Finnish adenoidectomy and tympanostomy rates in children; national variation

The impact of new evidence on regional variation in paediatric tonsillectomy and adenoidectomy: a historical review

BACKGROUND

Tonsillectomy and adenoidectomy have been among the most commonly performed procedures in children for approximately 100 years. These procedures were the first for which unwarranted regional variation was discovered, in 1938. Indications for these procedures have become stricter over time, which might have reduced regional practice variation.

METHODS

This paper presents a historical review on practice variation in paediatric tonsillectomy and adenoidectomy rates. Data on publication year, region, level of variation, methodology and outcomes were collected.

RESULTS

Twenty-one articles on practice variation in paediatric tonsil surgery were included, with data from 12 different countries. Significant variation was found throughout the years, although a greater than 10-fold variation was observed only in the earliest publications.

CONCLUSION

No evidence has yet been found that better indications for tonsillectomy and adenoidectomy have reduced practice variation. International efforts are needed to reconsider why we are still unable to tackle this variation.

Evaluation of Multidisciplinary Team Clinic for Patients With Isolated Cleft Lip

OBJECTIVE

To report the incidences of secondary lip and nose operations, otolaryngology procedures, speech-language therapy, neurodevelopmental concerns, and dental and orthodontic issues in children with isolated cleft lip to inform multidisciplinary cleft team protocols.

SETTING

An American Cleft Palate-Craniofacial Association-approved team at a tertiary academic children's hospital.

DESIGN

Retrospective cohort study of patients evaluated through longitudinal clinic visits by a multidisciplinary cleft palate and craniofacial team between January 2000 and June 2018.

PATIENTS, PARTICIPANTS

Children with nonsyndromic cleft lip with or without cleft alveolus (n = 92).

RESULTS

Median age at final team visit was 4.9 years (interquartile range: 2.4-8.2 years). Secondary plastic surgery procedures were most common between ages 3 and 5 (135 per 1000 person-years), and the majority of these procedures were minor lip revisions. The rate of tympanostomy tube insertion was highest before age 3 (122 per 1000 person-years). By their final team visit, 88% of patients had normal hearing and 11% had only slight to mild conductive hearing loss. No patients had speech errors attributable to lip abnormalities. Psychological interventions, learning disabilities, and dental or orthodontic concerns were uncommon.

CONCLUSIONS

Most patients with isolated cleft lip may not require long-term, longitudinal evaluation by cleft team specialists. Cleft teams should develop limited follow-up protocols for these children to improve resource allocation and promote value-based care in this patient population.

Variation in Utilization and Need for Tympanostomy Tubes across England and New England

OBJECTIVES

To compare rates of typmanostomy tube insertions for otitis media with effusion with estimates of need in 2 countries.

STUDY DESIGN

This cross-sectional analysis used all-payer claims to calculate rates of tympanostomy tube insertions for insured children ages 2-8 years (2007-2010) across pediatric surgical areas (PSA) for Northern New England (NNE; Maine, Vermont, and New Hampshire) and the English National Health Service Primary Care Trusts (PCT). Rates were compared with expected rates estimated using a Monte Carlo simulation model that integrates clinical guidelines and published probabilities of the incidence and course of otitis media with effusion.

RESULTS

Observed rates of tympanostomy tube placement varied >30-fold across English PCT (N = 150) and >3-fold across NNE PSA (N = 30). At a 25 dB hearing threshold, the overall difference in observed to expected tympanostomy tubes provided was -3.41 per 1000 child-years in England and -0.01 per 1000 child-years in NNE. Observed incidence of insertion was less than expected in 143 of 151 PCT, and was higher than expected in one-half of the PSA. Using a 20 dB hearing threshold, there were fewer tube insertions than expected in all but 2 England and 7 NNE areas. There was an inverse relationship between estimated need and observed tube insertion rates.

CONCLUSIONS

Regional variations in observed tympanostomy tube insertion rates are unlikely to be due to differences in need and suggest overall underuse in England and both overuse and underuse in NNE.

Effectiveness of the Ten-valent Pneumococcal Conjugate Vaccine Against Tympanostomy Tube Placements in a Cluster-randomized Trial

BACKGROUND

We evaluated the impact of the new pneumococcal Haemophilus influenzae protein D conjugate vaccine (PHiD-CV10, GSK Vaccines) on tympanostomy tube placements (TTPs).

METHODS

Finnish Invasive Pneumococcal disease vaccine trial was a nationwide phase III/IV cluster-randomized, double-blind trial. Children younger than 19 months received PHiD-CV10 in two thirds of clusters (N = 52) or hepatitis B or A vaccine as control in 26 clusters according to 3 + 1 or 2 + 1 schedules (infants younger than 7 months) or catch-up schedules. A secondary objective of the trial was to assess vaccine effectiveness (VE) against TTPs in children who received at least one vaccine dose before or after 7 months of age. Blinded follow-up lasted from the date of first vaccination (from February 2009 through October 2010) to December 31, 2011. Outcome data were collected through the National Care register and Social Insurance Institution reimbursement register.

RESULTS

More than 47,000 children were enrolled. In 30,527 infants younger than 7 months of age at enrolment, 4369 TTPs were reported in 3594 subjects. The incidence was 7.9 per 100 person-years in the infant control cohort. The VE estimate was 13% [95% confidence interval (CI): -2% to 26%] for combined PHiD-CV10 3 + 1 and 2 + 1 infant schedules. The VE estimates for the 3 + 1 and 2 + 1 infant schedules when estimated separately were similar. For the catch-up schedules, the VE was 11% (95% CI: -7% to 26%) for children enrolled at 7-11 months of age and -1% (95% CI: -21% to 16%) for children enrolled at 12-18 months of age.

CONCLUSIONS

Our study results suggest that PHiD-CV10 immunization according to a 3 + 1 or 2 + 1 schedule initiated before 12 months of age may reduce the frequency of TTPs, although the primary analysis did not reach statistical significance.

Implementation of neonatal screening for hearing impairment: influence on pediatric otitis media surgery in The Netherlands

OBJECTIVE

Screening for hearing impairment in the Netherlands took place at the age of 9 months for many years but was recently moved to the neonatal period. Since otitis media has its highest prevalence at the age of 9 months, it might be that screening for hearing impairment at this age is linked to treatment of otitis media. We were interested in what the impact would be on the number of children treated with ventilation tubes or adenoidectomy when they were no longer screened at the age of 9 months.

METHODS

National birth rates, data regarding screening for hearing impairment at the age of 9 months and at the neonatal period, as well as data regarding adenoidectomy and tube placement were used to study treatment of otitis media in children aged 0-2 years in the Netherlands.

RESULTS

The percentage of children treated with ventilation tubes after implementation of neonatal screening for hearing impairment did not decline (OR 1.198-1.112), and more children were treated at a younger age. The number of children treated with adenoidectomy did however decline (OR 0.724-0.890).

CONCLUSION

There seems to be an association between the implementation of neonatal screening for hearing impairment and the treatment of otitis media. During the whole studied period there was a slight but statistical significant increase in the odds for tube placement in all children aged 0-23 months. After implementation of the neonatal screen there was a distinct increase in the number of children aged 6-11 months treated with tubes. In the same period a statistical significant decline in the odds of undergoing adenoidectomy was observed.

Variability of adenoidectomy/tonsillectomy rates among children of the Veneto Region, Italy

BACKGROUND

Despite national guidelines in 2003 aimed at limiting the recourse to tonsillectomy and/or adenoidectomy (A/T), the latter are among the most frequent pediatric surgeries performed in Italy. Aim of the study is to investigate variability of A/T rates among children of the Veneto Region, Italy.

METHODS

All discharges of Veneto residents with Diagnosis-Related Groups 57-60 and ICD9-CM intervention codes 28.2 (tonsillectomy), 28.3 (adenotonsillectomy), 28.6 (adenoidectomy) were selected in the period 2000-2006 for a descriptive analysis. A multilevel Poisson regression model was applied to estimate Incidence Rate Ratios (IRR) with 95% Confidence Intervals (CI) for A/T surgery among children aged 2-9 years in 2004-2006, while taking into account clustering of interventions within the 21 Local Health Units.

RESULTS

Through 2000-2006, the overall number of A/T surgeries decreased (-8%); there was a decline of adenoidectomies (-20%) and tonsillectomies (-8%), whereas adenotonsillectomies raised (+18%). Analyses on children aged 2-9 resulted in an overall rate of 14.4 surgeries per 1000 person-years (16.1 among males and 12.5 among females), with a wide heterogeneity across Local Health Units (range 8.1-27.6). At random intercept Poisson regression, while adjusting for sex and age, intervention rates were markedly lower among foreign than among Italian children (IRR = 0.57, CI 0.53-0.61). A/T rates in the 10-40 age group (mainly tonsillectomies) computed for each Local Health Unit and introduced in the regression model accounted for 40% of the variance at Local Health Unit level of pediatric rates (mainly adenoidectomies and adenotonsillectomies).

CONCLUSION

A/T rates in the Veneto Region, especially adenoidectomies among children aged 2-9 years, remain high notwithstanding a decrease through 2000-2006. A wide heterogeneity according to nationality and Local Health Units is evident. The propensity to A/T surgery of each Local Health Unit is similar in different age groups and for different surgical indications.

Trends in otitis media surgery: a decrease in adenoidectomy

OBJECTIVE

Large variability in adenoidectomies and tympanostomy tube insertions between Norway and Finland has been suggested, but not yet confirmed. Objective is to compare trends in paediatric adenoidectomies and tympanostomy tube insertions for Norway and Finland from 1999 to 2005.

METHODS

National Finnish and Norwegian databases (STAKES and NPR) provided information on children between 0 and 7 years operated in the years 1999-2005. Surgical rates were viewed in the light of child density, age and gender, and compared bi-nationally.

RESULTS

Adenoidectomies were more common in Finland throughout the study period. Adenoidectomies in both countries decreased markedly from 1999 to 2005. The Finnish adenoidectomy rates were reduced from 212 to 133 per 10,000 children, equivalent Norwegian figures were 84 and 44 per 10,000 children. Tympanostomy tube insertions increased from 97 to 147 per 10,000 children in Finland in the same study period. In Norway the rates were more stable, 119 and 123 per 10,000 in 1999 and 2005, respectively. Peak-age for otitis media surgery was the second year of life in Finland, sixth in Norway. Boys were more frequently operated on in both countries.

CONCLUSION

Our study confirmed differences in the approach to otitis media surgery and revealed a decreasing trend in adenoidectomies in both countries. Similar data from other countries is needed to confirm the latter.