Are nocturnal hypoxemia and hypercapnia associated with desaturation immediately after adenotonsillectomy?

BACKGROUND: Children who undergo adenotonsillectomy for sleep-disordered breathing frequently have postoperative oxygen desaturations. Nocturnal hypoxia has been shown to predict postoperative respiratory complications; however, other gas exchange abnormalities detected on polysomnography (PSG) have not been evaluated. AIM: We sought to determine whether hypercapnia seen on preoperative nocturnal PSG can predict postoperative hypoxemia. METHODS: We conducted a retrospective review of 319 children who underwent polysomnography before adenotonsillectomy. Saturation levels were recorded for at least 2 h postoperatively, and the primary outcome was desaturation (<90%). RESULTS: The median patient age was 5 years (range, 5 months-17 years). Patients who desaturated postoperatively had higher median peak endtidal CO2 (EtCO2 ) levels (55.5 vs 52 mmHg; P = 0.02), lower saturation nadirs (80.5% vs 88%; P = 0.048), and were younger (2 vs 6 years; P < 0.001) than those without desaturation. Age was significantly correlated with peak EtCO2 (r = -0.16), respiratory disturbance index (RDI; r = -0.23), and oxygen saturation nadir (r = 0.25; all P < 0.01). In unadjusted analysis, age <3 years compared to ≥9 years (odds ratio [OR] = 10.09; 95% confidence interval [CI] = 2.13-96.26), peak EtCO2  > 55 mmHg (OR = 3.38; 95% CI = 1.21-9.47), and RDI ≥ 10 (OR = 2.89; 95% CI = 1.05-8.42) were associated with increased odds of desaturation. Multivariable logistic regression on age, race, sex, peak EtCO2 , RDI, opioid use, and saturation nadir showed that only age was significantly associated with postoperative desaturation. Patients 0-2 years old were 10.43 (95% CI = 1.89-110.9) times more likely to have desaturation than patients 9-17 years old. CONCLUSION: Patients <3 years of age are most likely to have postoperative hypoxemia after adenotonsillectomy. Gas exchange abnormalities did not correlate with postoperative desaturations, although age and peak EtCO2 did strongly correlate.

Voice quality in laryngotracheal stenosis: impact of dilation and level of stenosis.

OBJECTIVE: To assess the impact of suspension microlaryngoscopy with balloon dilation on voice-related quality of life (V-RQOL) in laryngotracheal stenosis (LTS). METHODS: Retrospective chart review of LTS patients dilated at a tertiary-care academic hospital from 2010 to 2013. Data were obtained and then analyzed. LTS was stratified by (1) subglottic or tracheal stenosis and (2) multilevel stenosis (MLS; glottic and subglottic/tracheal). Pre- and postoperative V-RQOL and grade, roughness, breathiness, asthenia, strain (GRBAS) scores were compared. The number and frequency of balloon dilation procedures over the lifetime were secondary outcome variables. RESULTS: Thirty-eight patients were identified: 26 subglottic/tracheal and 12 multilevel. Of these, 71.4% required multiple dilations, with greatest dilations/patient for multilevel stenosis (4.8). V-RQOL improved in the 27 patients with completed pre- and postoperative scores from a mean of 70.4 to 80 (P=.025). Pre/postoperative V-RQOLs for tracheal/subglottic (mean, 82.8/93.8) were significantly higher (P=.0001/.0001) than multilevel stenosis (48/55.3). Voice quality-of-life improvement was significant for the subglottic/tracheal cohort (P=.036) but not for the MLS group. GRBAS was performed pre- and postoperatively in 10 patients with improvement in all domains except breathiness. CONCLUSION: Laryngotracheal stenosis is associated with dysphonia. Patients with glottic involvement have significantly worse voice quality of life than those with tracheal/subglottic stenosis. Endoscopic balloon dilation improves V-RQOL in patients with subglottic/tracheal stenosis.

Safety of radiofrequency ablation for adenotonsillectomy after cochlear implantation.

OBJECTIVE: While a cadaveric animal study has suggested that radiofrequency ablation can be safely used in patients with cochlear implants, no in vivo studies have been published to confirm that radiofrequency ablation does not alter the integrity of the cochlear implant device. METHODS: Cochlear implant impedance and functional performance were studied through a prospective case series in five children with seven functioning multichannel implants before and after radiofrequency ablation adenotonsillectomy. RESULTS: There were 4 females and 1 male patient, aged 6-10 years (mean 8.5 ±â€¯1.95 years) with 7 functioning implants. Pre- and post-surgical impedance testing revealed all electrodes were within normal operating limits. There was no statistically significant difference between the mean pre and post-operative impedances in 5 of the 7 tested implants (P = 0.2-0.8). The other two implants showed statistically significant improvement in impedance values which were not clinically significant (P = 0.02 and P < 0.001). Speech perception was unchanged as was functional performance for all 7 tested implants. CONCLUSIONS: We found that radiofrequency ablation used in the oropharynx during adenotonsillectomy did not alter the integrity of the cochlear implant devices when assessed using electrode impedance testing, audiometry and speech perception evaluation. These results confirm those reported in previous in vitro studies and confirm the safety of radiofrequency ablation adenotonsillectomy for children who have undergone previous cochlear implant placement.

Admission Criteria for Children With Obstructive Sleep Apnea After Adenotonsillectomy: Considerations for Cost.

STUDY OBJECTIVES: Postoperative respiratory complications (PRCs) are common among children with obstructive sleep apnea (OSA) after adenotonsillectomy. We analyzed postoperative admission guidelines to determine which optimally balanced patient safety and cost. METHODS: Retrospective study of children aged 12 years or younger undergoing adenotonsillectomy for OSA after polysomnography at a tertiary academic care center over 2 years. Demographics, medical History, and hospital course were collected. Advanced Excel modeling was used to assess the number of children with PRCs identified with guideline admission criteria and to validate the significance of these findings in our patient population with logistic regression. RESULTS: Six hundred thirty children were included; 116 had documented PRCs. Children with PRCs were younger (P = .024) and more frequently male (P = .012). There were no significant differences in race (P = .411) or obesity (P = .265). More children with PRCs had an apnea-hypopnea index (AHI) > 24 events/h (P < .001). Following guidelines from the American Academy of Pediatrics, American Academy of Otolaryngology - Head and Neck Surgery, and Nationwide Children's Hospital, 82%, 87%, and 99% of children with PRCs would be identified, costing $535,962, $647,165, and $1,053,694 for admission, respectively. Using a non-validated, forced model to refine predictors described in published guidelines, our model would have identified 95% of children with one or more PRCs, with a moderate cost. CONCLUSIONS: Current admission guidelines attempt to identify children with OSA at high risk for PRCs after adenotonsillectomy; however, none consider the economic cost to the health care system. We present a comparison of the number of patients identified with PRCs after adenotonsillectomy and the cost of expected admissions using currently published guidelines. COMMENTARY: A commentary on this article appears in this issue on page 1371.

Obstructive Sleep Apnea Resolution in Hypopnea- versus Apnea-Predominant Children after Adenotonsillectomy.

OBJECTIVE: Given that 30% to 40% of children have persistent obstructive sleep apnea (OSA) after adenotonsillectomy, we evaluated whether children with hypopnea-predominant OSA were more likely to have complete disease resolution after adenotonsillectomy than those with apnea-predominant disease. We also identified risk factors that might modify the relationship between disease resolution and polysomnographic event type (ie, hypopnea vs apnea). STUDY DESIGN: Case series with chart review. SETTING: Tertiary pediatric hospital. SUBJECTS/METHODS: Consecutive 1- to 18-year-old typically developing children diagnosed with OSA from March 2011 to December 2012 underwent adenotonsillectomy and completed pre- and postoperative polysomnography within 1 year of surgery. RESULTS: Fifty-eight children were included (27 female; mean ± SD: age, 5.6 ± 3.1 years; body mass index z score, 1.1 ± 1.7). Overall, adenotonsillectomy resulted in significant improvement in obstructive apnea-hypopnea index (oAHI) from 23.3 ± 40.0 to 4.3 ± 8.2 events per hour (P < .001), obstructive apnea index (5.1 ± 7.4 to 0.4 ± 0.8, P < .001), and obstructive hypopnea index (oHI; 18.1 ± 37.5 to 3.7 ± 8.1, P < .001). There was complete response (oAHI <1.0 event/h) in 24 of 58 patients (41%) but no difference by event type (P = .11). On univariate analysis, only race, sex, oxygen saturation nadir, and oHI were predictive of response to adenotonsillectomy, while multivariate analysis found that prematurity, age, oxygen saturation nadir, oHI, obstructive apnea index, and oAHI were predictive. Event type was not significant, even in a model controlling for age, race, sex, prematurity, asthma, body mass index, and baseline polysomnographic variables. CONCLUSION: This small study demonstrated no difference in disease resolution between children with hypopnea- and apnea-predominant OSA who underwent adenotonsillectomy. Additionally, adenotonsillectomy significantly improved OSA in most children, and high preoperative oAHI was associated with persistent postoperative OSA.

Prediction of obstructive sleep apnea using visual photographic analysis.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) has been historically underdiagnosed and may be associated with grave perioperative complications. The ASA and American Academy of Sleep Medicine recommend OSA screening prior to surgery; however, only a minority of patients are screened. The objective of this study was to determine the proficiency of anesthesiologists, otolaryngologists, and internists at predicting the presence of OSA by visual photographic analysis without the use of a computer program to assist, and determine if prediction accuracy varies by provider type. DESIGN: Prospective case series SETTING: Tertiary care hospital-based academic center PATIENTS: Fifty-six consecutive patients presenting to the sleep laboratory undergoing polysomnography had frontal and lateral photographs of the face and torso taken. INTERVENTIONS: Not applicable. MEASUREMENTS: Polysomnography outcomes and physician ratings. An obstructive apnea hypopnea index (oAHI) ≥15 was considered "positive." Twenty anesthesiologists, 10 otolaryngologists, and 11 internists viewed patient photographs and scored them as OSA "positive" or "negative" before and after being informed of patient comorbidities. MAIN RESULTS: Nineteen patients had an oAHI <15, 18 were ≥15 but <30, and 19 were ≥30. The mean oAHI was 28.7 ± 26.7 events/h (range, 0-125.7), and the mean body mass index was 34.1 ± 9.7 kg/m(2) (range, 17.4-63.7). Overall, providers predicted the correct answer with 61.8% accuracy without knowledge of comorbidities and 62.6% with knowledge (P < .0001). There was no difference between provider groups (P = .307). Prediction accuracy was unrelated to patient age (P = .067), gender (P = .306), or race (P = .087), but was related to body mass index (P = .0002). CONCLUSION: The ability to predict OSA based on visual inspection of frontal and lateral photographs is marginally superior to chance and did not differ by provider type. Knowledge of comorbidities did not improve prediction accuracy.

Anthropometric and Dental Measurements in Children with Obstructive Sleep Apnea.

STUDY OBJECTIVES: A number of authors have shown that children with OSA are more likely to have certain physical characteristics than healthy controls. With this in mind, our objectives were to collect normative baseline data and determine if there was a significant difference in anthropometric and dental measurements between children with OSA and age-matched nonsnoring controls. METHODS: Children 2 to 12 y of age, in whom OSA was diagnosed by overnight polysomnography, were recruited to our experimental group. Age-matched nonsnoring controls were screened for signs of sleep-disordered breathing. Anthropometric measurements, including waist, neck, and hip circumferences, and waist-hip and neck-waist ratios, were obtained on all study participants preoperatively. Dental casts were acquired to determine intertooth distances and palatal height. RESULTS: Sixty-one children (42 with OSA [69%] and 19 controls [31%]) with a mean age of 4.7 y participated in the study. Waist and hip circumferences were significantly larger in children with OSA (p = 0.001 and 0.001, respectively). However, there was no difference in neck circumference and waist-hip ratios between the two groups. Neck-waist ratio in children with OSA was significantly smaller than in controls (p = 0.001). Intertooth distance for the first (p < 0.0001) and second deciduous (p = 0.0002) and first permanent molars (p = 0.022) were significantly narrowed in children with OSA; however, no difference was seen in palatal height between groups. Body mass index was similar between groups (p = 0.76). CONCLUSIONS: Anthropometric and dental measurements were significantly different in children with OSA compared to nonsnorers. Future studies with a large sample size may allow us to determine if these measurements can be used by clinicians to identify children at risk for OSA. COMMENTARY: A commentary on this article appears in this issue on page 1213.

Shared Decision Making and Choice for Elective Surgical Care: A Systematic Review.

OBJECTIVE: Shared decision making (SDM), an integrative patient-provider communication process emphasizing discussion of scientific evidence and patient/family values, may improve quality care delivery, promote evidence-based practice, and reduce overuse of surgical care. Little is known, however, regarding SDM in elective surgical practice. The purpose of this systematic review is to synthesize findings of studies evaluating use and outcomes of SDM in elective surgery. DATA SOURCES: PubMed, Cochrane CENTRAL, EMBASE, CINAHL, and SCOPUS electronic databases. REVIEW METHODS: We searched for English-language studies (January 1, 1990, to August 9, 2015) evaluating use of SDM in elective surgical care where choice for surgery could be ascertained. Identified studies were independently screened by 2 reviewers in stages of title/abstract and full-text review. We abstracted data related to population, study design, clinical dilemma, use of SDM, outcomes, treatment choice, and bias. RESULTS: Of 10,929 identified articles, 24 met inclusion criteria. The most common area studied was spine (7 of 24), followed by joint (5 of 24) and gynecologic surgery (4 of 24). Twenty studies used decision aids or support tools, including modalities that were multimedia/video (13 of 20), written (3 of 20), or personal coaching (4 of 20). Effect of SDM on preference for surgery was mixed across studies, showing a decrease in surgery (9 of 24), no difference (8 of 24), or an increase (1 of 24). SDM tended to improve decision quality (3 of 3) as well as knowledge or preparation (4 of 6) while decreasing decision conflict (4 of 6). CONCLUSION: SDM reduces decision conflict and improves decision quality for patients making choices about elective surgery. While net findings show that SDM may influence patients to choose surgery less often, the impact of SDM on surgical utilization cannot be clearly ascertained.

Improvement in hearing loss over time in Cornelia de Lange syndrome.

OBJECTIVES: Patients with Cornelia de Lange Syndrome (CdLS) are reported to have conductive (CHL) and sensorineural hearing loss (SNHL), but there is little information pertaining to the progression of hearing loss over time. The goal of this study was to examine the prevalence of CHL and SNHL in adults and children with CdLS and look for changes in SNHL over time. METHODS: Retrospective chart review of patients with CdLS presenting to a CdLS clinic was conducted. Also, a written survey of clinical concerns was collected from additional patients/families seen in the clinic and through the Cornelia de Lange Foundation. RESULTS: Seventy-eight patients (50% female) were included in the chart review. Mean age was 16.8 ± 11.4 years (range-0.6-50 years) and mean age at diagnosis of hearing loss was 4.6 ± 10.6 years (n = 26). Five patients (6.4%) had severe to profound SNHL that improved with time, including 2 who had complete normalization of audiogram results. Thirty-five families/patients completed the clinical survey, and 45.5% of the families reported a noticeable improvement of hearing over time. CONCLUSIONS: Conductive hearing loss and SNHL are common in CdLS. More than 50% of the patients seen in an adult CdLS clinic reported improvement in hearing loss over time, and a subset of patients had an improvement in SNHL. In light of these findings, we recommend longitudinal evaluations of hearing loss in these patients with both auditory brainstem response and otoacoustic emissions testing if SNHL is identified.

Does Race/Ethnicity or Socioeconomic Status Influence Patient Satisfaction in Pediatric Surgical Care?

OBJECTIVE: To evaluate patient satisfaction in outpatient pediatric surgical care and assess differences in scores by race/ethnicity and socioeconomic status (SES). STUDY DESIGN: Observational, cross-sectional analysis. SETTING: Outpatient pediatric surgical specialty clinics at a tertiary academic center. SUBJECT AND METHODS: Families of patients received a patient satisfaction survey following their initial care visit in 2012. Mean scores were calculated and compared by child race/ethnicity and insurance type, where insurance with medical assistance (MA) served as a proxy for low SES. Kruskal-Wallis tests were used to compare scores between groups. Surveys were dichotomized to low and high scorers, and multivariate logistic regression was used to calculate the likelihood of high satisfaction. RESULTS: Of 527 surveys completed, 132 (25%) were for children with MA and 143 (27%) were for racial/ethnic minority children. The overall satisfaction score for all specialties was 84.8, which did not significantly differ by SES (P = .98) or minority status (P = .52). The survey item with the highest score in both SES groups was "degree to which provider talked with you using words you could understand" (overall mean 91.94, P = .23). Multivariate analysis showed that patient age, sex, race/ethnicity, insurance type, neighborhood SES, neighborhood diversity, or surgical department did not significantly influence satisfaction. CONCLUSION: This is the first study to evaluate the relationship between SES and race/ethnicity with patient satisfaction in outpatient pediatric surgical specialty care. In this analysis, no disparities were identified in the patient experience by individual- or community-level factors. Although the survey methodologies may be limited, these findings suggest that provision of care in pediatric surgical specialties can be simultaneously equitable, culturally competent, and family centered.

Influence of Tonsillar Size on OSA Improvement in Children Undergoing Adenotonsillectomy.

OBJECTIVE: To determine if pediatric obstructive sleep apnea (OSA) improves after adenotonsillectomy (AT) regardless of tonsil size. STUDY DESIGN: Case series with chart review. SETTING: Pediatric Otolaryngology Department, Johns Hopkins Hospital. SUBJECTS: Seventy children 1 to 18 years of age who underwent polysomnography (PSG) before and after AT. METHODS: Tonsil size was evaluated using the Brodsky grading scale. RESULTS: Children were stratified by tonsil size as 2+ (n = 20), 3+ (n = 36), and 4+ (n = 14). There was a significant improvement in obstructive apnea-hypopnea index (oAHI), apnea index (AI), and saturation nadir across all 3 groups after AT. Preoperative oAHI, AI, and hypopnea index (HI) were similar regardless of tonsil size (P > .05). Overall, oAHI improved from a median of 11.8 ± 21.7 to 2.0 ± 6.1 events/h, with 40% (28/70) of children having complete resolution. The oAHI (P < .0001-0.02), AI (P < .0001-0.017), HI (P < .0001-0.058), and saturation nadir (P < .0001-0.017) significantly improved for the 2+, 3+, and 4+ groups. Only the HI (P = .058) in the 2+ group did not. The median oAHI improvement was 3.4 ± 26.4 events/h in the 2+ group, 8.3 ± 16.6 events/h in the 3+ group, and 12.3 ± 19.5 events/h in the 4+ group, with 25% (5/20), 50% (18/36), and 36% (5/14), respectively, having complete resolution. There was no correlation between OSA severity and tonsil or adenoid size (P > .32). CONCLUSION: Tonsil size did not correlate with OSA severity. While a larger proportion of patients classified as 3+ and 4+ had complete resolution after surgery, significant improvement was seen in AI and saturation nadir even in those classified as 2+.

The association between secondhand smoke and sleep-disordered breathing in children: a systematic review.

OBJECTIVE: To systematically review existing literature on the association between secondhand smoke and sleep-disordered breathing in children. DATA SOURCES: PubMed, Embase, Cochrane CENTRAL, Web of Science, and Scopus. REVIEW METHODS: Inclusion criteria included English-language papers containing original human data, with seven or more subjects and age <18 years. Data were systematically collected on study design, patient demographics, clinical characteristics/outcomes, and level of evidence. Two investigators independently reviewed all manuscripts. RESULTS: The initial search yielded 72 abstracts; 18 articles were ultimately included with a total study population of 47,462 patients. Fifteen (83%) articles found a statistically significant association between secondhand smoke and sleep-disordered breathing. All were case-control studies. Quality of articles based on the Newcastle-Ottawa scale averaged 5.8/9 stars. Secondhand smoke was characterized by serum cotinine testing in only two (11%) studies. Sleep-disordered breathing was quantified by polysomnography in only four (22%) of the studies and only one (6%) classified subject using polysomnography exclusively. Habitual snoring was the most common form of sleep-disordered breathing studied in 14/18 (78%) studies, whereas obstructive sleep apnea was reported in one (6%) study and sleep-related hypoxia in another (6%) study. CONCLUSIONS: Although the majority of studies included in this review found a significant association between secondhand smoke and sleep-disordered breathing, all of them were evidence level 3b, for an overall grade of B (Oxford Centre for Evidence-based Medicine). Further higher-quality studies should be performed in the future to better evaluate the relationship between second- smoke and sleep-disordered breathing in children.

Is the OSA-18 predictive of obstructive sleep apnea: comparison to polysomnography.

OBJECTIVES/HYPOTHESIS: To examine the ability of the OSA-18 to predict Obstructive Sleep Apnea (OSA) in a racially diverse population when compared to overnight polysomnography (PSG). STUDY DESIGN: Cross-sectional retrospective. METHODS: Children 2 to 12 years of age diagnosed with OSA who were treated at a tertiary care institution between 2008 and 2013 and had complete PSG and OSA-18 data were included. We performed logistic regression with OSA as the dependent variable and the OSA-18 total symptom score (TSS), age, gender, race, asthma, and body mass index (BMI) as independent variables. RESULTS: Seventy-nine children (32 females) were included (mean age 5.2 ± 2.4 years). The positive predictive value (PPV) was greater than 90 for an obstructive apnea-hypopnea index (oAHI) ≥ 1. The PPV and specificity were higher for white than for nonwhite children; however, sensitivity and negative predictive value (NPV) of OSA-18 TSS were low for mild, moderate, and severe OSA regardless of race. Age, race, and BMI were not significantly associated with oAHI. CONCLUSIONS: This study, conducted in a racially diverse cohort, examined the ability of the OSA-18 to predict OSA when compared to PSG-the gold standard-and found that sensitivity and NPV were extremely low for both white and nonwhite children. This suggests that the OSA-18 is not sufficiently sensitive to detect OSA nor sufficiently specific to determine the absence of OSA. The OSA-18 should be used as a quality-of-life indicator and is not a reliable substitute for PSG. LEVEL OF EVIDENCE: 4.

Qualitative synthesis and systematic review of otolaryngology in undergraduate medical education.

OBJECTIVE: Although 25% of primary care complaints are otolaryngology related, otolaryngology instruction is not required in most medical schools. Our aim was to systematically review existing literature on the inclusion of otolaryngology in undergraduate medical education. DATA SOURCES: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Education Resources Information Center. STUDY DESIGN/REVIEW METHODS: Our search encompassed all indexed years through December 29, 2014. Inclusion criteria were English language, original human data, and a focus on medical student education. Data regarding study design, teacher, educational topic, educational methods, and setting were extracted from each article. Two investigators independently reviewed all articles. RESULTS: Our initial search yielded 436 articles; 87 underwent full-text evaluation and 47 remained in the final review. The majority of studies were conducted in the United States (40%), United Kingdom (23%), and Canada (17%) and represented a single institutional experience. Studies were classified as needs assessments (36%), curriculum descriptions (15%), educational methods (36%), and skills assessments (32%); 81% were levels of evidence 3 or 4. Most reports indicated that otolaryngology rotations are not compulsory. CONCLUSIONS: Studies indicated the need for increased exposure to otolaryngology. Educational methods such as team-based learning, simulation, online learning, and clinical skills assessments may offer ways to increase exposure without overburdening clinical faculty and require further study. Data suggest that a universal otolaryngology medical student curriculum would be valuable and aid in resource sharing across institutions. We recommend that an assessment be performed to determine topics and skills that should comprise this curriculum. LEVEL OF EVIDENCE: NA.

Public insurance and timing of polysomnography and surgical care for children with sleep-disordered breathing.

IMPORTANCE: Although children with low socioeconomic status (SES) have increased risk for sleep-disordered breathing (SDB), their access to subspecialty care is often limited. Polysomnography (PSG) is the gold standard diagnostic test used to characterize SDB and diagnose obstructive sleep apnea; however, it is unknown whether SES impacts timeliness of obtaining PSG and surgical treatment with adenotonsillectomy (AT). OBJECTIVE: To evaluate the impact of SES on the timing of PSG, surgery with AT, and loss to follow-up for children with SDB. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort analysis conducted in tertiary outpatient pediatric otolaryngology clinics among patients newly evaluated for SDB over a 3-month period who did not have prior PSG ordered and had a minimum of 1-year follow-up. MAIN OUTCOMES AND MEASURES: Public insurance (Medical Assistance [MA]) was used as a proxy for low SES. Demographics and disposition between groups were compared using t tests and χ2 analysis. Logistic regression adjusting for disposition and insurance was used to predict loss to follow-up. Days to PSG and days to AT were evaluated using the Kaplan-Meier estimator, and the log-rank test was used to compare distribution of time to events between insurance groups. RESULTS: A total of 136 children (without PSG) were evaluated for SDB over the course of 3 months; 62 (45.6%) had MA. Polysomnography was recommended for 55 children (27 of 55 [49%] with MA vs 28 of 55 [50%] with private insurance; P > .99). After the initial visit, 24 of 55 children with PSG requested (44%) were completely lost to follow-up (9 of 27 [33%] with MA vs 15 of 28 [54%] private insurance; P = .34). Children with MA who obtained PSG experienced longer intervals between initial encounter and PSG (mean interval, 141.1 days) than privately insured children (mean interval, 49.9 days) (P = .001). For those children who ultimately underwent AT surgery after obtaining PSG (n = 14), mean (SD) time to AT was longer for children with MA (222.3 [48.2] days vs 95.2 [66.1] days; P = .001). CONCLUSIONS AND RELEVANCE: Children with public insurance experienced longer intervals from initial evaluation to PSG or surgery. Almost half of patients with PSG requested were lost to follow-up, regardless of SES. These findings suggest that PSG may be a deterrent for definitive care for all children, and particularly for children with public insurance or low SES. This study emphasizes the need to understand factors contributing to disparities surrounding delay in care with PSG and surgery for children with SDB.

Medical management of chronic rhinosinusitis in cystic fibrosis: a systematic review.

OBJECTIVES/HYPOTHESIS: To systematically review existing literature on the effectiveness of medical management of chronic rhinosinusitis (CRS) in cystic fibrosis (CF) patients. STUDY DESIGN: Systematic review. METHODS: We performed a literature search of PubMed, Embase, and Cochrane CENTRAL from 1987 to 2012. Inclusion criteria included English language as containing original data, with five or more subjects, measurable clinical outcomes, and readily available interventions. Data were systematically collected on study design, patient demographics, clinical characteristics and outcomes, and level of evidence. Two investigators independently reviewed all manuscripts and performed a comprehensive quality assessment. RESULTS: Of 415 abstracts identified, 12 articles were included. These 12 studies reported on 701 adult and pediatric CF patients who underwent medical therapy. Medical treatment included antibiotics (4/12), topical steroids (4/12), dornase alfa (3/12), and ibuprofen (1/12). Outcome measures included symptom scores (7/12), endoscopic findings (7/12), radiographic findings (4/12), pulmonary function testing (4/12), and rhinomanometry (2/12). Most studies found improvement in at least one of the outcome measures. There was statistical significance in clinical outcomes with dornase alfa, beclomethasone, and betamethasone. Most studies were level 3 or 4 evidence (9/12), but three studies were level 1 or 2 evidence (two dornase alfa studies, one betamethasone study). CONCLUSIONS: Dornase alfa and, to a lesser extent, topical steroids demonstrated significant benefits in the medical treatment CRS in CF. There was a lack of evidence to support antibiotic therapy in the outcomes assessed. Further high-quality studies should be carried out to determine the efficacy of various medical therapies for CRS in CF. LEVEL OF EVIDENCE: NA.

Whose experience is measured? A pilot study of patient satisfaction demographics in pediatric otolaryngology.

OBJECTIVES/HYPOTHESIS: Despite a national emphasis on patient-centered care and cultural competency, minority and low-income children continue to experience disparities in health care quality. Patient satisfaction scores are a core quality indicator. The objective of this study was to evaluate race and insurance-related disparities in parent participation with pediatric otolaryngology satisfaction surveys. STUDY DESIGN: Observational analysis of patient satisfaction survey respondents from a tertiary pediatric otolaryngology division. METHODS: Demographics of survey respondents (Press Ganey Medical Practice Survey©) between January and July 2012 were compared to a clinic comparison group using t test and chi-square analyses. Multivariate logistic regression analyses were performed to assess likelihood to complete a survey based on race or insurance status. RESULTS: A total of 130 survey respondents were compared to 1,251 patients in the comparison group. The mean patient age for which the parent survey was completed was 5.7 years (6.1 years for the comparison group, P = 0.18); 59.2% of children were ≤ 5 years old. Relative to the comparison group, survey respondents were more often white (77.7% vs. 58.1%; P <0.001) and privately insured (84.6% vs. 60.8%; P <0.001). Similarly, after controlling for confounding variables, parents of children who were white (OR 1.8, 95% CI 1.13-2.78, P = 0.013) or privately insured (OR 2.9, 95% CI 1.74-4.85, P <0.001) were most likely to complete a survey. CONCLUSION: Methods to evaluate satisfaction did not capture the racial or socioeconomic patient distribution within this pediatric division. These findings challenge the validity of applying patient satisfaction scores, as currently measured, to indicate health care quality. Future efforts to measure and improve patient experience should be inclusive of a culturally diverse population.

Financial incentive of home continuous positive airway pressure machine use in the inpatient hospital setting.

OBJECTIVES/HYPOTHESIS: Obstructive sleep apnea (OSA) is increasingly recognized as a significant factor in perioperative and inpatient health. Because of this, hospitalized OSA patients are encouraged to utilize continuous positive airway pressure (CPAP) therapy while inpatients. We investigated the cost difference of patient-owned versus hospital-provided CPAP machine use by admitted adult patients with OSA. STUDY DESIGN: Prospective cohort study at a tertiary academic center. METHODS: All new-patient admissions >18 years of age who were prescribed CPAP while inpatients over a 2-month period were included. Demographic information was collected, and cost analysis was performed. RESULTS: CPAP was used for 162 (1.2%) admissions. Mean patient age was 59 ± 13 years; the majority were white (56.8%) and male (64.2%). Average CPAP utilization was 5.3 ± 5.5 nights. The differential cost per day for patients using hospital-provided CPAP was $416.10 more than for patients using home CPAP machines. This cost included direct costs of an extended respiratory therapy (RT) initial visit, machine rental fee ($27.50), and additional RT evaluation time (mean, 85-145 relative value units). The base initial visit was the same for all patients. Over the 2-month study period, the total cost difference in charges was $195,912; this extrapolates to $1,175,471 yearly. CONCLUSIONS: This is the first study to characterize the magnitude of cost savings from utilization of home versus hospital-provided CPAP machines in patients requiring inpatient CPAP machine use. The use of patient-owned CPAP machines may reflect an opportunity to provide cheaper care while maintaining high patient safety and quality care. The actual economic impact to an individual hospital would vary based on the insurance payer mix.

Does surgery for obstructive sleep apnea improve depression and sleepiness?

OBJECTIVES/HYPOTHESIS: To determine if surgical intervention for OSA (obstructive sleep apnea), particularly multilevel surgery, decreases depression and sleepiness. STUDY DESIGN: Prospective cohort study. METHODS: Chart and prospective outcome database review of patients who underwent surgery from August 2008 through November 2012. Patients were evaluated before and after surgery using the Epworth Sleepiness Scale (ESS), the Beck Depression Index (BDI), and overnight polysomnography. RESULTS: Forty-four patients (12 females; 32 males) met inclusion criteria. Mean age of participants was 44.0 years (SD, 10.2); mean body mass index was 31.9 (SD, 9.3). The mean preoperative obstructive respiratory disturbance index (RDI) was 35.8 events/hour (SD, 21.9; range, 6.6-94.2), which decreased to 17.1 (SD, 19.5; range, 0.8-78.1; P < 0.0001). Mean ESS improved from 10.8 (SD, 4.7) to 6.3 (SD, 3.7; P = 0.0001); whereas BDI scores improved from 8.4 (SD, 8.2) to 4.9 (SD, 6.0; P = 0.0051). There were 22 (50.0%) patients with excessive daytime sleepiness and 12 (27.3%) patients with depression before surgery. Surgery was associated with resolution of sleepiness in 17 patients (77.3%) and depression in 9 patients (75.0%). In multivariable regression analysis, only change in ESS (P = 0.003) and baseline BDI (P < 0.001) were associated with improvement in depression. RDI was not significant (P = 0.15). CONCLUSIONS: Surgical treatment of OSA, especially multilevel surgery, resulted in significantly reduced depression, with resolution in 75% of patients. Similarly, surgery resulted in significantly reduced sleepiness, with resolution in 77% of patients. Reduction in sleepiness scores, but not OSA severity, was predictive of improvement in depression scores. Further evaluation with a larger sample size and a control group is warranted. LEVEL OF EVIDENCE: 4.

Directed educational training improves coding and billing skills for residents.

OBJECTIVES: To determine if coding and billing acumen improves after a single directed educational training session. STUDY DESIGN: Case-control series. METHODS: Fourteen otolaryngology practitioners including trainees each completed two clinical scenarios before and after a directed educational session covering basic skills and common mistakes in otolaryngology billing and coding. Ten practitioners had never coded before; while, four regularly billed and coded in a clinical setting. RESULTS: Individuals with no previous billing experience had a mean score of 54% (median 55%) before the educational session which was significantly lower than that of the experienced billers who averaged 82% (median 83%, p=0.002). After the educational billing and coding session, the inexperienced billers mean score improved to 62% (median, 67%) which was still statistically lower than that of the experienced billers who averaged 76% (median 75%, p=0.039). The inexperienced billers demonstrated a significant improvement in their total score after the intervention (P=0.019); however, the change observed in experienced billers before and after the educational intervention was not significant (P=0.469). CONCLUSIONS: Billing and coding skill was improved after a single directed education session. Residents, who are not responsible for regular billing and coding, were found to have the greatest improvement in skill. However, providers who regularly bill and code had no significant improvement after this session. These data suggest that a single 90min billing and coding education session is effective in preparing those with limited experience to competently bill and code.