Mehta, Nishchay; (2018) Investigating the drivers of regional variation in tonsillectomy rates and patient and surgeon preference elicitation in treatment choice of adults with recurring tonsillitis. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Introduction Rates of surgery vary considerably across the UK. Many assume that this on the one hand exposes residents of certain UK regions to unnecessary surgical risks, and on the other hand prevents those of neighbouring regions from receiving important surgical care. Nowhere is this more apparent than for tonsillectomy – an operation that involves removing the tonsils in patients suffering with severe recurring sore throats. With 40,000 tonsillectomies per year, it is one of the most common operations in the NHS, but remarkably, tonsillectomies are done seven times more frequently in some UK regions than in others. Despite national efforts to reduce these differences (e.g. re-education programmes for ENT surgeons, creation of national guidance on how to manage recurring sore throat, and financial penalties locally imposed to restrict high numbers of surgeries) this disparity has only got worse over the past 17 years. I undertook my research to examine the causes of these differences in more detail, to guide future policies. Aims The aim of my thesis was to develop a better understanding of the drivers of regional tonsillectomy rate variation by quantifying regional variation of tonsillectomy rates in relation to regional demands, and by exploring the role of professional uncertainty and treatment preference on the treatment chosen. Objectives The objectives were to establish the: A. Rate and regional variation of self-reported sore throat and help seeking behaviour in the community; B. Rate and regional variation of recurring sore throat in primary care; C. Rate and regional variation of tonsillectomy in secondary care, after adjusting for local rates of recurring sore throat; D. Constructs of clinical decision making and thereby ascertain which concepts were most likely to be related to surgical rate variation; E. Role of surgeon and patient decisional uncertainty on the treatment chosen for recurring tonsillitis; F. Role of surgeon and patient treatment preference on the treatment chosen for recurring tonsillitis; Methods By using the largest UK population based study of upper respiratory symptoms and primary-secondary care linked medical record databases, I was able to investigate regional surgical rate variations across the entire patient-disease pathway: from sore throat in the community (used as a surrogate marker for tonsillitis), through recurrent sore throat consultations in primary care and finally tonsillectomy in hospitals. Following systematic review and thematic analysis of patient focus groups, I designed an instrument to elicit patient and surgeon preference. By undertaking the largest observational study of decision-making in adults with recurring tonsillitis, I was able to investigate the role of both patient and surgeon treatment preference and decisional uncertainty on treatment choice. Results My results suggest: A. There is considerable variation in the incidence of self-reported severe sore throat between regions. However, once patient risk factors are accounted for there is no statistical evidence for disparity between regions. In those who self-report a severe sore throat there is also a degree of regional variation in the rate of relevant consultations for sore throat symptoms, however, once disease characteristics were accounted for, this regional disparity disappears. B. There is regional disparity in recurring sore throat consultations in primary care, however, once patient characteristics are accounted for, this regional variation reduces considerably. C. Similarly, there is regional disparity in tonsillectomy rates; this variation reduces considerably once patient characteristics are accounted for. D. In the literature concepts related to shared-decision-making are strongly inter-related and often poorly defined. Decisional uncertainty and treatment preference are amongst the best described, most measurable, and most appropriate constructs to investigate in a study of surgical rate variation. E. Decisional uncertainty, either patient’s or surgeon’s, was found to have no role to play in the treatment chosen during a consultation for recurring sore throat. F. Patients’ treatment preferences did not influence their treatment chosen, but surgeons’ treatment preferences did. Discussion There are three key findings of my thesis. Firstly, regional rate of consultation for sore throat – which was used as a proxy for the underlying tonsillitis rate in the population throughout – was mirrored in the regional rate of tonsillectomy. This implies the regional tonsillectomy rate variations reflect regional variations in the ‘need’ of the population. Secondly, regional tonsillectomy rate variations are greater for children than adults. Finally, treatment decisions for adults with recurring tonsillitis are more influenced by surgeon’s treatment preferences than patient preferences or severity. There is a strong culture within the NHS of addressing variations of all kinds as a means of increasing healthcare quality and decreasing cost. There are currently metrics of variation across almost every aspect of care, however few of these account for patient characteristics to the extent that this thesis has, meaning that the initiatives may be a waste of effort at best and harmful at worst. The work presented in my thesis uses a unique set of mixed methods to demonstrate the complexity of regional tonsillectomy rate variation, which too frequently has been investigated using poorly controlled cross-sectional studies and reduced to soundbites like the “Surgical Signature”. Whilst my study shows “surgical signature” is important, it fails to describe the true complexity of the variation observed. My study sheds more light on the complexity of this variation and provides a plausible reason as to why the policies to reduce tonsillectomy rate variations may have failed. This mixed methods approach could be used more broadly to inform discussions under regional surgical rate variations. Most importantly, the findings in this thesis also demonstrate where future policy could be targeted to reduce unwarranted regional tonsillectomy rate variation.

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