A Pragmatic Clinical Trial of Hearing Screening in Primary Care Clinics: Effect of Setting and Provider Encouragement.

OBJECTIVES: The prevalence of hearing loss increases with age. Untreated hearing loss is associated with poorer communication abilities and negative health consequences, such as increased risk of dementia, increased odds of falling, and depression. Nonetheless, evidence is insufficient to support the benefits of universal hearing screening in asymptomatic older adults. The primary goal of the present study was to compare three hearing screening protocols that differed in their level of support by the primary care (PC) clinic and provider. The protocols varied in setting (in-clinic versus at-home screening) and in primary care provider (PCP) encouragement for hearing screening (yes versus no). DESIGN: We conducted a multisite, pragmatic clinical trial. A total of 660 adults aged 65 to 75 years; 64.1% female; 35.3% African American/Black completed the trial. Three hearing screening protocols were studied, with 220 patients enrolled in each protocol. All protocols included written educational materials about hearing loss and instructions on how to complete the self-administered telephone-based hearing screening but varied in the level of support provided in the clinic setting and by the provider. The protocols were as follows: (1) no provider encouragement to complete the hearing screening at home, (2) provider encouragement to complete the hearing screening at home, and (3) provider encouragement and clinical support to complete the hearing screening after the provider visit while in the clinic. Our primary outcome was the percentage of patients who completed the hearing screening within 60 days of a routine PC visit. Secondary outcomes following patient access of hearing healthcare were also considered and consisted of the percentage of patients who completed and failed the screening and who (1) scheduled, and (2) completed a diagnostic evaluation. For patients who completed the diagnostic evaluation, we also examined the percentage of those who received a hearing loss intervention plan by a hearing healthcare provider. RESULTS: All patients who had provider encouragement and support to complete the screening in the clinic completed the screening (100%) versus 26.8% with encouragement to complete the screening at home. For patients who were offered hearing screening at home, completion rates were similar regardless of provider encouragement (26.8% with encouragement versus 22.7% without encouragement); adjusted odds ratio of 1.25 (95% confidence interval 0.80-1.94). Regarding the secondary outcomes, roughly half (38.9-57.1% depending on group) of all patients who failed the hearing screening scheduled and completed a formal diagnostic evaluation. The percentage of patients who completed a diagnostic evaluation and received a hearing loss intervention plan was 35.0% to 50.0% depending on the group. Rates of a hearing loss intervention plan by audiologists ranged from 28.6% to 47.5% and were higher compared with those by otolaryngology providers, which ranged from 15.0% to 20.8% among the groups. CONCLUSIONS: The results of the pragmatic clinical trial showed that offering provider encouragement and screening facilities in the PC clinic led to a significantly higher rate of adherence with hearing screening associated with a single encounter. However, provider encouragement did not improve the significantly lower rate of adherence with home-based hearing screening.

A pragmatic clinical trial of hearing screening in primary care clinics: cost-effectiveness of hearing screening.

BACKGROUND: Hearing loss is a high prevalence condition among older adults, is associated with higher-than-average risk for poor health outcomes and quality of life, and is a public health concern to individuals, families, communities, professionals, governments, and policy makers. Although low-cost hearing screening (HS) is widely available, most older adults are not asked about hearing during health care visits. A promising approach to addressing unmet needs in hearing health care is HS in primary care (PC) clinics; most PC providers (PCPs) do not inquire about hearing loss. However, no cost assessment of HS in community PC settings has been conducted in the United States. Thus, this study conducted a cost-effectiveness analysis of HS using results from a pragmatic clinic trial that compared three HS protocols that differed in the level of support and encouragement provided by the PC office and the PCPs to older adults during their routine visits. Two protocols included HS at home (one with PCP encouragement and one without) and one protocol included HS in the PC office. METHODS: Direct costs of the HS included costs of: (1) educational materials about hearing loss, (2) PCP educational and encouragement time, and (3) access to the HS system. Indirect costs for in-office HS included cost of space and minimal staff time. Costs were tracked and modeled for each phase of care during and following the HS, including completion of a diagnostic assessment and follow-up with the recommended treatment plan. RESULTS: The cost-effectiveness analysis showed that the average cost per patient is highest in the patient group who completed the HS during their clinic visit, but the average cost per patient who failed the HS is by far the lowest in that group, due to the higher failure rate, that is, rate of identification of patients with suspected hearing loss. Estimated benefits of HS in terms of improvements in quality of life were also far greater when patients completed the HS during their clinic visit. CONCLUSIONS: Providing HS to older adults during their PC visit is cost-effective and accrues greater estimated benefits in terms of improved quality of life. TRIAL REGISTRATION: clinicaltrials.gov (Registration Identification Number: NCT02928107).

Screening for Eustachian Tube Dysfunction in Clinical Practice Using the Eustachian Tube Dysfunction Questionnaire-7.

OBJECTIVES/HYPOTHESIS: To evaluate the ability of the Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7) to discriminate between patients with Eustachian tube dysfunction (ETD) and Non-ETD diagnoses, and identify symptom information to improve ability to discriminate these groups. STUDY DESIGN: Cohort study. METHODS: Pilot retrospective study with consecutive adult patients presenting to otology clinics and one general otolaryngology clinic in an academic health system. Patients were administered ETDQ-7 with eight additional symptom items. Electronic health records were reviewed for demographic and diagnostic information. Patients were grouped into diagnosis categories: 1) True ETD, 2) experiencing ear fullness (EF) not due to ETD, and 3) Control patients without ETD-related disorders or EF. ETDQ-7 and symptom item scores were compared by the diagnosis group. Receiver-operative characteristics curves and area under the curve (AUC) were generated for each ETD diagnosis group based on ETDQ-7 and symptom scores. RESULTS: Of the 108 patients included in this study 74 (68.5%) were diagnosed with ETD. Patients with ETD had higher (indicating worse symptom burden) overall ETDQ-7 scores than Control group (Median [Q1, Q3] 3.0, [1.7, 4.1]; versus 1.5 [1.0, 3.4] P = .008). There was no statistically significant difference between overall ETDQ-7 scores for ETD and Non-ETD EF patients (P = .389). The AUC for the ETDQ-7 in discriminating ETD from other conditions that cause EF was 0.569; the addition of 8 symptom questions to the ETDQ-7 improved AUC to 0.801. CONCLUSION: Additional patient-reported symptom information may improve the ability to discriminate ETD from other similarly presenting diagnoses when using ETDQ-7. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2217-2223, 2022.

The Association Between Hearing Loss and Surgical Complications in Older Adults.

OBJECTIVES: In this study, we sought to evaluate whether older patients with hearing loss who underwent surgery were at greater risk of postsurgical complications, increased inpatient length-of-stay (LOS), and hospital readmission. DESIGN: This was a retrospective cohort study of patients receiving surgery at a tertiary medical center. Utilizing electronic health record data from two merged datasets, we identified patients 65 years and older, undergoing major surgery between January 1, 2014 and January 31, 2017, and who had audiometric evaluation before surgery. Patients were classified as having either normal hearing or hearing loss based on pure-tone average in the better ear. A Generalized Estimating Equations approach was used to fit multivariable regression models for outcome variables of interest. RESULTS: Of patients ≥65 years undergoing major surgery in our time frame, a total of 742 surgical procedures were performed on 621 patients with available audiometric data. After adjusting for age, sex, race, and comorbidities, hearing loss was associated with an increase in the odds of developing postoperative complications. Every 10 dB increase in hearing loss was associated with a 14% increase in the odds of developing a postoperative complication (odds ratio = 1.14, 95% confidence interval = 1.01-1.29, p = 0.031). Hearing loss was not significantly associated with increased hospital LOS, 30-day readmission, or 90-day readmission. CONCLUSIONS: Hearing loss was significantly associated with developing postoperative complications in older adults undergoing major surgery. Screening for hearing impairment may be a useful addition to the preoperative assessment and perioperative management of older patients undergoing surgery.

A preliminary assessment of guideline adherence and clinical variation in oral cancer treatment: a MarketScan database study.

BACKGROUND: To assess variations in adherence to guideline-recommended processes of care for oral cavity cancer patients. METHODS: Retrospective study using a U.S. healthcare research database (MarketScan). Index diagnoses were considered from 2010 to 2012 with follow-up from 2013 to 2014. Diagnostic and procedure codes were utilized to identify oral cavity patients with a defined treatment modality. Compliance with guideline-recommended processes of care, which included pre-treatment imaging, thyroid-function testing (TFTs), multidisciplinary consultation and gastrostomy-tube insertion rates, were assessed. RESULTS: A total of 2752 patients were identified. Surgery alone was the most common treatment (60.8%), followed by surgery with adjuvant chemoradiotherapy (20.4%) and surgery with adjuvant radiotherapy (18.8%). Head/neck and chest imaging were obtained in 60% and 62.5% of patients respectively. Significant geographical differences in head and neck imaging were observed between North-central (64%), South (58.4%) and West (56.1%) regions (p = 0.026). Differences in chest imaging were also present between North-east (65%) and West (56.8%; p = 0.007). TFTs were obtained in 54.4% of the patients after radiation treatment, and 18.6% of patients had multidisciplinary consultation during the 6 months before and 3 months after initiation of treatment. During the year after treatment initiation, 21.2% of patients underwent G-tube placement, with significantly higher rates in patients receiving triple modality treatment (58%) when compared to surgery plus radiation (27%) and surgery alone (15%; p < 0.01). CONCLUSION: Adherence to evidence-based practices was low based on the database coding. These data suggest a potential to improve adherence and increase the routine use of practices delineated in national clinical practice guidelines. CLINICAL RELEVANCE: This study reflects a suboptimal adherence to guidelines based on the database employed. This study should be considered by healthcare providers and efforts should be maximized to follow the processes of care which have proven to impact on patient's outcomes.

Comparative implementation-effectiveness of three strategies to perform hearing screening among older adults in primary care clinics: study design and protocol.

BACKGROUND: The burden of hearing loss among older adults could be mitigated with appropriate care. This study compares implementation of three hearing screening strategies in primary care, and examines the reliability and validity of patient self-assessment, primary care providers (PCP) and diagnostic audiologists in the identification of 'red flag' conditions (those conditions that may require medical consultation and/or intervention). METHODS: Six primary care practices will implement one of three screening strategies (2 practices per strategy) with 660 patients (220 per strategy) ages 65-75 years with no history of hearing aid use or diagnosis of hearing loss. Strategies differ on the location and use of PCP encouragement to complete a telephone-based hearing screen (tele-HS). Group 1: instructions for tele-HS to complete at home and educational materials on warning signs and consequences of hearing loss. Group 2: PCP counseling/encouragement on importance of hearing screening, instructions to take the tele-HS from home, educational materials. Group 3: PCP counseling/encouragement, in-office tele-HS, and educational materials. Patients from all groups who fail the tele-HS will be referred for diagnostic audiological testing and medical evaluation, and complete a self-assessment of red flag conditions at this follow-up appointment. Due to the expected low incidence of ear disease in the PCP cohort, we will enroll a complementary population of patients (N = 500) from selected otolaryngology head and neck surgery clinics in a national practice-based research network to increase the likelihood of occurrence of medical conditions that might contraindicate hearing aid fitting. The primary outcome is the proportion of patients who complete the tele-HS within 2 months of the PCP appointment comparing Group 3 (PCP encouragement, in-office tele-HS, education) versus Groups 2 and 1 (education and tele-HS at home, with and without PCP encouragement, respectively). The several secondary outcomes include direct and indirect costs, patient, family and provider attitudes of hearing healthcare, and accuracy of red flag condition evaluations compared with expert medical assessment by an otolaryngology provider. DISCUSSION: Determining the relative effectiveness of three different strategies for hearing screening in primary care and the assessment accuracy of red flag conditions can each lead to practice and policy changes that will reduce individual, family and societal burden from hearing loss among older adults. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02928107; 10/10/2016 protocol version 1.

The use of balloon dilation in revision sinus surgery.

BACKGROUND: Recent studies have demonstrated a dramatic increase in the use of balloon sinus dilation (BSD) in the United States. However, the use of BSD specifically in revision sinus surgery has not been investigated. This study addresses the question of how BSD is utilized as a tool in revision sinus surgery. METHODS: Data from MarketScan (Truven Health) over a 5-year period (2012-2016) were analyzed. Patients who underwent a sinus procedure with a minimum of 2 years of follow-up were included. RESULTS: A total of 62,304 patients met inclusion criteria; 6847 (10.99%) underwent revision. Age >55 years, the South geographical region, and medical comorbidities increased the odds of revision on multivariate analysis. For patients undergoing revision, BSD was used 11%, 21%, and 13% of the time for revisions of the maxillary, frontal, and sphenoid sinuses, respectively. For a sinus that underwent revision after an initial BSD, a repeat BSD was done close to 40% of the time. CONCLUSION: BSD is used frequently in the revision setting, especially for the frontal sinus and for patients who had already undergone an initial BSD. Our findings highlight the prevalent role of BSD in revision surgery and the need to evaluate such practices.

The effect of lateral neck dissection on complication rate for total thyroidectomy.

PURPOSE: To determine the complication profile for total thyroidectomy with and without concomitant lateral neck dissection using a large administrative database. MATERIALS AND METHODS: The IBM MarketScan® Commercial Database (2010-2014) analytic cohort was queried for patients ≥18 years or older undergoing total thyroidectomy (or equivalent procedures) from January 1, 2010 to June 30, 2014. Subgroup analysis was performed for patients undergoing concomitant unilateral and bilateral lateral neck dissection. The complication profiles were described. RESULTS: 55,204 patients underwent total thyroidectomy or equivalent procedures. Hypoparathyroidism or hypocalcemia was coded in 20.3% overall, with 4.7% having permanent hypoparathyroidism. Vocal cord paralysis was coded in 3.3% overall with permanent rate of 0.7%. Tracheotomy was performed in 0.3% of patients. 2743 underwent total thyroidectomy with concomitant unilateral lateral neck dissection, and 560 of these patients underwent bilateral lateral neck dissection. In patients undergoing unilateral lateral neck dissection, 30.5% of patients have hypoparathyroidism/hypocalcemia coded, with a permanent rate of 8.8%. Vocal cord paralysis was coded in 8.3% of patients, with a permanent rate of 1.9%. Tracheotomy was performed in 1.2% of patients. In patients undergoing bilateral lateral neck dissection, 39.6% had hypoparathyroidism/hypocalcemia coded, with a permanent rate of 10.9%. These patients had vocal cord paralysis coded in 10.2% of cases, with a permanent rate of 2.1%. Tracheotomy was performed in 2.5% of patients. CONCLUSION: The addition of unilateral and especially bilateral lateral neck dissection increases both overall and permanent complication rates for total thyroidectomy. These data may help to inform preoperative discussions with patients.

Using Google Trends to Predict Pediatric Respiratory Syncytial Virus Encounters at a Major Health Care System.

To assess whether Google search activity predicts lead-time for pediatric respiratory syncytial virus (RSV) encounters within a major health care system. Internet user search and health system encounter database analysis. Pediatric RSV encounter volumes across all clinics and hospitals in the Duke Health system were tabulated from 2005 to 2016. North Carolina Google user search activity for RSV were obtained over the same time period. Time series analysis was used to compare RSV encounters and search activity. Cross-correlation was used to determine the 'lag' time difference between Google user search interest for RSV and observed Pediatric RSV encounter volumes. Google search activity and Pediatric RSV encounter volumes demonstrated strong seasonality with predilection for winter months. Granger Causality testing revealed that North Carolina RSV Google search activity can predict pediatric RSV encounters at our health system (F = 5.72, p < 0.0001). Using cross-correlation, increases in Google search activity provided lead time of 0.21 weeks (1.47 days) prior to observed increases in Pediatric RSV encounter volumes at our health system. RSV is a common cause of upper airway obstruction in pediatric patients for which pediatric otolaryngologists are consulted. We demonstrate that Google search activity can predict RSV patient interactions with a major health system with a measurable lead-time. The ability to predict when illnesses in a population result in increased health care utilization would be an asset to health system providers, planners and administrators. Prediction of RSV would allow specific care pathways to be developed and resource needs to be anticipated before actual presentation.

A pathway to value-based care of chronic rhinosinusitis using a claims database.

OBJECTIVE: To construct a comprehensive picture of the typical chronic rhinosinusitis (CRS) patient in the United States including the demographics, comorbidities, and geographic prevalence. The study will also identify the diagnostic and treatment regimens, their cost, and pattern of use for both medically and surgically managed patients. STUDY DESIGN: Historical cohort study utilizing private and public payer databases. METHODS: Medical claims data from the Truven Health MarketScan Research Databases from the years 2010 to 2012 for patients with acute rhinosinusitis (ARS) and CRS 18 and older were analyzed. RESULTS: There were 54 million unique patients in the databases from 2010 to 2012. Approximately 8 million had at least one diagnosis of ARS and 298,337 had a diagnosis of CRS. Females represented 63.7% of patients with ARS and 59.4% with CRS. Medicare patients represented 6.7% of the ARS population and 10.2% of the CRS population. The mean cost of a CRS episode for those commercially insured was $1024 and $762 in Medicare. CRS patients underwent diagnostic procedures including diagnostic endoscopy (55.1%), cultures (23.6%), sinus CT scan (82.1%) and MRI (0.2%). Endoscopic sinus surgery (ESS) was performed on 14.4% of those patients with CRS. Change in frequency of medication use from the 6 months prior to ESS to the 6 months post-ESS yielded a reduction in total costs of 34.2% or $3.9 M. The most commonly operated sinuses (with or without septoplasty on same day as ESS) were the maxillary (94%/76.1%); followed by ethmoid (82.1%/66.6%); frontal (38.8%/35.1%); and sphenoid (28.5%/28.1%). In total, 16.6% had one sinus operated on, 39.1% had two, 24.6% had three, and 18.7% had four sinuses operated on. CONCLUSIONS: This data paints a much clearer understanding of the current medical and surgical management. This study confirms the previously described "value proposition" for the surgical management of those CRS patients refractory to medical management. LEVEL OF EVIDENCE: 4.

Steroid Use for Sudden Sensorineural Hearing Loss: A CHEER Network Study.

OBJECTIVE: The objective of this study was to describe patterns of corticosteroid treatment for sudden sensorineural hearing loss and to evaluate effectiveness based on delivery mode (oral vs intratympanic vs both). STUDY DESIGN: Cross-sectional repeated measures. SETTING: Patients were recruited from practices within the Creating Healthcare Excellence through Education and Research (CHEER) Network. CHEER is a National Institutes of Health-funded nationwide network of 30 community and academic otolaryngology practice sites. SUBJECTS AND METHODS: A subset of 117 patients who had been treated with steroids for sudden sensorineural hearing loss were recruited from within a larger initial CHEER Network study on clinical practice guideline compliance. Outcomes included audiometric and speech scores and patient-perceived improvement. Descriptive analyses, Wilcoxon rank-sum tests, and Fisher exact tests were run. RESULTS: Two categories (oral and simultaneous oral + intratympanic) had adequate sample sizes to support statistical comparison of treatment results. Improvements were seen in both audiometry and speech testing scores; 57% of patients self-reported improvement perceived as either minor or major. There were no significant differences in degree of improvement between these treatment groups. CONCLUSIONS: We observed that a majority of steroid-treated patients demonstrated hearing improvement, but this improvement did not meet criteria for statistical significance. As in other studies on this topic, the relatively small sample size may have prevented differentiation of effectiveness among steroid treatments. We propose that the use of alternative approaches, such as pragmatic clinical trials and multidisciplinary electronic health record systems and megadatabases, may hold the most promise for an approach to best practice development.

Balloon Catheter Dilation of the Sinuses: A 2011-2014 MarketScan Analysis.

OBJECTIVE: This study uses a large national claims-based database to analyze recent practice patterns related to balloon catheter dilation (BCD) of the sinuses. STUDY DESIGN: Retrospective study. SETTING: Academic. SUBJECTS AND METHODS: Patients with chronic rhinosinusitis (CRS) undergoing BCD and functional endoscopic sinus surgery (FESS) from 2011 to 2014 were identified in Truven Health MarketScan Databases with codes from the International Classification of Diseases, Ninth Revision, Clinical Modification and Current Procedural Terminology, Fourth Edition. Prevalence of CRS and frequency of sinus procedures were trended over the study period. Information related to site of service, demographics, and comorbidities was analyzed. RESULTS: Although the prevalence of CRS and sinus procedures remained stable over the study period, there was a consistent increase in the annual number of BCD procedures performed in the office. Among BCD procedures, multisinus dilation had the largest increase. A higher proportion of patients undergoing BCD were women, aged ≥65 years, and from the South. There was a higher prevalence of headache disorder and allergic rhinitis in the BCD group, as compared with the FESS and hybrid groups. CONCLUSION: BCD, especially in the office, has risen in popularity since the introduction of Current Procedural Terminology codes in 2011. This study reveals significant differences in demographics and comorbidities between patients undergoing BCD and those undergoing FESS. Such disparities may highlight the need for better-defined indications for use of this technology.

Idiopathic Sudden Sensorineural Hearing Loss Is Not a Sentinel Event for Acute Myocardial Infarction.

OBJECTIVE: Given ongoing debate about the suggested association, the primary objective was to determine if idiopathic sudden sensorineural hearing loss (ISSNHL) was a sentinel event for acute myocardial infarction (AMI) in adults. STUDY DESIGN: Case-control study. SETTING: United States MarketScan administrative health claims database. PATIENTS: Aged 18 years or older, had a diagnosis of ISSNHL on or after January 1st, 2011 and had sufficient follow-up data available to assess for AMI occurrence. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Incidence rates (per 1,000 patient years) of AMI for cases and controls were computed. Adjusted and unadjusted Cox proportional hazards models were created to explore possible associations between ISSNHL and initial AMI. RESULTS: A total of 10,749 ISSNHL cases and 10,749 matched controls were included. There were no significant differences in the incidence rate of AMI between ISSNHL cases (8.29 events/1,000 person-years) and controls (9.25 events/1,000 person-years), nor were there differences within age groups, sex, or comorbidity status (overall incidence rate ratio 0.90; 95% confidence interval [CI] 0.70-1.15 p = 0.39). The unadjusted and adjusted Cox proportional hazards models did not demonstrate an association between ISSNHL and initial AMI (hazard ratio [HR]: 0.90, 95% CI: 0.70-1.15; HR: 0.86, 95% CI: 0.67-1.10, respectively). CONCLUSIONS: ISSNHL is not a predictor of an initial AMI in adult patients from the United States. Considerable inconsistencies in associations between cardiovascular risk factors and ISSNHL exist in the literature. Further work is needed to confirm or refute direct associations between cardiovascular disease risk factors and ISSNHL before definitive mechanistic conclusions can be made.

Patterns of Migraine Disease in Otolaryngology: A CHEER Network Study.

Objective To evaluate the prevalence of migraine disease in an otolaryngologic cohort and migraine-related otologic and sinonasal symptoms in this population. Study Design Cross-sectional study utilizing the CHEER (Creating Healthcare Excellence through Education and Research) network for recruitment. Setting Patients were recruited in a cross-sectional and pragmatic manner in 14 CHEER sites between June 2015 and March 2017 (9 academic, 5 community based). Subjects and Methods Patients were included if they were aged ≥18 years and seen for any concern that was not head and neck cancer. Patients with any history of brain abnormality or headaches that began within 2 weeks of a medical illness, trauma, or head injury were excluded. Patients were screened for migraine with a validated instrument. If they screened positive on the Migraine Assessment Tool (MAT+), the subjects also filled out validated and custom questionnaires for sinonasal, otologic, and migraine-specific symptoms. Results Of 1458 patients screened, 235 (16.1%) screened positive for migraine (MAT+), which is higher than general population (13%, P < .001). The MAT+ group was significantly younger (47.2 vs 55.6 years of age, P < .001) and predominantly women (80.0% vs 55.9%, P < .001). The MAT+ cohort commonly reported ear- and sinus-related symptoms, such as tinnitus (70.5%), ear pressure (61.9%), balance problems (82%), facial pressure (85%), and rhinorrhea (49.9%). There were significantly higher levels of sinus burden with higher levels of dizziness handicap, Jonckheere-Terpstra test = 11,573.00, z = 7.471, P < .001. Conclusion Migraine disease has a higher prevalence in an otolaryngologic cohort than in the general population, presenting with a high rate of sinonasal and otologic symptoms that may be due to or exacerbated by migraines.

Payer database and geospatial analysis to evaluate practice patterns in treating allergy in North Carolina.

OBJECTIVE: The objective of this study was to characterize the delivery of allergy care in North Carolina using a large payer charge database and visualization techniques. STUDY DESIGN: Geospatial database analysis. SETTING: North Carolina State claims database. SUBJECTS & METHODS: Medical data from the 2013 FAIR Health National Private Insurance Claims (FH NPIC) database for North Carolina was mined for CPT codes and charges for allergy testing, and for the preparation and provision of allergen immunotherapy. Provider and patient variables were analyzed. Analyses were performed to compare differences in allergy care delivery. A visualization strategy complemented the analytic approach. RESULTS: 162,037 CPT charge entries were analyzed. Allergy-immunology specialists were the most common provider specialty to perform allergy immunotherapy treatments (68.9%, p<0.05). Among other specialties, there were no significant differences between specialists performing immunotherapy when comparing otolaryngology, family practice, and internal medicine (16.3%; 4.6%; 2.6%; p>0.05). Providers with an M.D. degree were the most common provider type. The three most commonly treated diagnoses were allergic rhinitis variants. Females were more likely to receive allergy treatments versus males (55.9% vs. 51.5%; p<0.001), and were more likely to receive allergy testing (65.3% vs. 34.7%: p<0.005). Internal medicine providers charged higher than any other specialist type (p<0.05) for allergy immunotherapy. CONCLUSIONS: Using a large payer database coupled with visualization techniques was an efficient approach to characterizing the state-wide provision patterns of allergy diagnostic and therapy services in North Carolina. This first tier approach to efficiently exploring questions and describing populations is valuable.

Investigating the effects of laryngotracheal stenosis on upper airway aerodynamics.

OBJECTIVE: Very little is known about the impact of laryngotracheal stenosis (LTS) on inspiratory airflow and resistance, especially in air hunger states. This study investigates the effect of LTS on airway resistance and volumetric flow across three different inspiratory pressures. METHODS: Head-and-neck computed tomography scans of 11 subjects from 2010 to 2016 were collected. Three-dimensional reconstructions of the upper airway from the nostrils to carina, including the oral cavity, were created for one subject with a normal airway and for 10 patients with LTS. Airflow simulations were conducted using computational fluid dynamics modeling at three different inspiratory pressures (10, 25, 40 pascals [Pa]) for all subjects under two scenarios: 1) inspiration through nostrils only (MC), and 2) through both nostrils and mouth (MO). RESULTS: Volumetric flows in the normal subject at the three inspiratory pressures were considerably higher (MC: 11.8-26.1 L/min; MO: 17.2-36.9 L/min) compared to those in LTS (MC: 2.86-6.75 L/min; MO: 4.11-9.00 L/min). Airway resistances in the normal subject were 0.051 to 0.092 pascal seconds per milliliter (Pa.s)/mL (MC) and 0.035-0.065 Pa.s/mL (MO), which were approximately tenfold lower than those of subjects with LTS: 0.39 to 0.89 Pa.s/mL (MC) and 0.45 to 0.84 Pa.s/mL (MO). Furthermore, subjects with glottic stenosis had the greatest resistance, whereas subjects with subglottic stenosis had the greatest variability in resistance. Subjects with tracheal stenosis had the lowest resistance. CONCLUSION: This pilot study demonstrates that LTS increases resistance and decreases airflow. Mouth breathing significantly improved airflow and resistance but cannot completely compensate for the effects of stenosis. Furthermore, location of stenosis appears to modulate the effect of the stenosis on resistance differentially. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:E141-E149, 2018.

Burden of Hearing Loss on Communication Partners and Its Influence on Pursuit of Hearing Evaluation.

OBJECTIVE: Describe how the burden on the communication partner (CP) from the patient's hearing loss, as perceived by both the patient and their CP, influences a patient's pursuit of hearing evaluation. DESIGN: Cross-sectional design. Demographics, perception of patient's hearing loss, and associated burden on the CP were collected from both patient and CP via online questionnaires. Patients and their CPs from Duke University Medical Center Otolaryngology Clinic, 55 to 75 years of age, being seen for any reason, who indicated a CP has expressed concern about their hearing. Final sample was 245 matched pairs. RESULTS: Based on completed questionnaires, on average, patients perceived their own hearing loss as more burdensome to the CP than the CP did. However, CPs of patients who believed themselves to have no hearing handicap scored the patient's hearing loss 54.3% higher than the patient. The patient's perspective about the amount of burden their hearing loss placed on the CP predicted patients seeking a hearing evaluation. CONCLUSIONS: Recognition of early stage hearing loss and associated burden on CPs may be delayed in patients; CPs may help elucidate unrecognized concerns. Educational approaches that raise awareness of burden of hearing loss on CPs along with hearing loss indications could be a feasible, multidimensional strategy to promote help seeking behaviors.

CHEER National Study of Chronic Rhinosinusitis Practice Patterns: Disease Comorbidities and Factors Associated with Surgery.

Objectives (1) Describe national patterns of chronic rhinosinusitis (CRS) care across academic and community practices. (2) Determine the prevalence of comorbid disorders in CRS patients, including nasal polyposis, allergic rhinitis, asthma, and cystic fibrosis. (3) Identify demographic, clinical, and practice type factors associated with endoscopic sinus surgery (ESS). Study Design Multisite cross-sectional study. Setting Otolaryngology's national research network CHEER (Creating Healthcare Excellence through Education and Research). Subjects and Methods A total of 17,828 adult patients with CRS were identified, of which 10,434 were seen at community practices (59%, n = 8 sites) and 7394 at academic practices (41%, n = 10 sites). Multivariate logistic regression was used to evaluate the association between demographic, practice type, and clinical factors and the odds of a patient undergoing ESS. Results The average age was 50.4 years; 59.5% of patients were female; and 88.3% were Caucasian. The prevalence of comorbid diseases was as follows: allergic rhinitis (35.1%), nasal polyposis (13.3%), asthma (4.4%), and cystic fibrosis (0.2%). In addition, 24.8% of patients at academic centers underwent ESS, as compared with 12.3% at community sites. In multivariate analyses, nasal polyposis (odds ratio [OR], 4.28), cystic fibrosis (OR, 2.42), and academic site type (OR, 1.86) were associated with ESS ( P < .001), while adjusting for other factors. Conclusions We describe practice patterns of CRS care, as well as demographic and clinical factors associated with ESS. This is the first study of practice patterns in CRS utilizing the CHEER network and may be used to guide future research.

Nonadherence to Guideline Recommendations for Tympanostomy Tube Insertion in Children Based on Mega-database Claims Analysis.

Objective To estimate the nonadherence rate of pressure equalization (tympanostomy) tube (PET) placement in the preceding 3-year period before release of the 2013 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline (CPG). Study Design Analysis of the Truven Health MarketScan Research Databases (2010-2012). Subjects and Methods Medical claims data from 2010 to 2012 were analyzed. Children aged ≤12 years with otitis media (OM)-related diagnoses were identified. Adherence and nonadherence rates for OM and PET placement were analyzed through administrative codes extrapolated from the key action statements (KASs) of the CPG. KASs were aggregated to estimate the overall nonadherence and determine areas for quality improvement. Results A total of 9,726,411 visits with OM-associated codes among 3,710,730 children were identified: 2.9% (80,451 of 3,239,700) were considered nonadherent to KAS 1 because a code for PET placement occurred with a first episode of OM with effusion <3 months; 52.1% (14,534 of 27,913) underwent PET placement for OM with effusion of >3 months and had a concurrent hearing loss code. For those without hearing loss who underwent PET placement, 48.3% (52,921 of 109,583) had a diagnosis code indicating risk for speech, language, or learning problems. For each KAS, we found heterogeneity of computed nonadherence rates by region, age, and season. Conclusion Before guideline dissemination, we found low to moderate rates of nonadherence to guideline recommendation. Deeper analysis of mega-databases could provide better insights for measurement of guideline adherence. The expansion of administrative and clinical databases provides a unique opportunity to investigate the impact of CPGs.