Project Summary/Abstract
Tonsillectomy, with or without adenoidectomy, is one of the most common surgical procedures in the
United States, performed in more than 500,000 children annually. Tonsillectomies in children are most
commonly performed for obstructive sleep disordered breathing (oSDB) or recurrent throat infection. The
procedure improves oSDB symptoms, behavior, and quality of life in children with oSDB. It is also an effective
treatment for children with severe recurrent tonsillitis. Nevertheless, many children experience a resolution of
oSDB or mild tonsillar infections over time without having surgery. As such, tonsillectomy is subject to
considerable variation in use and likely overuse in some groups. Evidence of potential overuse comes from the
fact that the rate of tonsillectomy for recurrent throat infection is 2-3 times higher in rural white children than
non-rural white children or either black or Hispanic children. In contrast, black and Hispanic children are far
more likely than white children to have oSDB, but they are less likely to undergo tonsillectomy for this
condition. It is likely that factors acting across multiple levels and domains drive these differences in
tonsillectomy use, including factors acting at the patient/family, primary care provider (PCP), primary care
practice, surgeon, and community levels. Although it is often supposed that the large sociodemographic and
geographic variation seen in tonsillectomy use is largely explained by the varying opinions and preferences of
providers, a large body of research suggests that patient knowledge, preferences, and expectations have as
great or greater an impact than provider opinion on sociodemographic differences in rates of adult elective
surgery. An understanding of the relative importance of patient/family, clinician, and community-level factors on
racial/ethnic and geographic differences in pediatric tonsillectomy use is critically needed to maximize the
benefits of this common surgical procedure in the pediatric population, while minimizing the unnecessary costs
and complications with which it is associated. This mixed-methods project will identify and quantify the impact
of factors acting across multiple levels and domains on racial/ethnic and geographic differences in pediatric
tonsillectomy use. We will analyze healthcare utilization data from 2016-2019 on all publicly insured U.S.
children. We will also conduct interviews with diverse samples of caregivers whose children have undergone
tonsillectomy and with PCPs who refer for and otolaryngologists who perform tonsillectomy. Our findings will
facilitate future improvements in the appropriateness of care of children being considered for tonsillectomy by
informing the development and targeted dissemination of educational materials and shared decision-making
tools that can be used by families and clinicians.
