Clinical and Economic Impact of Non‐Opioid Analgesia Guidelines in Pediatric Adenotonsillectomy: A Multi‐Institutional Database Study

OBJECTIVE: To evaluate the impact of the paradigm shift toward opioid-sparing analgesia following the 2019 AAO-HNS clinical practice guideline on postoperative complications and healthcare costs after pediatric adenotonsillectomy (AT). STUDY DESIGN: Retrospective cohort study. SETTING: TriNetX, a multi-institutional federated electronic health record database. METHODS: Patients < 18 years old undergoing AT were stratified by surgical year: pre-2019 (Jan 2014-Dec 2017) or post-2019 (Jan 2021-Dec 2025). Opioid prescription data was recorded. Using 1:1 propensity score matching (PSM), the incidence of postoperative dehydration, hemorrhage, throat pain, intravenous (IV) fluid administration, and emergency department (ED) visits were compared. A number needed to treat (NNT) analysis was performed based on inflation-adjusted costs per ED visit to estimate economic cost savings. RESULTS: Following 1:1 PSM (n = 66,844 per cohort), the pre-2019 cohort demonstrated significantly higher risk ratios (RR) of dehydration (1.27; 95% CI 1.17-1.38), IV fluid needs (1.27; 95% CI 1.17-1.37), ED visits (1.21; 95% CI 1.16-1.27), and nausea/vomiting (1.24; 95% CI 1.12-1.39) compared to the post-2019 cohort (P < .0001). Postoperative hemorrhage rates were statistically stable (P = .145). Post-2019 opioid prescriptions decreased significantly (RR 1.47; 95% CI 1.44-1.50; P < .0001), notably with a 25-fold reduction in codeine prescriptions. The NNT to prevent one ED visit was 101.7, resulting in an estimated cost avoidance of $3.2 million within the studied cohort. CONCLUSION: The incidence of post-tonsillectomy dehydration, pain, and ED utilization has decreased over time, concomitant with decreased opioid prescribing, suggesting that opioid-sparing protocols have been consistent with broadly improved patient outcomes.