Evidence-Based Medicine in Otolaryngology Part 10: Cost-Effectiveness Analyses in Otolaryngology.

Clinicians seek to pursue the most clinically effective treatment strategies, but costs have also become a key determinant in contemporary health care. Economic analyses have thus emerged as a valuable resource to both quantify and qualify the value of existing and emerging interventions and programs. Cost-effectiveness analyses estimate the benefits gained per monetary unit, providing insights to guide resource allocation. Herein, we delineate the related concepts and considerations to facilitate understanding and appraisal of these analyses, so as to better inform the stakeholders in our otolaryngology community.

The increasing cost of pediatric otolaryngology care.

INTRODUCTION: Defining the costs associated with healthcare is vital to determining and understanding ways to reduce costs and improve quality of healthcare delivery. The objective of the present study was to identify the current public health burden of inpatient admissions for conditions commonly treated by pediatric otolaryngologists and compare trends in healthcare utilization with other common surgical diagnoses. METHODS: A retrospective cohort study using the Kids' Inpatient Database for pediatric discharges in the United States from 2000 to 2012. A list of the top 500 admission diagnoses was identified and subsequently grouped into surgical diagnoses typically managed by otolaryngologists and those managed by any other surgical discipline with the top 10 in each category included. Database analyses generated national estimates of summary statistics and comparison of trends over the twelve-year period. RESULTS: Of the top pediatric admission diagnoses, the most common conditions managed by surgical specialties involved inflammatory or infectious causes. Hospital charges significantly increased during this time across all diagnoses. On average, the charges for otolaryngologic diagnoses increased by 37.13% while costs increased by almost 12%. In comparison, the charges for non-otolaryngologic diagnoses increased by 35.87% and the costs by 10.43%. CONCLUSIONS: The public health impact and rising costs of healthcare are substantial. It is of critical significance that the healthcare system be aware of opportunities and lessons that may be learned across specialties to identify the primary drivers of healthcare cost while maintaining high quality standards for patient care.

A Preliminary Case Report of a High-Quality Cost-effective Rigid Laryngoscopy Setup.

OBJECTIVE: To evaluate a cost-effective modified rigid laryngoscopy setup with a portable light source and high-resolution commercially available digital camera for use in smaller otolaryngology and family practice clinics. METHODS: The modified setup was used to obtain images of the larynx using both a traditional light source and a portable light source. Varying shutter speeds and ISOs were evaluated, and the optimal settings were determined for the modified setup. RESULTS: Picture quality was adequate, and the portable light source was bright enough. ISO from 640 to 1600 with shutter speeds ranging from 1/60 to 1/160 are ideal under the normal light source, while it is better to set the ISO between 4000 and 10 000 with shutter speeds from 1/60 to 1/100 under the portable light source. Picture quality was adequate with a resolution of 2768 pixels × 1848 pixels with 350 dpi × 350 dpi. CONCLUSIONS: Results show that the modified setup obtains images of adequate quality for use in the clinic. Additionally, since the larynx requires the most illumination for endoscopic imaging, a similar setup would work for imaging the ear and nose. This setup may make laryngoscopic exams more accessible to patients at smaller laryngoscopy clinics or family practice providers.

Pediatric otolaryngologic conditions: Racial and socioeconomic disparities in the United States.

OBJECTIVES/HYPOTHESIS: Determine the national incidence and disparities for common pediatric otolaryngologic conditions. STUDY DESIGN: Cross-sectional analysis of a nationally representative database. METHODS: The National Health Interview Survey (2012) was analyzed, extracting children with frequent ear infections (FEI), nonstreptococcal sore throat (NSST), streptococcal pharyngitis (SP), hay fever, and sinusitis. Demographic data including age, sex, race, Hispanic ethnicity, geographic region, poverty level, and insurance status were extracted. The annual incidences of these conditions were determined. Disparities in the incidence of each condition was determined according to race and ethnicity, adjusting for other demographic variables. RESULTS: Among 73.3 million children (average age, 8.6 years; 51.1% male), the incidences were: FEI (4.0 million, 5.5% of children), NSST (11.9 million, 20.6% of children), SP (8.0 million, 13.8% of children), hay fever (6.6 million, 9.0% of children), and sinusitis (4.5 million, 7.9% of children). Black and Hispanic children were less likely to be diagnosed with FEI than white children (odds ratio: 0.503 [95% confidence interval: 0.369-0.686] and odds ratio: 0.661 [95% confidence interval: 0.515-0.848]), adjusting for all other demographic variables. Black and Hispanic children were also less likely to be diagnosed with SP than white children (odds ratio: 0.433 [95% confidence interval: 0.342-0.547] and odds ratio: 0.487 [95% confidence interval: 0.401-0.592], respectively). Similar decreased odds ratios for black and Hispanic children were evident for hay fever (odds ratio: 0.704 [95% confidence interval: 0.556-0.890] and odds ratio: 0.708 [95% confidence interval: 0.565-0.888], respectively) and for sinusitis (odds ratio: 0.701 [95% confidence interval: 0.543-0.905] and odds ratio: 0.596 [95% confidence interval:0.459-0.773], respectively). CONCLUSIONS: Black and Hispanic children are consistently less likely to be identified or diagnosed with FEI, hay fever, SP, and sinusitis compared to white children. These data likely highlight a significant health care disparity according to race/ethnicity in otolaryngology. LEVEL OF EVIDENCE: 2b Laryngoscope, 127:746-752, 2017.

[The influence of current social, medical, and political trends on the future of otorhinolaryngology]. / Auswirkungen aktueller Trends in Gesellschaft, Medizin und Politik auf die Zukunft der HNO-Heilkunde.

BACKGROUND: All medical specialties are changing permanently, including otorhinolaryngology. Analyzing trends in social changes, medical progress, and political decisions will allow the effects of these on ENT medicine to be at least partially anticipated. TRENDS: Demographic changes and medical progress lead to an increasing demand for medical treatments. In addition, increasing numbers of female physicians are observed, as are many changes in the lifestyles of young physicians. Medical treatment will develop toward more individualized therapies in the future. ENT surgery will become a more ambulatory medical specialty. Driven by political decisions, digital medicine will become more important. Particular services once provided by physicians will be delegated to non-physician professionals. DISCUSSION: The lack of physicians and the progress in medicine require better networking between in- and outpatient services in the future. The potential of such collaborations is currently not completely realized. However, these developments will also increase the cost of health care. CONCLUSION: These trends will develop otorhinolaryngology into a conservative and surgical ambulatory care driven medical specialty. Embedded in decentralized networks and cooperations, and supported by IT technologies and specialized non-physician professionals, ENT physicians will work in hospitals as well as in practices on a permanent basis. Nevertheless, the question of funding these changes has yet to be clarified.

Management of the early symptoms of influenza-like illnesses and ear, nose and throat (ENT) disorders by pharmacists.

BACKGROUND: Pharmacists play a key role in primary healthcare, but the characteristics of patients who consult a pharmacist directly rather than going to their general practitioner (GP) are unknown. Our aim was to describe the socio-demographic and clinical characteristics of patients who seek direct therapeutic advice from a pharmacist for influenza-like illness (ILI) or ear, nose and throat (ENT) disorders, the types of medicines dispensed and patient satisfaction with the advice received. METHODS: This prospective, observational study was carried out on a random sample of French pharmacies between November 2010 and March 2011. Patients (≥12-years) with early symptoms of ILI or ENT disorders (<36 h duration) who received treatment were included. Socio-demographic data, symptom severity and disease impact on daily activities and sleep were recorded at inclusion. Symptom evolution and patient satisfaction were assessed after 3 days of treatment. RESULTS: 573 patients (mean age: 42.5 ± 16.2 years; 61.9% female) were recruited by 133 pharmacies. Two-thirds of patients (63.2%) visited the pharmacy early (<24 h) after symptom onset. The most common symptoms were runny nose (56.4%), sore throat (54.6%) and cough (49.0%). Patients were given 2.6 ± 1.2 medications; 98.4% of patients received allopathic (usually paracetamol, 33.5%) and 25.3% homeopathic (Oscillococcinum, 56.6%) treatment, usually combined with allopathy. Compliance was good and 77.2% of patients continued treatment for 3 days. Most symptoms improved significantly after 3 days and quality of life was enhanced. 85.9% of patients were satisfied with the advice received. CONCLUSIONS: Seeking a pharmacist's advice for the management of ILI and ENT disorders has several public health benefits. The clinical improvement and high patient satisfaction observed validate the role of the pharmacist as a health professional of first resort.

Pediatric otolaryngology in a field hospital in the Philippines.

BACKGROUND: Major natural disasters adversely affect local medical services and resources. We sought to characterize pediatric patients presenting with otolaryngology-head and neck surgery (OTO-HNS)-related diseases/injuries to a field hospital over 11 days of operation, which was deployed to assist the healthcare facilities in Bogo, the Philippines, in the aftermath of typhoon Haiyan (Yolanda). METHODS: We reviewed charts of pediatric patients aged 0-18 years visiting our field hospital, who presented with OTO-HNS-related diseases/injuries. We also describe the structure of the field hospital, equipment, facilities and capabilities of our service, discuss medical and ethical concerns, and propose several recommendations for future similar missions. RESULTS: Of the 863 pediatric visits, 91 (11%) presented with OTO-HNS-related diseases/injuries, 3 of them were of recurring patients. Of the 88 included individual patients, 47 (53%) were boys, with an average age of 6.9±4.9 years. Ear-related diseases, mostly acute otitis media (AOM), and neck-related diseases were the most common pathologies (49% and 16% of the patients, respectively). Antibiotic therapy was administered to 36 (41%) patients, mostly to children with AOM. Despite limited resources, we were able to perform surgical interventions on 8 (9%) patients, which included laceration suturing, abscess drainage and neck surgery. CONCLUSIONS: Otolaryngologists have an important role in the treatment of children affected in a disaster area, at a time of an increased demand for healthcare. Unlike 'acute phase' missions, where traumatic injuries are the focus for treatment, 'subacute' phase missions provide more routine medical and surgical care.

Implementation of a novel otolaryngology clinic for indigent patients.

OBJECTIVES/HYPOTHESIS: This study was designed to describe the implementation, utilization, and outcomes of an otolaryngology clinic for indigent patients employing a novel design. STUDY DESIGN: Pilot study. METHODS: A tertiary-care academic otolaryngology department partnered with a nonprofit outpatient clinic for indigent patients in order to provide free subspecialty consultation services. A novel format was utilized in which the department provided on-site, scheduled outpatient multidisciplinary consultation on weekends, staffed by volunteer health care providers and ancillary staff. A review of the program was conducted using prospectively collected data. Clinic design, staffing, utilization, and feasibility were described, along with demographic and clinical data for all patients participating in the clinic from October 2010 through January 2012. RESULTS: Five clinics were held over 15 months, totaling 74 patient visits, with positive feedback regarding accessibility and quality of services provided. A total of 60 procedures were performed, including audiograms, endoscopies, otologic procedures, biopsies and/or excisions. The estimated value of medical services that were provided was $37,302. Four potentially life-threatening conditions were newly diagnosed. Twenty patients received conclusive evaluation and treatment at the time of their first visit. Eighteen patients required further subspecialty treatment and/or surgery that could not be provided in the outpatient setting, and were referred appropriately. CONCLUSIONS: The partnership between an academic otolaryngology department and a nonprofit clinic provided free on-site consultation for indigent patients. Such an arrangement is feasible, well utilized, and successful in delivering comprehensive specialized services to indigent patients who lack traditional access to medical care.

[Interdisciplinary teleconsultation: first practical experiences with 100 patients]. / Interdisziplinäre Telekonsultation: Erste praktische Erfahrungen mit 100 Patienten.

UNLABELLED: PROBLEM DEFINITION: Increasing specialization can be observed in the various medical fields and as a consequence there is little professional exchange between ear nose and throat (ENT) specialists and general practitioners. At the same time there has been significant technological development in telemedicine over the last 5 years; however, this potential is not being sufficiently exploited. The objective of this project is to implement a practicable solution for teleconsulation between ENT specialists and general practitioners. MATERIALS AND METHODS: The connection is based on a secure broadband internet connection, the corresponding server structure and a video endoscopic system. In the period from 01 January 2011 to 30 June 2012 (18 months) a total of 102 patients were included in the study in which 4 general practitioners and 5 ENT specialists participated. The protocol comprised the following parameters: indications and typical questions, number of patients presenting to the ENT specialist due to the available teleconsultation service (CBO), number of patients referred to the ENT specialist after teleconsultation (CIO), assessment of the quality of the additional expert opinion (LOQ GP), assessment of the accuracy of the specialist physician tele-diagnosis (TDS-FA) and assessment of the impact of the expert physician diagnosis on the general medical treatment (COS). RESULTS: Teleconsultation was most frequently used for diagnostics on tonsils (37% of the presented cases), the external auditory canal (32%) and the inner nose (15%). Of the patients analyzed were 53.9% presented to the ENT specialist only because the teleconsultation service provided an effortless opportunity and after teleconsultation 40.1% of the patients were referred to the ENT specialist. General practitioners assessed the benefit from the specialist opinion with 64 points. Diagnostic certainty of the specialist opinion, i.e. the validity scale of the diagnosis made, was on average 2.0. In approximately 35.3% of the cases (36 out of 102 patients) participating general practitioners documented a considerable impact of teleconsultation on the diagnosis and/or therapy. CONCLUSIONS: Teleconsultation between general practitioners and ENT specialists can provide an advantage in treatment quality and patient comfort. According to the experience gained there is a very low risk of diminishing the professional competency of ENT medicine and the involvement of the expert group in the early project stage allows a greater leeway in project implementation. This could also have an impact on future medical performance specifications. According to the ENT experts involved in the project further applications of teleconsultation are very conceivable.

Structured clinical assessment of the ear, nose and throat in patients with granulomatosis with polyangiitis (Wegener's).

The objective of this prospective cross-sectional study is to describe the clinical otorhinolaryngological manifestations of granulomatosis with polyangiitis (Wegener's) (GPA) in a prospective cohort. All patients suffering from GPA seen in a tertiary centre between March 2007 and November 2008 had a detailed clinical assessment by an ENT surgeon of their ear, nose and head and neck complaints. An evaluation of whether there was disease activity and/or infection in each ENT area was made using the European Vasculitis Study Group guidelines. The number of patients assessed was 144. The proportion of female patients was 47 % (n = 69) and the median age was 57.7 years (IQ range 42.5-68.5). The prevalence of ENT involvement was 87 % (125/144). Hearing loss and abnormal tympanic membrane appearance were more common in patients with active disease and no infection (7/8 and 6/8, respectively, in active disease cf. 59/131 and 52/131, respectively, in remission). Nasal crusting was the most common nasal complaint recorded (52/144, 36 %) and bloody rhinorrhoea was the most common symptom in patients with disease activity. Rhinoscopy was highly sensitive in diagnosing disease activity (100 %). Subglottic stenosis was the most common head and neck manifestation (27/121, 22 %) and 74 % were symptomatic. In conclusion, the pattern and frequency of clinical ENT manifestations in GPA have been described in a large patient cohort. The use of tools readily available in the ENT clinic was essential to assess these patients accurately. This dataset will form the basis of an objective scoring system to measure disease activity in the ENT system.

[Epidemiology and prophylaxis of ENT diseases in the cadets of the Nakhimov Naval School].

The objective of the present study was to determine the prevalence of otorhinolaryngological morbidity among the cadets of the Nakhimov Naval School and propose the effective measures for its reduction and prevention. A total of 335 children at the age from 11 to 17 years were available for the examination. The analysis of otorhinolaryngological morbidity during September and October 2011 revealed the high frequency of acute respiratory diseases (46 cases) and maxillary sinus symptoms (12 cases). The newly recruited children accounted for 40% of the affected patients. The results of the screening carried out in the military educational institution suggest the necessity of improvement of the quality of primary medical screening, timely diagnostics and correction of pathological conditions. They can be used to formulate the long-range objectives for the improvement of individual recommendations for the medical observation of the cadets presenting with chronic ENT diseases.

Potential impact of the financial crisis on outpatient hospital visits due to otorhinolaryngologic disorders in Crete, Greece.

The public health effect of financial crises has been emphasized in previous studies. In addition, a series of otorhinolaryngologic disorders and manifestations has been related to psychological factors in the literature. Such conditions include temporomandibular joint disorders, laryngopharyngeal reflux, chronic tinnitus, and vertigo. Focusing on the outpatient database records of a large hospital in Crete, Greece, the objective of this retrospective study was to explore possible occurrence variations within the prementioned otorhinolaryngologic morbidity which may be potentially attributed to increased levels of socioeconomic stress. Results revealed that although the total number of visits between two periods - before and after the beginning of the financial crisis in Greece - was comparable, a significant increase in the diagnosis of two disorders, namely vertigo and tinnitus was found. In addition, a trend toward increased rate of diagnosis for reflux and temporomandibular joint disorders was noted. Potential implications of these findings are discussed. In conclusion, health care providers in this as well as in other countries facing similar socio-economic conditions should be aware of potential changes in the epidemiologic figures regarding specific medical conditions.

The Alaska experience using store-and-forward telemedicine for ENT care in Alaska.

This article discusses the development, evaluation, and growth of telemedicine in Alaska. Store-and-forward telemedicine has been used to deliver ear, nose, and throat (ENT) care to rural Alaska since 2002. It has proved valuable in the treatment of many conditions of the head and neck, and it is particularly well suited for the diagnosis and treatment of ear disease. Usage has grown steadily as telemedicine has become widely accepted. Store-and-forward telemedicine has been shown within the Alaska Native Health System to improve access for care and reduce wait times, as well as decrease travel-associated costs for patients.

[Expert opinions in ORL according to the new healthcare system act : rights for social compensation and the severely handicapped]. / HNO-Begutachtung nach der neuen Versorgungsmedizin-Verordnung : Soziales Entschädigungsrecht und Schwerbehindertenrecht.

The medically approved indications for social rights for compensation and the rights of severely disabled persons have been accepted for decades. After the introduction of the healthcare system act on 12th December 2008 these indications can no longer be applied. These rights now have the status of law. Since 1st January 2009 health disorders are not estimated according to the scale of disability but according to the scale of conditions due to injuries. The structure of the healthcare system act, the general modifications and certain consequences for the field of ORL will be described.

Accomplishment and opportunity in geriatric otolaryngology.

Geriatric otolaryngology is an emerging medical subspecialty developed in response to a pressing societal need. In this article, the author explains the rationale for this new subspecialty, reviews the landmark events that led to the creation of an organizational structure, celebrates the accomplishments that have been achieved thus far, and discusses the challenges that remain and the opportunities for future growth.

The role of ENT surgeons in snoring assessment: some prospective preliminary evidence.

OBJECTIVES: To determine (i) the prevalence of unsuspected upper aerodigestive tract disease in snorers, (ii) the diagnostic yield of routine flexible endoscopy and (iii) the relationship between symptoms of upper aerodigestive tract disease and examination findings in snorers. DESIGN: Prospective analytical cohort study. SETTING: Snoring clinic in Secondary Care Otolaryngology centre. PARTICIPANTS: Ninety-three patients referred with disruptive snoring. MAIN OUTCOME MEASURES: A structured history of upper aerodigestive tract symptoms was obtained by clinic interview. All patients underwent detailed ENT examination. Univariate analysis was undertaken on data collected. RESULTS: The prevalence of oropharyngeal and laryngeal pathology in the cohort was 3%. No unsuspected upper aerodigestive tract pathology was found on routine flexible endoscopy. A history of Hard Nasal Symptoms was an accurate predictor of underlying nasal pathology. CONCLUSION: The authors propose that the detailed examination of snorers by ENT specialists is unnecessary in the absence of Hard Nasal Symptoms, hoarseness or pain. We propose that a system of triage based on patient history could help identify the minority of snorers who require specialist assessment.