THE MEDICAL APPROPRIATENESS OF TYMPANOSTOMY TUBES PROPOSED FOR CHILDREN YOUNGER THAN 16 YEARS IN THE UNITED-STATES
THE MEDICAL APPROPRIATENESS OF TYMPANOSTOMY TUBES PROPOSED FOR CHILDREN YOUNGER THAN 16 YEARS IN THE UNITED-STATES
复制标题
DOI：
10.1001/jama.271.16.1250
复制
发表时间：
1994-04-27
影响因子：
120.7
通讯作者：
BROOK, RH
中科院分区：
文献类型：
--
作者：
KLEINMAN, LC;KOSECOFF, J;BROOK, RH
客观。-描述鼓膜造口管建议用于儿童的临床原因，并评估其适当性。分析国家利用审查（UR）公司在两步UR过程中前瞻性收集的数据，以评估鼓膜造孔管放置的医学适当性。护士采访耳鼻喉科医生和初级保健医生的办公室工作人员收集临床数据。对于随机选择的不适当病例子样本，我们回顾了医生评审员对耳鼻喉科医生的后续采访，他们寻找可能减轻的临床情况或可能改变适当性类别的其他临床数据。来自49个州和哥伦比亚特区的耳鼻喉科医生的实践。从1990年1月1日到1991年7月31日，所有6611名年龄小于16岁的儿童都由UR公司的三个客户投保，他们接受鼓膜造口管的建议由该系统进行了审查。研究中的保险公司在研究时为560万美国人提供了保险。鼓膜置管手术的医疗适当性根据明确的标准，由一个专家小组使用兰德/加州大学洛杉矶分校的修改德尔菲法。共有6429例（97%）病例被建议用于复发性急性中耳炎、渗出性中耳炎或两者兼而有之。做出慷慨的临床假设，出于这些原因的提案中有41%具有适当的适应症，32%的适应症模棱两可，27%的适应症不适当。考虑到从子样本审查中获得的额外信息，适当的比例为42%，可疑的35%，不适当的23%。在这项研究中，大约四分之一的儿童鼓膜造孔管插入是因为不合适的适应症，另外三分之一是因为不确定的适应症。
Objective.-To describe the clinical reasons tympanostomy tubes are proposed for children and to assess their appropriateness.Design.-Analysis of data previously collected prospectively by a national utilization review (UR) firm during a two-step UR process to assess the medical appropriateness of tympanostomy tube placement. Nurses interviewed otolaryngologists' and primary care physicians' office staff to collect clinical data. For a randomly selected subsample of cases found inappropriate, we reviewed subsequent interviews of the otolaryngologists by physician reviewers, who looked for possible extenuating clinical circumstances or additional clinical data that might have changed the appropriateness category.Setting.-Otolaryngologists' practices from 49 states and the District of Columbia.Patients.-All 6611 children younger than 16 years who were insured by three clients of the UR firm and whose proposal to receive tympanostomy tubes was reviewed by this system from January 1, 1990, through July 31, 1991. The insurance companies in the study insured 5.6 million Americans at the time of the study.Main Outcome Measure.-The medical appropriateness of tympanostomy tube surgery according to explicit criteria developed by an expert panel using the RAND/University of California-Los Angeles modified Delphi method.Results.-A total of 6429 (97%) of the cases were proposed for recurrent acute otitis media, otitis media with effusion, or both. Making generous clinical assumptions, 41% of the proposals for these reasons had appropriate indications, 32% had equivocal indications, and 27% had inappropriate ones. Considering the additional information available from the subsample review, the proportion appropriate was 42%, equivocal 35%, and inappropriate 23%.Conclusion.-About one quarter of tympanostomy tube insertions for children in this study were proposed for inappropriate indications and another third for equivocal ones.