Visits For Otitis Media Research Articles

The impact of adenotonsillectomy on healthcare utilization in children with obstructive sleep apnea: Experience of an integrated medical model

Background and objectivesStudies suggest that children with obstructive sleep apnea (OSA) have increased healthcare utilization patterns in comparison to matched controls. However, the effect of adenotonsillectomy (AT) on utilization patterns in these children is poorly understood. Additionally, no previous studies have compared the effect of AT on healthcare utilization patterns across different OSA severity groups. The aim of this retrospective cohort study is to assess the effects of surgical treatment on the level of healthcare utilization among children with OSA at a large integrated multicenter healthcare system. MethodsRetrospective analysis was performed of children aged 3–12 diagnosed with OSA via an attended polysomnogram (PSG) between December 2016 and February 2019. Demographic variables including age (at time of PSG), body mass index (BMI), race, and ethnicity were obtained. Variables for healthcare utilization were assessed for 12 months prior to PSG, and for 12 months after PSG (or after AT, delayed for the first 30 days after surgery to account for surgery-related visits). Healthcare utilization variables assessed included the total number of outpatient visits, inpatient, and emergency department (ED) visits, visits involving diagnostic codes associated with upper respiratory infection (URI), otitis media (OM), and allergic rhinitis (AR), prescription data involving intranasal steroids or leukotriene receptor antagonists (LTRA), and communication data such as secure message load and specialty referrals. Repeated measure linear difference-in-difference (D-I-D) models were used to assess the causal impact of AT on healthcare utilization outcomes. Sensitivity analyses were performed using modeling with a Poisson distribution and as an unadjusted model, with statistical significance set to p < 0.05. ResultsAnalysis elicited 577 children identified with OSA. Of these, 336 (58.2 %) underwent observation while 241 (41.8 %) underwent AT. The mean age was 6.4 years, with a slight male predominance (60.5 %). Analysis of baseline healthcare utilization patterns revealed that the treatment group had a significantly higher number of baseline inpatient/ED visits and OM visits in comparison to the observation group, but no differences in regards to baseline outpatient visits, or in visits involving URI or AR.Analysis of the entire OSA cohort via D-I-D modelling showed a significantly larger reduction in outpatient visits, secure messages, specialty referrals, and the use of intranasal steroid and LTRA in the treatment group compared to the observation group. Stratification of children based on OSA severity showed that the significant differences in healthcare utilization attributed to surgical treatment were primarily driven by the severe OSA group. Children with severe OSA who underwent AT showed significant reductions in most variables including outpatient visits, inpatient/ED visits, and OM visits. Alternatively, the only significant reductions in healthcare utilization among children with mild OSA treated with AT were in AR visits, intranasal steroid use, and LTRA use. Pattern changes among children with moderate OSA compared similarly to those with mild OSA. ConclusionTo the authors’ knowledge this study represents the largest available study assessing the impact of AT on healthcare utilization in children with OSA that also considers the effect of OSA severity on utilization patterns. AT appears to decrease healthcare utilization patterns, particularly in children with severe OSA. Alternatively, children with mild or moderate OSA treated with AT had only modest reductions in healthcare utilization patterns.

National impact of 13-valent pneumococcal conjugate vaccine on ambulatory care visits for otitis media in children under 5 years in the United States

ObjectiveThe 7- and 13-valent pneumococcal conjugate vaccines (PCV7 and PCV13) were approved in the US in 2000 and 2010, respectively, for active immunization against invasive disease caused by all vaccine serotypes and otitis media (OM) caused by 7 serotypes common to both vaccines, starting at ∼6 weeks of age. This study assessed the impact of PCV13 on OM by evaluating changes in US ambulatory care visit rates between the period before PCV7 (1997–1999), during PCV7 (2001–2009), and after the introduction of PCV13 (2011–2013) among US children <5 years old. MethodsThis ecological study used US National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data. Trend analyses using weighted least-squares regression and mean visit rates were calculated for OM and two control endpoints not likely to be related to either vaccine (skin rash and trauma). ResultsAmong children <5 and < 2 years old, the observed reduction in OM visit rates was 22% (95%CI: 12%–32%) and 24% (95%CI: 13%–35%) when comparing PCV13 to PCV7 periods, and 41% (95%CI: 30%–52%) and 48% (95%CI: 37%–59%) when comparing PCV13 to pre-PCV7 periods. Visit rates for skin rash and trauma remained stable. ConclusionSignificant reductions in US ambulatory care visit rates for OM were observed among children aged <5 years after introduction of PCV13 compared to the periods before and during PCV7; reductions were greatest among children <2 years old. The reductions beyond the PCV7 period support the effectiveness of the vaccine's 6 additional serotypes in preventing OM.

Air pollution influences the incidence of otitis media in children: A national population-based study.

BackgroundOtitis media (OM) is a major reason for children’s visits to physicians and a major cause of their being treated with antibiotics. It not only causes economic burdens but also influences hearing, speech, and education. To our knowledge, no nationwide population-based study has assessed the association between air pollution and OM. Therefore, this study evaluated the association between air pollution levels and the incidence of OM.MethodsWe identified cases of OM that occurred in South Korea between January 2011 and December 2012 from the Korea National Health Insurance Service-National Sample Cohort database, and evaluated its relationship with five air pollutants: particulate matter (PM10, particulates ≤10 μm in diameter), nitrogen dioxide (NO2), ozone (O3), sulfur dioxide, and carbon monoxide. Associations between the weekly incidence of OM and the five air pollutants were analyzed using generalized estimating equations. Conditional logistic regression analysis was used to obtain odds ratios (ORs) and their 99.9% Bonferroni-corrected confidence intervals after adjusting for gender, age, season, and region.ResultsWe based our analysis on 160,875 hospital visits for OM by children aged <15 years. Correlations with higher concentrations of the five pollutants showed higher ORs than did the reference values at most time lags. PM10 had the largest influence on the OM incidence at a time lag of 0 weeks, whereas NO2 and O3 had the largest impacts on OM incidence at time lags of 1 and 4 weeks, respectively.ConclusionThese findings support the notion that the incidence of OM is associated with ambient air pollution.

Ambulatory Visits for Otitis Media before and after the Introduction of Pneumococcal Conjugate Vaccination

To examine the long-term trend of otitis media (OM)-associated ambulatory visits from 1997 to 2014 and to evaluate the impact of 7-valent and 13-valent pneumococcal conjugate vaccines (PCV7 and PCV13) on OM ambulatory visits. We examined OM-associated ambulatory visits in children, using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. A total of 24 148 OM-related visits were identified from 363 240 ambulatory visits. OM visits accounted for 9.5% of all ambulatory visits in 1997-1999, 7.1% in 2002-2009, and 5.5% in 2012-2014. Between the pre-PCV7 and the post-PCV13 period, annual physician's office visits for OM declined from 826 to 387 visits per 1000 children among children younger than 2 years of age. Compared with the pre-PCV7 period, office visit rates for OM significantly declined by 51% (95% CI 42%-58%) among children younger than 2 years of age and by 37% (95% CI 23%-48%) among children 2-4 years of age during the post-PCV13 period. Among children younger than 2 years of age, emergency department visits for OM declined by 47% (95% CI 36%-55%) during the post-PCV13 period, and hospital outpatient visits declined by 30% (95% CI 8%-48%) during the PCV13-transition period. OM-related visits declined across sex, race/ethnicity, health insurance status, and geographic region. Our nationwide study shows that ambulatory visits for OM have declined following the introduction of PCV7 and PCV13. Future research on the evolving microbiology of OM and continued monitoring of the epidemiology of pneumococcal disease are needed.

Trends in Otitis Media and Myringotomy With Tube Placement Among American Indian and Alaska Native Children and the US General Population of Children After Introduction of the 13-valent Pneumococcal Conjugate Vaccine.

American Indian/Alaska Native (AI/AN) children have experienced higher otitis media (OM) outpatient visit rates than other US children. To understand recent trends, we evaluated AI/AN OM rates before and after 13-valent pneumococcal conjugate vaccine introduction. We analyzed outpatient visits listing OM as a diagnosis among AI/AN children <5 years of age from the Indian Health Service National Patient Information Reporting System for 2010-2013. OM outpatient visits for the general US child population <5 years of age were analyzed using the National Ambulatory Medical Care and National Hospital Ambulatory Care Surveys for 2010-2011. The 2010-2011 OM-associated outpatient visit rate for AI/AN children (63.5 per 100/year) was similar to 2010-2011 rate for same-age children in the general US population (62.8) and decreased from the 2003 to 2005 AI/AN rate (91.4). Further decline in AI/AN OM visit rates was seen for 2010-2011 to 2012-2013 (P < 0.0001). The AI/AN infant OM visit rate (130.5) was 1.6-fold higher than the US infant population. For 2010-2011, the highest AI/AN OM visit rate for <5 year olds was from Alaska (135.0). AI/AN <5-year-old OM visits declined by one third from 2003-2005 to 2010-2011 to a rate similar to the US general population <5 years. However, the AI/AN infant OM rate remained higher than the US infant population. The highest AI/AN <5-year-old OM rate occurred in Alaska.

Panel 6: Vaccines.

Objective To review the literature on progress regarding (1) effectiveness of vaccines for prevention of otitis media (OM) and (2) development of vaccine antigens for OM bacterial and viral pathogens. Data Sources PubMed database of the National Library of Science. Review Methods We performed literature searches in PubMed for OM pathogens and candidate vaccine antigens, and we restricted the searches to articles in English that were published between July 2011 and June 2015. Panel members reviewed literature in their area of expertise. Conclusions Pneumococcal conjugate vaccines (PCVs) are somewhat effective for the prevention of pneumococcal OM, recurrent OM, OM visits, and tympanostomy tube insertions. Widespread use of PCVs has been associated with shifts in pneumococcal serotypes and bacterial pathogens associated with OM, diminishing PCV effectiveness against AOM. The 10-valent pneumococcal vaccine containing Haemophilus influenzae protein D (PHiD-CV) is effective for pneumococcal OM, but results from studies describing the potential impact on OM due to H influenzae have been inconsistent. Progress in vaccine development for H influenzae, Moraxella catarrhalis, and OM-associated respiratory viruses has been limited. Additional research is needed to extend vaccine protection to additional pneumococcal serotypes and other otopathogens. There are likely to be licensure challenges for protein-based vaccines, and data on correlates of protection for OM vaccine antigens are urgently needed. Implications for Practice OM continues to be a significant health care burden globally. Prevention is preferable to treatment, and vaccine development remains an important goal. As a polymicrobial disease, OM poses significant but not insurmountable challenges for vaccine development.

Model estimates of the burden of outpatient visits attributable to influenza in the United States.

BackgroundAlthough many studies have modelled the national burdens of hospitalizations and deaths due to influenza, few studies have considered the outpatient burden. To fill this gap for the United States (US), we applied traditional statistical modelling approaches to time series derived from large medical claims databases held in the private sector.MethodsWe accessed ICD-9-coded office visit data extracted from Truven Health Analytics’ MarketScan Commercial database covering about one third of the US population <65 years during 2001–2009, and Medicare Supplemental data covering about one fifth of US seniors 65+ during 2006–2009. We extracted weekly time series of visits due to respiratory diagnoses, otitis media (OM), and urinary tract infections (UTI), a “negative control”. We used multiple linear regression modelling to estimate age-specific influenza-related excess in office visits.ResultsIn the <65 year age group, in the 8 pre-pandemic seasons studied and for the broadest defined respiratory outcome, the model attributed an average of ~14.5 M (Standard deviation [SD] across seasons 3.9 million) office visits to influenza (rate of 5,581/100,000 population). Of these, ~80 % of visits occurred in the 5–17 and 18–49 age group. In school children aged 5–17 year olds and adult 18–64 year age groups the majority of visits were due to influenza B, while A/H3N2 explained most visits in children <5 year olds. The model further attributed ~2.2 M OM visits (SD across seasons 790,000) annually to influenza, of which 86 % of these occurred in children <18 years; this indicates that 6.4 % of all infants <2 years and 4.9 % of all toddlers aged 2–4 years in the US have an influenza-attributable outpatient visit with an OM diagnosis. In seniors 65 years and older, our model attributed ~0.7 M (SD across seasons 351,000) respiratory visits to influenza (rate of 1,887/100,000 population). The model identified no significant excess UTI (negative control) visits in most seasons.ConclusionsThis is to our knowledge a first study of the outpatient burden of influenza in the US in a large database. The model estimated that 10 % of all children <18 years and 4 % of the entire population <65 years seek outpatient care for respiratory illness attributable to influenza annually.Trial registrationClinicalTrial.gov, NCT02019732.

The Air Quality Health Index and Emergency Department Visits for Otitis Media.

The purpose of this study was to explore novel multipollutant exposure assessments using the Air Quality Health Index in relation to emergency department visits for otitis media (OM). This study was a retrospective analysis using information from emergency department visits for OM, air pollution, and weather databases. For children 3 years of age or younger, there were 4,815 emergency department visits for OM over a 6-year period across hospitals in Windsor, Ontario, Canada. Both time-stratified case-crossover and nonlinear time series distributed lag analyses were applied to investigate the association between the Air Quality Health Index and visits for OM. Using case-crossover analysis, there was an increase in emergency department visits with OM diagnoses 6 to 7 days postexposure to increased ozone and 3 to 4 days after exposure to increased particulate matter. For every 1 unit increase in the Air Quality Health Index, discharge diagnosis of OM increased 5% to 6% three days postexposure. Effects were stronger using the nonlinear time series analysis. The overall risk for OM, in the first 15 days after an increase in the Air Quality Health Index, was 1.22 times the risk of OM on days following no increase in exposures. These findings confirm that there is an association between the multipollutant Air Quality Health Index and emergency department visits for OM. The findings can be used to inform risk communication, patient education, and policy. Clinicians can use the Air Quality Health Index as an education and advocacy tool to promote and protect the health of those at high risk for OM to reduce exposures.

Adoption of electronic medical record-based decision support for otitis media in children.

Substantial investment in electronic health records (EHRs) has provided an unprecedented opportunity to use clinical decision support (CDS) to increase guideline adherence. To inform efforts to maximize adoption, we characterized the adoption of an otitis media (OM) CDS system, the impact of performance feedback on adoption, and the effects of adoption on guideline adherence. A total of 41,391 OM visits with 108 clinicians at 16 pediatric practices between February 2009 and August 2010. Prospective cohort study of EHR-based CDS adoption during OM visits, comparing clinicians receiving performance feedback to none. CDS was available to all physicians; use was voluntary. Extraction from a common EHR. Clinicians and practices used the CDS system for a mean of 21 percent (range: 0-85 percent) and 17 percent (0-51 percent) of eligible OM visits, respectively. Clinicians who received performance feedback reports summarizing CDS use and guideline adherence had a relative increase in CDS use of 9.0 percentage points compared to others (p = .001). CDS adoption was associated with increased OM guideline adherence. Effects were greatest among clinicians with the lowest adherence prior to the study. Performance feedback increased CDS adoption, but additional strategies are needed to integrate CDS into primary care workflows.

Trends in Otitis Media–Related Health Care Use in the United States, 2001-2011

Otitis media (OM) is a leading cause of pediatric health care visits and the most frequent reason children consume antibiotics or undergo surgery. During recent years, several interventions have been introduced aiming to decrease OM burden. To study the trend in OM-related health care use in the United States during the pneumococcal conjugate vaccine (PCV) era (2001-2011). An analysis of an insurance claims database of a large, nationwide managed health care plan was conducted. Enrolled children aged 6 years or younger with OM visits were identified. Annual OM visit rates, OM-related complications, and surgical interventions were analyzed. Overall, 7.82 million unique children (5.51 million child-years) contributed 6.21 million primary OM visits; 52% were boys and 48% were younger than 2 years. There was a downward trend in OM visit rates from 2004 to 2011, with a significant drop that coincided with the advent of the 13-valent vaccine (PCV-13) in 2010. The observed OM visit rates in 2010 (1.00/child-year) and 2011 (0.81/child-year) were lower than the projected rates based on the 2005-2009 trend had there been no intervention (P < .001). Recurrent OM (≥3 OM visits within 6-month look-back) rates decreased at 0.003/child-year (95% CI, 0.002-0.004/child-year) in 2001-2009 and at 0.018/child-year (95% CI, 0.008-0.028/child-year) in 2010-2011. In the PCV-13 premarket years, there was a stable rate ratio (RR) between OM visit rates in children younger than 2 years and in those aged 2 to 6 years (RR, 1.38; 95% CI, 1.38-1.39); the RR decreased significantly (P < .001) during the transition year 2010 (RR 1.32; 95% CI, 1.31-1.33) and the postmarket year 2011 (RR 1.01; 95% CI, 1.00-1.02). Tympanic membrane perforation/otorrhea rates gradually increased (from 3721 per 100,000 OM child-years in 2001 to 4542 per 100,000 OM child-years in 2011; P < .001); the increase was significant only in the older children group. Mastoiditis rates substantially decreased (from 61 per 100,000 child-years in 2008 to 37 per 100,000 child-years in 2011; P < .001). Ventilating tube insertion rate decreased by 19% from 2010 to 2011 (P = .03). There was an overall downward trend in OM-related health care use from 2001 to 2011. The significant reduction in OM visit rates in 2010-2011 in children younger than 2 years coincided with the advent of PCV-13. Although tympanic membrane perforation/otorrhea rates steadily increased during that period, mastoiditis and ventilating tube insertion rates decreased in the last years of the study.

Respiratory Infection and Otitis Media Visits in Relation to Pneumococcal Conjugate Vaccine Use in Saskatchewan

In Saskatchewan, pneumococcal conjugate vaccination (PCV) was offered to high-risk children in 2002 and to all infants in 2005. To describe trends in the frequency of medical visits for lower respiratory tract infection (LRI) and otitis media (OM) in relation to PCV use during the period 1990 to 2008. Statistics regarding the number of children covered by the health insurance plan, PCV administration, and medical visits with a diagnostic code associated with LRI and OM were provided by Saskatchewan Health. Monthly rates were analyzed using dynamic state space models. In all series, there was a marked seasonal cycle and some higher-than-expected winter peak values, possibly associated with epidemics of specific respiratory viruses. Three abrupt decreases in baseline rate were observed for LRI and the final one, in February 2007, could be related to the increased proportion of children vaccinated with PCV. There was no statistical correlation between PCV use and OM visit frequency. Many environmental, biological and administrative factors may influence health services use, and an effect of low magnitude of a particular vaccine pertaining to nonspecific outcomes could be obscured in time-series analyses.

Air Pollution and Emergency Department Visits for Otitis Media: A Case-Crossover Study in Edmonton, Canada

BackgroundOtitis media (OM) is one of the most common early childhood infections, resulting in an enormous economic burden to the health care system through unscheduled doctor visits and antibiotic prescriptions.ObjectivesThe objective of this study was to investigate the potential association between ambient air pollution exposure and emergency department (ED) visits for OM.Materials and MethodsTen years of ED data were obtained from Edmonton, Alberta, Canada, and linked to levels of air pollution: carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), sulfur dioxide, and particulate matter (PM) of median aerometric diameter ≤ 10 and 2.5 μm (PM10 and PM2.5 respectively). A time-stratified case-crossover technique was applied to analyze the associations between ambient air pollution and health outcomes. Conditional logistic regression analysis with the subject’s identification number as a stratum variable was used to obtain odds ratios (ORs) and their corresponding 95% confidence intervals after adjustment for meteorological factors.ResultsWe based the analysis on 14,527 ED visits for OM over 10 years in children 1–3 years of age. We observed statistically significant positive associations between ED visits for OM and interquartile increases in CO and NO2 levels after adjusting for ambient temperature and relative humidity. We observed the strongest associations (expressed by ORs) in the warmer months (April–September) in girls and all patients for exposure to CO and NO2, and in boys for exposure to CO, for 2 days before an OM ED visit.ConclusionsThese results support the hypothesis that ED visits for OM are associated with ambient air pollution.

Antibiotic Prescription Rates for Acute Respiratory Tract Infections in US Ambulatory Settings

During the 1990s, antibiotic prescriptions for acute respiratory tract infection (ARTI) decreased in the United States. The sustainability of those changes is unknown. To assess trends in antibiotic prescriptions for ARTI. The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data (1995-2006) were used to examine trends in antibiotic prescription rates by antibiotic indication and class. Annual survey data and census denominators were combined in 2-year intervals for rate calculations. National annual visit rates and antibiotic prescription rates for ARTI, including otitis media (OM) and non-ARTI. Among children younger than 5 years, annual ARTI visit rates decreased by 17% (95% confidence interval [CI], 9%-24%), from 1883 per 1000 population in 1995-1996 to 1560 per 1000 population in 2005-2006, primarily due to a 33% (95% CI, 22%-43%) decrease in OM visit rates (950 to 634 per 1000 population, respectively). This decrease was accompanied by a 36% (95% CI, 26%-45%) decrease in ARTI-associated antibiotic prescriptions (1216 to 779 per 1000 population). Among persons aged 5 years or older, ARTI visit rates remained stable but associated antibiotic prescription rates decreased by 18% (95% CI, 6%-29%), from 178 to 146 per 1000 population. Antibiotic prescription rates for non-OM ARTI for which antibiotics are rarely indicated decreased by 41% (95% CI, 22%-55%) and 24% (95% CI, 10%-37%) among persons younger than 5 years and 5 years or older, respectively. Overall, ARTI-associated prescription rates for penicillin, cephalosporin, and sulfonamide/tetracycline decreased. Prescription rates for azithromycin increased and it became the most commonly prescribed macrolide for ARTI and OM (10% of OM visits). Among adults, quinolone prescriptions increased. Overall antibiotic prescription rates for ARTI decreased, associated with fewer OM visits in children younger than 5 years and with fewer prescriptions for ARTI for which antibiotics are rarely indicated. However, prescription rates for broad-spectrum antibiotics increased significantly.

Relationship of incidence of otitis media to weather, air pollutants, airborne allergens, and upper respiratory tract infection incidence

Study objectives: We study the effects of air pollutants, weather, airborne allergens, incidence of upper respiratory tract infection (URI), and the September 11, 2001, attack on the incidence of otitis media in the 11 public hospitals and 6 clinics run by the New York City Health and Hospital Corporation (HHC). Methods: This was a retrospective study of electronic records of all patients treated in 11 HHC Hospitals and 5 clinics in New York City with a diagnosis of otitis media. We obtained airborne pollutant levels from the Environmental Protection Agency, weather information from the National Weather Service, and otitis media incidence from the HHC billing computers. With the conservative autoregressive integrated moving average (ARIMA) modeling, epiphenomena that vary reliably during the course of the year are less likely to be viewed as significant. Results: The study covered 4,322 days, beginning January 1, 1991. The fifth, 50th, and 95th percentiles for visits per day were 70, 180, and 343, respectively, with marked seasonal variations. The ARIMA response variable was the change in the number of visits for otitis media from the previous week. Autoregressive terms for days 1, 7, and 365 and moving average term for day 7 were all significant (all P P x ) effect ( P =.0290) predicts that increasing NO x levels by 10% would result in 512 additional otitis media visits per year. Temperature effects were somewhat complex. A 14-day decrease in minimum temperature was associated with increased otitis media visits ( P =.0146). The effect is dynamic. If the temperature increased by a constant 1 degree per year, our model predicts a decrease in otitis media visits of 92 visits per year. The September 11 attack was associated with a decrease in otitis media visits ( P =.0022 on September 11 and P =.0085 on September 18.) We did not find significant exacerbating effects of pharyngitis incidence, airborne allergens, or other pollutants. Conclusion: We speculate that the decrease in number of otitis media visits seen around September 11 was due to decreased mobility within New York City. Using conservative ARIMA modeling, we found a positive relationship between the number of otitis media visits and increasing NO x levels, decreasing ambient temperature, and increasing URI incidence.

Tobacco Counseling at Well-Child and Tobacco-Influenced Illness Visits: Opportunities for Improvement

To assess the frequency of clinician-reported delivery of counseling for avoidance of child environmental tobacco smoke (ETS) exposure and tobacco use at periodic well-child visits and at illness visits for asthma and otitis media (OM). Combined data from the National Ambulatory Medical Care Survey and the outpatient portion of the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 were analyzed. The frequency of pediatric visits (<or=18 years) that included clinician-reported counseling for tobacco use/exposure prevention was assessed. Diagnosis-specific visits were determined by using International Classification of Diseases, Ninth Revision codes for asthma (493-), OM (381-, 382-), and well-child visits. Bivariate and regression analyses were performed. Of 33 823 ambulatory care visits by children, 1.5% were reported to include delivery of tobacco counseling. Only 4.1% of well-child visits, 4.4% of illness visits for asthma, and 0.3% of illness visits for OM included tobacco counseling. With the use of logistic regression models, adolescent patient visits (13-18 years) were more likely to include delivery of tobacco counseling than younger child visits [OR = 15.8, 95% CI (7.5-33.5)]. Visits by children with Medicaid and those seen by a nurse practitioner or a physician's assistant were also more likely to include tobacco counseling (odds ratio: 1.6; 95% confidence interval: 1.002-2.50; and odds ratio: 3.0; 95% confidence interval: 1.5-6.0, respectively). There were no significant differences in counseling delivery by race, ethnicity, or clinician specialty. Rates of tobacco counseling at well-child visits and at illness visits for diagnoses directly affected by tobacco use and ETS are extremely low. Significant opportunities exist to improve counseling rates for child ETS exposure and adolescent tobacco use in primary care.

Health Care Utilization and Cost in Children with Asthma and Selected Comorbidities

Children with asthma use significantly more health services than other children, yet the majority of their health care costs are for nonasthma services. The objective of this study was to measure the impact of asthma and specific upper respiratory comorbidities on the use and cost of health care by children. A population-based historical cohort study from January 1, 1992 to December 31, 1992 was conducted. Multiple visits for otitis media, sinusitis, and allergic rhinitis were considered comorbidities. The outcome measures were nonurgent outpatient care, pharmacy fills, urgent care visits, and hospital care along with the associated total costs. Children between ages 1 and 17 years were studied (n = 71,818). Children with asthma were more likely than children without asthma to have a comorbidity (26% vs. 9%). Children with multiple visits for otitis media, sinusitis, and allergic rhinitis were 1.8, 4, and 12 times more likely, respectively, to have a diagnosis of asthma in the same year. Children with asthma had a 47% probability of being in the highest total cost quintile compared to a 29% likelihood once adjusted for comorbidities. Visits for otitis media, sinusitis, and particularly allergic rhinitis appear to be overrepresented in children with asthma and contribute to their high utilization rate. Once a high-risk cohort is identified, the needs of those children can be addressed through targeted, organized systems of care that may include guidelines or other disease management strategies.

Utilization of Health Care for Infectious Illnesses at a Pediatric Practice 549

Objective: To determine the frequency of health care utilization for infectious illnesses in a pediatric practice and factors that affect utilization. Study Population: Children aged 6 weeks to 5 years who received health care at a large pediatric practice in Norfolk and Chesapeake, VA enrolled between 3/96 and 10/97 into an ongoing 3-year surveillance study. Methods: Attempts were made to enroll all age-eligible children in the practice. Demographic and medical history data were collected at enrollment and updated monthly. Office visit records were reviewed 2 weeks prior to enrollment for all children and when children were sick. Associations between parental education level and type of health care coverage on frequency of visits for illness were analyzed using Poisson regression analysis. Results: This analysis includes 506 (9%) of age-eligible children in the practice followed for 6618 child months (range 1-21 mos/child). 414 (82%) children had 1861 illness visits (mean 3.4/child-year) that resulted in 2526 diagnoses including 1615 (64%) that involved the upper respiratory tract. Otitis media (OM) was the most frequent primary diagnosis (21%) followed by uncomplicated upper respiratory infections (URI) (15%), sinusitis (4%), and Group A Streptococcus (GAS) pharyngitis (1%). 23% of diagnoses were combinations of the above. The mean number of visits for OM (1.0/child-year) was greater than for the other diagnoses (URI.6/child-year, sinusitis.1/child-year, GAS pharyngitis.06/child-year). 73% of parents had more than a high school education. 98% of families were covered by third party health insurance including: 82% by employer-administered health insurance(private insurance, HMO, PPO), Medicaid 9%, and CHAMPUS 7%. Children of parents with more than a high school education had more sick visits than parents with a high school education or less (Rate ratio=1.18, p=.002). Families with no insurance visited the physician the least often (Rate ratio=0.43, p=.008), followed by CHAMPUS (Rate ratio=.80, p=.03), private insurance, HMO, and PPO (reference group), and Medicaid (Rate ratio=1.13, p=.12). When level of education and type of health care coverage were adjusted, each influenced health care utilization (p<.03). Conclusions: Health care utilization in this pediatric practice was associated with type of health care coverage and parents' level of education. These findings may help target high-use and low-use groups of parents to improve appropriate health care utilization.

Impact of care setting on cost and quality under Medicaid.

Medicaid claims data were used to compare the costs and care quality of ambulatory visits for two childhood illnesses, urinary tract infection (UTI) and suppurative otitis media (OM), in the fee-for-service Medicaid program in Alabama across three care settings: offices where patients had been seen before, offices where patients had not been seen before, and outpatient hospital departments. Forty percent of UTI visits and 46 percent of OM visits occurred in return office settings. Visits to outpatient hospital and first-time office settings were more expensive than those to return office settings, due to the billing of facility fees and the provision of additional services. Adherence to common measures of quality of care for both types of visits was low; 52 percent of UTI visits included urine cultures and 40 percent of OM visits included recheck visits. Adherence to these quality measures was significantly lower in visits occurring in hospital settings.