Influence of Insurance Status and Demographic Factors on Outcomes Following Tracheostomy.

OBJECTIVES/HYPOTHESIS: Little data exists regarding the relationship between socioeconomic and demographic factors and tracheostomy outcomes. The goal of this study was to determine associations between socioeconomic status (SES), demographic factors, and insurance status with hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality following tracheostomy. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective analysis of all patients who underwent tracheostomy at an urban tertiary-care academic hospital from 2016 to 2017 was performed. Patients were aggregated into low-, middle-, and high-income brackets. Other variables included age, sex, race, ethnicity, body mass index, and Charlson Comorbidity Index (CCI). Outcomes included hospital and ICU LOS, in-hospital mortality, and 30-day mortality following tracheostomy. Outcomes were compared using Kruskal-Wallis tests for continuous variables and χ2 or Fisher exact tests for categorical variables. The α level was set to .05. RESULTS: In total, 523 patients were included in the study. Patients from high-income areas were more likely to be male (P < .01), white (P < .01), and had lower body mass index (P = .04). On multiple regression analysis, Hispanic or Latino ethnicity was associated with an increased odds of 30-day mortality (odds ratio [OR]: 4.43, P = .020). CCI was also associated with increased odds of 30-day mortality (OR: 1.12, P = .039). CONCLUSIONS: Lower SES was not associated with increased morbidity or mortality after tracheostomy. Although Hispanic patients tended to have a lower CCI score, they had increased 30-day mortality, suggesting there are factors specific to this population that may influence outcomes, and future targeted studies are warranted to study these relationships. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1463-1467, 2021.

Measuring the impact of dysphonia on quality of life using health state preferences.

OBJECTIVES: Formal evaluation of health states related to dysphonia have not been rigorously evaluated in affected patients. The objective of this project was to evaluate the health states of mild, moderate, and severe dysphonia using formal health state preference evaluation, and to compare these outcomes with the degree of voice handicap. DESIGN: Prospective health state preference assessment. METHODS: A convenience sample of patients presenting with voice complaints were enrolled from an academic voice center. Demographic and voice handicap index (VHI-10) data were obtained, and an assessment of preference for five health states (monocular blindness, binocular blindness, mild dysphonia, moderate dysphonia, and severe dysphonia) was performed. Utility scores were calculated on a scale from 0 (death) to 1 (perfect health). Analysis was performed with ANOVA testing with post-hoc comparisons and correlation statistics. RESULTS: Of 209 assessments, 149 (75.6%) met quality criteria. Relative to monocular blindness (score 0.61 [CI 0.57-0.64]), moderate dysphonia (0.58 [0.54-0.62]) was rated equivalently, with severe dysphonia (0.33 [0.29-0.37]) ranking significantly worse and mild dysphonia (0.96 [0.95-0.98]) significantly better. Binocular blindness (0.18 [0.15-0.21]) was the worst-ranked health state. There was a weak inverse correlation of VHI-10 with dysphonia-related preference scores; with worsening reported voice handicap, scores decreased. CONCLUSION: This study demonstrated that dysphonia had a significant impact of quality of life, with moderate dysphonia ranking equivalently with monocular blindness. These numerical estimates may be used for ongoing research into the value and cost-effectiveness of medical, therapeutic, and surgical interventions for voice disorders. LEVEL OF EVIDENCE: 2c (outcomes research) Laryngoscope, 130:E177-E182, 2020.

Recommended Protocols for Instrumental Assessment of Voice: American Speech-Language-Hearing Association Expert Panel to Develop a Protocol for Instrumental Assessment of Vocal Function.

Purpose: The aim of this study was to recommend protocols for instrumental assessment of voice production in the areas of laryngeal endoscopic imaging, acoustic analyses, and aerodynamic procedures, which will (a) improve the evidence for voice assessment measures, (b) enable valid comparisons of assessment results within and across clients and facilities, and (c) facilitate the evaluation of treatment efficacy. Method: Existing evidence was combined with expert consensus in areas with a lack of evidence. In addition, a survey of clinicians and a peer review of an initial version of the protocol via VoiceServe and the American Speech-Language-Hearing Association's Special Interest Group 3 (Voice and Voice Disorders) Community were used to create the recommendations for the final protocols. Results: The protocols include recommendations regarding technical specifications for data acquisition, voice and speech tasks, analysis methods, and reporting of results for instrumental evaluation of voice production in the areas of laryngeal endoscopic imaging, acoustics, and aerodynamics. Conclusion: The recommended protocols for instrumental assessment of voice using laryngeal endoscopic imaging, acoustic, and aerodynamic methods will enable clinicians and researchers to collect a uniform set of valid and reliable measures that can be compared across assessments, clients, and facilities.

Perceptions of the laryngology Match: A survey of program directors and recent trainees.

OBJECTIVES/HYPOTHESIS: Evaluate program director and recent trainee perceptions of the advantages and disadvantages of the laryngology Match. STUDY DESIGN: Web-based survey study. METHODS: A Web-based survey study was distributed to program directors and recent laryngology trainees to evaluate perceptions of the laryngology Match. A 15-item questionnaire with free-form, Likert, and multiple selection answers was emailed to 115 recent/current trainees and 22 laryngology directors. RESULTS: Fifty-nine percent (13/22) of the program directors and 47% (54/115) of the recent trainees responded to the survey. There were significant increases in the number of programs applied to, interview offers received, and interviews attended by laryngology trainees who applied after adoption of the Match compared to those who applied prior to the Match. Seventy-one percent (22/31) of applicants after 2012 participated in the Match; those who did not accepted positions outside of the Match. Ninety-five percent (21/22) who applied through the Match successfully matched. Two-thirds of recent trainees and three-quarters of directors believe the Match process primarily benefits the applicant. The number of candidates interviewed per program approximately doubled from three to six after institution of the Match. CONCLUSIONS: Overall, both program directors and recent or current laryngology trainees have a positive perception of the laryngology match process. The Match process increased the number of applicants and interviews per year, which both directors and trainees believe increases an applicant's chance at successfully matching. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:2818-2822, 2017.

Factors important in laryngology fellow and laryngology fellowship selection.

OBJECTIVES/HYPOTHESIS: To determine factors that laryngology fellowship directors believe are most important in choosing a fellow and that laryngology applicants believe are most important in choosing a program. The number of laryngology fellowship programs and the number of laryngology fellowship applicants have been increasing in recent years. Selection criteria in choosing a fellow or fellowship program have not been studied. METHODS: Survey study using anonymous online questionnaires of laryngology fellowship directors and recent laryngology fellowship applicants. Directors were asked to rate qualities for judging the strength of a fellowship applicant. Applicants were assessed for the importance of various factors in choosing a fellowship. RESULTS: Sixteen of 27 fellowship directors (59%) and 33 of 53 fellowship applicants (62%) contacted responded to the survey. Program directors listed interview performance, letters of recommendation, and personal knowledge of applicant as the most important factors. Gender or ethnicity, previous research in laryngology, and likelihood that the applicant will rank the director's program highly were ranked as least important factors. Applicants ranked personal rapport with fellowship mentor(s), large experience in endoscopic surgeries, and reputation of mentor(s) as most important, whereas call schedule, salary, and having more than one fellow per year were ranked as least important factors. CONCLUSION: Interview performance, trusted colleague's recommendation, and personal knowledge were ranked as the most important factors in fellow selection. These criteria are consistent with previous research on otolaryngology residency and pediatric otolaryngology fellow selection. When selecting a fellowship, laryngology fellowship applicants choose based on personal rapport with mentor, opportunity to learn endoscopic surgeries, and mentor reputation. LEVEL OF EVIDENCE: N/A.

Delayed otolaryngology referral for voice disorders increases health care costs.

BACKGROUND: Despite the accepted role of laryngoscopy in assessing patients with laryngeal/voice disorders, controversy surrounds its timing. This study sought to determine how increased time from first primary care to first otolaryngology outpatient visit affected the health care costs of patients with laryngeal/voice disorders. METHODS: Retrospective analysis of a large, national administrative claims database was performed. Patients had an International Classification of Diseases, 9(th) Revision-coded diagnosis of a laryngeal/voice disorder; initially saw a primary care physician and, subsequently, an otolaryngologist as outpatients; and provided 6 months of follow-up data after the first otolaryngology evaluation. The outpatient health care costs accrued from the first primary care outpatient visit through the 6 months after the first otolaryngology outpatient visit were determined. RESULTS: There were 260,095 unique patients who saw a primary care physician as an outpatient for a laryngeal/voice disorder, with 8999 (3.5%) subsequently seeing an otolaryngologist and with 6 months postotolaryngology follow-up data. A generalized linear regression model revealed that, compared with patients who saw an otolaryngologist ≤1 month after the first primary care visit, patients in the >1-month and ≤3-months and >3-months time periods had relative mean cost increases of $271.34 (95% confidence interval $115.95-$426.73) and $711.38 (95% confidence interval $428.43-$993.34), respectively. CONCLUSIONS: Increased time from first primary care to first otolaryngology evaluation is associated with increased outpatient health care costs. Earlier otolaryngology examination may reduce health care expenditures in the evaluation and management of patients with laryngeal/voice disorders.

Frequency and factors associated with use of videolaryngostroboscopy in voice disorder assessment.

OBJECTIVES/HYPOTHESIS: Videolaryngostroboscopy (VLS) is considered an important diagnostic tool in the evaluation of patients with laryngeal/voice disorders. We evaluated the frequency of, diagnoses associated with, and factors related to VLS use in the evaluation of outpatients with laryngeal/voice disorders. STUDY DESIGN: Retrospective analysis of a large, national administrative U.S. claims database. METHODS: Patients with a laryngeal disorder based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes from January 1, 2004, to December 31, 2008, seen by an otolaryngologist were included. Patient age, gender, geographic region, laryngeal diagnosis, comorbid conditions, and whether laryngoscopy or VLS was performed during the outpatient otolaryngology visit were collected. RESULTS: A total of 168,444 unique patients saw an otolaryngologist for 272,112 outpatient visits. Of those, 6.2% of outpatient otolaryngology visits had a VLS performed. Patient age was related to VLS use, with lower odds in the elderly (≥ 65 years of age) and those 0 to 17 years of age. Geographic variation was noted, with higher odds of VLS use in urban versus rural areas and greater odds in the Northeast versus the South. Laryngeal diagnosis was associated with VLS use with greatest odds for patients with multiple diagnoses, vocal fold paralysis, and paresis-followed by nonspecific dysphonia and benign vocal fold/laryngeal pathology and followed by acute and chronic laryngitis and laryngeal cancer. Patients with gastro-esophageal reflux (GER) had greater odds of VLS use than patients without GER. CONCLUSIONS: VLS was used in 6.2% of outpatient otolaryngology outpatient visits; and its use was influenced by multiple factors.

Factors influencing the health care expenditures of patients with laryngeal disorders.

OBJECTIVE: To identify factors related to the health care spending of patients with laryngeal disorders. STUDY DESIGN AND SETTING: Retrospective analysis of data from a large, nationally representative administrative US claims database. SUBJECTS AND METHODS: Patients with a laryngeal disorder based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004, to December 31, 2008, and who were continuously enrolled for 12 months were included. Age, sex, comorbidity, geography, provider type, visit type, and type of laryngeal pathology were collected. To identify which factors were related to the direct costs, a generalized linear regression with gamma distribution was used. RESULTS: Of almost 55 million individuals in the database, 309,300 patients with a laryngeal disorder and 12 months of follow-up data were identified (mean [SD] age, 47.3 [21.3] years; 63.5% female). Age, sex, geographic region, number of comorbid conditions, type of provider, visit type, and laryngeal pathology were significantly associated with the health care expenditures (all P values <.05). Costs increased with increasing age and were greater for male patients, higher in the South and Northeast compared with the West and North-central regions, greater in 2008 compared with 2004, higher for inpatient compared with outpatient care, higher with increasing number of comorbid conditions, and lower if a patient was treated by a primary care physician only. Among the various laryngeal pathologies, the greatest direct costs were for laryngeal cancer and patients with multiple diagnoses. CONCLUSION: This study identified multiple factors associated with the health care expenditures of patients with laryngeal disorders.

Direct health care costs of laryngeal diseases and disorders.

OBJECTIVES/HYPOTHESIS: To estimate the annual direct costs associated with the diagnosis and management of laryngeal disorders. STUDY DESIGN: Retrospective analysis of data from a large, nationally representative, administrative US claims database. METHODS: Patients with a laryngeal disorder based on International Classification of Diseases,Ninth Revision-Clinical Modification codes from January 1, 2004 to December 31, 2008 and who were continuously enrolled for 12 months were included. Data regarding age, gender, geographic location, and type of physician providing the diagnosis were collected. Medical encounter, medication, and procedure costs were determined. Total and mean costs per person for 12 months were determined. RESULTS: Of almost 55 million individuals in the database, 309,300 patients with 12 months follow-up, mean age of 47.3 years (standard deviation: 21.3), and 63.5% female were identified. Acute and chronic laryngitis, nonspecific causes of dysphonia, and benign vocal fold lesions were the most common etiologies. The total annual direct costs ranged between $178,524,552 to $294,827,671, with mean costs per person between $577.18 and $953.21. Pharmacy claims accounted for 20.1% to 33.3%, procedure claims 50.4% to 69.9%, and medical encounter claims 16.3% to 8.6% of overall direct costs. Antireflux medication accounted for roughly 10% and antibiotics 6% of annual direct costs. CONCLUSIONS: This study establishes the economic impact of the assessment and management of patients with laryngeal disorders and permits cost comparisons with other diseases.

Prevalence and causes of dysphonia in a large treatment-seeking population.

OBJECTIVES/HYPOTHESIS: To determine the prevalence and common causes of dysphonia as diagnosed by primary care physicians (PCPs) and otolaryngologists and to evaluate differences in etiologies offered by these providers. STUDY DESIGN: Retrospective analysis of data from a large, nationally representative administrative U.S. claims database. METHODS: Patients were identified as dysphonic based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004, to December 31, 2008. Data regarding age, sex, geographic location, and type of physician providing the dysphonia diagnosis were collected. Overall and age-related prevalence rates, as well as frequency of specific etiologies by provider type, were calculated. RESULTS: Of the almost 55 million individuals in the database, 536,943 patients (ages 0 to >65 years) were given a dysphonia diagnosis (point prevalence rate of 0.98%). The prevalence rate was higher among females as compared to males (1.2% vs. 0.7%) and among those >70 years of age (2.5%). The most frequent diagnoses overall were acute laryngitis, nonspecific dysphonia, benign vocal fold lesions, and chronic laryngitis. PCPs more commonly diagnosed acute laryngitis, whereas otolaryngologists more commonly diagnosed nonspecific dysphonia and laryngeal pathology. Gastroesophageal reflux was more commonly diagnosed as a comorbid condition by otolaryngologists than by PCPs. Overall laryngeal cancer prevalence in this treatment-seeking population was 2.2% and was greatest among males >70 years of age. CONCLUSIONS: This analysis of insurance claims data from a nationally representative database represents the largest study of its kind. Important differences in dysphonia prevalence related to age, sex, diagnosis, and physician type were identified.