Surgical management of uncomplicated otitis media in a pediatric Medicaid population

The objective of this study was to document the frequency and timing of otitis media-related visits, audiological consultations, and surgical interventions following a new episode of otitis media. A retrospective descriptive study was performed on a Medicaid administrative database that follows individual patients over time. The study included 14,453 children enrolled in Medicaid during 1991 and 1992 who were 30 months of age or younger and had a "new" episode of otitis media. Among 14,321 patients with an uncomplicated episode of otitis media, there were 10,443 with additional otitis media visits. Audiological testing was performed in 1,134 (10.9%). The testing occurred within 2 months of the onset of otitis media in 52.2% of the children and within 3 months in 66.6%. Physicians referred 400 children (3.8%) to an otolaryngologist; 299 (75%) underwent 1 or more surgical procedures. These surgical interventions included placement of ventilating tubes in 296 children, adenoidectomy in 34 children (all of whom also had placement of ventilating tubes), mastoidectomy in 2 children, and tympanoplasty in 1 child. The proportion of children who underwent surgical placement of ventilating tubes who had prior audiological testing was 174 of 296 (58.8%). The overall surgical rate for ventilating tubes was 2.9%. Among children who underwent surgery, the procedure occurred within 2 months of the onset of otitis media in 21.4% of children. Attempts to rationalize the management of otitis media in early childhood must deal with the difficulties in distinguishing among the otitis media conditions. The findings of this study suggest a need to know whether insertions of ventilating tubes within 3 months after a new episode of otitis media are related to unresponsive or recurrent infections.

Direct expenditures related to otitis media diagnoses: extrapolations from a pediatric medicaid cohort

BACKGROUND

Treatment of otitis media in children is associated with substantial expenditures because of its high frequency during childhood. Vaccines against respiratory pathogens causing otitis media are now being developed. Information about otitis media-related medical expenditures will be needed to determine the cost-effectiveness of these preventive interventions.

METHODS

This study used utilization data from claims to impute otitis media-related expenditures for medical visits, pharmaceuticals, and surgical procedures for 87 057 children 13 years of age and younger who were continuously enrolled in Colorado's fee-for-service Medicaid program during 1992. International Classification of Disease, Ninth Revision diagnostic codes were used to identify visits for otitis media. An antibiotic was considered to have been prescribed to treat otitis media if it was dispensed up to 24 hours before or within 48 hours after a physician encounter showing a diagnosis of otitis media. All tympanostomies, mastoidectomies, and adenoidectomies were assumed to be related to otitis media. Expenditures were imputed from utilization using a Medicaid fee schedule. National expenditures for 1992 to treat otitis media were extrapolated from Colorado's Medicaid data. We adjusted for differences between Colorado and the United States as a whole in terms of price, number, and intensity of services; for differences in reimbursement rates by service between Medicaid and private insurance; and for differences in utilization between Medicaid enrollees and the uninsured. To provide a more current expression of medical expenditures for otitis media, we inflated the 1992 expenditure estimates to 1998 dollars using the Consumer Price Index published by the US Bureau of Labor Statistics.

RESULTS

Twenty-eight percent of children experienced at least 1 episode of diagnosed otitis media. The proportion of children with a diagnosis of otitis media was highest (42%-60%) in the 7-month to 36-month age range. The proportion was also higher among white (34.5%) and Hispanic (25.3%) children than among black children (18.5%), as well as among rural (34.5%) compared with urban children (27.2%). Children 19 to 24 months of age incurred the highest total annual expenditures per child with otitis media ($239.68). Expenditures for drugs, visits, and procedures were all highest for this group. The per-patient cost to Medicaid was greater for visits than for drugs or procedures across all age groups. Total per-patient expenditures were higher for males ($174.67) than for females ($154.47) and higher for white children ($176.59) than for Hispanic ($154.12) or black children ($134.44). The differences among the ethnic groups can be attributed almost entirely to differences in expenditures for procedures and drugs. Although mean expenditures per patient varied substantially by some patient characteristics (eg, race), these differences accounted for only a small fraction of the enormous variation in costs per patient. Including children with and without otitis media, age-specific estimated expenditures per child peaked among children 1 ($132.94) and 2 years of age ($88.72). Children 3 to 6 years of age incurred expenditures only one third as great as those incurred by children 1 year of age. Total national expenditures were estimated to have been approximately $4.1 billion in 1992 dollars and $5.3 billion in 1998 dollars. Over 40% of national expenditures to treat otitis media in children younger than 14 years of age were incurred for children between 1 and 3 years of age ($453 per capita in 1992 dollars over these 2 years vs $1027 for all years of age from 2 to 13). Nationally, expenditures for visits remained the largest component of expenditures.

LIMITATIONS

This study assessed expenditures from the point of view of the health care system; that is, no social costs, such as lost work time, or expenditures not normally covered by insurance, such as those for transportation, we

Enduring effects of nurse home visitation on maternal life course: a 3-year follow-up of a randomized trial

CONTEXT

A home visitation program using nurses to improve maternal and child outcomes had favorable results in a randomized trial with a primarily white, semirural population. Many of the short-term findings have been replicated with urban blacks, but whether the program will continue to demonstrate effectiveness after its conclusion is uncertain.

OBJECTIVE

To determine the effectiveness of a prenatal and infancy home visitation program on the maternal life course of women in an urban environment 3 years after the program ended.

DESIGN AND SETTING

Three-year follow-up of a randomized controlled trial of women seen consecutively between June 1990 and August 1991 at an obstetrical clinic in Memphis, Tenn, who were enrolled in a visitation program for 2 years after the birth of their first child.

PARTICIPANTS

A cohort of 743 women who were primarily black, were pregnant for less than 29 weeks, had no previous live births, and had at least 2 sociodemographic risk factors (unmarried, <12 years of education, or unemployed).

INTERVENTION

An average of 7 (range, 0-18) home visits during pregnancy and 26 (range, 0-71) from birth to the child's second birthday.

MAIN OUTCOME MEASURES

Rate of subsequent pregnancy, mean interval between first and second birth, and mean number of months of welfare use.

RESULTS

Compared with the control group, women who received home visits by nurses had fewer subsequent pregnancies (1.15 vs 1.34; P=.03), fewer closely spaced subsequent pregnancies (0.22 vs 0.32; P=.03), longer intervals between the birth of the first and second child (30.25 vs 26.60 months; P=.004), and fewer months of using Aid to Families with Dependent Children (32.55 vs 36.19; P=.01) and food stamps (41.57 vs 45.04; P=.005). Compared with the effect of the program while the program was in operation, the effect after it ended was essentially equal for Aid to Families with Dependent Children, greater for food stamps, greater for rates of closely spaced subsequent pregnancies, and smaller for rates of subsequent pregnancy overall.

CONCLUSIONS

We found enduring effects of a home visitation program on the lives of black women living in an urban setting. While these results were smaller in magnitude than those achieved in a previous trial with white women living in a semirural setting, the direction of the effects was consistent across the 2 studies.

Analysis of construction injury burden by type of work

BACKGROUND

To lay groundwork for identifying patterns of injury etiology, we sought to describe injury experience associated with types of work performed at construction sites by examining workers' compensation (WC) claims for the 32,081 construction workers who built Denver International Airport (DIA).

METHODS

Injury rates and WC payment rates were calculated for 25 types of work based on claims and payroll data reported to DIA's owner-controlled insurance program according to National Council on Compensation Insurance job classifications. By linking DIA claims with corresponding lost-work-time (LWT) claims filed with Colorado's Workers' Compensation Division, we were also able to obtain and examine both total and median lost days for each type of work.

RESULTS

Injury experience varied widely among the types of construction work. Workers building elevators and conduits and installing glass, metal, or steel were at particularly high risk of both LWT and non-LWT injury. Median days lost by injured workers was highest (202 days) for driving/trucking. Median days lost for most types of work was much greater than previously reported for construction: 40 days or more for 18 of the 25 types of work analyzed. WC payment rates reflect both number and severity of injuries and were generally not significantly different from expected losses. They were, however, significantly higher than expected for driving/trucking, metal/steel installation, inspection/analysis, and elevator construction.

CONCLUSIONS

Analysis of injury data by type of work allows targeting of safety resources to high risk construction work and would be useful in prospective surveillance at large construction sites with centrally administered workers' compensation plans.

The influence of having an assigned Medicaid primary care physician on utilization of otitis media-related services

OBJECTIVE

This study documents the influence of having an assigned Medicaid primary care physician (PCP) on the utilization of otitis media-related services.

DESIGN/METHODS

This is a retrospective study using the 1991 Colorado Medicaid administrative database that followed 28 844 children <13 years who had at least 1 visit for otitis media.

RESULTS

Children continuously enrolled in Medicaid throughout the entire year were >4 times (odds ratio: 4.2 and 4.89, respectively) as likely to always or sometimes have a PCP compared with children who were discontinuously enrolled. The likelihood of ever using the emergency department for an otitis media-related visit was increased by 26% and 50%, respectively, when a child sometimes or never had a PCP compared with always having a PCP. The likelihood of ever filling an antibiotic for otitis media was reduced by 23% and 34%, respectively, when a child sometimes or never had a PCP compared with always having a PCP. The likelihood of ever having otitis media-related surgery was not affected by PCP status, but young children, 13 to 18 months of age, had higher referral rates when they had an assigned PCP.

CONCLUSIONS

These findings suggest that having an assigned Medicaid PCP influences the utilization patterns of some otitis media-related medical services.

Influence of a family history of cancer within and across multiple sites on patterns of cancer mortality risk for women

A case-control study nested within a large cohort, the American Cancer Society Cancer Prevention Study-1, was conducted to test associations between a family history of cancer and cancer mortality in women. By using logistic regression, the authors analyzed family history, as reported by 429,483 women enrolled in 1959, relative to subsequent mortality through 1972 from cancer within and across multiple sites. The associations between family history and cancer mortality were generally stronger within cancer sites than across cancer sites. Within-site associations were found for breast cancer (odds ratio (OR) = 1.9), colorectal cancer (OR = 1.6), stomach cancer (OR = 1.9), and lung cancer (OR = 1.7). Across-site associations were observed for a family history of 1) breast cancer as a risk factor for ovarian cancer mortality (OR = 1.6), 2) stomach cancer as a risk factor for ovarian cancer mortality (OR = 1.5), and 3) uterine cancer as a risk factor for pancreatic cancer mortality (OR = 1.6). A general pattern of positive associations was observed between a family history of cancer at several sites and subsequent death from pancreatic cancer. These findings support the growing body of evidence from cancer genetics suggesting that inherited cancer-susceptibility genes increase the risk for cancer at many sites and are not specific to cancer risk within a single site.

Contractor safety practices and injury rates in construction of the Denver International Airport

BACKGROUND

We sought to explain the variation in injury rates found for categories of companies and contracts involved in the construction of the Denver International Airport (DIA) by surveying contractors about company and contract-level safety practices.

METHODS

We conducted 213 telephone interviews (83% response) with representatives of contracts with payrolls of more than $250,000. We investigated the bivariate relationship between safety actions reported in the survey and injury occurrence by calculating the aggregate injury rates (lost work-time (LWT) rates and non-LWT rates) for the group of respondent contracts reporting always taking the action and for the group not always taking the action. Using Poisson regression, we examined the association between contract injury rates and contract safety practices while controlling for variables previously shown to affect contract-level injury rates.

RESULTS

In Poisson regression, two actions, 1) disciplinary action always resulting when safety rules were violated and 2) always considering experience modification ratings when selecting subcontractors, were associated with lower LWT injury rates. Three actions or contract characteristics resulted in lower non-LWT rates: management always establishing goals for safety for supervisors, conducting drug testing at times other than badging or after an accident, and completing the DIA contract on budget, rather than over budget. Reportedly consistent use of a number of accepted safety practices was associated with significantly higher injury rates in bivariate and multivariate analyses.

CONCLUSIONS

The pattern of counterintuitive results found in this study suggests that questions reflecting agreed-upon safety practices, when asked of the person responsible for all on-site construction activities, are likely to elicit normative responses. Objective validation of reported safety practices is critical to evaluating their efficacy in reducing injury rates, along with measures of both time at risk and outcome and control for prevailing risk of the work performed.

Risk factors for injury among construction workers at Denver International Airport

BACKGROUND

The Denver International Airport construction project provided a rare opportunity to identify risk factors for injury on a large construction project for which 769 contractors were hired to complete 2,843 construction contracts. Workers' compensation claims and payroll data for individual contracts were recorded in an administrative database developed by the project's Owner-Controlled Insurance Program.

METHODS

From claims andy payroll data linked with employee demographic information, we calculated injury rates per 200,000 person-hours by contract and over contract characteristics of interest. We used Poisson regression models to examine contract-specific risk factors in relation to total injuries, lost-work-time (LWT), and non-LWT injuries. We included contract-specific expected loss rates (ELRs) in the model to control for prevailing risk of work and used logistic regression methods to determine the association between LWT and non-LWT injuries on contracts.

RESULTS

Injury rates were highest during the first year of construction, at the beginning of contracts, and among older workers. Risk for total and non-LWT injuries was elevated for building construction contracts, contract for special trades companies (SIC 17), contracts with payrolls over $1 million, and those with overtime payrolls greater than 20%. Risk for LWT injuries only was increased for site development contracts and contract starting in the first year of construction. Contracts experiencing one or more minor injuries were four times as likely to have at least one major injury (OR = 4.0, 95% CI (2.9, 5.5)).

CONCLUSIONS

Enhancement of DIA's safety infrastructure during the second year of construction appears to have been effective in reducing serious (LWT) injures. The absence of correlation between injury rates among contracts belonging to the same company suggest that targeting of safety resources at the level of the contract may be an effective approach to injury prevention. Interventions focused on high-risk contracts, including those with considerable overtime work, contracts held by special trades contractors (SIC 17), and contracts belonging to small and mid-sized companies, and on high-risk workers, such as those new to a construction site or new to a contract may reduce injury burden on large construction sites. The join occurrence of minor and major injuries on a contract level suggests that surveillance of minor injuries may be useful in identifying opportunities for prevention of major injures.

Construction injury rates may exceed national estimates: evidence from the construction of Denver International Airport

BACKGROUND

Construction of Denver International Airport (DIA) provided a unique opportunity to describe the magnitude of injury on a major construction project for which complete data on injury and hours at risk were available for over 32,000 employees working 31 million hours.

METHODS

Comprehensive payroll data for all workers, who were paid standard Davis-Bacon wages, allowed calculation of person-hours at risk by job classification. Complete reporting, facilitated by a single workers' compensation plan covering all contracts and by an on-site medical clinic and designated provider system, allowed us to determine both total and lost-work-time (LWT) injury rate per 200,000 hours at risk by industrial sector, company size, and year of construction. Workers' compensation payment rates were calculated and compared with expected loss rates, derived by the National Council on Compensation Insurance, by sector, company size, and year.

RESULTS

DIA's overall total injury rates were over twice those published by the Bureau of Labor Statistics (BLS) for the construction industry for each year of DIA construction. Differences in LWT injury rates were more modest. Total injury rates were also at least twice BLS's rates for all contractor sizes. The injury rate pattern by company size at DIA differed from BLS's in that small firms had injury rates that were lower than or comparable to most other size categories; BLS's rates for small firms were lower than those for all but the very largest (250 or more employees) contractors. DIA's total workers' compensation (WC) payment rate of $7.06 per $100 payroll was only 11% higher than Colorado-specific expected loss rates reported by the National Council on Compensation Insurance.

DISCUSSION

Complete reporting, facilitated by the existence of a single WC plan, an on-sites medical clinic, and designated medical providers, yielded injury rates significantly higher than previously reported. The relatively small difference between DIA payment rates significantly higher than previously that the discrepancy between DIA's injury rates and national estimates is due to underreporting of non-LWT injuries of the BLS. The burden of on-site work-related construction injury may be higher and more costly than has been evident from national data.

Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric medicaid population

BACKGROUND

Treatment of otitis media is the most frequent reason for administering antibiotics to children in the United States. However, only limited data are available on medical effectiveness of antibiotic prescribing patterns for otitis media and their associated expenditures or the factors that influence antibiotic prescribing.

METHODS

The study population consisted of 131 169 children during 1991 and 157 065 children during 1992 who were </=13 years of age and enrolled in Colorado's fee-for-service Medicaid program. Among these children, 5127 (1991) and 7254 (1992) were enrolled in the cohort treated for a "new" episode of acute otitis media. An analysis using this cohort was performed to document the antibiotics used to treat a new episode of acute otitis media, factors influencing antibiotic selection, and the short-term outcomes of therapy. An analysis using the entire Medicaid population was performed to document the annual use of antibiotics for otitis, the associated antibiotic expenditures, and factors influencing antibiotic selection.

RESULTS

In the cohort analysis, office-based physicians prescribed second- and third-generation cephalosporins more often than did physicians in other settings (17% vs 9.7% and 11.8%), whereas hospital clinics prescribed trimethoprim plus sulfamethoxazole more frequently than did office-based physicians (19.2% vs 7.1% and 10.9%). Family physicians prescribed second- and third-generation cephalosporins more often than did pediatricians (16.6% vs 12.3%) but trimethoprim plus sulfamethoxazole and erythromycin plus sulfisoxazole less often than did pediatricians (10.5% vs 17%). The average rate of prescribing a second course of antibiotics within 24 days after initial antibiotic treatment of a new acute otitis media episode was 11.6% when less expensive antibiotics (amoxicillin, trimethoprim plus sulfamethoxazole, or erythromycin plus sulfisoxazole) were prescribed, and 13.2% when more expensive antibiotics (cefaclor, amoxicillin plus clavulanate, or cefixime) were prescribed. The average adverse drug reaction rate was 5.9% when less expensive antibiotics were prescribed, compared with 6.1% when more expensive antibiotics were prescribed. In each of the two study years, amoxicillin accounted for almost half of the total antibiotic fills but only 9% to 10% of the expenditures. Low-cost antibiotics (amoxicillin, trimethoprim plus sulfamethoxazole, and erythromycin plus sulfisoxazole) were prescribed for 66% to 67% of the total fills and accounted for 21% of the total projected expenditures. More expensive antibiotics (cefaclor, cefixime, amoxicillin plus clavulanate) prescribed for 30% of the fills generated 76% to 77% of expenditures. Cefaclor, prescribed for 17% to 18% of the total fills, generated 43% to 45% of total antibiotic expenses.

CONCLUSIONS

The findings of this study document a preference for amoxicillin as the initial antibiotic for a new episode of acute otitis media. Although there was a wide variation in the selection of antibiotics to treat otitis, the more expensive antibiotics were not associated with better outcomes. This wide variation has important financial implications because of differences in antibiotic costs. Changes in prescribing patterns among initially uncomplicated children that reduce the use of high-cost antibiotics could reduce expenditures substantially without compromising short-term outcomes.

Utilization of services for otitis media by children enrolled in Medicaid

OBJECTIVE

To provide population-based information about the utilization of ambulatory visits, antibiotic prescriptions, and surgical procedures related to the diagnosis and management of otitis media.

DESIGN

A descriptive study in which utilization rates per child and per child-year were calculated. Child-year rates stratified by age were calculated only for children having at least 1 ambulatory visit with a diagnosis of otitis media.

SETTING

Administrative data from Colorado Medicaid for the 1991 and 1992 calendar years.

PATIENTS

All children enrolled in Medicaid who are younger than 13 years and not participating in a prepaid health care plan during the study years (n = 131,169 and n = 157,065) were included in the analysis.

RESULTS

Approximately 22% of children made at least 1 ambulatory visit with a diagnosis of otitis media, with the peak prevalence (46.8%) occurring between ages 1 and 2 years. Among all children younger than 13 years enrolled in Medicaid, there were 0.5 ambulatory visits for otitis media per child (0.7 ambulatory visits per child-year), with 70% occurring in a physician office setting, 14.8% in a hospital clinic or community health center, and 15.2% in a hospital emergency department. For all children enrolled in Medicaid, the rate of antibiotic courses for otitis media was 0.34 per child (0.48/child-year). Each child with otitis media had an annual average of 1.55 antibiotic courses (1.82 antibiotic courses per child-year). The average ratio of antibiotic courses to ambulatory visits related to otitis media was 65%. There was an annual rate of 12 surgical procedures related to otitis media per 1000 children (16.6/1000 child-years). The peak rate of ventilating tube insertion occurred in children ages 1 to 2 years and for adenoidectomy in children 3 to 6 years. Mastoidectomy rates were low, 92% occurring in children older than 2 years.

CONCLUSIONS

This study represents preliminary techniques to profile the care of children with otitis media. Our findings support the need to measure volatility of enrollment in an insured population before calculating rates of utilization. Additional research is needed to measure the effects of discontinuous eligibility, access to a regular source of primary care, site of treatment, and physician preferences on the quantity and quality of treatments for otitis media.

Finding temporal patterns--a set-based approach

We created an inference engine and query language for expressing temporal patterns in data. The patterns are represented by using temporally-ordered sets of data objects. Patterns are elaborated by reference to new objects inferred from original data, and by interlocking temporal and other relationships among sets of these objects. We found the tools well-suited to define scenarios of events that are evidence of inappropriate use of prescription drugs, using Medicaid administrative data that describe medical events. The tools' usefulness in research might be considerably more general.

Using smoothing splines to make inferences about the shape of gas-exchange curves

Respiratory gas-exchange data from progressive exercise tests are typically interpreted by visual inspection. Attempts to objectify such interpretation have applied particular parametric models which limit the measures which can be studied and the inferences which can be made. We use a known spline-smoothing procedure which fits a continuous curve to such data, yielding confidence intervals for the curve and for its first and second derivatives. Rules can be made which use the derivatives to infer features of a curve's shape and to relate features from different curves in the same data set. In this way complex interpretations can be made objective, so that they may be adequately tested.

Survey of reproductive hazards among oil, chemical, and atomic workers exposed to halogenated hydrocarbons

Several halogenated hydrocarbons are suspected of causing adverse reproductive effects. Because of such concerns, the Oil, Chemical, and Atomic Workers International Union surveyed the reproductive histories of two groups of workers. One group worked at plants engaged in the production or use of halogenated hydrocarbons (exposed) whereas the others had no such opportunity for exposure (nonexposed). Although a low response rate precludes firm conclusions, the 1,280 completed questionnaires provide useful data for generating hypotheses in this developing field of interest. A history of diagnosed cancer was reported more frequently among exposed workers. The infant mortality rate was also significantly elevated among the offspring of exposed workers. No risk gradient was observed for episodes of infertility, fetal loss, congenital defects, or low-birthweight offspring. Concerns with nonresponse, exposure characterization, possible confounding factors, and limited statistical power are addressed. The results provide further suggestions which help to direct studies of occupational reproductive risks.