1. Racial and Geographic Variations in the Use of Tympanostomy Tubes in Young Children in the United States Lawrence C. Kleinman, MD, MPH Departments of Health Policy and Pediatrics Mount Sinai School of Medicine

2. Lawrence C. Kleinman, MD, MPH, FAAP has no financial conflicts to disclose

3. Purpose Describe variations in the use of tympanostomy tubes among children less than 6 years old in the United States by region, race, and insurance status

4. Clinical Background Otitis Media ubiquitous in children –2 clinical syndromes Acute Otitis Media (ear infections) –Usually Infectious »Viral predominates »Exudate –Often painful, fever Otitis Media with Effusion (fluid in ear, “glue ear”) –Usually inflammatory or mechanical (sterile) »Transudate –Often hearing loss, fever rare

5. Treatment of Otitis Media Acute Otitis Media (AOM) –Antibiotics or watchful waiting Otitis Media with Effusion (OME) – or watchful waiting Tympanostomy Tubes (aka “pressure equalization Tubes”) –Done for Recurrent AOM or Persistent OME –Most common operation in children –Limited national data on their use Most recent National Ambulatory Surgery Survey 1996 (2006 pending release)

6. Tympanostomy Tubes Small synthetic prosthesis inserted through tympanic membrane (ear drum) Equalizes pressure between the middle ear and outer ear

7. Tympanostomy Tubes In the UK –Evidence for an epidemic of tube use in the 1980s and 1990s Clinical Epidemiology of Tympanostomy Tubes in the United States not as well characterized –Evidence for overuse of tympanostomy tubes

8. Overuse of Tympanostomy Tubes National sample of privately insured children (1990-91)* –Using RAND-type criteria developed by expert panel convened by private UR firm only 2 in 5 were considered appropriate –Substituting 1994 AHCPR Guideline on OME in young children (ages 1 through 3 years) more than 4 in 5 “Not Recommended” (unpublished) *Kleinman et al. The Medical Appropriateness of Tympanostomy Tubes in the United States. JAMA 1994.

9. Overuse of Tympanostomy Tubes New York City area children (2002) * –Many NYC children receiving tubes have minimal or mild OM –Less than half are concordant with any of various standards (unpublished, Dr. Keyhani) * Keyhani et al. Clinical characteristics of New York City children who received tympanostomy tubes in 2002. Pediatrics. 2008

10. Methods: Data Elements Integrated nationally representative data: –1996 National Survey of Ambulatory Surgery (NSAS) –1996 National Ambulatory Medical Care Survey (NAMCS) –1996 National Hospital Ambulatory Medical Care Survey (NHAMCS) 1996 census estimates –Estimated population by race and region 1996 Medical Expenditure Panel Survey –Estimated proportion with public, private or no insurance –Weighted average of state rates to get regional rates

11. Methods: Analysis Children < 6 years old Imputed race from NSAS data –Black, White, Other –Unknown race allocated using region-specific proportions Developed measures to account for potential differences in incidence of OM or referral rates to ENT –Surgeries per visit for OM Visits can be specified by site (MDO, OPD, ED) Visits can be specified by type of MD

12. Findings: Population Rates N = 402,478

13. Per 100 OM visits to Physician Offices Race imputed

14. Per 100 OM Visits by Specialty Race imputed

15. 17.24 Per 1000 Population, By Race and Insurance Race NOT imputed

16. Conclusion Insertions of tympanostomy tubes in US remain common –2 years after publications that might have reduced utilization AHCPR guideline JAMA article Rates vary by geographic region, insurance, and race –Per capita –Per other OP services for OM

17. Implications Integrating data from NSAS, NAMCS, and NHAMCS and the census allows for the estimation of innovative rates to describe clinical epidemiology of surgical procedures such as tympanostomy tubes

18. Geographic variations Geographic variations exist –West consistently lowest utilization –Midwest generally highest Cause of variations not well understood

19. Racial Variations Use of clinical utilization measures in denominator “adjusts” for disease burden Even though lower utilization rates may represent higher quality care –Racial differences are disturbing –Different or same doctors

20. Final Thought The clinical epidemiology of the most common surgery for children is poorly understood Critical need to study both clinical practice and the underlying process of decision making for children with OM