Single Visit Evaluation and Tympanostomy Tube Placement for the Treatment of Acute Otitis Media in Children.

OBJECTIVE: To review our experiences with development of a single visit surgery (SVS) program for children with recurrent acute otitis media (AOM) undergoing tympanostomy tube (TT) placement the same day as their otolaryngology surgical consultation. STUDY DESIGN: Retrospective cohort analysis. METHODS: Retrospective series of patients participating in SVS from inception March 1, 2014 to April 30, 2020 were analyzed, with attention to factors associated with increasing interest and participation in SVS and parent experiences/satisfaction. RESULTS: A total of 224 children had TT placed through SVS for AOM management. The average age of patients was 18.1 months (standard deviation 7.8 months), and 130 (58.0%) were male. The median interval between initial contact to schedule SVS, and the SVS date was 15 days (interquartile range 9-23 days). When analyzing year-over-year volumes from inception of SVS, notable increases were seen in 2016 and 2017 after a radio advertisement was played locally. A marked increase in volume was noted after implementation of a Decision Tree Scheduling (DTS) algorithm for children with recurrent AOM. Sixty-six (28.8%) procedures were performed after institution of DTS. A parent survey demonstrated high levels of satisfaction with the SVS experience. Estimations of savings to families in terms of time away from work demonstrated potential for indirect healthcare benefits. CONCLUSIONS: SVS for TT placement was a successful, alternative model of care for management of children with AOM. Marketing strategies regarding SVS, and the inclusion of SVS pathway in DTS platforms increased rates of interest and choice of this option. Parents of children undergoing TT through SVS were satisfied with the overall experience. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2823-2829, 2021.

Helping Children with Special Needs: Who Receives Tympanostomy Tubes?

OBJECTIVES: Tympanostomy tubes can prevent sequelae of otitis media that adversely affect long term hearing and language development in children. These negative outcomes compound the existing difficulties faced by children who are already diagnosed with developmental disorders. This study aims to characterize this subset of children with developmental disorders undergoing myringotomy and tympanostomy tube insertion. METHODS: A retrospective review using the Kids' Inpatient Database (KID) was conducted, with codes from International Classification of Diseases, Ninth Revision used to query data from the years 2003 to 2012 to determine a study group of children with a diagnosis of a developmental disorder undergoing myringotomy and tympanostomy insertion. This group was compared statistically to patients undergoing these procedures who did not have a diagnosed developmental disorder. RESULTS: In total, 21 945 cases of patients with myringotomy with or without tympanostomy tube insertion were identified, of which 1200 (5.5%) had a diagnosis of a developmental disorder. Children with developmental disorders had a higher mean age (3.3 years vs 2.9 years, P = .002) and higher mean hospital charges ($43 704.77 vs $32 764.22, P = .003). This cohort also had higher proportions of black (17.6% vs 12.3%, P < .001) and Hispanic (23.9% vs 20.6%, P = .014) patients, and had lower rates of private insurance coverage (39.6% vs 49%, P < .001). CONCLUSION: The population of children with developmental disorders undergoing myringotomy or tympanostomy tube placement has a different demographic composition than the general population and faces distinct financial and insurance coverage burdens. Further study should be done to assess if these differences impact long term outcomes.

Cost and efficiency of myringotomy procedures in minor procedure rooms compared to operating rooms.

OBJECTIVES: Minor pediatric surgeries performed in the minor procedure room (MPR) may be more time efficient and less costly compared to those performed in the operating room (OR). STUDY DESIGN: Retrospective review. METHODS: This was a retrospective study on cost and efficiency differences of bilateral myringotomy with tube insertions performed in the MPR versus the OR. Charts were reviewed from June 2015 to May 2017. Cost data was based on supply cost and case costing of medical personnel including nurses, aides, and anesthesia assistants. RESULTS: Two hundred eighteen patients were included in the study. The median age was 2.7 years (range: 0.8-16.7), and there were no differences in gender between locations. One hundred twenty-three patients had surgery in the MPR (56.4%), and 95 had surgery in the OR (43.6%). The median length of time in the procedure room was 11 minutes shorter for patients who underwent surgery in the MPR (12.0 minutes, range: 3.0-33.0) compared to patients in the OR (23.0 minutes, range: 11.0-52.0; P < .0001). Median hospital stay (2.0 hours vs. 4.3 hours; P < 0.0001) and median patient turnover time (6.0 minutes vs. 14.0 minutes; P < .0001) was shorter in the MPR compared to OR. The total overall cost of a myringotomy with tube insertion, including labor and supply cost, was $189.41 in the MPR compared to $468.56 in the OR, a difference of $279.15 per case. CONCLUSION: Bilateral myringotomy with tube insertions are more time and cost-efficient when performed in the MPR. This study supports the need for increased availability of MPR time for appropriate surgeries. LEVEL OF EVIDENCE: 3 Laryngoscope, 130:242-246, 2020.

The effect of losing federal coverage through the Affordable Care Act on ear tube placements at an urban children's hospital.

PURPOSE: 15-31% of the population in a large Mid-western city is between 100 and 400% of the Federal Poverty Level, thus qualifying for health care coverage under the Affordable Care Act (ACA). Coverage for their children would potentially be available under Children's Health Insurance Program (CHIP) or Medicaid programs. Loss of funding for these programs could be devastating for this community. METHODS: We retrospectively reviewed 1162 charts of pediatric patients with tympanostomy tube (TT) placement pre-ACA from November 2012 to December 2013 and 1606 charts post-ACA from January 2014 to July 2015. We filtered demographics by health insurance (Medicaid/CHIP/Other), residential zip codes, identified race/ethnicity within those zip codes as well as gender and age of patients getting TT during these periods. RESULTS: Bivariate analysis of these demographics between the two periods showed statistical significance (p = 0.0098) between White Hispanic/Latino children receiving ear tubes (pre-ACA = 3.8%, post-ACA = 6.4%). However, there was no statistical significance for insurance enrollment (Medicaid or non-Medicaid) and other races (White-not Hispanic/Latino (nHL), African American, Other/Unknown/Refused) with respect to TT placement. Using pre-ACA period and White nHL females as arbitrary reference, a multivariate logistic regression showed that patients requiring TT surgery were equally likely to be covered on Medicaid either before or after ACA. CONCLUSION: We demonstrated that the pre and post ACA Medicaid coverage for TT surgery did not change. Underserved children did not obtain other forms of insurance during this time. This demonstrates a potentially catastrophic loss of coverage for children should Medicaid/CHIP benefits be lost to sole coverage under the ACA.

Tympanostomy tube placement and ear drops: Evidence-based cost saving models.

OBJECTIVES/INTRODUCTION: Tympanostomy tube placement is the most common surgical procedure in the pediatric population with important financial implications to our healthcare institutions. The purpose of this study is to apply various cost models in different clinical environments to determine the most cost effective way to prescribe ear drops after tympanostomy tube insertion. METHODS: Two distinct practice models were designed: a Uniform Treatment Model and a Disease Specific Model. Different cost simulations were run based on which medication(s) was chosen for all tympanostomy tube cases performed over the course of 1 year in a practice composed of four pediatric otolaryngologist. Two categories of ear drop medications were seen: high cost and low cost. The cost associated with initiation of drops in the operating room versus initiation as an outpatient via a prescription was evaluated. RESULTS: In both Uniform Treatment and Disease Specific Models, the most expensive simulations included antibiotic/steroid combination drop use intraoperatively. The treatment with an antibiotic/steroid combination drop was lower when delayed until the post-operative period. The hospital cost for ear drops increased by as much as 478% when dispensed within the operating room rather than from the hospital's outpatient pharmacy. CONCLUSIONS: Otolaryngologists should make an effort to become familiar with the cost of ototopical medications and the significant variability between inpatient and outpatient settings. Cost of ototopical agents should be shifted to the institution's outpatient pharmacy whenever possible especially for branded, higher cost combination drops. Patients should be treated based on the status of their ear disease at time of middle tube insertion.

Variation in costs among surgeons and hospitals in Pediatric tympanostomy tube placement.

OBJECTIVES/HYPOTHESIS: 1) Identify the major expenses for outpatient pediatric tympanostomy tube placement in a multihospital network. 2) Compare differences for variations in costs among hospitals and surgeons. METHODS: An observational cohort study in a multihospital network using a standardized activity-based accounting system to determine hospital costs for tympanostomy tube placement from February 2011 to January 2015. Children aged 6 months to less than 3 years old who underwent same-day surgery (SDS) for tympanostomy tubes at 15 hospital facilities were included. Subjects with additional procedures were excluded. Hospital costs were subdivided into categories including operating room (OR), SDS preoperative, SDS postoperative, postanesthesia care unit, anesthesia, pharmacy, and OR supplies. RESULTS: The study cohort included 5,623 patients undergoing tympanostomy tube placement by 67 surgeons. Mean cost per surgery was $769 ± $3. Significant variations (P < 0.001) in mean cost per procedure were identified by hospital (range $1212 ± $38 to $509 ± $11) and by surgeon (range $1330 ± $75 to $660 ± $11). Operating room and SDS preoperative were the greatest expenditures; each category accounted for over 30% of overall costs. Pharmacy costs and OR costs were some of the major drivers of cost variation among surgeons. CONCLUSION: This study demonstrates that OR and SDS preoperative costs accounted for the greatest expenditure in tympanostomy tube placement, and significant variation exists among surgeons and hospitals within a multihospital network. Further research is needed to elucidate factors accounting for such variation in cost and the overall impact on patient outcomes. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1935-1939, 2016.

[Outpatient Surgery in German ENT in Teaching Hospitals--Economic Nonsense?]. / Ambulante Operationen in HNO-Ausbildungskliniken - ökonomischer (Un)sinn?

INTRODUCTION: There is an ever-increasing demand to increase efficiency and decrease costs in health care. This leads to an growing number of outpatient surgeries which are less cost effective. Especially in the setting of university teaching hospitals, this may lead to both an undersupply of qualified physicians, as well as to a worsening of clinical training of residents. In order to quantify a possible undersupply and estimate the expense of teaching residents, the time for medical procedures needs to be quantified and compared between board-certified physicians and residents. This was the aim of the current study. MATERIAL AND METHODS: All outpatient adenotomies of children with or without paracentesis or tympanic drainage insertion performed in 2012 in 2 ENT teaching hospitals were analyzed. The length of the surgical procedure as well as the level of training of the surgeon was analyzed. Operating times of residents in training were analyzed stratified by training level and then compared to operation times of board-certified ENT surgeons. RESULTS: 255 procedures were analyzed. Significant differences of the mean operation time could be identified depending on the level of training of residents compared to board-certified ENT surgeons for all investigated training levels. E. g. 1(st) year residents' surgeries required 2.4 times more time than those of board-certified ENT surgeons. CONCLUSION: Based on an analysis of outpatient ENT-surgical procedures it becomes apparent that due to the extended operating times of residents in training outpatient surgery is by far less cost-effective than by board-certified physicians. To cope with the demand of teaching residents for their clinical training, more resources are necessary in the setting of teaching hospitals.

A model-based cost-effectiveness analysis of a grommets-led care pathway for children with cleft palate affected by otitis media with effusion.

There is a paucity of evidence to guide the management of otitis media with effusion (OME), which is a common problem causing significant hearing impairment in children with cleft palate. The insertion of grommets is currently being used to correct hearing impairment and prevent complications of unmanaged OME, but there is ongoing discussion about whether the benefits of grommets outweigh the costs and risks. A decision-tree model was developed to assess the surgical insertion of grommets with two non-surgical alternatives (hearing-aids and do-nothing strategies) in cleft palate children with persistent bilateral OME. The model assumed a 2-year time horizon and a UK National Health Service perspective. Outcomes were valued using quality-adjusted life-years (QALYs) estimated by linking utility values with potential hearing gains measured in decibels. Multiple data sources were used, including reviews of the clinical effectiveness, resource use and utility literature, and supplemented with expert opinion. Uncertainty in the model parameters was assessed using probabilistic sensitivity analysis. Expected value of perfect information analysis was used to calculate the potential value of future research. The results from the probabilistic sensitivity analysis indicated that the grommets strategy was associated with an incremental cost-effectiveness ratio of £9,065 per QALY gained compared with the do-nothing strategy, and the hearing-aids strategy was extended dominated by the grommets strategy. The population expected value of perfect information was £5,194,030 at a willingness to pay threshold of £20,000 per QALY, implying that future research could be potentially worthwhile. This study found some evidence that the insertion of grommets to manage cleft palate children with bilateral OME is likely to be cost-effective, but further research is required to inform this treatment choice.

Assessment of the feasibility and clinical value of further research to evaluate the management options for children with Down syndrome and otitis media with effusion: a feasibility study.

BACKGROUND: There is clinical uncertainty of the benefits and costs of different treatment options for children with Down syndrome who have glue ear. This study was designed to assess the extent of this lack of knowledge and determine if pursuing further information would be practical, beneficial and cost-effective. OBJECTIVES: To assess the level and practical effect of current uncertainty around treatment options for children with Down syndrome and glue ear. To assess the feasibility of studying the options for management of glue ear in children with Down syndrome via a randomised controlled trial (RCT) or multicentre prospective cohort study by evaluating the willingness of (1) parents to agree to randomisation for their children and (2) clinicians to recruit participants to a definitive study. To undertake value of information analyses to demonstrate the potential economic benefit from undertaking further research. DESIGN: A feasibility study exploring the views of parents of children with Down syndrome and professionals who have responsibility for the health and education of children with Down syndrome, on the participation in, and value of, future research into interventions for glue ear. Data were collected from parents via self-completed questionnaires, face-to-face interviews and focus groups and from professionals via online questionnaires and a Delphi review exercise. Development of economic models to represent clinical pathways of care and a RCT informed a value of information (VOI) analysis. SETTING: UK (professionals); East Midlands region of the UK (parents). PARTICIPANTS: Parents of children aged 1-11 years with Down syndrome (n = 156). Professionals including audiologists, ear, nose and throat surgeons, audiological physicians, speech and language therapists, and teachers of the deaf (n = 128). MAIN OUTCOME MEASURES: Quantitative and qualitative data on parental views and experiences of glue ear and its effects; interventions and treatment received; taking part in research and factors that would encourage or discourage participation; and the importance of various outcome domains to them and for their children. For professionals: information on caseloads; approaches to clinical management; opinions on frequency and significance of the consequences of glue ear for this population; importance of different outcome measures; opinions of interventions and their role in future research; views on health research; facilitators and barriers to recruitment, and participation in research involving RCTs. RESULTS: The complexity of the experience and individual characteristics of children with Down syndrome poses challenges for the design of any future research but these challenges were not considered by professionals to raise sufficient barriers to prevent it being undertaken. Parents were generally supportive of the need for, and value of, research but identified practical and emotional issues that would need addressing. Glue ear was considered to impact more on speech, language and communication than on hearing. Outcome measures for future research would need to evaluate these elements but measures should be designed specifically for the population. Parents and professionals identified randomisation as a significant barrier to participation. The VOI analyses identified lack of data as problematic but concluded that a future trial involving surgical intervention would be feasible at costs of < £650,000. CONCLUSIONS: Future research into the benefits of interventions for glue ear in children with Down syndrome would be feasible and could be cost-effective but should be carefully designed to facilitate and maximise participation from parents and professionals responsible for recruitment. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Economic evaluation of surgical insertion of ventilation tubes for the management of persistent bilateral otitis media with effusion in children.

BACKGROUND: The surgical insertion of Ventilation Tubes (VTs) for the management of persistent bilateral Otitis Media with Effusion (OME) in children remains a contentious issue due to the varying opinions regarding the risks and benefits of this procedure. The aim of this study was to evaluate the economic impact of VTs insertion for the management of persistent bilateral OME in children, providing an additional perspective on the management of one of the commonest medical conditions of childhood. METHODS: A decision-tree model was constructed to assess the cost-effectiveness of VTs strategy compared with the Hearing Aids (HAs) alone and HAs plus VTs strategies. The model used data from published sources, and assumed a 2-year time horizon and UK NHS perspective for costs. Outcomes were computed as Quality-Adjusted Life-Years (QALYs) by attaching a utility value to the total potential gains in Hearing Level in decibels (dBHL) over 12 and 24 months. Modelling uncertainty in the specification of decision-tree probabilities and QALYs was performed through Monte Carlo simulation. Expected Value of Perfect Information (EVPI) and partial EVPI (EVPPI) analyses were conducted to estimate the potential value of future research and uncertainty associated with the key parameters. RESULTS: The VTs strategy was more effective and less costly when compared with the HAs plus VTs strategy, while the incremental cost-effectiveness ratio for the VTs strategy compared with the HAs strategy was £ 5,086 per QALY gained. At the willingness-to-pay threshold of £ 20,000 per QALY, the probability that the VTs strategy is likely to be more cost-effective was 0.58. The EVPI value at population level of around £ 9.5 million at the willingness-to-pay threshold of £ 20,000 indicated that future research in this area is potentially worthwhile, while the EVPPI analysis indicated considerable uncertainty surrounding the parameters used for computing the QALYs for which more precise estimates would be most valuable. CONCLUSIONS: The VTs strategy is a cost-effective option when compared with the HAs alone and HAs plus VTs strategies, but the need for additional information from future study is evident to inform this surgical treatment choice. Future studies of surgical and non-surgical treatment of OME in childhood should evaluate the economic impact of pertinent interventions to provide greater context.

Effects of increased payment for ventilation tube insertion on decision making for paediatric otitis media with effusion.

OBJECTIVE: The National Health Insurance (NHI) in Taiwan raised the physician fee for myringotomy with ventilation tube insertion (VTI) from $61.5 to $117.6 in July 2004. This study aimed to evaluate if the increased payment affected the decision making of physicians. METHODS: This study is a retrospective analysis by using NHI databank in Taiwan. All children less than 12 years old who underwent VTI from 1 July 2003 to 30 June 2006 were included. Waiting time and case numbers before and after the increased VTI payment were compared. The waiting time between public and private hospitals was also examined. RESULTS: From the 7408 cases evaluated, there was no difference in waiting time before and after the raise of VTI payment, and no difference within each year group. The case number of VTI increased significantly after the increase in VTI payment (P < 0.05). The waiting time of VTI performed in private hospitals was shorter than that in public hospitals (P = 0.0001). CONCLUSION: The waiting time of VTI for children with otitis media with effusion (OME) has not been shortened after the increase in VTI payment. Waiting time in private hospitals is shorter than that in public hospitals. Increased payment for VTI has no effect on the physicians' decision making regarding to waiting time for children with OME in Taiwan.

[Cost-effectiveness analysis of pneumococcal vaccination in Spain]. / Análisis de coste-efectividad de la vacunación antineumocócica en España.

OBJECTIVE: To perform a cost-effectiveness analysis of pediatric pneumococcal vaccination in Spain. METHODS: A deterministic population-based model in the form of a decision-tree with a 1-year time horizon was used to estimate the impact of vaccination with Synflorix® or Prevenar13® in children aged less than 2 years in Spain from the perspective of the National Health System. Epidemiological data were obtained from the hospital discharge minimum data set (MDS) and the literature. Data on costs were obtained from national health costs databases. The main outcomes measured were the number of cases avoided of invasive pneumococcal disease, acute otitis media (AOM) and myringotomies, and hospital admissions for pneumonia. All costs were expressed in 2010 euros. Effectiveness was measured as the number of quality-adjusted life years (QALYs) gained. RESULTS: The efficacy of Synflorix® in preventing episodes of AOM caused by non-typeable Haemophilus influenzae could lead to additional prevention of 41,513 episodes of AOM, 36,324 antibiotic prescriptions and 382 myringotomy procedures and 143 QALYs gained compared with Prevenar13®. The total vaccination cost with Synflorix® would result in savings of 22 million euros. CONCLUSIONS: Pneumococcal vaccination with Synflorix® in comparison with Prevenar13® in children aged less than 2 years old in Spain could achieve a higher number of QALYs and a substantial cost offset. Vaccination with Synflorix® would be a dominant strategy in terms of cost-effectiveness.

Disparities in children with otitis media: the effect of insurance status.

OBJECTIVES: To determine the difference between children with private and public insurance at the time of referral to a pediatric otolaryngologist. STUDY DESIGN: Prospective study. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: Data relating to the severity of a patient's otitis media (number of infections, doctor visits, antibiotic courses) were collected by phone interview. All patients referred to a pediatric otolaryngologist at an urban tertiary care hospital over a 5-month period were included. RESULTS: One hundred eighty-three children were studied: 87 consecutive patients in the private third-party insurance group (PIN) and 96 patients in the state-based Medicaid insurance group (PA). During the 6 months prior to referral, children in the PIN group had a median 4 acute otitis media infections with 5 courses of oral antibiotics and 6 primary care visits compared to 3 infections with 3 courses of antibiotics and 4 primary care visits for the PA group (P = .0009, P ≤ .0001, P = .0003, respectively). For recurrent acute otitis media, the PA group had a significantly longer time with disease prior to referral than the PIN group (P = .0478). CONCLUSION: Children in this metropolitan area referred for tympanostomy tube placement with PIN are younger, have more episodes of acute otitis media, receive more antibiotic courses, and have more primary care visits in the 6 months prior to referral than their PA counterparts. Additional research is required to determine why these differences exist, especially in light of ongoing changes to the health care system.

New vaccines against otitis media: projected benefits and cost-effectiveness.

OBJECTIVE: New vaccines that offer protection against otitis media caused by nontypeable Haemophilus influenzae and by Moraxella catarrhalis are under development. However, the potential health benefits and economic effects of such candidate vaccines have not been systematically assessed. METHODS: We created a computerized model to compare the projected benefits and costs of (1) the currently available 7-valent pneumococcal conjugate vaccine, (2) a candidate pneumococcal-nontypeable H influenzae vaccine that has been tested in Europe, (3) a hypothetical pneumococcal-nontypeable H influenzae-Moraxella vaccine, and (4) no vaccination. The clinical probabilities of acute otitis media and of otitis media with effusion were generated from multivariate analyses of data from 2 large health maintenance organizations and from the Pittsburgh Child Development/Otitis Media Study cohort. Other probabilities, costs, and quality-of-life values were derived from published and unpublished sources. The base-case analysis assumed vaccine dose costs of $65 for the 7-valent pneumococcal conjugate vaccine, $100 for the pneumococcal-nontypeable H influenzae vaccine, and $125 for the pneumococcal-nontypeable H influenzae-Moraxella vaccine. RESULTS: With no vaccination, we projected that 13.7 million episodes of acute otitis media would occur annually in US children aged 0 to 4 years, at an annual cost of $3.8 billion. The 7-valent pneumococcal conjugate vaccine was projected to prevent 878,000 acute otitis media episodes, or 6.4% of those that would occur with no vaccination; the corresponding value for the pneumococcal-nontypeable H influenzae vaccine was 3.7 million (27%) and for the pneumococcal-nontypeable H influenzae-Moraxella vaccine was 4.2 million (31%). Using the base-case vaccine costs, pneumococcal-nontypeable H influenzae vaccine use would result in net savings compared with nontypeable 7-valent pneumococcal conjugate use. Conversely, pneumococcal-nontypeable H influenzae-Moraxella vaccine use would not result in savings compared with pneumococcal-nontypeable H influenzae vaccine use, but would cost $48 000 more per quality-adjusted life-year saved. The results were sensitive to variations in assumptions on vaccine effectiveness and vaccine dose costs but not to variations in other assumptions. CONCLUSIONS: New candidate vaccines against otitis media have the potential to prevent millions of disease episodes in the United States annually. If priced comparably with other recently introduced vaccines, these new otitis vaccines could achieve cost-effectiveness comparable with or more favorable than that of the 7-valent pneumococcal conjugate vaccine.

Existence of important variations in the United States in the treatment of pediatric mastoiditis.

OBJECTIVE: To determine national variations in resource utilization in the treatment of pediatric mastoiditis. DESIGN: Retrospective review. SETTING: National pediatric inpatient database. PATIENTS: The Kids' Inpatient Database for 2003 was used to extract data for admissions for mastoiditis. RESULTS: A total of 1049 patients (57% were male, and the mean age was 6.3 years) were identified. Median total charges for an admission were $9600; total charges were less than $28,604 in 90% of admissions. The mean length of stay (LOS) was 4.3 days (range, 0-87 days). A total of 792 procedures were performed; 50.0% of patients underwent tympanostomy tube placement and/or myringocentesis, and 21.6% underwent mastoidectomy. The LOS for nonsurgical patients was 3.7 days. The LOS for children undergoing tube placement was 4.6 days, with mean total charges of $15,713; for mastoidectomy, the LOS was 5.5 days, with mean total charges of $23,185. The primary payer was private insurance in 51.5% and Medicaid in 39.4%. Predictors of increased charges were treatment at teaching hospitals (P = .005), treatment at children's hospitals (P < .001), LOS (P < .001), the number of procedures (P < .001), and hospital region (P = .003). Wide geographic variation was noted with respect to the mean total charges per admission, which ranged from $5016 to $35,898. CONCLUSIONS: In 2003, the median charge for a pediatric mastoiditis admission was $9600; 50% of patients underwent tympanostomy tube placement, and about 21.6% underwent a mastoidectomy. There was wide variation in total charges for admissions. Resource utilization was higher in teaching hospitals and in children's' hospitals.

Decreasing rates of middle ear surgery in Western Australian children.

OBJECTIVE: To investigate temporal, social, demographic, and health care utilization factors associated with myringotomy with ventilation tube insertion (MVTI) in Western Australian (WA) children. DESIGN: Observational retrospective population-based cohort study using hospital administrative data. SETTING: All WA hospitals. PARTICIPANTS: A total of 53 673 children younger than 15 years who underwent surgery for MVTI in the period 1981-2004. MAIN OUTCOME MEASURES: Age-specific incidence rates and incidence rate ratios. RESULTS: The rate of MVTI in children younger than 15 years peaked in 1997 at 6.7 per 1000 person-years and decreased to 5.6 per 1000 person-years by 2004. Based on 2004 rates, 8.4% of WA children will undergo at least 1 MVTI procedure before reaching age 15 years. The rate of MVTI was 37% lower in Indigenous children, and the procedures were performed at an older age compared with non-Indigenous children. Higher rates of MVTI were associated with areas of higher economic resources, lower education and occupation status, and living in metropolitan areas. CONCLUSIONS: The rate of MVTI in WA is showing evidence of a decline, even among children younger than 5 years. There remains an issue regarding equity of access to care for Indigenous children. Increasing parental economic resources may be associated with higher rates of MVTI independent of educational status.

[Comparative analysis of the therapeutic costs to control the recurrent acute otitis media]. / Análisis comparativo de los costos terapéuticos para el control de la otitis media aguda de repetición.

In order to assess a cost analysis in the management of recurrent acute otitis media (RAOM) in children, we performed a prospective study with data obtained from 80 patients with RAOM, evaluated between january 1998 and february 2000. A good outcome with the antibiotic prophylaxis was obtained in 67 cases (83,7%), with either amoxicillin or azythromicin. Applying the model of assumptions the control of RAOM with ear tube insertion was obtained in 66 children (82,5%). Thus, the cost of antibiotic chemoprophylaxis was Euro 83,60 for the amoxicillin patients and Euro 116,60 for the azythromicin ones. Surgical approach of this entity with the use of ear tubes costs Euro 392,95 per case. To sum up, in pediatric patients, without medical contraindications, the initial treatment for RAOM is chemoprophylaxis, with ear tubes reserved its failure.

Análisis comparativo de los costos terapéuticos para el control de la otitis media aguda de repetición / Comparative analysis of the therapeutic costs to control the recurrent acute otitis media

Con el objeto de calcular los costos en el manejo de la otitis media aguda de repetición (OMAR), se realizó un estudio prospectivo sobre 80 pacientes vistos entre enero de 1998 y febrero de 2000. En 67 de los 80 pacientes (83,7%) se controlaron los episodios de O MAR mediante una profilaxis antibiótica (bien con amoxicilina o con azitromicina). Según el modelo de estimación estadística, en 66 niños se hubiese conseguido el mismo objetivo utilizando los TDT (82,5%). El coste por enfermo de cada tipo de terapia fue: 83,60€ para los enfermos tratados con amoxicilina, 116,60 € para los tratados con azitromicina y 392,95 € en los operados. Así, en niños sin contraindicaciones médicas, el manejo inicial más conveniente de la OMAR parece ser la profilaxis antibiótica, reservando los TDT para sus fracasos

In arder to assess a cost analysis in the management of recurrent acute otitis media (RAOM) in children, we performed a prospective study with data obtained from 80 patients with RAOM, evaluated between january 1998 and february 2000. A good outcome with the antibiotic prophylaxis was obtained in 67 cases (83,7%), with either amoxicillin or azythromicin. Applying the model of assumptions the control of RAOM with ear robe insertion was obtained in 66 children (82,5%). Thus, the cost of antibiotic chemoprophylaxis was € 83,60 for the amoxicillin patients and € 116,60 for the azythromicin ones. Surgical approach of this entity with the useof ear robes costs € 392,95 per case. To sum up, in pediatric patients, without medical contraindications, the initial treatment for RAOM is chemoprophylaxis, with ear robes reserved its failure

A cost threshold analysis of ciprofloxacin-dexamethasone versus ofloxacin for acute otitis media in pediatric patients with tympanostomy tubes.

OBJECTIVE: The aim of this study was to determine the cost-effectiveness hreshold of a ciprofloxacin 0.3% and dexamethasone 0.1% (CD) otic suspension relative to olfloxacin otic solution (OFX) for the treatment of acute otitis media in pediatric patients with tympanostomy tubes (AOMT). METHODS: This study used a decision-analytic model to simulate the costs and consequences of the ototopical treatment of AOMT. The AOMT model consisted of 3 tiers of antimicrobial therapy. Each successive tier represented the repeat treatment of clinical failures from the preceding tier. Patients were modeled for treatment until cured or until third-tier therapy was complete, at which time patients were considered cured. First-tier therapy modeled a comparison of CD and OFX using efficacy rates taken from a randomized clinical trial with a population of 599 patients. Second-tier therapy modeled the use of amoxicillin and clavulanic acid using an efficacy rate taken from the medical literature. Third-tier therapy was modeled as being pathogen specific and could follow 1 of 3 possible clinical pathways: (1) PO fluconazole, (2) IM ceftriaxone, or (3) IV antibiotics administered in a hospital setting. Third-tier therapeutic pathway probabilities were based on the microbiologic spectrum of the treatment failures from the clinical trial. Cost information (in year-2003 US dollars) was taken from accepted cost reference sources and presented from the perspective of a third-party payer. The economic outcome of interest was the cost-effectiveness threshold of CD relative to OFX. RESULTS: Given the model parameters, CD had a cost-effectiveness threshold value of 4.5 times the wholesale acquisition cost of OFX. Based on actual cost, first-tier CD therapy was more cost-effective than OFX up to a threshold price of US 152.64 dollars. CONCLUSION: In this decision-analytic model, CD was more cost-effective than OFX for AOMT therapy in pediatric patients up to a threshold price of 4.5 times the price of OFX.