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.

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.

The effect of expanding Medicaid prenatal services on birth outcomes.

OBJECTIVES: Over 80% of US states have implemented expansions in prenatal services for Medicaid-enrolled women, including case management, nutritional and psychosocial counseling, health education, and home visiting. This study evaluates the effect of Washington State's expansion of such services on prenatal care use and low-birthweight rates. METHODS: The change in prenatal care use and low-birthweight rates among Washington's Medicaid-enrolled pregnant women before and after initiation of expanded prenatal services was compared with the change in these outcomes in Colorado, a control state. RESULTS: The percentage of expected prenatal visits completed increased significantly, from 84% to 87%, in both states. Washington's low-birthweight rate decreased (7.1% to 6.4%, P = .12), while Colorado's rate increased slightly (10.4% to 10.6%, P = .74). Washington's improvement was largely due to decreases in low-birthweight rates for medically high-risk women (18.0% to 13.7%, P = .01, for adults; 22.5% to 11.5%, P = .03, for teenagers), especially those with preexisting medical conditions. CONCLUSIONS: A statewide Medicaid-sponsored support service and case management program was associated with a decrease in the low-birthweight rate of medically high-risk women.

Prescription to over-the-counter switches: the physician perspective.

Changes in a drug's availability from prescription only to over-the-counter (OTC) status is of concern to physicians from both public health and individual patient perspectives. While acknowledging the potential benefits of these switches, the author notes important caveats, including the need for scientifically derived pediatric dosages; information in the medical record regarding OTC use that allows cohesive monitoring; clarity and precision in labeling for consumers; and continued coverage of such drugs for medically indigent patient populations. Current actions by physician organizations are noted.

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

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.

Pharmacists as agents of change for rational drug therapy.

We analyze what is known and unknown about the contribution of the pharmacist as patient educator, physician consultant, and agent to affect patient outcomes in ambulatory settings. The need for pharmacist services is discussed, as are the theoretical underpinnings and quality of the scientific evidence to support their efficacy. The analysis is conducted in the context of a shift in pharmacists' roles from product to patient orientation as well as recent U.S. legislation mandating enhanced pharmacists' roles via drug utilization review for all Medicaid patients. We conclude with a research and action agenda, calling for stronger research designs in evaluating pharmacists' interventions. The shifting paradigm in the pharmacy profession, coupled with the implementation of the Omnibus Budget Reconciliation Act of 1990, provide unique opportunities for rigorous evaluations of pharmacists as agents of change for rational drug therapy.

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.