In-office insertion tympanostomy tubes in children using single-pass device

Economic impact of in-office pediatric tympanostomy tube placement using a tympanostomy tube delivery device in a commercially- and Medicaid-insured US population

AIMS

Pediatric tympanostomy tube placement (TTP) is performed primarily in operating room (OR) settings under general anesthesia. Recent studies have demonstrated TTP completed in the otolaryngologist's office with a topical anesthetic and delivery device to be safe and effective. This study estimated the financial impact to commercial and Medicaid health plans by shifting pediatric TTP from the OR to an office setting.

MATERIALS AND METHODS

This budget impact model estimated the financial impact of using the Hummingbirdi Tympanostomy Tube System (HTTS) for in-office pediatric tympanostomy tube placement by shifting 25% of utilization away from the OR - hospital outpatient department (HOPD) or ambulatory surgery center (ASC) - in a commercially- and Medicaid-insured population.

RESULTS

The annual TTP estimate in a one-million-member health plan was 2,872 for a commercial plan and 4,534 for a Medicaid plan. Cost inputs for HOPD and ASC procedures were $5,743 and $3,609 (Commercial) and $2,199 and $1,663 (Medicaid), respectively. Cost inputs for in-office procedures utilizing HTTS were $2,000 (Commercial) and $1,600 (Medicaid). All surgical cost estimates assumed a bilateral (two ear) procedure. A 25% shift led to cost savings of $1,991,790 (14.5%) for commercial plans and $365,562 (4.2%) for Medicaid plans; translating into $0.17 per member per month (PMPM) and $58 per treated member per month (PTMPM) savings in a commercial plan and $0.03 PMPM and $7 PTMPM in Medicaid. Per patient cost of TTP decreased by $3,743/65.2% (HOPD) or $1,609/44.6% (ASC) for Commercial and $519/24.5% (HOPD) and $63/3.8% (ASC) for Medicaid.

LIMITATIONS

Costs in HOPD and ASC setting were based on averages in the MarketScan administrative claims databases which are limited by contributor, data coding, and entry errors.

CONCLUSIONS

In-office TTP utilizing HTTS substantially reduces cost for U.S. commercial and Medicaid health insurers, offering a significant opportunity to deliver value-based care.

In-office Tympanostomy Tube Placement in Children

Tympanostomy tube placement is routinely performed in adults in the office setting without sedation and with only topical or locally applied anesthetic. Innovative tools are now available to facilitate placement of tympanostomy tubes in children in the office, rather than under general anesthesia. We discuss the current state of an in-office approach to tympanostomy tube placement in children. An experienced team and a well-defined workflow are key to the successful placement of tympanostomy tubes in children without sedation. Shared decision-making between clinicians and caregivers will help determine the most appropriate setting for their child's ear tube placement.

Protocol implementation for in-office manual tympanostomy tube insertion

Bilateral myringotomy/tympanostomy tube insertion (BTI) can decrease the frequency, severity, and quality of life burden of acute otitis media and chronic otitis media with effusion for pediatric patients and their caregivers. Implementing a practice protocol for in-office BTI (IO-BTI) can benefit patients by eliminating the risks associated with general anesthesia, pre-procedure fasting, and post-anesthetic effects such as emergence delirium. However, adaptation of IO-BTI has largely relied on proprietary devices that may limit cost savings and access to care. The goal of this study was to develop a protocol for manual IO-BTI without single use device to yield the aforementioned benefits, as well as lower health care costs to families and improve access to and timeliness of care. Described is a protocol for manual IO-BTI in an ambulatory clinic setting. The caregivers of 178 pediatric patients who underwent IO-BTI between 04/01/2023-07/31/2024 were administered a binary satisfaction survey. Surgical outcomes such as post-operative pain, early tympanostomy tube extrusion, and tympanostomy tube plugging were examined via retrospective chart review. The cost of BTI with general anesthesia in the operating room (OR) setting, device manual IO-BTI, and IO-BTI with single use devices were also examined. Survey responses demonstrated a 99 % post-procedure satisfaction rate among patient caregivers. There were low frequencies of post-operative pain (0.7 %), premature tympanostomy tube extrusion (0.8 %), and plugging of tympanostomy tubes (1.5 %). Gross cost analysis of device manual IO-BTI compared to IO-BTI with single use devices and BTI with general anesthesia in the OR revealed a 1.5x and 6x cost increase, respectively. The presented study demonstrates that manual IO-BTI is safe, feasible, cost effective, and yields high caregiver satisfaction and positive surgical outcomes for pediatric patients.

Assessment of In-Office Tympanostomy Tube Insertion Tolerability in Children Under 2 Years

Objective: In-office tympanostomy tube insertion (TTI) is becoming more available in the practice of pediatric otolaryngology. This study evaluated the tolerability of this procedure in young children. Method: Four methods were used to assess tolerability. (1) Standardized video recordings were collected from 30 patients under 24 months who underwent in-office TTI with a single-pass insertion device with topical anesthesia alone. The videos were then reviewed by 3 independent experts in pediatric care and rated at 5 procedural time points using a defined response scale developed with the U.S. Food and Drug Administration. (2) Separately, overall tolerability was subjectively assessed by the same experts. (3) Patient recovery was assessed by the participating otolaryngologist and support staff. (4) Patient caregivers were surveyed for their impressions of the procedure, including whether they would recommend it to other caregivers. Results: In a total of 90 reviews, 100% of children were successfully treated and were rated as having acceptably tolerated the in-office tympanostomy tube procedure. All patients returned to an acceptable baseline without inappropriate crying and were assessed as fully recovered immediately following the procedure or by the time the child was leaving clinic. For caregivers, 93% agreed or strongly agreed that they would recommend the use of in-office TTI to other caregivers. Conclusions: In-office TTI in young children was determined to be universally well tolerated in young children and is a procedure that patient caregivers would recommend to other caregivers for their children. These results should help reassure otolaryngology specialists and caregivers alike that in-office ear tube placement is a viable option for young children with middle ear disease.

Use of Topical Phenol in Awake Young Children for Tympanostomy Tube Placement

Importance: Phenol kits cleared by the Food and Drug Administration (FDA) are indicated as a topical anesthetic for the tympanic membrane (TM) in adults. However, there is no existing literature that reports outcomes to support the safety and use of phenol on the TM of awake children. Objective: Determine if topical phenol is safe and at low risk for complications and therefore be used effectively in awake children to facilitate office otologic procedures as in adults. Design, Setting, and Participants: Children under 21 years of age whose parents agreed to participate in an awake office setting for tympanostomy tube (TT) placement. All children had TT placement after phenol placement on the TM prior to insertion. Main Outcomes and Measures: TM perforation or other signs of TM complications through a minimum of 6-month clinical follow-up, along with assessment of the tolerability of the procedure by the child. Results: A total of 228 children with an age range of 6 months to 15.9 years and 435 TMs completed TT placement using phenol as a local anesthetic while awake in the office. There were no complications reported in the 204 children at the first follow-up visit post TM placement within 3 to 10 weeks. Of the 93 children followed up at least 6 months, there were no TM complications reported. Conclusions: This is the first study to report the outcomes on the use of phenol in an office setting in children. In this large experience, phenol appears to be tolerable and safe for use in young children in the office and is a potential safe choice of topical anesthesia for surgeons if they choose to perform office procedures such as myringotomies or TT placement on children.

Office Insertion of Tympanostomy Tubes and the Role of Automated Insertion Devices

OBJECTIVE

Insertion of tubes in an office setting and automated tube insertion devices were identified as high-priority quality improvement opportunities during the update process for the 2013 clinical practice guideline on tympanostomy tubes from the American Academy of Otolaryngology-Head and Neck Surgery. The guideline update group, however, decided to avoid any recommendations on these topics, based on limited research evidence, and instead selected a subset of group members to author this state of the art review, with the goal of facilitating informed decisions in clinical practice.

DATA SOURCES

PubMed through September 2021, Google search of device manufacturer websites, and SmartTots research website for articles on anesthesia neurotoxicity.

REVIEW METHODS

A state of the art review format emphasizing evidence from the past 5 years, with manual cross-checks of reference lists of identified articles for additional relevant studies.

CONCLUSIONS

The existing literature is too sparse to make recommendations about procedure setting and optimal technique or assess long-term outcomes. The role of automated devices is uncertain, given the increased equipment cost and limited information on characteristics of the proprietary preloaded tubes, including intubation duration and rates of otorrhea, obstruction, medialization, granulation tissue, and persistent perforation.

IMPLICATIONS FOR PRACTICE

Whether to undertake in-office tube insertion in awake children should be based on clinician experience, clinician ability to interact with and reassure caregivers, shared decisions with caregivers, and judgment regarding the level of cooperation (or lack thereof) to be expected from a given child. Clinicians should remain alert to new research and expect increasing queries from patients and families.