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Clinical Prediction Rules, Adenotonsillectomy and Children With Obstructive Sleep Apnea: What's Next?

Journal of Clinical Sleep Medicine, Vol. 13, No. 12, 2017 Adenotonsillectomy (AT) is a common surgical procedure in children with highly variable perioperative1 and resource intensive postoperative care.2 Children with obstructive sleep apnea (OSA) add an additional layer of complexity with their increased risk for opioid-related respiratory complications, including anoxic brain injury or death.3 In this issue of the Journal of Clinical Sleep Medicine, Smith et al.4 should be congratulated for their work to retrospectively derive a clinical prediction rule (CPR) for postoperative respiratory complications (PRCs) in polysomnography (PSG)-tested children younger than 13 years old following AT. In this high-stakes environment, any intervention that can improve patient care has important implications in the future treatment of this atrisk population. The study by Smith and colleagues is timely because pediatric CPRs are extremely uncommon, inferior in quality, and rarely incorporated into practice, compared with CPRs in adults.5 Unlike previous prediction rules, the CPR Smith et al. derived considered cost in their model, with the goal to optimize the identification of children at risk for PRCs while limiting third-payer costs associated with unnecessary elective postoperative admissions. Such CPRs will play an important role toward improving patient care outcomes because they resonate with the “Quadruple Aim” 6 of health care-service delivery encapsulated within the “Perioperative Surgical Home.”7,8 The study is important in that it highlights the next steps that will be required to improve CPRs designed to care for children with OSA undergoing AT in terms of rule development, predictor variable determination, and costeffectiveness analysis. CPRs are designed to be an adjuvant tool for clinical care. By definition, they incorporate three or more variables from history, physical examination, or simple tests to provide the probability of an outcome or suggest a diagnostic/therapeutic course of action for a patient.5,9 The Smith research team implemented a unique methodology using pediatric AT admission guidelines from the surgery (American Academy of Otolaryngology – Head and Neck Surgery; AAO-HNS),10 pediatric (American Academy of Pediatrics; AAP)11 and anesthesiology (Nationwide Children’s Hospital; NCH)12 literature COMMENTARY