Racial, ethnic and language disparities in healthcare utilization in pediatric patients following tonsillectomy.

IMPORTANCE: Tonsillectomy is one of the most common surgical procedures performed in the United States. However, there is little known about the intersectionality of race, ethnicity, and language and how these factors influence post-tonsillectomy outcomes such as ED utilization and hospital readmission rates. OBJECTIVE: To examine disparities in emergency department (ED) utilization and hospital readmissions for post-tonsillectomy complications based on insurance status, patient race, ethnicity and language spoken. DESIGN: This was retrospective cohort over four years. SETTING: Tertiary Care Children's Hospital. PARTICIPANTS: All children (n = 10,215) who underwent tonsillectomy or adenotonsillectomy at a tertiary children's hospital from January 2015 to December 2018 were identified and included. There were no exclusion criteria. EXPOSURE: The exposure of interest was tonsillectomy. MAIN OUTCOMES AND MEASURES: Outcomes and variables of interest were defined prior to data collection. The primary outcome of this study was emergency department (ED) utilization defined as any ED or urgent care visit within 21 days of the tonsillectomy for surgery-related concerns. The secondary outcome of this study was readmissions following tonsillectomy. RESULTS: A total of 10215 pediatric patients (median age, 6 years; 5096 [50 %] male) who underwent tonsillectomy were included in the analysis. 13 % of patients presented to the ED with surgery-related complaints. Among English proficient patients, multi-racial patients were the only group with an elevated odds of ED utilization (OR:1.5, 95 % CI: 1.2, 1.9). Non-English language preference (NELP) patients of Black, Hispanic, Asian, and American Indian/Alaskan Native race/ethnicity also had elevated odds of ED use post-tonsillectomy compared to non-Hispanic White English proficient patients. Six percent of all patients had an unplanned hospital readmission. Asian patients with non-English language preference had 2.1 times the odds of readmission (95 % CI: 1.2, 3.6); and were disproportionately admitted for post-tonsillectomy hemorrhage. CONCLUSIONS: and Relevance: Language disparities in ED use and readmission persist after adjusting for risk factors. Non-English language preference populations have a higher rate of ED utilization, especially for minor complications. Disparities may result from differential health literacy or predispositions to complications. Future directions include additional research on mechanisms and targeted interventions to increase education and access to language-appropriate resources.

Acquired hemophilia A in the setting of dual anticoagulation therapy and lupus anticoagulant: a case report.

BACKGROUND: Acquired hemophilia A is a disorder caused by autoantibodies against coagulation factor VIII that may present with severe bleeding. We report a rare case of acquired hemophilia A presenting with coexisting lupus anticoagulant. CASE PRESENTATION: An 81-year-old Caucasian female presented with large ecchymoses over the torso and extremities in the setting of an enoxaparin bridge to warfarin. Anticoagulation was held, but she continued to develop bruises with significant anemia and prolonged coagulation studies that failed to correct with mixing. Workup revealed factor VIII activity < 1% and a positive lupus anticoagulant. Initial testing for a factor VIII inhibitor was confounded by the presence of lupus anticoagulant, requiring a chromogenic Bethesda assay to confirm the presence of the inhibitor, establishing the diagnosis of acquired hemophilia A. The patient was initially treated with oral prednisone 80 mg daily and factor VIII inhibitor bypassing activity 25 units/kg twice daily before transitioning to susoctocog alfa 50 units/kg twice daily after placement of a tunneled line for outpatient rituximab infusions. On discharge, the patient's ecchymoses were resolving and factor VIII levels improved. Following completion of rituximab therapy, the patient's factor VIII activity normalized and factor VIII inhibitor was suppressed. CONCLUSIONS: Diagnosis of acquired hemophilia A can be confounded by other causes of abnormal coagulation studies and may require specialized testing, such as a chromogenic Bethesda assay, to confirm the presence of a factor VIII inhibitor.