The Variations and Deviations in the Use of Tympanostomy Tubes for Children with Otitis Media

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The Variations and Deviations in the Use of
Tympanostomy Tubes for Children with Otitis Media

• Salomeh Keyhani MD MPH
• Lawrence C. Kleinman MD MPH
• Michael Rothschild MD
• Joseph M Bernstein MD
• Rebecca Anderson MPH
• Melissa Simon
• Mark Chassin MD MPP MPH
• Funding Agency for Health Care Research
• and Quality

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Background

• Otitis Media (OM) is the most common illness with
  which children present to the doctor.
• OME, AOM
• Tympanostomy tube insertion is the most common
  procedure requiring general anesthesia for
  children in the US.
• Rationale?
• Previous research identified significant over
  utilization of tympanostomy tubes.

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Guidelines-OME

• 1994 Guidelines (AHRQ)
• 1) Antibiotic therapy or bilateral myringotomy
  with insertion of tympanostomy tubes to manage
  bilateral otitis media with effusion that has
  lasted a total of 3 months in an otherwise
  healthy child age 1 through 3 years who has a
  bilateral hearing deficit.
• 2) Insertion of tympanostomy tubes to manage
  bilateral otitis media with effusion that has
  lasted a total of 4 to 6 months in an otherwise
  healthy child age 1 through 3 years who has
  bilateral hearing deficit.

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Guidelines-RAOM

• Expert Panel
• Tympanostomy tubes are indicated for patients
  with a high frequency of infection.
• High frequency was defined by more than 4
  infections in the 6 months preceding surgery or 6
  or more infections in 12 months and greater than
  2 infections in 6 months preceding surgery.

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Objective

• To report on the clinical characteristics of a
  cohort of New York City children who received
  tympanostomy tubes in 2002

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Methods-Study Population

• We conducted a retrospective study of all
  tympanostomy tubes placed in 2002 in five New
  York City metropolitan area hospitals.
• Identified all children under the age of 18 who
  underwent tympanostomy tube insertion that
  occurred between January 1, 2002 and December 31,
  2002 in 5 NYC hospitals.
• Patients who received ICD9 Code 20.01 as either
  the primary or secondary procedure were included
  in the cohort.

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Exclusions
6 Adults
Hospital 1
16 craniofacial procedures
Hospital 2
18 wrong coding
Hospital 3
1087 TT Insertions
1 missing chart
Hospital 4
1046 Cases in Cohort
Hospital 5
35 cases Missing ENT Chart
59 cases Missing hospital chart
682 cases with complete data
270 cases missing PCP chart
Clinical Analysis
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Data Collection

• Socio-demographic information (age, sex, race)
• Clinical information (otoscopic findings, hearing
  loss, speech delay, etc)
• Data collected from each visit for every child in
  the study from hospital, primary care and
  otolaryngologist charts for all 12 months prior
  to surgery.

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Key Data Collection Assumptions

• When OME was last documented in an ear, we
  assumed it to be present for 60 more days (or
  until the date of surgery) unless the chart
  documented that it had cleared in a subsequent
  visit.
• When AOM was last noted on exam, we assumed the
  child did not have a normal otoscopic exam for 28
  days unless a subsequent exam documented
  otherwise.

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Baseline Socio-demographic and Clinical
Characteristics
Mean, Median Age (years) 3.8, 3.3
Female () 42.8
White () 61
Insured () 95.2
At Risk Condition () 17
Prior Tubes () 26.5
Any other procedure at time of Tube Insertion () 21.7
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Otolaryngologists Reported Indication for
Surgery-682 Cases

• Otitis Media with Effusion (OME)-60.4
• Eustachian Tube Dysfunction (ETD)-10.6
• Recurrent Acute Otitis Media (RAOM)-20.7
• RAOM/OME-3.1
• Other-5.2

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Summary Data-Extent of Disease
Mean Median IQR
infections 6 months prior to TT 1.7 1 0-3
infections 12 months prior to TT 2.6 2 1-4
Consecutive days bilateral effusion 27.2 14 0-42
Consecutive days unilateral effusion 35.6 23 2-53
Cumulative days bilateral effusion 86.2 77 36-121
Cumulative days unilateral effusion 109 103 59-152

Total Number of visits 15.9 14 10-21
Number of PCP visits 12.1 11 6-17
Coefficient of variation ranged from 51 to 129
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Summary Data-Extent of Disease
All Cases Yes ()
Speech Delay? 28.5
Marked Otoscopic Findings? 3.3
Severe disruption of family life? 2.2
Cased with OME
Any abnormal audiogram? 77.9
Bilateral abnormal audiogram (mild) 26.2
Bilateral abnormal audiogram (severe) 14.8
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Duration of effusion (months) by subpopulations
of children whose primary reason for surgery was
OME
Months
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Mean number of episodes of AOM in the year prior
to surgery by subpopulations of children whose
primary reason for surgery was RAOM
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1994 Guideline?

• Limiting cases to 186 children with OME1-3
  years of age
• 90.9 Not Concordant with guideline
• 9.1 Concordant with guideline

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Limitations

• Missing data
• Medical records
• We needed to translate the intermittent
  assessments from the charts into the continuous
  variables we used in our analysis.
• We rely on the otoscopic skills of a group of
  community practicing clinicians for diagnosis.

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Conclusions

• A substantial amount of practice departs from
  expert recommendations.

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Implications

• The extent of variation in treating this
  familiar condition with limited treatment options
  suggests both the importance and difficulty of
  managing common clinical practice to comport with
  guidelines.

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Implications

• Future research needs to explore both the
  optimal course of treatment and why clinical
  practice so frequently deviates from accepted
  guidelines.

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Key Data Collection Assumptions
Episode AOM on Day 50
30 days
30 days
30 days
30 days
Episode OME Day 1
Total Days AOM --28 OME --110