Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort

doi:10.1136/bmj.a1607

Published 3 October 2008, doi:10.1136/bmj.a1607
Cite this as: BMJ 2008;337:a1607

Research

Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort

Salomeh Keyhani, assistant professor¹, Lawrence C Kleinman, associate professor¹, Michael Rothschild, clinical professor², Joseph M Bernstein, assistant professor³, Rebecca Anderson, former project manager¹, Mark Chassin, president⁴

¹ Department of Health Policy, Mount Sinai School of Medicine, One Gustave L Levy Place, Box 1077, New York, NY 10029, USA, ² Departments of Otolaryngology and Pediatrics, Mount Sinai School of Medicine, ³ Departments of Otolaryngology and Pediatrics, New York University School of Medicine, New York, ⁴ The Joint Commission, Oakbrook Terrace, IL, USA

Correspondence to: S Keyhani Salomeh.Keyhani{at}mountsinai.org

Objectives To compare tympanostomy tube insertion for childrenwith otitis media in 2002 with the recommendations of two setsof expert guidelines.

Design Retrospective cohort study.

Setting New York metropolitan area practices associated withfive diverse hospitals.

Participants 682 of 1046 children who received tympanostomytubes in the five hospitals for whom charts from the hospital,primary care physician, and otolaryngologist could be accessed.

Results The mean age was 3.8 years. On average, children withacute otitis media had fewer than four infections in the yearbefore surgery. Children with otitis media with effusion hadless than 30 consecutive days of effusion at the time of surgery.Concordance with recommendations was very low: 30.3% (n=207)of all tympanostomies were concordant with the explicit criteriadeveloped for this study and 7.5% (n=13) with the 1994 guidelinefrom the American Academy of Pediatrics, American Academy ofFamily Medicine, and American Academy of Otolaryngology—Headand Neck Surgery. Children who had previously had tympanostomytube surgery, who were having a concomitant procedure, or whohad "at risk conditions" were more likely to be discordant.

Conclusions A significant majority of tympanostomy tube insertionsin the largest and most populous metropolitan area in the UnitedStates were inappropriate according to the explicit criteriaand not recommended according to both guidelines. Regardlessof whether current practice represents a substantial overuseof surgery or the guidelines are overly restrictive, the persistentdiscrepancy between guidelines and practice cannot be good forchildren or for people interested in improving their healthcare.

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