reported experience of care in pediatrics. This study evaluates the association of race with patient satisfaction scores in an inpatient pediatric tertiary care hospital in one year. Risk-adjusted multivariable logistic regression was performed to evaluate the association of minority race with the likelihood to provide a top-box (=5) satisfaction score for 38 individual questions across 8 domains. Of the 904 participants, 269 (29.8%) identified as belonging to a minority race. Parents of minority children reported 30% to 50% lower satisfaction across questions related to well-established themes of interpersonal communication and cultural competency. Overall, minorities also reported lower satisfaction for the domain of nursing care (odds ratio 0.7, P = .016). These findings suggest a need for training and interventions to improve communication and mitigate disparities in how minority patients and their families perceive pediatric care.

Introduction Despite recent concerns about potential overuse of tympanostomy tube (TT) placement to treat otitis media in children, utilization of this common procedure in the U.S. has been shown to be relatively less common among minority children. It is not known if the indications for TT differ by child race/ethnicity and/or socioeconomic status (SES). Our objective is to analyze the association of patient- and neighborhood-level demographics and SES with clinical indications for TT. Methods We conducted a retrospective chart review of children who underwent TT at single urban academic tertiary pediatric care center in a 6-month period (8/2013-3/2014). Children with congenital anomalies or syndromic diagnoses were excluded (50/137 children, 36.5%). Children were grouped by primary TT indication, recurrent acute otitis media (RAOM) or chronic otitis media with effusion (OME). Group characteristics were compared using t-tests and chi-square analyses, and logistic regression was performed to assess the association between demographics and TT indication. Results 87 children were included in this analysis (mean age = 2.8 years, 1–6 years). The most common indication for TT was RAOM (53%), and these children had a mean of 6 AOM episodes/year. Indications for TT varied significantly by the patient's neighborhood SES (median neighborhood income $70,969.09-RAOM vs $58, 844.95-OME, p-value = 0.009). Those undergoing TT for RAOM were less likely to live in a high-poverty neighborhood (OR = 0.36,p-value = 0.02), whereas children who underwent TT for OME were more likely to live in a high-poverty neighborhood. There was no significant difference in indication by race/ethnicity or insurance type. Conclusions In this population, TT indications differed by SES. Among children receiving tubes, those from high poverty areas were more likely than those from low poverty neighborhoods to receive tubes for the indication of OME as opposed to RAOM. This finding suggests that concerns for appropriate use of TT in the setting of RAOM may be specific to a more affluent population. Future prospective patient-centered research will evaluate cultural and economic influences for families pursuing TT placement, as well as factors considered by physicians who make surgical recommendations.