Original Research—Pediatric Otolaryngology
Complications of Pediatric Otitis Media
Jennifer M. Lavin, MD1, Thomas Rusher2, and Rahul K. Shah, MD, MBA1
No sponsorships or competing interests have been disclosed for this article.
Abstract Objective. Otitis media (OM) is a common diagnosis in the pediatric population that is usually managed on an outpatient basis. A small proportion of children are admitted due to a complex disease course. The aim of this study was to investigate the demographics of those patients and the resources utilized during their admissions. Study Design. Retrospective review based on the 2009 Kids’ Inpatient Database. Setting. Nationwide administrative database. Subjects and Methods. A review based on the 2009 Kids’ Inpatient Database was conducted. Inclusion criteria were clinical modification codes for OM (ICD-9 code 382). Data recorded included patient demographics, concurrent discharge diagnosis codes, length of stay, total charges, and frequency of procedures performed. Results. There were 61,783 (92,548 nationally weighted) admissions with OM, which were analyzed. The average age (SD) for the patients was 2.18 (3.49) years, and the average length of stay was 2.88 days. The majority (80.75%) of patients did not have to undergo a procedure during admission, whereas a small proportion (5.4%) underwent a major operating room procedure. There were 21 deaths recorded (0.03%). A diagnosis of mastoiditis, meningitis, venous sinus thrombosis, or intracranial abscess was associated with significantly increased length of stay, incidence of procedures, and total cost of admission. Conclusions. Complicated pediatric OM remains of concern requiring prompt and thorough management. Major complications include mastoiditis and meningitis, and unfortunately, fatalities still occur in patients with OM. An understanding of resource utilization and socioeconomic implications can identify and drive opportunities for targeted quality improvement. Keywords otitis media, complications, administrative database Received July 23, 2015; revised September 3, 2015; accepted September 24, 2015.
Otolaryngology– Head and Neck Surgery 2016, Vol. 154(2) 366–370 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815611860 http://otojournal.org
P
ediatric otitis media (OM) is one of the most common conditions treated in primary care clinics and is associated with significant health care costs, especially in patients aged 1 to 3 years.1 While the majority of OM is uncomplicated and is treated on an outpatient basis, a small proportion of patients develop complications that require inpatient admission and, occasionally, surgical intervention. Several single-institution studies have described the incidence and outcomes of complicated OM; however, characterization of specific patient populations at risk for, and health care costs associated with, complicated OM has been limited.2-4 Administrative databases have demonstrated utility in safety and quality improvement due to their ability to identify macrolevel trends that may not be apparent in singleinstitution studies.5 This includes the ability to identify demographic trends and comorbid conditions associated with specific diagnoses. To date, administrative databases have not been utilized to investigate trends in patient risk factors and health care expenditures associated with complicated OM. The purpose of this study was to perform a search of an administrative database to potentially identify nationwide trends in complicated OM. Specifically, data were sought about the demographic distribution of patients and economic costs associated with this diagnosis. Finally, we aimed to investigate which patient populations were most at risk for specific complications, such as mastoiditis, meningitis, venous sinus thrombosis, and intracranial abscess.
Methods Data were obtained from the 2009 Kids’ Inpatient Database (KID), part of the Healthcare Cost and Utilization Project, sponsored by the Agency for Healthcare Research and Quality. It is the only all-payer pediatric-only database, and it samples discharge data from all nonrehabilitation hospitals in 1 Divison of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC, USA 2 School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
This article was presented at the 2015 AAO-HNSF Annual Meeting & OTO EXPO; September 27-30, 2015; Dallas, Texas. Corresponding Author: Jennifer M. Lavin, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Box 25, Chicago, IL 60611, USA. Email: [email protected]
Lavin et al participating states.6 As with the use of all administrative databases for research purposes, private health information is not available; thus, no Institutional Review Board approval was required. A search was conducted for patients discharged with recorded International Classification of Diseases, Ninth Revision (ICD-9) code 382 (OM). Demographic data obtained included age, race, sex, median income quartile for zip code, and payer status (defined as public aid vs private insurance). Concurrent discharge diagnoses, total costs, data on inpatient procedures, and length of stay (LOS) were also recorded. Demographic data were compared to specific diagnosis codes for major complications of OM, defined as mastoiditis (ICD-9 383), meningitis (ICD-9 320), venous sinus thrombosis (ICD-9 325), and intracranial abscess (ICD-9 324) to determine if any trends were present. These specific diagnosis codes were then analyzed for total costs and number of procedures. As the KID utilizes a representative sample of pediatric discharges instead of that from the total population, data used for statistical analysis were weighted to accurately reflect national trends. In accordance with the data use agreement, no data with numbers \10 were reported. Data were analyzed with chi-square analysis. Statistical significance was defined as P \ .05.
Results Demographics A total of 61,783 patients (weighted total, 92,548) were admitted with a diagnosis of OM in 2009. The average age of patients was 2.18 years (Table 1). The most common race/ethnicity was white, with 27,926 admissions (53.58%); 21,660 patients (35.93%) were in the lowest socioeconomic quartile by zip code. In general, children admitted with a diagnosis of OM were healthy, with 51,585 patients (83.49%) having 1 chronic condition.
Patient Hospitalization Data For all patients admitted with a diagnosis of OM, the average LOS was 2.88 days (range, 0-362 days; SD, 5.18). Most children were managed medically, with 49,891 (80.75%) undergoing zero procedures (range, 0-27; SD, 1.10). Major operating room procedures were reported in 3336 patients (5.40%). Average total charges for admission were $13,270 (range, $125-$1,448,087; SD, $30,298).
Major Complications of OM The major complications of OM investigated in this study included mastoiditis, meningitis, venous sinus thrombosis, and intracranial abscess (inclusive of epidural, subdural, and intraparenchymal abscess; Table 2). Even in patients admitted for OM, a diagnosis of these major complications was rare. Acute mastoiditis was the most common major complication, with 1505 cases reported (2.4%). Meningitis, venous sinus thrombosis, and intracranial abscesses were reported in \1% of patients. There were 21 deaths recorded during admission (0.03%); however, the specific cause of death for each patient was not available.
367 Table 1. Demographic Distribution of Patients Admitted with a Diagnosis of Otitis Media in 2009. Variable Age, y, mean 6 SD Sex Male Female Race/ethnicity White Black Hispanic Asian Other Median household income quartile by zip code, $ 1: 1-38,999 2: 39,000-47,999 3: 48,000-62,999 4: 63,0001 Payer status Medicaid Private insurance Self-pay
n (%)a 2.18 6 3.49 35,814 (58.13) 25,797 (41.87) 27,926 (53.58) 7468 (14.33) 11,942 (22.91) 1137 (2.18) 3644 (6.99)
21,660 (35.93) 16,614 (27.56) 12,871 (21.35) 9138 (15.16) 33,961 (55.05) 23,712 (38.43) 1,784 (2.89)
a Values represent number (and percentages) of admissions, unless otherwise indicated.
Table 2. Incidence of Major Complications in Patients Admitted with a Diagnosis of Otitis Media. Diagnosis Acute mastoiditis Meningitis Venous sinus thrombosis Intracranial abscess
n (%) 1505 (2.4) 181 (0.3) 48 (0.1) 37 (0.1)
When patients with any major complication were compared with all other admitted patients, patients with major complications had longer hospital stays, were older, underwent more operating room and minor procedures, and had increased health care costs associated with their stays (Table 3). These findings were also present when individual diagnoses of mastoiditis, meningitis, venous sinus thrombosis, and intracranial abscess were analyzed. When patient demographics were examined for each major complication, mixed results were found. For patients with mastoiditis, there was a statistically significant difference in race compared with those without mastoiditis (P \ .0001; Figure 1). This corresponded to a slightly increased rate of disease in Hispanic patients (2.81%) versus white (2.62%) and black (1.52%) patients. There was also a significant difference in the rates of mastoiditis among socioeconomic groups as reported
368
Otolaryngology–Head and Neck Surgery 154(2)
Table 3. Trends in Patients Admitted with Major Complications of Otitis Media. Average for Patients
Any major complication Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $ Mastoiditis Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $ Meningitis Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $ Venous sinus thrombosis Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $ Intracranial abscess Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $
room
room
room
room
room
With Diagnosis
Without Diagnosis
P Value
4.47 5.30 0.91 1.48 0.37 26,831
2.85 2.84 0.80 0.36 0.05 12,876
\.0001 \.0001 .008 \.0001 \.0001 \.0001
4.14 5.34 0.90 1.41 0.38 24,794
2.85 2.10 0.81 0.36 0.05 12,946
\.0001 \.0001 .02 \.0001 \.0001 \.0001
10.27 5.48 1.36 2.59 0.23 51,862
2.87 2.18 0.81 0.38 0.05 13,162
\.0001 \.0001 .006 \.0001 .0014 \.0001
8.71 6.85 1.25 3.84 0.66 73,536
2.88 2.18 0.81 0.38 0.05 13,183
.0002 \.0001 .01 \.0001 \.0001 \.0001
11.55 6.61 1.51 4.78 0.92 108,348
2.88 2.18 0.81 0.39 0.53 13,167
\.0001 \.0001 .02 \.0001 \.0001 \.0001
by average income by zip code (P \ .0001), with increasing frequency corresponding with increasing income quartile (1.95%, 2.29%, 2.57%, and 3.41%). A statistically significant difference in payer status was also found in mastoiditis patients (P \ .0001), with self-pay status (3.53%) being slightly more associated with the diagnosis than private insurance (2.87%) and Medicaid (1.95%). No differences in race, income, and payer status were found in patients with meningitis and venous sinus thrombosis. Similarly, no differences in race were found among intracranial abscess patients; however, a slight but significant increase was noted in abscess incidence for privately insured patients (0.09%) as compared with Medicaid patients (0.04%; P = .02). Income data for intracranial abscess could
not be reported because of low numbers and the data use agreement.
Discussion With a worldwide incidence of 709 million cases per year, OM is one of the most common diseases in the pediatric patient.7 Because of its frequency, the health care and economic burden of uncomplicated OM is well established.8 Despite the high incidence of pediatric OM, major complications are rare. This is believed to be especially true owing to increased antibiotic utilization in the United States, as countries where antibiotic usage is decreased have increased rates of acute mastoiditis.9 Due to
Lavin et al
Figure 1. Percentage of patients with mastoiditis by (A) race, (B) income quartile, and (C) payer status.
this rarity, the economic and health care burdens of major complications of OM have not been well described. In this study, we utilized the 2009 KID as a tool to characterize economic and demographic trends in patients
369 admitted with OM. Selection of all patients admitted with a diagnosis of OM is justified, as a study by Kvaerner et al demonstrated that hospital admission for OM is a reliable marker for disease severity.10 As with any condition that is rare, single-institution studies are frequently insufficiently powered to fully characterize its morbidity and economic and demographic implications. While several single-institution studies have investigated the incidence and outcomes of complicated OM, characterization of specific patient populations at risk for, and health care costs associated with, complicated OM has been limited.2-4 When all patients admitted with a diagnosis of OM were examined, several trends were noted. Patients were young, with an average age of 2.18 years, corresponding to the average age of the outpatient OM population.1 Overall, patients admitted with OM were otherwise healthy, with \20% having .1 chronic medical condition. Average LOS in these patients was short, with a mean value of 2.88 days, and the majority of patients were managed medically, with \20% undergoing any inpatient procedure and only 5.4% undergoing major operating room procedures. When only patients with major complications of OM were examined—that is, mastoiditis, meningitis, venous sinus thrombosis, and intracranial abscess—overall demographic and economic trends changed. Patients with these diagnoses were older, averaging 5 to 6 years. While the exact reason for this age difference is unclear, it may be attributable either to increased aeration of mastoid air cells with advancing age or to a lower threshold to admit younger children with milder symptoms. Average LOS, incidence of minor and operating room procedures, and average health care costs also increased dramatically in this patient population. In patients with mastoiditis, LOS increased by 45%, with a corresponding 93% increase in health care costs. The more serious complications of meningitis, venous sinus thrombosis, and intracranial abscess were associated with an increase of LOS and health care costs of 200%-300% and 300%-800%, respectively. While there was a statistically significant increase in the number of chronic conditions among patients with major complications of OM, this increase was small and may be reflective of the large population studied rather than any clinical significance. As the nature of the KID limits analysis to admitted patients, patients with major complications of OM were compared only with patients otherwise admitted with OM. This eliminates truly uncomplicated patients from analysis and suggests that the increase in patient morbidity and economic burden of disease of major complications of OM are likely even more profound when compared with the typical patient with OM. Given these findings, one can conclude that, despite their rarity, major complications of OM represent a serious economic and clinical concern. Review of the database revealed 21 deaths (0.03%) among patients admitted with OM. Due to the nature of administrative databases, this number should be interpreted with caution as the exact cause of death may not be directly attributable to OM itself. Nonetheless, at least some patients presumably
370 died as a direct result of complicated OM, again emphasizing the importance of properly treating this condition. The final aim in this study was to investigate whether certain demographic variables were associated with increased incidence of major complications of OM. Patients with meningitis, venous sinus thrombosis, and intracranial abscess showed no or minimal demographic predispositions with respect to race, socioeconomic status (SES), or payer mix. In contrast, patients with mastoiditis had a small but statistically significant difference with patients of different race, SES, and payer status. The percentage of admitted patients with mastoiditis was slightly higher in Hispanic and white patients when compared with black patients. We also found an increased incidence of mastoiditis in self-pay and privately insured patients versus patients with Medicaid. While the reason for this phenomenon is unclear, one possible explanation may be secondary to overordering of computed tomography scans by primary care providers of privately insured patients and by emergency department physicians caring for those who are self-pay. Further investigation of this trend would require an additional study with a different data source. In this study, the relative percentage of patients admitted with mastoiditis versus those admitted with more minor complications of OM increased with increasing average income by zip code. Prior studies have demonstrated that OM is more common in patients of lower SES.11 Another study suggested that infectious disease–related emergency room visits were more common in patients of lower SES.12 It is unclear whether the increased incidence of mastoiditis in higher SES is reflective of a truly increased incidence or a tendency for patients of higher SES to be treated on an outpatient basis until major complications arise. As with all database studies, limitations of this study are present. Due to the nature of the database, one is not able to review individual patient charts and instead must rely on the accuracy of the billing and coding record. Furthermore, limitations set by inclusion of only participating hospitals and states point to the need for caution when extrapolating findings. This is somewhat offset through use of nationally weighted data for analysis.
Conclusion Despite their rarity, major complications of OM are associated with patient morbidity, involving increased frequency of invasive procedures and prolonged hospitalizations. The resultant dramatic increase in economic burden of these conditions remains of concern. The incidence of mastoiditis may be increased in patients of Hispanic origin and higher SES; however, further investigation in this area is warranted before final conclusions can be made.
Otolaryngology–Head and Neck Surgery 154(2) Author Contributions Jennifer M. Lavin, study design, data acquisition and interpretation, drafting and revising manuscript, final approval, accountable for all aspects; Thomas Rusher, data acquisition, revising manuscript, final approval, accountable for all aspects; Rahul K. Shah, study design, revising manuscript, final approval, accountable for all aspects.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
References 1. Bondy J, Berman S, Glazner J, et al. Direct expenditures related to otitis media diagnoses: extrapolations from a pediatric medicaid cohort. Pediatrics. 2000;105:E72. 2. Goldstein NA, Casselbrant ML, Bluestone CD, et al. Intratemporal complications of acute otitis media in infants and children. Otolaryngol Head Neck Surg. 1998;119:444-454. 3. Maranhao A, Andrade J, Godofredo V, et al. Epidemiology of intratemporal complications of otitis media. Int Arch Otorhinolaryngol. 2014;18:178-183. 4. Mattos JL, Colman KL, Casselbrant ML, et al. Intratemporal and intracranial complications of acute otitis media in a pediatric population. Int J Pediatr Otorhinolaryngol. 2014;78:21612164. 5. Boss EF, Shah RK. An overview of administrative and national survey databases for use in otolaryngology research. Otolaryngol Head Neck Surg. 2013;148:711-716. 6. Healthcare Cost and Utlization Project. Indroduction to the HCUP Kids’ Inpatient Database (KID) 2012. Rockville, MD: Agency for Healthcare Research and Quality; 2012. 7. Monasta L, Ronfani L, Marchetti F, et al. Burden of disease caused by otitis media: systematic review and global estimates. PloS One. 2012;7:e36226. 8. Klein JO. The burden of otitis media. Vaccine. 2000;19(suppl 1):S2-S8. 9. Van Zuijlen DA, Schilder AG, Van Balen FA, et al. National differences in incidence of acute mastoiditis: relationship to prescribing patterns of antibiotics for acute otitis media? Pediatr Infect Dis J. 2001;20:140-144. 10. Kvaerner KJ, Austeng ME, Abdelnoor M. Hospitalization for acute otitis media as a useful marker for disease severity. Pediatr Infect Dis J. 2013;32:946-949. 11. Smith DF, Boss EF. Racial/ethnic and socioeconomic disparities in the prevalence and treatment of otitis media in children in the United States. Laryngoscope. 2010;120:2306-2312. 12. Hasegawa K, Tsugawa Y, Cohen A, et al. Infectious diseaserelated emergency department visits among children in the United States. Pediatr Infect Dis J. 2015;34:681-685.
Complications of Pediatric Otitis Media
Jennifer M. Lavin, MD1, Thomas Rusher2, and Rahul K. Shah, MD, MBA1
No sponsorships or competing interests have been disclosed for this article.
Abstract Objective. Otitis media (OM) is a common diagnosis in the pediatric population that is usually managed on an outpatient basis. A small proportion of children are admitted due to a complex disease course. The aim of this study was to investigate the demographics of those patients and the resources utilized during their admissions. Study Design. Retrospective review based on the 2009 Kids’ Inpatient Database. Setting. Nationwide administrative database. Subjects and Methods. A review based on the 2009 Kids’ Inpatient Database was conducted. Inclusion criteria were clinical modification codes for OM (ICD-9 code 382). Data recorded included patient demographics, concurrent discharge diagnosis codes, length of stay, total charges, and frequency of procedures performed. Results. There were 61,783 (92,548 nationally weighted) admissions with OM, which were analyzed. The average age (SD) for the patients was 2.18 (3.49) years, and the average length of stay was 2.88 days. The majority (80.75%) of patients did not have to undergo a procedure during admission, whereas a small proportion (5.4%) underwent a major operating room procedure. There were 21 deaths recorded (0.03%). A diagnosis of mastoiditis, meningitis, venous sinus thrombosis, or intracranial abscess was associated with significantly increased length of stay, incidence of procedures, and total cost of admission. Conclusions. Complicated pediatric OM remains of concern requiring prompt and thorough management. Major complications include mastoiditis and meningitis, and unfortunately, fatalities still occur in patients with OM. An understanding of resource utilization and socioeconomic implications can identify and drive opportunities for targeted quality improvement. Keywords otitis media, complications, administrative database Received July 23, 2015; revised September 3, 2015; accepted September 24, 2015.
Otolaryngology– Head and Neck Surgery 2016, Vol. 154(2) 366–370 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815611860 http://otojournal.org
P
ediatric otitis media (OM) is one of the most common conditions treated in primary care clinics and is associated with significant health care costs, especially in patients aged 1 to 3 years.1 While the majority of OM is uncomplicated and is treated on an outpatient basis, a small proportion of patients develop complications that require inpatient admission and, occasionally, surgical intervention. Several single-institution studies have described the incidence and outcomes of complicated OM; however, characterization of specific patient populations at risk for, and health care costs associated with, complicated OM has been limited.2-4 Administrative databases have demonstrated utility in safety and quality improvement due to their ability to identify macrolevel trends that may not be apparent in singleinstitution studies.5 This includes the ability to identify demographic trends and comorbid conditions associated with specific diagnoses. To date, administrative databases have not been utilized to investigate trends in patient risk factors and health care expenditures associated with complicated OM. The purpose of this study was to perform a search of an administrative database to potentially identify nationwide trends in complicated OM. Specifically, data were sought about the demographic distribution of patients and economic costs associated with this diagnosis. Finally, we aimed to investigate which patient populations were most at risk for specific complications, such as mastoiditis, meningitis, venous sinus thrombosis, and intracranial abscess.
Methods Data were obtained from the 2009 Kids’ Inpatient Database (KID), part of the Healthcare Cost and Utilization Project, sponsored by the Agency for Healthcare Research and Quality. It is the only all-payer pediatric-only database, and it samples discharge data from all nonrehabilitation hospitals in 1 Divison of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC, USA 2 School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
This article was presented at the 2015 AAO-HNSF Annual Meeting & OTO EXPO; September 27-30, 2015; Dallas, Texas. Corresponding Author: Jennifer M. Lavin, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Box 25, Chicago, IL 60611, USA. Email: [email protected]
Lavin et al participating states.6 As with the use of all administrative databases for research purposes, private health information is not available; thus, no Institutional Review Board approval was required. A search was conducted for patients discharged with recorded International Classification of Diseases, Ninth Revision (ICD-9) code 382 (OM). Demographic data obtained included age, race, sex, median income quartile for zip code, and payer status (defined as public aid vs private insurance). Concurrent discharge diagnoses, total costs, data on inpatient procedures, and length of stay (LOS) were also recorded. Demographic data were compared to specific diagnosis codes for major complications of OM, defined as mastoiditis (ICD-9 383), meningitis (ICD-9 320), venous sinus thrombosis (ICD-9 325), and intracranial abscess (ICD-9 324) to determine if any trends were present. These specific diagnosis codes were then analyzed for total costs and number of procedures. As the KID utilizes a representative sample of pediatric discharges instead of that from the total population, data used for statistical analysis were weighted to accurately reflect national trends. In accordance with the data use agreement, no data with numbers \10 were reported. Data were analyzed with chi-square analysis. Statistical significance was defined as P \ .05.
Results Demographics A total of 61,783 patients (weighted total, 92,548) were admitted with a diagnosis of OM in 2009. The average age of patients was 2.18 years (Table 1). The most common race/ethnicity was white, with 27,926 admissions (53.58%); 21,660 patients (35.93%) were in the lowest socioeconomic quartile by zip code. In general, children admitted with a diagnosis of OM were healthy, with 51,585 patients (83.49%) having 1 chronic condition.
Patient Hospitalization Data For all patients admitted with a diagnosis of OM, the average LOS was 2.88 days (range, 0-362 days; SD, 5.18). Most children were managed medically, with 49,891 (80.75%) undergoing zero procedures (range, 0-27; SD, 1.10). Major operating room procedures were reported in 3336 patients (5.40%). Average total charges for admission were $13,270 (range, $125-$1,448,087; SD, $30,298).
Major Complications of OM The major complications of OM investigated in this study included mastoiditis, meningitis, venous sinus thrombosis, and intracranial abscess (inclusive of epidural, subdural, and intraparenchymal abscess; Table 2). Even in patients admitted for OM, a diagnosis of these major complications was rare. Acute mastoiditis was the most common major complication, with 1505 cases reported (2.4%). Meningitis, venous sinus thrombosis, and intracranial abscesses were reported in \1% of patients. There were 21 deaths recorded during admission (0.03%); however, the specific cause of death for each patient was not available.
367 Table 1. Demographic Distribution of Patients Admitted with a Diagnosis of Otitis Media in 2009. Variable Age, y, mean 6 SD Sex Male Female Race/ethnicity White Black Hispanic Asian Other Median household income quartile by zip code, $ 1: 1-38,999 2: 39,000-47,999 3: 48,000-62,999 4: 63,0001 Payer status Medicaid Private insurance Self-pay
n (%)a 2.18 6 3.49 35,814 (58.13) 25,797 (41.87) 27,926 (53.58) 7468 (14.33) 11,942 (22.91) 1137 (2.18) 3644 (6.99)
21,660 (35.93) 16,614 (27.56) 12,871 (21.35) 9138 (15.16) 33,961 (55.05) 23,712 (38.43) 1,784 (2.89)
a Values represent number (and percentages) of admissions, unless otherwise indicated.
Table 2. Incidence of Major Complications in Patients Admitted with a Diagnosis of Otitis Media. Diagnosis Acute mastoiditis Meningitis Venous sinus thrombosis Intracranial abscess
n (%) 1505 (2.4) 181 (0.3) 48 (0.1) 37 (0.1)
When patients with any major complication were compared with all other admitted patients, patients with major complications had longer hospital stays, were older, underwent more operating room and minor procedures, and had increased health care costs associated with their stays (Table 3). These findings were also present when individual diagnoses of mastoiditis, meningitis, venous sinus thrombosis, and intracranial abscess were analyzed. When patient demographics were examined for each major complication, mixed results were found. For patients with mastoiditis, there was a statistically significant difference in race compared with those without mastoiditis (P \ .0001; Figure 1). This corresponded to a slightly increased rate of disease in Hispanic patients (2.81%) versus white (2.62%) and black (1.52%) patients. There was also a significant difference in the rates of mastoiditis among socioeconomic groups as reported
368
Otolaryngology–Head and Neck Surgery 154(2)
Table 3. Trends in Patients Admitted with Major Complications of Otitis Media. Average for Patients
Any major complication Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $ Mastoiditis Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $ Meningitis Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $ Venous sinus thrombosis Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $ Intracranial abscess Length of stay, d Age, y Chronic conditions Average procedures, any Average procedures, operating Average charges, $
room
room
room
room
room
With Diagnosis
Without Diagnosis
P Value
4.47 5.30 0.91 1.48 0.37 26,831
2.85 2.84 0.80 0.36 0.05 12,876
\.0001 \.0001 .008 \.0001 \.0001 \.0001
4.14 5.34 0.90 1.41 0.38 24,794
2.85 2.10 0.81 0.36 0.05 12,946
\.0001 \.0001 .02 \.0001 \.0001 \.0001
10.27 5.48 1.36 2.59 0.23 51,862
2.87 2.18 0.81 0.38 0.05 13,162
\.0001 \.0001 .006 \.0001 .0014 \.0001
8.71 6.85 1.25 3.84 0.66 73,536
2.88 2.18 0.81 0.38 0.05 13,183
.0002 \.0001 .01 \.0001 \.0001 \.0001
11.55 6.61 1.51 4.78 0.92 108,348
2.88 2.18 0.81 0.39 0.53 13,167
\.0001 \.0001 .02 \.0001 \.0001 \.0001
by average income by zip code (P \ .0001), with increasing frequency corresponding with increasing income quartile (1.95%, 2.29%, 2.57%, and 3.41%). A statistically significant difference in payer status was also found in mastoiditis patients (P \ .0001), with self-pay status (3.53%) being slightly more associated with the diagnosis than private insurance (2.87%) and Medicaid (1.95%). No differences in race, income, and payer status were found in patients with meningitis and venous sinus thrombosis. Similarly, no differences in race were found among intracranial abscess patients; however, a slight but significant increase was noted in abscess incidence for privately insured patients (0.09%) as compared with Medicaid patients (0.04%; P = .02). Income data for intracranial abscess could
not be reported because of low numbers and the data use agreement.
Discussion With a worldwide incidence of 709 million cases per year, OM is one of the most common diseases in the pediatric patient.7 Because of its frequency, the health care and economic burden of uncomplicated OM is well established.8 Despite the high incidence of pediatric OM, major complications are rare. This is believed to be especially true owing to increased antibiotic utilization in the United States, as countries where antibiotic usage is decreased have increased rates of acute mastoiditis.9 Due to
Lavin et al
Figure 1. Percentage of patients with mastoiditis by (A) race, (B) income quartile, and (C) payer status.
this rarity, the economic and health care burdens of major complications of OM have not been well described. In this study, we utilized the 2009 KID as a tool to characterize economic and demographic trends in patients
369 admitted with OM. Selection of all patients admitted with a diagnosis of OM is justified, as a study by Kvaerner et al demonstrated that hospital admission for OM is a reliable marker for disease severity.10 As with any condition that is rare, single-institution studies are frequently insufficiently powered to fully characterize its morbidity and economic and demographic implications. While several single-institution studies have investigated the incidence and outcomes of complicated OM, characterization of specific patient populations at risk for, and health care costs associated with, complicated OM has been limited.2-4 When all patients admitted with a diagnosis of OM were examined, several trends were noted. Patients were young, with an average age of 2.18 years, corresponding to the average age of the outpatient OM population.1 Overall, patients admitted with OM were otherwise healthy, with \20% having .1 chronic medical condition. Average LOS in these patients was short, with a mean value of 2.88 days, and the majority of patients were managed medically, with \20% undergoing any inpatient procedure and only 5.4% undergoing major operating room procedures. When only patients with major complications of OM were examined—that is, mastoiditis, meningitis, venous sinus thrombosis, and intracranial abscess—overall demographic and economic trends changed. Patients with these diagnoses were older, averaging 5 to 6 years. While the exact reason for this age difference is unclear, it may be attributable either to increased aeration of mastoid air cells with advancing age or to a lower threshold to admit younger children with milder symptoms. Average LOS, incidence of minor and operating room procedures, and average health care costs also increased dramatically in this patient population. In patients with mastoiditis, LOS increased by 45%, with a corresponding 93% increase in health care costs. The more serious complications of meningitis, venous sinus thrombosis, and intracranial abscess were associated with an increase of LOS and health care costs of 200%-300% and 300%-800%, respectively. While there was a statistically significant increase in the number of chronic conditions among patients with major complications of OM, this increase was small and may be reflective of the large population studied rather than any clinical significance. As the nature of the KID limits analysis to admitted patients, patients with major complications of OM were compared only with patients otherwise admitted with OM. This eliminates truly uncomplicated patients from analysis and suggests that the increase in patient morbidity and economic burden of disease of major complications of OM are likely even more profound when compared with the typical patient with OM. Given these findings, one can conclude that, despite their rarity, major complications of OM represent a serious economic and clinical concern. Review of the database revealed 21 deaths (0.03%) among patients admitted with OM. Due to the nature of administrative databases, this number should be interpreted with caution as the exact cause of death may not be directly attributable to OM itself. Nonetheless, at least some patients presumably
370 died as a direct result of complicated OM, again emphasizing the importance of properly treating this condition. The final aim in this study was to investigate whether certain demographic variables were associated with increased incidence of major complications of OM. Patients with meningitis, venous sinus thrombosis, and intracranial abscess showed no or minimal demographic predispositions with respect to race, socioeconomic status (SES), or payer mix. In contrast, patients with mastoiditis had a small but statistically significant difference with patients of different race, SES, and payer status. The percentage of admitted patients with mastoiditis was slightly higher in Hispanic and white patients when compared with black patients. We also found an increased incidence of mastoiditis in self-pay and privately insured patients versus patients with Medicaid. While the reason for this phenomenon is unclear, one possible explanation may be secondary to overordering of computed tomography scans by primary care providers of privately insured patients and by emergency department physicians caring for those who are self-pay. Further investigation of this trend would require an additional study with a different data source. In this study, the relative percentage of patients admitted with mastoiditis versus those admitted with more minor complications of OM increased with increasing average income by zip code. Prior studies have demonstrated that OM is more common in patients of lower SES.11 Another study suggested that infectious disease–related emergency room visits were more common in patients of lower SES.12 It is unclear whether the increased incidence of mastoiditis in higher SES is reflective of a truly increased incidence or a tendency for patients of higher SES to be treated on an outpatient basis until major complications arise. As with all database studies, limitations of this study are present. Due to the nature of the database, one is not able to review individual patient charts and instead must rely on the accuracy of the billing and coding record. Furthermore, limitations set by inclusion of only participating hospitals and states point to the need for caution when extrapolating findings. This is somewhat offset through use of nationally weighted data for analysis.
Conclusion Despite their rarity, major complications of OM are associated with patient morbidity, involving increased frequency of invasive procedures and prolonged hospitalizations. The resultant dramatic increase in economic burden of these conditions remains of concern. The incidence of mastoiditis may be increased in patients of Hispanic origin and higher SES; however, further investigation in this area is warranted before final conclusions can be made.
Otolaryngology–Head and Neck Surgery 154(2) Author Contributions Jennifer M. Lavin, study design, data acquisition and interpretation, drafting and revising manuscript, final approval, accountable for all aspects; Thomas Rusher, data acquisition, revising manuscript, final approval, accountable for all aspects; Rahul K. Shah, study design, revising manuscript, final approval, accountable for all aspects.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
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