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  • We conducted a retrospective, population-based cohort study using data from the National Health Insurance Research Database (NHIRD); the NHI commenced in 1995 and covers over 99% of the population in Taiwan [24]. The Longitudinal Health Insurance Database (LHID) contains the complete claims data from 2005 of 1 million beneficiaries. The authors used the registry files from 1997 to 2010 and all applications for reimbursements regarding the inpatient and outpatient healthcare services provided to each patient for analysis. The Institutional Review Board of Cardinal Tien Hospital approved this study (CTH-103-3-5-035) and waived informed consent because the datasets consisted of anonymized, de-identified nationwide data. All patients who had undergone a tonsillectomy without adenoidectomy (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] procedure code 28.2) or tonsillectomy with adenoidectomy (ICD-9-CM procedure code 28.3) between 1997 and 2010 were identified from the representative samples from the NHI program. Patients who underwent an adenoidectomy without tonsillectomy (ICD-9-CM procedure code 28.6) were excluded. All claims data, including demographic administrative and clinical information from both the inpatient and outpatient databases, were used in the analysis. The index date was defined as the time that the tonsillectomy or AT was performed. A list of diagnoses (according to the ICD-9-CM) was obtained from the database for each patient on the index date of surgery. These top three diagnoses were categorized into either infectious or inflammatory indications (recurrent infection or chronic inflammation [RICI]), obstructive indications (tonsillar hypertrophy or upper airway obstruction [UAO]), or neoplastic indications (suspicious benign or malignant neoplasms [Tumor]). If more than one diagnosis fit into a particular category, only the first appearing diagnosis was used to define the indication for AT. The leading ICD-9-CM codes for the indications of RICI, UAO, and Tumor were 474, 780, and 146, respectively. Table 1 shows the complete list of ICD-9-CM codes (top three diagnoses) in these categories of surgical indications. Table data removed from full text. Table identifier and caption: 10.1371/journal.pone.0193317.t001 The complete list of ICD-9-CM codes in the categories of surgical indications (top three diagnoses). ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification.RICI: recurrent infection or chronic inflammation.UAO: tonsillar hypertrophy or upper airway obstruction.Tumor: suspicious benign or malignant neoplasms. We investigated the distribution of the three major categories of surgical indication according to sex, age group (<5 years, 5–11 years, 11–17 years, 18–40 years, and >40 years), hospital level (medical centers, regional hospitals, and local hospitals), and insured residence areas according to the NHI divisions (Taipei, Northern, Central, Southern, Kaoping, and Eastern). These variables were considered as the possible factors associated with the incidence of and indications for AT. We presented the data in three different groups, i.e., a total study population, an adult subgroup (≥18 years), and a pediatric subgroup (<18 years) for comparison. We evaluated the incidence of AT by the calendar year from 1997 to 2010 according to the index date of surgery. We presented the distribution of the three major categories of surgical indication (RICI, UAO, and Tumor) as the number and percentage of patients and analyzed the trends of changing surgical indications. SAS version 9.2 (SAS Institute, Inc., Cary, NC, USA) was used for all the analyses. Descriptive statistics were analyzed using Pearson’s chi-square test. We performed a simple linear regression model to examine the trends in surgical rates and indications by the calendar year. Multinomial logistic regression was established after adjustment for potential confounding effects of age, sex, hospital level, and insured residence areas to identify the possible factors associated with the different surgical indications. The significance was set at a two-sided p < 0.05.
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