Increased rates of ENT surgery among young children: have clinical guidelines made a difference?

High Variation of Intravitreal Injection Rates and Medicare Anti-Vascular Endothelial Growth Factor Payments per Injection in the United States

PURPOSE

To estimate geographic variation of intravitreal injection rates and Medicare anti-vascular endothelial growth factor (VEGF) drug costs per injection in aging Americans.

DESIGN

Observational cohort study using 2013 Medicare claims database.

PARTICIPANTS

United States fee-for-service (FFS) Part B Medicare beneficiaries and their providers.

METHODS

Medicare Provider Utilization and Payment Data furnished by the Centers for Medicare and Medicaid Services was used to identify all intravitreal injection claims and anti-VEGF drug claims among FFS Medicare beneficiaries in all 50 states and the District of Columbia in 2013. The rate of FFS Medicare beneficiaries receiving intravitreal injections and the mean Medicare-allowed drug payment per anti-VEGF injection was calculated nationally and for each state. Geographic variations were evaluated by using extremal quotient, coefficient of variation, and systematic component of variance (SCV).

MAIN OUTCOME MEASURES

Rate of FFS Medicare Part B beneficiaries receiving intravitreal injections (Current Procedural Terminology [CPT] code, 67028), nationally and by state; mean Medicare-allowed drug payment per anti-VEGF injection (CPT code, 67028; and treatment-specific J-codes, J0178, J2778, J9035, J3490, and J3590) nationally and by state.

RESULTS

In 2013, the rate of FFS Medicare beneficiaries receiving intravitreal injections varied widely by 7-fold across states (range by state, 4 per 1000 [Wyoming]-28 per 1000 [Utah]), averaging 19 per 1000 beneficiaries. The mean SCV was 8.5, confirming high nonrandom geographic variation. There were more than 2.1 million anti-VEGF drug claims, totaling more than $2.3 billion in Medicare payments for anti-VEGF agents in 2013. The mean national Medicare drug payment per anti-VEGF injection varied widely by 6.2-fold across states (range by state, $242 [South Carolina]-$1509 [Maine]), averaging $1078 per injection. Nationally, 94% of injections were office based and 6% were facility based.

CONCLUSIONS

High variation was observed in intravitreal injection rates and in Medicare drug payments per anti-VEGF injection across the United States in 2013. Identifying factors that contribute to high variation may help the ophthalmology community to optimize further the delivery and use of anti-VEGF agents.

Increasing rate of middle ear ventilation tube insertion in children in Denmark

OBJECTIVE

To study the incidence rates of middle ear ventilation tube insertion in children aged 0 to 15 years in Denmark from 1997 to 2010.

METHODS

Using two national registers, the Danish National Health Service Register and the Danish National Patient Register, practically all cases of middle ear ventilation tube insertion performed in Denmark in the period were identified. A possible change in incidence rate over time was examined using Poisson regression analysis, while the cumulative incidence proportion was estimated using life-tables.

RESULTS

A total of 502,569 uni- or bilateral ventilation tube insertions distributed among 269,459 different children were identified. From 1997 to 2010 the age standardized incidence rate in 0-15-year-olds increased from 26 to 40 per 1000 person years with an estimated annual increase of 2.0% (95% confidence interval 1.9-2.1%). The largest increase in incidence rate was found in 1-year-olds with an annual increase of 4.5% (95% confidence interval 4.4-4.6%). Age-specific incidence rates remained at maximum around the age of 14 months throughout the period. The cumulative incidence proportion for the 2010 birth cohort by the time they reach the age of 5 years was estimated to 29% (95% confidence interval 28-29%).

CONCLUSION

The rate for middle ear ventilation tube insertion in Denmark was high compared to other developed countries, and an estimated 3 in 10 children born in 2010 will undergo at least one ventilation tube insertion before their fifth birthday.

Strategies for reducing regional variation in the use of surgery: a systematic review

OBJECTIVE

To review the literature evaluating the effect of practice guidelines and decision aids on use of surgery and regional variation.

BACKGROUND

The use of surgical procedures varies widely across geographic regions. Although practice guidelines and decision aids have been promoted for reducing variation, their true effectiveness is uncertain.

METHODS

Studies evaluating the influence of clinical practice guidelines or consensus statements, shared decision making and decision aids, or provider feedback of comparative utilization, on rates of surgical procedures were identified through literature searches of Ovid MEDLINE, EMBASE, and Web of Science.

RESULTS

A total of 1946 studies were identified and 27 were included in the final review. Of the 12 studies evaluating implementation of guidelines, 6 reported a significant effect. Those examining overall population-based rates had mixed effects, but all studies evaluating procedure choice described at least a small increase in use of recommended therapy. Three of 5 studies examining the effect of guidelines on regional variation reported a significant reduction after dissemination. Of the 15 studies examining decision aids, 5 revealed significant effects. Many studies of decision aids reported decreases in population-based procedure rates. Nearly all studies evaluating the impact of decision aids on procedure choice reported increases in rates of less invasive procedures. Only one study of decision aids assessed changes in regional variation and found mixed results.

CONCLUSIONS

Both practice guidelines and decision aids have been proven effective in many clinical contexts. Expanding the clinical scope of these tools and eliminating barriers to implementation will be essential to further efforts directed toward reducing regional variation in the use of surgery.

New horizons: otitis media research in Australia

Otitis media affects nearly all children worldwide. Despite an enormous amount of research, our understanding of this common condition continues to be challenged. New pathogens involved in otitis media are still being identified. The importance of interactions between viral and bacterial infection and the role of new vaccines need to be clarified. The proposal that bacteria can become more resistant to therapy through biofilm formation and intracellular infection could have important implications for treatment. The most important clinical research findings have been summarised in systematic reviews. In developed countries, research supporting "watchful waiting" of otitis media with effusion and acute otitis media have had most impact on evidence-based clinical practice guidelines. Indigenous Australian children remain at risk of more severe otitis media. Research programs targeting this population have been well supported. Unfortunately, interventions that can dramatically improve outcomes have remained elusive. For children at high risk of otitis media, health care services should concentrate on accurate diagnosis, antibiotic treatment of suppurative infections, and scheduled follow-up of affected children. Despite the lack of recent studies, strategies to minimise the impact the hearing loss associated with otitis media are important. Improvements in education, hygiene practices, and living conditions are likely to reduce the incidence and severity of otitis media. Studies of these types of interventions are needed.

The impact of ear, nose and throat surgery on children's subsequent use of health services: An 8-year cohort study

AIM

High rates of paediatric ear, nose and throat (ENT) surgery persist. Little is known about its impact on health service utilisation. This study investigated whether children who had ENT surgery used more health services prior to surgery (excluding the perisurgery period), and, if so, whether surgery resulted in reduced utilisation.

METHODS

A retrospective population cohort study of health services use (measured by Medicare claims) by 6239 New South Wales children from the time of their birth in January 1990 until December 1997. We compared: (i) number of claims during the 8-year period for the 359 children who had privately-funded ENT surgery (tonsillectomy, myringotomy or adenoidectomy) with claims made by 5880 children who did not have ENT surgery; and (ii) among children who had surgery: we compared claims made before surgery with those made after surgery.

RESULTS

Children who had privately funded ENT surgery (comprising 59% of all paediatric ENT surgery) used significantly more services than other children in total (103.8 claims vs. 57.1 over 8 years) and in each three months of age from birth to eight years, including services for non-ENT-related conditions. Tonsillectomy resulted in a decline in claims, but not to the level of children who did not have surgery. Most children who had myringotomy continued high-level health services use following surgery.

CONCLUSIONS

High volume health services utilisation is a potential predictor of ENT surgery in this population. These results suggest a need to investigate non-clinical factors that influence service utilisation, which may include higher parental expectations or anxiety regarding their children's health.

The impact of pneumococcal conjugate vaccine on rates of myringotomy with ventilation tube insertion in Australia

BACKGROUND

In randomized controlled trials and postmarketing studies the heptavalent pneumococcal conjugate vaccine (7vPCV) has been shown to reduce myringotomy with ventilation tube insertion (MVTI) procedures in a 4-dose schedule. In Australia, a 3-dose schedule at 2, 4, and 6 months of age is routinely used in non-Indigenous children. Our aim was to determine if a reduction in MVTI comparable to that documented in the United States occurred in Australia despite the absence of the booster dose.

METHODS

All episodes of MVTI in Australia from July 1998 to June 2007 among children aged <or=9 years were identified in an electronic database of national hospitalization records, including the public and private sectors. Age-stratified rates of MVTI before and after introduction of 7vPCV into the national immunization program in 2005 were determined, with Poisson regression modeling used to determine the vaccine impact after adjusting for background and seasonal trends.

RESULTS

A total of 238,634 hospital separations were identified. In the 2.5 years after routine 7vPCV introduction, there was a significant adjusted reduction in MVTI in children aged <1, 1, and 2 years of 23%, 16%, and 6%, respectively. A nonsignificant reduction was observed in those aged 3 and 4 years, while a significant increase of 5% was observed for the 5- to 9-year age group.

CONCLUSIONS

Although ecologic data such as this have limitations, the significant differential effects observed by time period and age group are suggestive of a vaccine effect of similar magnitude to that documented by postmarketing surveillance in the United States. The rapid uptake of 7vPCV in Australia, including catch up to 2 years of age, is an important difference to the United States and it is possible that an even greater effect would have been observed with a booster dose in the second year of life. Longer term data will be needed to fully assess the role of a booster dose.

Surgery for otitis media and infectious susceptibility in 10-year old school children

OBJECTIVES

Assess infectious susceptibility in children previously operated for otitis media and evaluate reliability of parental reported otitis media surgery in the same group of children.

METHODS

Population based, cross-sectional survey of 10-year olds in the city of Oslo, Norway studying otitis media and surgical intervention in n=3406 with reliability assessments in a subset of n=2027.

RESULTS

Ten percent of children had otitis media surgery. Peak age was 2.5 years for adenoidectomy and tympanostomy tubes and 3 years for myringotomy. The crude odds ratio (cOR) with 95% confidence interval (95% CI) for one or more episodes of otitis media at 10 years in children with previous otitis media surgery was 3.4 (2.7-4.4). Intervention after the child was 4 years increased the risk further, crude odds ratio 4.2 (2.9-6.1). Kappa coefficients for agreement in answers to questions on otitis media surgery performed in children between 0 and 4 years were 0.9 for adenoidectomy, 1.0 for tympanostomy tubes, and 0.6 for myringotomy.

CONCLUSION

Otitis media in 10-year old children was associated with previous surgical intervention, particularly when performed after 4 years of age. Parental reports of tympanostomy tubes and adenoidectomy in early childhood were found reliable.

Trends in otitis media surgery: a decrease in adenoidectomy

OBJECTIVE

Large variability in adenoidectomies and tympanostomy tube insertions between Norway and Finland has been suggested, but not yet confirmed. Objective is to compare trends in paediatric adenoidectomies and tympanostomy tube insertions for Norway and Finland from 1999 to 2005.

METHODS

National Finnish and Norwegian databases (STAKES and NPR) provided information on children between 0 and 7 years operated in the years 1999-2005. Surgical rates were viewed in the light of child density, age and gender, and compared bi-nationally.

RESULTS

Adenoidectomies were more common in Finland throughout the study period. Adenoidectomies in both countries decreased markedly from 1999 to 2005. The Finnish adenoidectomy rates were reduced from 212 to 133 per 10,000 children, equivalent Norwegian figures were 84 and 44 per 10,000 children. Tympanostomy tube insertions increased from 97 to 147 per 10,000 children in Finland in the same study period. In Norway the rates were more stable, 119 and 123 per 10,000 in 1999 and 2005, respectively. Peak-age for otitis media surgery was the second year of life in Finland, sixth in Norway. Boys were more frequently operated on in both countries.

CONCLUSION

Our study confirmed differences in the approach to otitis media surgery and revealed a decreasing trend in adenoidectomies in both countries. Similar data from other countries is needed to confirm the latter.

A cost minimisation analysis of a telepaediatric otolaryngology service

Background

Paediatric ENT services in regional areas can be provided through telemedicine (tele-ENT) using videoconferencing or with a conventional outpatient department ENT service (OPD-ENT) in which patients travel to see the specialist. The objective of this study was to identify the least-cost approach to providing ENT services for paediatric outpatients.

Methods

A cost-minimisation analysis was conducted comparing the annual costs of the two modes of service provided by the Royal Children's Hospital (RCH) in Brisbane. Activity records were reviewed to analyse volume of activity during a 12 month period in 2005, i.e. number of clinics, duration of clinics, number of consultations via telemedicine and in outpatient clinics, diagnoses, and travel related information. A sensitivity analysis was conducted using factors where there was some uncertainty or potential future variation.

Results

During the study period, 88 ENT consultations were conducted via videoconference for 70 patients at Bundaberg Base Hospital. 177 ENT consultations were conducted at the RCH for 117 patients who had travelled from the Bundaberg region to Brisbane. The variable cost of providing the tele-ENT service was A$108 per consultation, compared with A$155 per consultation for the conventional outpatient service. Telemedicine was cheaper when the workload exceeded 100 consultations per year. If all 265 consultations were conducted as tele-ENT consultations, the cost-savings would be $7,621.

Conclusion

The cost-minimisation analysis demonstrated that under the circumstances described in this paper, the tele-ENT service was a more economical method for the health department of providing specialist ENT services.

Otitis media surgery: large variability between Finland and Norway

OBJECTIVE

Bi-national comparison of surgical treatment for paediatric otitis media.

METHODS

Registry based cross-sectional study with complete data on surgery for otitis media in 2002; 21,811 Finnish and Norwegian children aged 0-16 years.

RESULTS

Total rates for otitis media surgery were 82.5 and 146.5 per 10,000 children in Norway and Finland, respectively. Adenoidectomies were four times more frequently performed in Finland and rates for tympanostomy tube insertions differed 2-3-fold, Finland having the higher rate. The contrast in surgery rates was most striking in the age group 0-2 years. Further, the more sparsely populated regions had significantly higher overall surgery rates.

CONCLUSION

The large variability in the incidence of otitis media surgery between two similar countries questions whether present guidelines ensure equal treatment in similarly affected children and pinpoints the difficulty in giving advice on age, time and type of surgery.

The influence of birch pollination on the adenoid size in children with intermittent allergic rhinitis

INTRODUCTION

Allergic sensitization of the airways occurs not only in the mucosa of the shock organ, but also in the lymphatic stations draining these structures. The lymphatic structure closest to the nasal mucosa in humans is the adenoid. Many researches show that in part of children allergic rhinitis can be a risk factor for adenoid hypertrophy.

MATERIALS AND METHODS

We used acoustic rhinometry and endoscopy to evaluate the influence of the birch pollination on the adenoid size in 67 children between 5 and 12 years old. Four separate groups of children were examined. The study group consisted of 28 children hypersensitive to tree pollen with seasonal allergic rhinitis (interview, positive skin prick test results, presence of sIgE in the serum and positive nasal provocation test with birch pollen allergens). The first control group consisted of 14 atopic children hypersensitive to motherwort pollen. The second control group consisted of 15 non-atopic children. The third control group consisted of 10 children hypersensitive to tree pollen, they have got anti-allergic treatment (topical nasal steroid and antihistaminic) a week before birch pollination. In all of the groups the adenoid size was examined before, during and after birch pollination. In the study group, we examined the influence of specific nasal provocation test on the adenoid size too.

RESULTS

In most children from the study group (71.4%) we observed the significant increase of adenoid size in endoscopic examination and decrease of nasopharyngeal cavity volume in acoustics rhinometry (92.9%) during the birch pollination. The changes returned after pollination period in most children (90%). In the first and the second control group there were almost no changes observed (p>0.05). The medical treatment used in the third control group avoided the increase of adenoid size during birch pollination season. In the study group there was no statistically significant correlation between the changes in nasopharyngeal volume during the pollination period and the results of nasal provocation test (r=0.18).

CONCLUSION

The result of our study suggests that in children with seasonal allergic rhinitis the exposure on the allergenic factor can influence the adenoid size. Properly administered nasal glucocorticoid together with antihistaminic in standard doses can probably avoid this effect.

An analysis of the incidence of adenoid hypertrophy in allergic children

INTRODUCTION

The adenoidectomy is the most often made operation in small children but the reasons of adenoid hypertrophy are not completely explained. Some researches show that in part of children, allergy can be a risk factor for adenoid hypertrophy. The main aim of this study was the analysis of adenoid hypertrophy in children with different allergic diseases.

MATERIAL AND METHODS

Two separate groups of children were examined. The study group consisted of 436 children between 4 and 9 years old with allergic rhinitis and/or bronchial asthma and/or atopic dermatitis hypersensitive to house dust mites (interview, positive skin-prick test results). The control group consisted of 229 non-atopic children (negative interview and skin-prick tests) in the similar age. In the both groups we examined the incidence of adenoid hypertrophy and its dependence of the kind of allergic disease, age, sex, infections, results of skin-prick test and other sensitization.

RESULTS

The probability of adenoid hypertrophy was statistically more significant (logistic regression analysis) only in children from the study group with allergic rhinitis. There were no differences in adenoid hypertrophy incidence between children with other allergic diseases and the control group. The children from the study group with adenoid hypertrophy were more often hypersensitive to pollen and moulds allergens than the children without adenoid hypertrophy (chi square test). But there were no differences in the incidence of infection, age, sex and results of skin-prick tests.

CONCLUSION

The result of our study suggests that the chance of adenoid hypertrophy in allergic children hypersensitive to dust mites is greater only in them with allergic rhinitis.