A Charge Comparison of Audiometric Testing in the Pediatric Population.

OBJECTIVE: To determine the charges associated with performing combined tympanometry and otoacoustic emissions vs a comprehensive audiogram in the pediatric population and to analyze its implications for future practice. STUDY DESIGN: Retrospective charge analysis. SETTING: Tertiary care academic center. SUBJECTS AND METHODS: Analysis was performed on 538 pediatric patients who underwent audiometric hearing testing from May through October 2014. RESULTS: In total, 401 patients had combined tympanometry and otoacoustic emissions testing and 91 patients underwent a comprehensive audiogram, while 46 patients underwent all 3 tests. The technical and professional charges for combined tympanometry and otoacoustic emissions were $139 and $116, respectively, with an overall charge of $255. The technical and professional charges for an audiogram were $124 and $198, respectively, with an overall charge of $322. CONCLUSION: Objective testing with a combination of tympanometry and otoacoustic emissions charges insurers $67 less than an audiogram. Given the questionable reliability of behavioral audiometry in very young children, this is a factor to consider when choosing the appropriate test. With a large number of pediatric auditory hearing tests performed each year, the cost savings within the health care system could be substantial.

Cost-utility analysis of topical intranasal steroids for otitis media with effusion based on evidence from the GNOME trial.

OBJECTIVES: To estimate the cost-effectiveness of topical intranasal steroids for the treatment of otitis media with effusion (OME) in primary care from the perspective of the UK National Health Service. METHODS: An economic evaluation was conducted based on evidence from the double-blind, randomized, placebo-controlled GPRF [General Practice Research Framework] Nasal Steroids for Otitis Media with Effusion (GNOME) trial. Participants comprised 217 children aged 4-11 years who had at least one episode of otitis media or related ear problem in the previous 12 months and had tympanometrically confirmed bilateral OME. Children were randomly allocated to receive either mometasone furoate 50 microg or placebo spray once daily into each nostril for 3 months. The main outcome measure was the incremental cost per quality-adjusted life-year (QALY) gained for topical steroids compared with placebo. The nonparametric bootstrap method was used to present cost-effectiveness acceptability curves at alternative willingness to pay thresholds. RESULTS: Children receiving topical steroids accrued nonsignificantly higher costs (incremental cost/child: pound11, 95% confidence interval [CI]: - pound199 to pound222) and nonsignificantly fewer QALYs (incremental QALY gain/child: -0.0166, 95% CI: -0.0652 to 0.0320) than those receiving placebo. Topical steroids had a 24.19% probability of being cost-effective at a pound20,000 per QALY gained threshold, a 23.82% probability of being more effective and a 46.25% probability of being less costly. Sensitivity and subgroup analyses showed incremental costs and benefits to be highly sensitive to the methods used and the patient group considered, although differences between groups did not reach statistical significance in any analysis. CONCLUSIONS: Topical steroids are unlikely to be a cost-effective treatment for OME in general practice.

Ultra high resolution nonenhanced fast spin echo magnetic resonance imaging: cost-effective screening for acoustic neuroma in patients with sudden sensorineural hearing loss.

The financial burden for the evaluation of patients for acoustic neuroma in an otolaryngology practice is substantial. Patients with sudden sensorineural hearing loss represent a portion of that population seen with unilateral, asymmetric auditory symptoms who require investigation for acoustic neuroma. For these patients, gadolinium-enhanced magnetic resonance imaging is the diagnostic gold standard. Auditory brain stem response testing has been used in the past as a screening test for acoustic neuroma, but its apparent sensitivity has fallen as the ability to image smaller acoustic neuromas has improved. Fast spin echo magnetic resonance imaging techniques without gadolinium have been shown to be as effective in the detection of acoustic neuroma as contrast-enhanced magnetic resonance imaging. Limited nonenhanced fast spin echo magnetic resonance imaging now provides an inexpensive alternative for high-resolution imaging of the internal auditory canal and cerebellopontine angle. Fast spin echo magnetic resonance imaging can now be done at a cost approximating auditory brain stem response testing while providing the anatomic information of contrast-enhanced magnetic resonance imaging. Cost analysis was done in the cases of 58 patients with sudden sensorineural hearing loss by comparing the costs for routine workup and screening of acoustic neuroma with the cost of fast spin echo magnetic resonance imaging with the use of screening protocols based on literature review. The potential cost savings of evaluating patients with sudden sensorineural hearing loss with fast spin echo magnetic resonance imaging for acoustic neuroma was substantial, with a 54% reduction in screening costs. In an era of medical economic scrutiny, fast spin echo magnetic resonance imaging has become the most cost-effective method to screen suspected cases of acoustic tumors at our institution by improving existing technology while reducing the cost of providing that technology and eliminating charges for impedance audiometry, auditory brain stem response testing, and contrast-enhanced magnetic resonance imaging.

Progression of tympanometry and acoustic reflectometry. Findings in children with acute otitis media.

The presence of middle ear effusion (MEE) following acute otitis media (AOM) has been assessed by impedance tympanometry and acoustic reflectometry but has not been assessed serially from the time of presentation for AOM in the same group of patients. This descriptive study examined serial measurements by tympanometry and reflectometry in children with clinical AOM at the time of diagnosis, 3 to 5 days later, and at final follow-up 12 to 15 days after diagnosis. The study entry criteria were conservative in order to represent obvious cases of AOM and included 90 patients representing 107 ears. The objective was to describe the evolution of instrumental findings and to attempt to identify unique patient subpopulations with differing prognoses. We found that combined use of initial tympanometry and reflectometry, while yielding intriguing results, does not allow for identification of subpopulations with good or poor progression for MEE clearance at 2-week follow-up. It is our conclusion that initial tympanometry and reflectometry add to the cost of AOM diagnosis without clear benefit for the individual patient.

Evaluation of pure tone audiometry and impedance screening in infant schoolchildren.

STUDY OBJECTIVE: The aims were (1) to evaluate impedance measurements against pure tone audiometry as a screening method for the detection of middle ear changes associated with hearing loss in infant school children; (2) to estimate the costs of the health authority of each method. DESIGN: The study involved two stage screening in which both methods were offered, pure tone audiometry being carried out by school nurses and impedance screening by a doctor. SETTING: 18 infant or primary schools in Langbaurgh, Cleveland, UK. PARTICIPANTS: 610 previously unscreened infant school children took part in the study. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were the sensitivity, specificity, and predictive value of each screening method, using clinical assessment and action as the validating technique. The sensitivity and the predictive value of a positive test in two stage impedance screening was markedly superior to that of pure tone audiometry. The specificity was similar using the two methods. In addition the impedance methods was more rapid and estimated to consume less resource as a screening procedure than pure tone audiometry. CONCLUSIONS: The superiority of the use of impedance screening established in this study should be confirmed in a subsequent audit carried out purely by school nurses.