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

Otitis Media

Salomeh Keyhani MD MPHLawrence C. Kleinman MD MPH

Michael Rothschild MDJoseph M Bernstein MDRebecca Anderson MPH

Melissa SimonMark Chassin MD MPP MPH

Funding: Agency for Health Care Research and Quality

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.

Guidelines-OME1994 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.

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.

Objective

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

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.

Hospital 1

Hospital 2

Hospital 3

Hospital 4

Hospital 5

1087 TTInsertions

1046 Cases in Cohort

Exclusions

6 Adults

18 wrongcoding

1 missingchart

682 caseswith completedata

270 cases missing PCPchart

35 casesMissing ENTChart

59 cases Missing hospitalchartClinical

Analysis

16 craniofacialprocedures

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.

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.

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

Otolaryngologist’s 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%

Summary Data-Extent of DiseaseMean 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%

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

Duration of effusion (months) by subpopulations of children whose primary

reason for surgery was OME

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Cumulative MonthsUnilateral Effusion

Cumulative MonthsBilateral Effusion

Consecutive MonthsUnilateral Effusion

Consecutive MonthsBilateral Effusion

Measure of Effusion

None Concurrent SurgeryHistory of Prior TubesAt Risk Condition Months

Mean number of episodes of AOM in the year prior to surgery by subpopulations of children whose

primary reason for surgery was RAOM

0

0.5

1

1.5

2

2.5

3

3.5

4

None Concurrent Surgery History of Prior Tubes At Risk Condition

Potential Extenuating Circumstances

1994 Guideline?

Limiting cases to 186 children with OME1-3 years of age:

90.9% Not Concordant with guideline

9.1% Concordant with guideline

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.

Conclusions

A substantial amount of practice departs from expert recommendations.

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.

Implications

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

Key Data Collection Assumptions

Episode OME Day 1

30 days

Episode AOM on Day 50

30 days 30 days

Total DaysAOM --28OME --110

30 days