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Article
April 27, 1994

The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger Than 16 Years in the United States

Author Affiliations

From the Department of Pediatrics, Harvard Medical School, and Department of Hospital Epidemiology and Quality Improvement and Division of General Pediatrics, Children's Hospital, Boston, Mass (Dr Kleinman); Value Health Sciences (Drs Kosecoff and Dubois) and RAND Health Science Program, (Dr Brook) Santa Monica, Calif; and the Divisions of General Internal Medicine (Dr Kosecoff) and Geriatrics (Dr Brook), School of Medicine, and Department of Health Services, School of Public Health (Dr Brook), University of California-Los Angeles. Prior to undertaking this study, Dr Kleinman occasionally worked as a physician reviewer for Value Health Sciences. Dr Kosecoff and Dr Dubois are stockholders and employees of Value Health Sciences. Dr Brook and Dr Kosecoff are married. This work was initiated when Dr Kleinman was a Robert Wood Johnson Clinical Scholar and member of the Divisions of General Internal Medicine and General Pediatrics at University of California-Los Angeles.

JAMA. 1994;271(16):1250-1255. doi:10.1001/jama.1994.03510400036028
Abstract

Objective.  —To describe the clinical reasons tympanostomy tubes are proposed for children and to assess their appropriateness.

Design.  —Analysis of data previously collected prospectively by a national utilization review (UR) firm during a two-step UR process to assess the medical appropriateness of tympanostomy tube placement. Nurses interviewed otolaryngologists' and primary care physicians' office staff to collect clinical data. For a randomly selected subsample of cases found inappropriate, we reviewed subsequent interviews of the otolaryngologists by physician reviewers, who looked for possible extenuating clinical circumstances or additional clinical data that might have changed the appropriateness category.

Setting.  —Otolaryngologists' practices from 49 states and the District of Columbia.

Patients.  —All 6611 children younger than 16 years who were insured by three clients of the UR firm and whose proposal to receive tympanostomy tubes was reviewed by this system from January 1,1990, through July 31,1991. The insurance companies in the study insured 5.6 million Americans at the time of the study.

Main Outcome Measure.  —The medical appropriateness of tympanostomy tube surgery according to explicit criteria developed by an expert panel using the RAND/University of California—Los Angeles modified Delphi method.

Results.  —A total of 6429 (97%) of the cases were proposed for recurrent acute otitis media, otitis media with effusion, or both. Making generous clinical assumptions, 41% of the proposals for these reasons had appropriate indications, 32% had equivocal indications, and 27% had inappropriate ones. Considering the additional information available from the subsample review, the proportion appropriate was 42%, equivocal 35%, and inappropriate 23%.

Conclusion.  —About one quarter of tympanostomy tube insertions for children in this study were proposed for inappropriate indications and another third for equivocal ones.(JAMA. 1994;271:1250-1255)

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