Abstract
During 2018–2020, data from the Norwegian Tonsil Surgery Register (NTSR) showed large differences in recontact rates due to postoperative pain in the participating ear, nose and throat (ENT) units. On average, 27% (range 12–39%) of the patients had contacted the healthcare system due to problems with postoperative pain after tonsil surgery. Because of these high rates and large variations, we conducted a quality improvement project introducing a standardised pain management programme for adult patients. The goal was to reduce the pain-related recontact rate to below 15% in the participating ENT units.
Five ENT units with an average recontact rate of 33.6% (range 29.0–38.1%) participated in this project. In a workshop, the units agreed on a standardised pain management programme consisting of a patient information brochure and a prescription including multimodal analgesics with paracetamol and COX-2 inhibitor (etoricoxib) with supplementary analgesic (tramadol). The units introduced the programme in their daily practice from June 2022 to July 2024. At follow-up in 2024, the recontact rate had decreased from 33.6% to 15.5% in the participating units.
Introducing a standardised pain management programme, including a standard prescription of analgesics and a standard patient information brochure, seems to improve the patients’ pain management after tonsil surgery. This study shows that data from the NTSR can identify areas requiring improvement, initiate improvement projects and evaluate the changes in clinical practice.
Keywords: Pain Management, Patient education, Quality improvement, Surgery, Clinical practice guidelines
WHAT IS ALREADY KNOWN ON THIS TOPIC
Postoperative pain after tonsillectomy is a well-recognised and persistent challenge for both patients and healthcare providers.
WHAT THIS STUDY ADDS
This study shows that implementing a standardised treatment protocol, combined with comprehensive patient education, can lead to significantly better pain control following tonsil surgery.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The findings highlight the value of structured treatment plans and clear patient communication in enhancing postoperative pain management. This protocol may also serve as a benchmark for future studies evaluating new pain management strategies.
Problem
In Norway, approximately 10 000 patients undergo tonsil surgery annually.1 Postoperative pain is a predictable part of the experience after tonsil surgery in adults.2 Data from the Norwegian Tonsil Surgery Register (NTSR) from the years 2018 to 2020 show that 27% (range 12–39%) of adult patients seek contact with healthcare services due to postoperative pain following tonsil surgery.3,5 The NTSR is a national quality register that aims to increase the quality of diagnosis and treatment of patients undergoing tonsil surgery and collects data from the surgical procedure and patient-reported data 30-day and 6 months postoperatively.6 Research has reported that many patients seem to receive insufficient analgesia after tonsillectomy,7 and analgesics are not always systematically administered due to fear of addiction or of adverse effects.8 In Norway, there are currently no national guidelines for pain management after tonsil surgery, and there are different practices nationwide. Because of high recontact rates and large variations, we conducted a quality improvement project (QIP) involving five ear, nose and throat (ENT) units with high recontact rates, introducing a standardised pain management programme. The aim was to reduce the recontact rate to 15% in the participating units.
Background
Tonsil surgery is one of the most common surgical procedures worldwide.9 The main indications for tonsil surgery are: (1) upper airway obstruction causing sleep-disordered breathing, and (2) infection-related problems (recurrent tonsillitis, chronic tonsillitis or peritonsillitis).10 Postoperative pain is expected after tonsil surgery in adults,2 and tonsillectomy is considered one of the most painful procedures, even more painful than large abdominal surgeries.7,11 The slightly invasive surgery, tonsillotomy, is known to be less painful than tonsillectomy.12 13
Pain after tonsil surgery is complex and influenced by multiple factors. High pain levels are associated with chronic preoperative pain due to other diseases, female sex, young adults, surgical technique and the surgery indication.7 14 15 There is greater uncertainty about how pain is affected by the type of medication.16,18 Research has reported that many patients seem to receive insufficient analgesia after tonsil surgery,7 and analgesics are not always systematically administered due to fear of addiction or of adverse effects.8 Moreover, the degree of pain associated with tonsil surgery may be underestimated as it is considered a minimally invasive surgical procedure.19
Adequate pain management after tonsil surgery is essential for maintaining optimal functions for fluids, nutrition and sleep, and preventing complications like haemorrhage or infections. Unsatisfactory pain management can lead to increased costs to both patient and society regarding an increased number of medical consultations, extended sick leave periods, unnecessary travel to the healthcare system and incorrect use of medication.
In 2023, 83% of the surgeries in the NTSR were performed as day surgery.20 Early discharge increases the need for detailed information to enable the patients to manage their care at home, for example, pain management. Studies have reported poor management of postoperative pain, inadequate patient information and frequent recontact after early discharge after tonsil surgery.21 22 Post-tonsil surgery pain is the most common reason for physician contact after discharge.20 23 24
Measurement
The rate of patient recontacts with the healthcare system due to postoperative pain after tonsil surgery is based on a single item from the patient-reported 30-day questionnaire: Have you contacted healthcare services due to pain after the surgery? In addition, patients are asked to report the number of days they used analgesics, as well as the number of days elapsed before resuming their usual diet.
In 2023, 82% of the patients answered the 30-day questionnaire,20 ensuring high data validity. Baseline rates were calculated as the average recontact rate from 2018 to 2020 and were 33.6% (range 29–38.1%) in the participating units, and the national recontact rate was 27%.
To achieve our project goal of reducing the pain-related recontact rates, results were monitored quarterly from the project start in January 2022. Measures were implemented in June 2022, and follow-up data were collected to the end of June 2024. The follow-up recontact rate was calculated from 01 July 2023 to 30 June 2024. To track changes in recontact rate over time, we used statistical process control (SPC) with p charts, which are based on the binomial distribution. P charts help assess process stability and detect special-cause variation, indicated by data points outside control limits (defined as three times the SD) (figure 1) and identify potential trends. Categorical variables are presented as numbers (n) and percentages (%), while continuous variables are shown as mean, SD and median (table 1). SPC was used as the performance measurement method25 and binomial tests were applied to compare baseline and follow-up rates (p values). Recontact rates from the participating units were compared with recontact rates from the six non-participating units (figure 2) and the national recontact rate.
Figure 1. P chart recontact rate due to pain in participating ear, nose and throat units.
Table 1. Baseline and follow-up data from the participating hospitals.
| Baseline (2018–2020) | Agro | Elverum | Kalnes | Skien | St Olavs | Total group |
|---|---|---|---|---|---|---|
| Total number of patients reporting 30 days after tonsil surgery* (n) | 91 | 130 | 245 | 155 | 248 | 869 |
| Number of tonsillectomy (n) | 91 | 130 | 239 | 151 | 239 | 850 |
| Number of tonsillotomy (n) | 0 | 0 | 6 | 4 | 9 | 19 |
| Sex male/female (n) | 21/70 | 40/90 | 71/174 | 42/113 | 73/175 | 247/622 |
| Age mean (SD) | 24.7 (7.3) | 27.1 (11.9) | 28 (9.7) | 26 (8.8) | 26.6 (10.2) | 26.8 (9.9) |
| Males mean (SD) | 26.6 (8) | 27.8 (11.1) | 29.1 (7.5) | 30.6 (9.9) | 28.9 (9.8) | 28.9 (9.3) |
| Females mean (SD) | 24.2 (7) | 26.8 (12.4) | 27.5 (10.4) | 24.3 (7.7) | 25.6 (10.2) | 25.9 (10) |
| Cold dissection (n) | 91 | 130 | 83 | 126 | 178 | 608 |
| Hot dissection (n) | 162 | 29 | 70 | 261 | ||
| Total recontact rate % (n) | 35.2 (32) | 31.5 (41) | 35.9 (88) | 38.1 (59) | 29.0 (72) | 33.6 (292) |
| Males % (n) | 23.8 (5) | 22.5 (9) | 29.6 (21) | 16.7 (7) | 20.5 (15) | 23.1 (57) |
| Females % (n) | 38.6 (27) | 35.6 (32) | 38.5 (67) | 46.0 (52) | 32.6 (57) | 37.8 (235) |
| Tonsillectomy % (n) | 35.2 (32) | 31.5 (41) | 36.4 (87) | 39.1 (59) | 28.9 (69) | 33.9 (288) |
| Tonsillotomy % (n) | – | – | 16.7 (1) | 0 (0) | 33.3 (3) | 21.1 (4) |
| Cold dissection % (n) | 35.2 (32) | 31.5 (41) | 20.5 (17) | 37.3 (47) | 27.0 (48) | 30.4 (72) |
| Hot dissection % (n) | – | – | 43.8 (71) | 41.4 (12) | 34.2 (24) | 41.0 (107) |
| Days’ use of analgesics (median) | 12 | 11 | 12 | 12 | 12 | 12 |
| Days before solid food (median) | 8 | 8 | 10 | 10 | 9 | 10 |
| Follow-up (01 July 2023–30 June 2024) | Agro | Elverum | Kalnes | Skien | St Olavs | Total group |
|---|---|---|---|---|---|---|
| Total number of patients reporting 30 days after tonsil surgery* (n) | 69 | 98 | 180 | 51 | 105 | 503 |
| Number of tonsillectomy (n) | 69 | 96 | 130 | 51 | 104 | 450 |
| Number of tonsillotomy (n) | – | 2 | 50 | – | 1 | 53 |
| Sex male/female (n) | 21/48 | 33/65 | 56/124 | 17/34 | 37/68 | 164/339 |
| Age mean (SD) | 25.2 (7.5) | 26.5 (9.8) | 27 (10.4) | 25.8 (12.2) | 24.3 (8.2) | 26 (9.7) |
| Males mean (SD) | 22 (4.4) | 25.8 (8.6) | 28.3 (13) | 26.7 (9) | 24.9 (9.9) | 26.1 (10.4) |
| Females mean (SD) | 26.6 (8.1) | 26.8 (10.4) | 26.4 (9.1) | 25.4 (13.6) | 23.9 (7.1) | 25.9 (9.4) |
| Cold dissection (n) | 95 | 130 | 47 | 101 | 373 | |
| Hot dissection (n) | 69 | 3 | 50 | 4 | 4 | 130 |
| Total recontact rate % (n) | 14.5 (10) | 10.2 (10) | 21.1 (38) | 19.6 (10) | 9.5 (10) | 15.5 (78) |
| Males % | 19 (4) | 3 (1) | 7.1 (4) | 17.6 (3) | 5.4 (2) | 8.5 (14) |
| Females % | 12.5 (6) | 13.8 (9) | 27.4 (32) | 20.6 (7) | 11.8 (8) | 18.9 (64) |
| Tonsillectomy % (n) | 14.5 (10) | 10.4 (10) | 23.8 (31) | 19.6 (10) | 9.6 (10) | 15.8 (71) |
| Tonsillotomy % (n) | – | 0 (0) | 14 (7) | – | 0 (0) | 13.2 (7) |
| Cold dissection % (n) | – | 10.5 (10) | 24.6 (32) | 19.1 (9) | 9.9 (10) | 16.4 (61) |
| Hot dissection % (n) | 14.5 (10) | – | 8.3 (6) | 25 (1) | – | 15.7 (17) |
| Days’ use of analgesics (median) | 12 | 10 | 10 | 12 | 12 | 10 |
| Days before solid food (median) | 8 | 7 | 8 | 10 | 9 | 8 |
| P value for change in recontact rate baseline—follow-up | 0.001† | <0.001† | <0.001* | 0.035† | <0.001† | <0.001† |
All results calculated from the number of patients reporting on the questionnaire 30 days after tonsil surgery. Age presented as mean (SD). Days presented as median. Proportions presented as a percentage (n). – denotes no cases.
P values calculated using a binomial test. Significance level <0.05.
Figure 2. Recontact rate due to pain in participating ENT units and in six ENT units that declined. ENT, ear, nose and throat.
Design
The project was carried out from January 2022 to June 2024 and was conducted using the Plan-Do-Study-Act (PDSA) model, a continuous process in five phases: prepare, plan, execute, evaluate and follow up.26
The project team consisted of the NTSR’s secretariat, including an otolaryngologist serving as clinical lead, a project manager, register coordinators, an improvement advisor and a designated otolaryngologist from the participating ENT units. In 2021, data from NTSR were used to identify ENT units with high recontact rates due to pain (>30%).3,5 11 units were invited to participate in the QIP, where five units agreed to participate (table 1). In January 2022, NTSR conducted a national survey to explore pain management routines after tonsil surgery (medications, dosage and administration method). This survey provided knowledge about the most commonly used analgesics and the content of patient information in most ENT units in Norway performing tonsillectomy. This knowledge provided a solid foundation for the subsequent workshop, during which the project’s measure, the standardised pain management programme, was developed. In June 2022, the programme was implemented in each participating ENT unit, followed by continuous monitoring and evaluation of the project team up until the end of June 2024.
Patient and public involvement
The NTSR’s user representative was involved in the design of the QIP and participated in the evaluation meetings during the project period.
Strategy
PDSA cycle 1—development phase was conducted from January 2022 to the end of April 2022
A structured workshop was conducted in April 2022 as part of the project’s preparatory phase. The workshop programme included expert-led lectures on surgical pain mechanisms, pharmacological options for analgesics and strategies for postoperative pain management.
To inform the development of evidence-based interventions, the project team reviewed findings from the initial national survey (January–February 2022) on pain management practices following tonsil surgery in Norway. Additionally, previously published data from a study conducted by the NTSR were presented, identifying the most frequently reported reasons for patient contact with healthcare services due to postoperative pain.27 Based on available evidence and clinical practice, the participating units reached consensus on a standardised prescription for analgesics and a patient information brochure, and committed to implementing these measures.
Standard prescription of analgesics
The prescription included paracetamol (a non-opioid analgesic and antipyretic agent), etoricoxib (non-steroidal anti-inflammatory drugs, selective COX-2 inhibitor), with tramadol (opioid agonist, a serotonin–norepinephrine reuptake inhibitor) (online supplemental material 1, standard prescription for analgesics).
Consensus among ENT surgeons and anaesthesiologists supports a combination of paracetamol and NSAIDs as first-line treatment for postoperative pain, with opioids reserved as supplementary analgesics.28 When composing the standard prescription of analgesics, we knew from the previous study27 that there were four main reasons for recontacting the healthcare system due to pain: intolerance to the prescribed analgesics, insufficient quantity, inadequate pain relief and other reasons, for example, lack of information. Therefore, the prescription had to secure a sufficient amount of tablets (50 tablets of 1 g paracetamol, 14 tablets of 90 mg etoricoxib and 40 tablets of 50 mg tramadol) in adequate doses, and the patients had to tolerate the analgesics. These analgesics were selected for their compatibility and ease of administration. In general, we know that most patients accept paracetamol. Etoricoxib offers once-daily dosing and improved gastrointestinal safety compared with non-selective NSAIDs. Tramadol was selected due to its compatibility with paracetamol and is considered to have a lower potential for abuse relative to certain other opioids. Integration of the standard prescription into the electronic journal system was reported to streamline surgeons’ workflow and improve compliance with the programme.
Standard patient information brochure
The patient information brochure was developed based on a summary from the initial national survey regarding pain management routines and included clear instructions on dosage and administration. It emphasised the importance of regular intake of prescribed analgesics and provided practical recommendations for daily life during the first 2 weeks after surgery (online supplemental material 2, standard patient information brochure).
We believe that the standard patient information brochure contributed to decreased recontact rates due to pain. Previous studies have linked poor pain management and inadequate patient information to increased patient contact with the healthcare system.21 22 29 30 Other studies have suggested that providing written information to patients about ‘after care’ has the potential to reduce demands on health services.31
Early discharge increases the need for detailed and assessable information that enables the patients to effectively manage their care at home, for example, pain management. A 2003 Cochrane review31 reports on two studies that recommend both verbal and written information on discharge from the hospital to improve patients’ knowledge and satisfaction.32 33 In the present QIP, both user representatives and patients contributed to the development of the standard patient information brochure, informed by NTSR’s survey findings. We ensured that the prescription covered 2 weeks’ use of analgesics, preventing patient recontact due to prescription extensions. Further, we may assume that the standard patient information brochure supported more structural verbal information from health personnel and ensured highlighting of important issues, for example, postoperative pain. Moreover, the brochure allowed patients to revisit key information at home. Our focus was to educate the patients to prevent pain, rather than to treat it reactively. The patient information included a regular analgesic schedule with ‘around-the-clock’ instructions. This approach aligns with a study from Sutters et al, who found that scheduled analgesic administration improved postoperative pain control programme in children at home after tonsillectomy.34
PDSA cycle 2—implementation phase was conducted from June 2022 to September 2023
PDSA cycle 2.1—incorporating the standardised pain management programme into routine clinical practice
In June 2022, the participating ENT units implemented the standardised pain management programme into routine clinical practice for patients ≥16 years of age undergoing tonsil surgery. Each unit received both digital and printed versions of the protocol, which were incorporated into patient education materials. The prescription template was embedded in the electronic prescribing system to streamline workflow.
PDSA cycle 2.2—information and training of staff were carried out in June 2022
The ENT specialist responsible at each unit ensured that all relevant staff—surgeons, nurses and administrative personnel—were informed and trained. To reinforce consistent use, informational posters were displayed in surgical wards and outpatient clinics.
PDSA cycle 2.3—follow-up with preliminary results was conducted from June 2022 to September 2023
The project manager provided regular contact with the participating ENT units via phone and e-mail, with increased frequency during the initial implementation period.
Pain-related recontact rates due to pain were continuously monitored in the NTSR, and quarterly reports were distributed to each unit. Units also had access to their own data in NTSR. Significant deviations in recontact rates triggered targeted follow-ups. To ensure data completeness, units routinely reminded patients to complete the electronic 30-day postoperative questionnaire. Feedback from participating units was largely positive, with reports of improved workflow and enhanced patient communication.
PDSA cycle 3—multilingual adoption took place in December 2022
Following a suggestion at the 6-month follow-up meeting, the standard prescription and patient information brochure were translated into six languages to improve adherence among non-native speakers.
PDSA cycle 4—extended evaluation period ran from June 2023 through June 2024
At the 15-month evaluation, unit-specific and aggregate recontact rates were reviewed. Based on SPC methodology, the project period was extended to 24 months to ensure sufficient data points for detecting sustained improvement. The final evaluation of the project was performed via a digital meeting in June 2024.
Unanticipated spread of intervention
Several non-participating units adopted the programme during the project period, likely influenced by presentations at the national ENT meetings in 2022 and 2023. Preliminary positive outcomes appeared to encourage broader uptake.
Changes in pain-related recontact rates across participating units, non-participating units and nationally are presented in the results section.
Results
Brief summary of findings related to aims
Tonsil surgery is a well-established surgical procedure. Postoperative pain for 1–2 weeks is expected for most patients. Insufficient pain management is a negative experience for the patient and places an unnecessary burden on the healthcare system. In this study, we evaluated the impact of a standardised pain management programme in five ENT units with high recontact rates due to pain after tonsil surgery. The recontact rate decreased significantly from an average of 33.6% before project start to 15.5% at the end of the project period. We also found that the national recontact rate decreased from 27% to 20.2%.
Our results show that the introduction of our standard prescription of analgesics and our standard patient information brochure has led to better pain treatment with reduced recontact rate due to pain after tonsil surgery.
Patient data at baseline and follow-up are shown in table 1.
During the project period, the recontact rate in the participating ENT units decreased from 33.6% to 15.5% (figures1 2). In the units that declined participation, the recontact rate decreased from 32.1% to 21.8% in the same period. In addition, the national recontact rate decreased from 27% to 20.2%. The recontact rate for the 39 other non-participating ENT units in NTSR decreased from 25.8% to 21.1%. Even though the non-participating hospitals also had a decrease in the recontact rate, there is a statistically significant difference between the participating and non-participating hospitals postproject, and the rate for the group of participating hospitals is lower (p=0.002).
In figure 1, we observed the average recontact rates due to pain at different points in time before the project start and after the project start for the participating units. We observed that how the rates are reduced after project start (PDSA 1) and continue to be lower throughout the whole project period (PDSA 2–4). After the project start, we observed that all nine consecutive measurements were below the centre line (mean), which means we found a special cause of variation, proving a decrease in the recontact rate due to pain for the participating ENT units.35 The implementation of the standardised pain management programme seems to result in lower recontact rates due to pain postoperatively.
Subanalysis in participating ENT units
Gender
In this study, women underwent tonsil surgery more frequently and had higher pain-related recontact rates compared with men, consistent with previous studies.7 11 This suggests that greater attention should be given to preoperative and postoperative information for women, as they appear to experience more challenges with postoperative pain. Gender differences should therefore be considered when tailoring patient communication.
Surgery method
Table 1 shows that the reduction in recontact rates was less pronounced among tonsillotomy patients than among those who underwent tonsillectomy, which aligns with findings from previous studies.12 13 This suggests that postoperative pain is generally less problematic following tonsillotomy than after tonsillectomy.
In total, at baseline, 850 patients underwent tonsillectomy, while 19 patients underwent tonsillotomy. In total, at follow-up, 450 patients underwent tonsillectomy, while 53 patients underwent tonsillotomy. At follow-up, 50 of the tonsillotomies were performed at Kalnes Hospital. Because of more tonsillotomies at follow-up, we performed subanalyses of the recontact rate at Kalnes Hospital for tonsillectomy and tonsillotomy. The recontact rate in the tonsillectomy group at Kalnes Hospital decreased from 36.4% at baseline to 23.8% (p=0.003) at follow-up. For the tonsillotomy patients at Kalnes Hospital, the recontact rate decreased from 16.7% to 14%.
When Kalnes Hospital was totally removed from the analysis, the recontact rate due to pain in the remaining four ENT units decreased from 32.6% at baseline to 12.4% (p<0.001) at follow-up.
Analgesics/solid food postoperatively
At follow-up, the median number of days the patients used analgesics decreased from 12 days to 10 days (p<0.039), and the median number of days before the patients reported they could resume their usual diet decreased from 10 days to 8 days (p<0.001) in the participating units.
Influence on other ENT units in Norway
The preliminary results from the project were presented at NTSR’s seminar and at the annual ENT meeting in October 2023. We believe these preliminary reports encouraged other ENT units to implement the same measures in their daily practice. It is possible this influenced the decrease in the national recontact rate.
Lessons and limitations
A key strength of this study is the high response rate to the 30-day questionnaire, with 80% of patients reporting to the registry. The use of patient-reported outcome measures within the NTSR contributes to the validity and reliability of the data. All five participating units were actively involved in developing the quality improvement measures, fostering a strong sense of ownership and engagement with the project. The measures were straightforward to implement and could be easily adapted to each unit’s existing materials. Importantly, patient feedback, particularly regarding reasons for pain-related recontact, was used when developing the measures.27 The use of an electronic reporting system enabled each unit to monitor their recontact rates throughout the project period. This allowed for ongoing evaluation and demonstrated that the reduction in recontact rates was not only measurable but also sustainable over time.
One limitation in this QIP is the uncertainty regarding adherence to the standardised pain management programme by all surgeons across the participating ENT units. To address this, each participating unit received quarterly reports summarising their outcomes, helping to maintain focus on the QIP objectives.
Another potential limitation is the possibility that some ENT units may have implemented additional changes or measures to enhance surgical practices during the project period, which could have influenced the results independently of the standardised programme. Different surgery techniques can also have influences on our results. Furthermore, the analgesic tramadol is a prodrug, similar to codeine. Its metabolism can be slower in individuals who are poor metabolisers of the CYP2D6 enzyme—approximately 7% of the population.36 Low levels of tramadol’s active metabolite may have led to insufficient pain relief, which could have influenced our results.
Finally, an important limitation should be emphasised. Because the study’s main findings are based on a single-item questionnaire, the results offer only a limited understanding of patients ’ experiences. This narrow approach also restricts the ability to identify the broader and more complex challenges faced by ENT departments postoperatively.
Conclusion
This QIP aimed to improve pain management in adult patients after tonsil surgery by implementing a standardised pain management programme. The goal was to reduce pain-related recontact rate to below 15% in the participating ENT units.
Following the implementation of a standardised prescription of analgesics and a patient information brochure, recontact rates significantly decreased from 33.6% to 15.5% in the participating units, and from 27% to 20.2% nationally. Several non-participating ENT units also adopted the programme, contributing to reductions in their recontact rates.
We believe the standardised pain management programme is cost-effective, as it reduces the burden on patients by preventing unnecessary pain and potential postoperative complications. Fewer medical consultations and reduced need for prolonged sick leave enable more efficient use of limited healthcare resources and benefit society overall.
The programme was feasible to implement at the participating ENT units. Future steps include encouraging participating ENT units to maintain their efforts and motivating remaining units to adopt the programme. In addition, exploring other types of analgesia to further improve recontact rates due to pain. Finally, our QIP might contribute to developing future national guidelines for pain management in adults after tonsil surgery.
Supplementary material
Acknowledgements
We are grateful to the ENT units at Agro ENT Clinic, Innlandet Hospital Trust Elverum, Telemark Hospital Trust Skien, Østfold Hospital Trust Kalnes and St Olav's University Hospital who willingly participated in this quality improvement project. We are also grateful to all ENT units and patients who report to the NTSR.
Footnotes
Funding: This project was supported by the Norwegian Centre for Quality Improvement of Clinical Practice (SKDE), through the National Support System for Medical Quality Registries, under grant agreement number 2021/1929. The article processing charge was funded by the Publication Fund at the Norwegian University of Science and Technology (NTNU).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and the Regional Committee for Medical and Health Research Ethics in Central Norway (REK midt/817200) approved the QIP. The Norwegian Tonsil Surgery Register (NTSR) is a national quality registry that collects data on all tonsil surgeries performed in Norway. Surgeons are responsible for registering each procedure in the system. Patients are informed about the registry in connection with their surgery and are given the right to opt out. If a patient chooses not to participate, all personal data related to that individual are removed from the register.
Data availability free text: Data used in this study are included in the database of NTSR.
Patient and public involvement: Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.
Data availability statement
Data are available upon reasonable request.
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Data Availability Statement
Data are available upon reasonable request.