Intended for healthcare professionals


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

BMJ 2008; 337 doi: (Published 03 October 2008) Cite this as: BMJ 2008;337:a1607
  1. Salomeh Keyhani, assistant professor1,
  2. Lawrence C Kleinman, associate professor1,
  3. Michael Rothschild, clinical professor2,
  4. Joseph M Bernstein, assistant professor3,
  5. Rebecca Anderson, former project manager1,
  6. Mark Chassin, president4
  1. 1Department of Health Policy, Mount Sinai School of Medicine, One Gustave L Levy Place, Box 1077, New York, NY 10029, USA
  2. 2Departments of Otolaryngology and Pediatrics, Mount Sinai School of Medicine
  3. 3Departments of Otolaryngology and Pediatrics, New York University School of Medicine, New York
  4. 4The Joint Commission, Oakbrook Terrace, IL, USA
  1. Correspondence to: S Keyhani Salomeh.Keyhani{at}
  • Accepted 4 August 2008


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

Design Retrospective cohort study.

Setting New York metropolitan area practices associated with five diverse hospitals.

Participants 682 of 1046 children who received tympanostomy tubes 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 with acute otitis media had fewer than four infections in the year before surgery. Children with otitis media with effusion had less 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 criteria developed for this study and 7.5% (n=13) with the 1994 guideline from the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology—Head and Neck Surgery. Children who had previously had tympanostomy tube surgery, who were having a concomitant procedure, or who had “at risk conditions” were more likely to be discordant.

Conclusions A significant majority of tympanostomy tube insertions in the largest and most populous metropolitan area in the United States were inappropriate according to the explicit criteria and not recommended according to both guidelines. Regardless of whether current practice represents a substantial overuse of surgery or the guidelines are overly restrictive, the persistent discrepancy between guidelines and practice cannot be good for children or for people interested in improving their health care.


  • Expert panel: Ellen M Friedman, chief, Pediatric Otolaryngology, Texas Children’s Hospital, Houston, TX; G Scott Giebink, professor of pediatrics and otolaryngology, University of Minnesota Medical School, Minneapolis, MN; Gregory Hayden, professor of pediatrics, University of Virginia Health System, Charlottesville, VA; John Hickner, professor and vice chair, Department of Family Medicine, University of Chicago Pritzker School of Medicine; Margaret A Kenna, professor of otology and laryngology, Harvard Medical School, Boston, MA; Jack L Paradise, professor of pediatrics, University of Pittsburgh, Pittsburgh, PA; Seth H Pransky, director, Pediatric Otolaryngology, Children’s Hospital, San Diego, CA; Oliver Roddey, Eastover Pediatrics, Charlotte, NC. One panel member from the Seattle, WA, area preferred to remain anonymous.

  • Contributors: MC and MR were responsible for the conception and design of the project. SK, MC, and RA were responsible for data collection. SK, LCK, MC, and RA were responsible for data analysis. All authors were involved in interpretation of the data. SK, LCK, MR, JMB, and MC were involved in drafting and revising the manuscript. SK is the guarantor.

  • Funding: Agency for Health Care Research and Quality (R01 HS 10302). The funding agency had no role in the design or implementation of the study; all views presented are the authors’ own and may not reflect the views of AHRQ.

  • Competing interests: MC was the principal investigator on this study before he left his position as chair of the Department of Health Policy to become the president of the Joint Commission.

  • Ethical approval: Institutional review boards of all five hospitals. This is a retrospective medical record review and no contact with patients was permitted.

  • This work was presented at the June 2007 and 2008 annual AcademyHealth meetings.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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