Adenotonsillectomy and Health Care Utilization in Children With Snoring and Mild Sleep Apnea (2025)

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Original Investigation

March17, 2025

Jessie P.Bakker,MS, PhD1; FangZhang,PhD2; RaoufAmin,MD3; et al Cristina M.Baldassari,MD4; Ronald D.Chervin,MS, MD5,7; Susan L.Garetz,MD5,6,7; FauziyaHassan,MD7,15; SallyIbrahim,MD8; Stacey L.Ishman,MD9; Erin M.Kirkham,MD, MPH6; ArielLinden,DrPH11; Ron B.Mitchell,MD10,12; KamalNaqvi,MD13; Carol L.Rosen,MD14; KristieRoss,MD8; Ignacio E.Tapia,MD16; Lisa R.Young,MD16; Phoebe K.Yu,MD, MS17; SusanRedline,MD, MPH1; RuiWang,PhD1,2,18

Author Affiliations Article Information

¹Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
²Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
³Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
⁴Department of Otolaryngology, Eastern Virginia Medical School, Children’s Hospital of The King’s Daughters, Norfolk
⁵Department of Neurology, University of Michigan, Ann Arbor
⁶Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor
⁷Sleep Disorders Center, University of Michigan, Ann Arbor
⁸Department of Pediatrics, University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, Ohio
⁹Division of Otolaryngology Head and Neck Surgery, University of Wisconsin–Madison School of Public Health, Madison
¹⁰Department of Otolaryngology–Head and Neck Surgery, UT Southwestern Medical Center, Children’s Medical Center, Dallas, Texas
¹¹Department of Medicine, School of Medicine, University of California, San Francisco
¹²Sleep Disorders Center, Department of Neurology, UT Southwestern Medical Center, Children’s Medical Center, Dallas, Texas
¹³Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
¹⁴Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
¹⁵Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor
¹⁶Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
¹⁷Department of Otolaryngology, Massachusetts Eye and Ear, Boston
¹⁸Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

JAMA Pediatr. Published online March 17, 2025. doi:10.1001/jamapediatrics.2025.0023

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Visual Abstract.Adenotonsillectomy and Health Care Utilization in Children With Snoring and Mild Sleep Apnea

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Editorial The Butterfly Effect of Adenotonsillectomy
Derek J.Lam,MD, MPH

JAMA Otolaryngology–Head & Neck Surgery

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Key Points

Question Among children who snore without frequent obstructive events, does early adenotonsillectomy compared with watchful waiting with supportive care reduce health care utilization over 12 months of follow-up?

Findings In this randomized clinical trial including 459 children with mild sleep-disordered breathing (SDB), adenotonsillectomy compared with watchful waiting resulted in reductions in both total health care encounters and prescriptions. The clinical categories demonstrating the greatest difference between surgery and no surgery were encounters related to respiratory and sleep conditions.

Meaning In children with mild SDB, adenotonsillectomy resulted in reduced health care utilization.

Abstract

Importance The literature indicates that health care utilization (HCU) of children with untreated moderate-to-severe obstructive sleep apnea is greater than that of matched controls before diagnosis, and treatment is associated with a decline in HCU not observed in those who remain untreated. Research on this topic has been limited to retrospective analyses and observational cohort studies; little is known about HCU among the many children with snoring and mild sleep-disordered breathing (SDB).

Objective To determine whether adenotonsillectomy in comparison with watchful waiting with supportive care is associated with fewer health care encounters and prescriptions.

Design, Setting, and Participants This randomized clinical trial, Pediatric Adenotonsillectomy Trial for Snoring (PATS), was a 12-month, parallel-arm trial conducted from 2016 to 2022 in tertiary care centers in the United States. Participants were recruited from otolaryngology, sleep, pulmonary, or general pediatric clinics; aged 3 to 13 years; diagnosed with mild SDB; had a tonsillar hypertrophy grade of 2 or more; and had a body mass index z score less than 3. Children referred from a clinician outside of the local electronic medical record system were excluded. Data analysis was conducted from June 2022 to April 2024.

Intervention Early adenotonsillectomy.

Main Outcomes and Measures Evaluation of HCU was a prespecified secondary aim of PATS. Total encounters and total prescriptions over the 12 months after randomization were analyzed.

Results Among 459 children who were randomized, the analytic sample included 381 children, after excluding those referred from outside the local electronic medical record system. The median (IQR) age was 6 (4-8) years; 192 participants (50%) were female and 189 (50%) male. Adenotonsillectomy was associated with a 32% reduction in total health care encounters (mean difference, −1.25 per participant per year; 95% CI, −1.96 to −0.53) and a 48% reduction in prescriptions (mean difference, −2.53 per participant per year; 95% CI, −4.12 to −0.94). The difference in encounters was primarily driven by fewer office visits and outpatient procedures rather than by reduced hospitalizations or urgent care visits.

Conclusions and Relevance This study found that adenotonsillectomy was associated with reduced all-cause HCU in children with mild SDB, supporting early intervention for children with mild SDB. Future research focused on the cost effectiveness of adenotonsillectomy for pediatric SDB is warranted.

Trial Registration ClinicalTrials.gov Identifier: NCT02562040

Editorial The Butterfly Effect of Adenotonsillectomy
JAMA Otolaryngology–Head & Neck Surgery

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Bakker JP, Zhang F, Amin R, et al. Adenotonsillectomy and Health Care Utilization in Children With Snoring and Mild Sleep Apnea: A Randomized Clinical Trial. JAMA Pediatr. Published online March 17, 2025. doi:10.1001/jamapediatrics.2025.0023

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Adenotonsillectomy and Health Care Utilization in Children With Snoring and Mild Sleep Apnea (2025)

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