Kleinman L C, Kosecoff J, Dubois R W, Brook R H
Department of Pediatrics, Harvard Medical School, Boston, MA.
JAMA. 1994 Apr 27;271(16):1250-5.
To describe the clinical reasons tympanostomy tubes are proposed for children and to assess their appropriateness.
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.
Otolaryngologists' practices from 49 states and the District of Columbia.
All 6611 children younger than 16 years who were insured by three clients of the UR firm and whose proposal to receive tympanostomy tubes were 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.
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.
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%.
About one quarter of tympanostomy tube insertions for children in this study were proposed for inappropriate indications and another third for equivocal ones.
描述为儿童建议置入鼓膜造孔管的临床原因，并评估其合理性。
对一家全国性利用审查（UR）公司在两步UR过程中先前前瞻性收集的数据进行分析，以评估鼓膜造孔管置入的医疗合理性。护士采访了耳鼻喉科医生和初级保健医生办公室工作人员以收集临床数据。对于随机抽取的被判定为不适当的病例子样本，我们审查了医生评审员随后对耳鼻喉科医生的访谈，他们寻找可能情有可原的临床情况或可能改变合理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诊所。
所有16岁以下的儿童，他们由UR公司的三个客户承保，并且其接受鼓膜造孔管的建议在1990年1月1日至1991年7月31日期间由该系统进行了审查。研究中的保险公司在研究时为560万美国人提供保险。
根据专家小组使用RAND/加利福尼亚大学洛杉矶分校改良德尔菲法制定的明确标准，评估鼓膜造孔管手术的医疗合理性。
总共6429例（97%）病例因复发性急性中耳炎、中耳积液或两者皆有而被建议置入鼓膜造孔管。在做出宽松的临床假设的情况下，因这些原因提出的建议中，41%有适当指征，32%指征不明确，27%指征不适当。考虑到子样本审查中可获得的额外信息，适当的比例为42%，不明确的为35%，不适当的为23%。
本研究中约四分之一为儿童置入鼓膜造孔管的指征不适当，另有三分之一指征不明确。
