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  • Effect of a health system payment and quality improvement programme for tonsillectomy in Ontario, Canada: an interrupted time series analysis

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Original research
Effect of a health system payment and quality improvement programme for tonsillectomy in Ontario, Canada: an interrupted time series analysis
  1. Sanjay Mahant1,2,3,
  2. Jun Guan4,
  3. Jessie Zhang5,
  4. Sima Gandhi4,
  5. Evan Jon Propst6,7,
  6. Astrid Guttmann1,2,3,4,8
  1. 1 Department of Paediatrics, University of Toronto Termerty Faculty of Medicine, Toronto, Ontario, Canada
  2. 2 Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  3. 3 Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
  4. 4 Life Stage Program, ICES, Toronto, Ontario, Canada
  5. 5 University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
  6. 6 Otolaryngology–Head and Neck Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
  7. 7 Otolaryngology–Head and Neck Surgery, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
  8. 8 Leong Centre For Healthy Children, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Sanjay Mahant, Paediatrics, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; sanjay.mahant{at}sickkids.ca

Abstract

Background Tonsillectomy is among the most common and cumulatively expensive surgical procedures in children, with known variations in quality of care. However, evidence on health system interventions to improve quality of care is limited. The Quality-Based Procedures (QBP) programme in Ontario, Canada, introduced fixed episode hospital payment per tonsillectomy and disseminated a perioperative care pathway. We determined the association of this payment and quality improvement programme with tonsillectomy quality of care.

Methods Interrupted time series analysis of children undergoing elective tonsillectomy at community and children’s hospitals in Ontario in the QBP period (1 April 2014 to 31 December 2018) and the pre-QBP period (1 January 2009 to 31 January 2014) using health administrative data. We compared the age-standardised and sex-standardised rates for all-cause tonsillectomy-related revisits within 30 days, opioid prescription fills within 30 days and index tonsillectomy inpatient admission.

Results 111 411 children underwent tonsillectomy: 51 967 in the QBP period and 59 444 in the pre-QBP period (annual median number of hospitals, 86 (range 77–93)). Following QBP programme implementation, revisit rates decreased for all-cause tonsillectomy-related revisits (0.48 to −0.18 revisits per 1000 tonsillectomies per month; difference −0.66 revisits per 1000 tonsillectomies per month (95% CI −0.97 to −0.34); p<0.0001). Codeine prescription fill rate continued to decrease but at a slower rate (−4.81 to −0.11 prescriptions per 1000 tonsillectomies per month; difference 4.69 (95% CI 3.60 to 5.79) prescriptions per 1000 tonsillectomies per month; p<0.0001). The index tonsillectomy inpatient admission rate decreased (1.12 to 0.23 admissions per 1000 tonsillectomies per month; difference −0.89 (95% CI −1.33 to −0.44) admissions per 1000 tonsillectomies per month; p<0.0001).

Conclusions The payment and quality improvement programme was associated with several improvements in quality of care. These findings may inform jurisdictions planning health system interventions to improve quality of care for tonsillectomy and other paediatric procedures.

  • hospital medicine
  • paediatrics
  • healthcare quality improvement
  • surgery

Data availability statement

No data are available.

https://doi.org/10.1136/bmjqs-2021-013110

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    Footnotes

    • Contributors SM conceptualised and designed the study, interpreted the data and drafted and revised the manuscript. JG designed the study, extracted the data, carried out the analyses and interpretation of data and revised the manuscript. SG, JZ and EJP designed the study, interpreted the data and revised the manuscript. AG conceptualised and designed the study, interpreted the data, drafted the initial manuscript and revised the manuscript. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work.

    • Funding This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health.

    • Disclaimer Parts of this material are based on data and information compiled and provided by the Ontario Ministry of Health and the Canadian Institute for Health Information (CIHI). The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.

    • Competing interests SM and EJP reported being a member of the Ontario Quality-Based Procedures tonsillectomy expert clinical panel and did not receive any payment for this work.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.