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
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.
Objective
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-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.
Methods-Study Population
• We conducted a retrospective study of all
tympanostomy tubes placed in 2002 in five New
York City metropolitan area hospitals.
To report on the clinical characteristics of
a cohort of New York City children who
received tympanostomy tubes in 2002
• 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.
Exclusions
Data Collection
6 Adults
Hospital 1
16 craniofacial
procedures
Hospital 2
1087 TT
Insertions
Hospital 3
• Socio-demographic information (age, sex, race)
18 wrong
coding
1 missing
chart
• Clinical information (otoscopic findings, hearing
loss, speech delay, etc)
Hospital 4
1046
Cases in Cohort
Hospital 5
Clinical
Analysis
682 cases
with complete
data
270 cases
missing PCP
chart
35 cases
Missing ENT
Chart
59 cases
Missing hospital
chart
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.
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%
• 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.
Baseline Socio-demographic and
Clinical Characteristics
Mean, Median Age (years)
Female (%)
White (%)
Insured (%)
At Risk Condition (%)
Prior Tubes (%)
Any other procedure at time of
Tube Insertion (%)
3.8, 3.3
42.8
61
95.2
17
26.5
21.7
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%
Summary Data-Extent of Disease
All Cases
Speech Delay?
Marked Otoscopic Findings?
Severe disruption of family life?
Duration of effusion (months) by
subpopulations of children whose primary
reason for surgery was OME
Yes (%)
28.5
3.3
2.2
4.5
4
None
Concurrent Surgery
History of Prior Tubes
At Risk Condition
3.5
Cased with OME
Months
3
2.5
Any abnormal audiogram?
77.9
Bilateral abnormal audiogram (mild)
26.2
Bilateral abnormal audiogram (severe)
14.8
2
1.5
1
0.5
0
Cumulative Months
Unilateral Effusion
Cumulative Months
Bilateral Effusion
Consecutive Months Consecutive Months
Unilateral Effusion
Bilateral Effusion
Measure of Effusion
Mean number of episodes of AOM in the year prior
to surgery by subpopulations of children whose
primary reason for surgery was RAOM
1994 Guideline?
Limiting cases to 186 children with OME1-3
years of age:
4
3.5
90.9% Not Concordant with guideline
9.1% Concordant with guideline
3
2.5
2
1.5
1
0.5
0
None
Concurrent Surgery History of Prior Tubes
At Risk Condition
Potential Extenuating Circumstances
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
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.
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 AOM on Day 50
30 days 30 days
Episode OME
Day 1
Total Days
AOM --28
OME --110
30 days
30 days