Tonsillectomy may increase costs without benefits in some children

A Dutch study suggests that among children with mild or moderate symptoms of throat infections, surgery to remove the tonsils may be more expensive but not necessarily more beneficial than watchful waiting, according to a report in the November issue of Archives of Otolaryngology–Head & Neck Surgery, one of the JAMA/Archives journals.

Tonsillectomy—removal of the tonsils—with or without removal of the adenoids (tissue at the back of the throat) is one of the most frequently performed surgical procedures on children, according to background information in the article. However, the number of procedures performed varies widely by country. In 1998, adenotonsillectomies were performed on 115 per 10,000 children in the Netherlands, 65 per 10,000 British children and 50 per 10,000 American children. This suggests that different indications for surgery are used in each country.

Erik Buskens, M.D., Ph.D., of University Medical Center Utrecht, Utrecht, the Netherlands, and colleagues conducted a clinical trial involving 300 children age 2 to 8 who were recommended for adenotonsillectomy between 2000 and 2003. A group of 151 children were randomly assigned to have surgery within six weeks, while 149 were assigned to watchful waiting, which involved close monitoring and additional interventions as necessary. Parents kept diaries of all the children’s upper respiratory tract symptoms, measured their temperature daily and recorded any costs associated with their care. Follow-up visits occurred after three, six, 12, 18 and 24 months.

Throughout the study, annual costs among the watchful waiting group were about €551 or $500 (at the 2002 exchange rate) per year, while the group undergoing surgery had costs of €803 or about $730—a 46 percent increase. Children in the adenotonsillectomy group experienced fewer fevers and throat infections (.21 per child per year) and upper respiratory tract infections (.53 fewer per child per year). “The incremental costs per episode of fever, throat infection and respiratory tract infection avoided were €1,136 ($1,033), €1,187 ($1,079) and €465 ($423), respectively,” the authors write.

“Overall, the balance between costs and effects in this population seemed unfavorable for adenotonsillectomy, with incremental cost-effectiveness ratios in excess of €465 ($423) per disease episode averted,” they continue. “Note that this estimate includes societal costs such as parental leave of absence associated with their child’s illness. Had these costs been left out of the equation, the figures would be even somewhat less favorable. With time, the child’s immune system matures and the difference in adverse episodes disappears. Thus, the initial cost increment in the adenotonsillectomy group will never be counterbalanced by a continued positive health effect.”

The authors note that in the Netherlands, a relatively inexpensive procedure is used to perform adenotonsillectomy; in countries using more costly procedures, the cost-effectiveness balance would be even less favorable. However, additional research may identify children in whom surgery is cost-effective.

(Arch Otolaryngol Head Neck Surg. 2007;133(11):1083-1088. Available pre-embargo to the media at www.jamamedia.org.)

Editor’s Note: This study was supported by a grant from the Dutch Health Care Insurance Board. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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