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Objective: Eustachian tube dysfunction (ETD) prompts >2 million adult visits in the United States annually. While disease prevalence and health care utilization are established for children, practice patterns for adults remain unknown. Our objective was to determine national resource utilization for adult ETD., Study Design: Cross-sectional study., Setting: National database sample., Subjects and Methods: The Truven Health MarketScan Databases (2010-2014) analytic cohort included health care encounters of patients ≥18 years of age with a diagnosis of ETD, otitis media with effusion, or tympanic membrane retraction. Visits associated with recent diagnoses of acute upper respiratory infection, head and neck cancer, or radiation therapy were excluded. Acute ETD (<3 months) and chronic ETD (≥3 months) were subgroups. Medication usage was quantified by class., Results: ETD was diagnosed for 1,298,987 patients, 11% of which was chronic. Over 92% of patients were seen in outpatient clinics, most often by otolaryngology (57%) for chronic ETD and by general medicine (49%) for acute ETD. Medications were frequently utilized, as 530,146 (53.7%) patients received ≥1 prescription. Top prescriptions for chronic ETD included intranasal corticosteroids (22%), antibiotics (22%), oral corticosteroids (13%), and analgesics (6%). The overall annual cost of prescribed medications associated with visits in which either acute or chronic ETD was diagnosed exceeded $8.5 million for a mean of $80.78 per patient who filled a prescription., Conclusion: Adult ETD is frequently treated with several medication classes by a variety of provider types. Understanding the potential adverse effects and cost associated with these practices should be a priority.

Objectives Our objectives were (1) to assess patterns of intranasal steroid administration when otitis media with effusion (OME) has been diagnosed in children, (2) to investigate whether usage varies according to visit setting, and (3) to determine if practice gaps are such that quality improvement could be tracked. Study Design Cross-sectional analysis of an administrative database. Subjects and Methods National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005 to 2012; univariate, multivariate, and stratified analyses of intranasal steroid usage were performed. The primary outcome was intranasal steroid administration, and the primary predictor was a diagnosis of OME. The impact of location of service was also analyzed. Results Data representing 1,943,177,903 visits demonstrated that intranasal steroids were administered in 10.0% of visits in which OME was diagnosed, in comparison to 3.5% of visits in which OME was not diagnosed (univariate odds ratio, 3.07; 95% confidence interval [CI], 1.85-5.08; P < .001). After adjusting for age, sex, race/ethnicity, and other confounding conditions, multivariate analysis demonstrated that OME remained associated with an increase in intranasal steroid usage (odds ratio, 3.58; 95% CI, 1.60-8.01; P = .002). This practice pattern was more prevalent in the ambulatory office setting (risk difference 6.6%, P < .001) and less seen in a hospital-based office or emergency department. Conclusion Despite randomized controlled trials showing a lack of efficacy for isolated OME, nasal steroids continue to be used in treating children with OME in the United States. Related quality improvement opportunities to prevent usage of an ineffective treatment exist.

Otitis media with effusion (OME) is the focus of an updated multidisciplinary clinical practice guideline published by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) and the American Academy of Pediatrics (AAP). Based on data from clinical trials, the guideline recommends against using antihistamines, antibiotics, oral steroids, and intranasal steroids for OME. To understand practice patterns related to these guidelines, we assessed nationally representative data. Despite controlling for age, sex, race/ethnicity, and other potential confounders individualized for each medication class, an increased risk of antihistamine (odds ratio [OR], 3.53), antibiotic (OR, 4.31), and intranasal steroid administration (OR, 3.58) was seen when OME was diagnosed. These analyses have demonstrated opportunities for quality improvement in the care of patients with OME, quantifying gaps in practice relevant to proposed quality measures. Education targeted according to practice setting may facilitate appropriate therapy and/or referral for definitive intervention in children with OME.

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.

Objectives: (1) Compare postoperative bleeding in the CHEER network (Creating Healthcare Excellence through Education and Research) among age groups, diagnoses, and practice types. (2) Report the incidence of bleeding by individual CHEER practice site based on practice guidelines., Study Design: Retrospective data collection database review of the CHEER network based on ICD-9 and CPT codes related to tonsillectomy patients., Setting: Multisite practice-based network., Subjects and Methods: A total of 8347 subjects underwent tonsillectomy as determined by procedure code within the retrospective data collection database, and 107 had postoperative hemorrhage. These subjects had demographic information and related diagnoses based on the CPT and ICD-9 codes collected. Postoperative ICD-9 and CPT codes were used to identify patients who also had postoperative bleed. Variables included age (<12 vs ≥12 years), diagnoses (infectious vs noninfectious), and practice type (community vs academic). Statistical analysis included multivariate logistic regression variables predictive of postoperative bleeding, with P < .05 considered significant., Results: Thirteen sites contributed data to the study (7 academic, 6 community). There was postoperative bleeding for an overall bleed rate of 1.3%. Patients ≥12 years old had a significantly increased bleed rate when compared with the younger group (odds ratio, 5.98; 95% confidence interval: 3.79-9.44; P < .0001). There was no significant difference in bleed rates when practices or diagnoses were compared., Conclusion: A site descriptor database built to expedite clinical research can be used for practice assessment and quality improvement. These data were also useful to identify patient risk factors for posttonsillectomy bleed., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Importance: Antireflux medication has been endorsed as a useful adjunctive therapy for chronic rhinosinusitis, but its use remains controversial., Objectives: To determine whether chronic rhinosinusitis is associated with administration of proton pump inhibitors, histamine2-receptor antagonists, antacids, or prokinetic agents; whether practice patterns vary according to visit setting; and whether those patterns vary according to the presence or absence of potentially confounding conditions., Design, Setting, and Participants: A cross-sectional analysis was performed of data from January 1, 2005, to December 31, 2010, from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, which included 590 772 observations representing 7 191 711 480 ambulatory care visits. Univariate, multivariate, and stratified analyses were performed from January 1, 2005, to December 31, 2010., Exposures: Chronic rhinosinusitis., Main Outcomes and Measures: The probability of receiving antireflux medications was the main measured outcome., Results: Of 7 191 711 480 ambulatory care visits, those for chronic rhinosinusitis were not more likely to result in the administration of proton pump inhibitors (odds ratio, 1.00; 95% CI, 0.62-1.63; P = .99) or antacids and prokinetic agents (odds ratio, 1.24; 95% CI, 0.30-5.10; P = .77). In addition, patients with chronic rhinosinusitis were less likely to receive histamine2-receptor antagonists than were those without chronic rhinosinusitis, even when adjusted for age, sex, race/ethnicity, visit setting, other antireflux agents, and presence or absence of gastroesophageal reflux, laryngopharyngeal reflux, or allergy diagnoses (odds ratio, 0.25; 95% CI, 0.12-0.57; P = .001)., Conclusions and Relevance: National practice patterns observed thus far have not favored the use of proton pump inhibitors, histamine2-receptor antagonists, antacids, or prokinetic agents for chronic rhinosinusitis.

Objective: (1) Integrate practice-based patient encounters using the Dartmouth Atlas Medicare database to understand practice treatments for Ménière's disease (MD). (2) Describe differences in the practice patterns between academic and community providers for MD., Study Design: Practice-based research database review., Setting: CHEER (Creating Healthcare Excellence through Education and Research) network academic and community providers., Subjects and Methods: MD patient data were identified with ICD-9 and CPT codes. Demographics, unique visits, and procedures per patient were tabulated. The Dartmouth Atlas of Health Care was used to reference regional health care utilization. Statistical analysis included 1-way analyses of variance, bivariate linear regression, and Student's t tests, with significance set at P < .05., Results: A total of 2071 unique patients with MD were identified from 8 academic and 10 community otolaryngology-head and neck surgery provider centers nationally. Average age was 56.5 years; 63.9% were female; and 91.4% self-reported white ethnicity. There was an average of 3.2 visits per patient. Western providers had the highest average visits per patient. Midwest providers had the highest average procedures per patient. Community providers had more visits per site and per patient than did academic providers. Academic providers had significantly more operative procedures per site (P = .0002) when compared with community providers. Health care service areas with higher total Medicare reimbursements per enrollee did not report significantly more operative procedures being performed., Conclusion: This is the first practice-based clinical research database study to describe MD practice patterns. We demonstrate that academic otolaryngology-head and neck surgery providers perform significantly more operative procedures than do community providers for MD, and we validate these data with an independent Medicare spending database., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Objectives: (1) Describe thyroid-related diagnoses and procedures in Creating Healthcare Excellence through Education and Research (CHEER) across academic and community sites. (2) Compare management of malignant thyroid disease across these sites. (3) Provide practice-based data related to flexible laryngoscopy vocal fold assessment before and after thyroid surgery based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation's clinical practice guidelines., Study Design: Review of retrospective data collection (RDC) database of the CHEER network using ICD-9 and CPT codes related to thyroid conditions., Setting: Multisite practice-based network., Subjects and Methods: There were 3807 thyroid patients (1392 malignant, 2415 benign) with 10,160 unique visits identified from 1 year of patient data in the RDC. Analysis was performed for identified cohort of patients using demographics, site characteristics, and diagnostic and procedural distribution., Results: Mean number of patients with thyroid disease per site was 238 (range, 23-715). In community practices, 19% of patients with thyroid disease had cancer versus 45% in the academic setting (P < .001). While academic sites manage more cancer patients, community sites are also surgically treating thyroid cancer and performed more procedures per cancer patient (4.2 vs 3.5, P < .001). Vocal fold function was assessed by flexible laryngoscopy in 34.0% of preoperative patients and in 3.7% postoperatively., Conclusion: This is the first overview of malignant and benign thyroid disease through CHEER. It shows how the RDC can be used alone and with national guidelines to inform of clinical practice patterns in academic and community sites. This demonstrates the potential for future thyroid-related studies utilizing the otolaryngology-head and neck surgery practice-based research network., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objective: We used a national otolaryngology practice-based research network database to characterize the utilization of vestibular function testing in patients diagnosed with dizziness and/or a vestibular disorder., Study Design: Database review., Setting: The Creating Healthcare Excellence through Education and Research (CHEER) practice-based research network of academic and community providers, Subjects and Methods: Dizzy patients in the CHEER retrospective database were identified through ICD-9 codes; vestibular testing procedures were identified with CPT codes. Demographics and procedures per patient were tabulated. Analysis included number and type of vestibular tests ordered, stratified by individual clinic and by practice type (community vs academic). Chi-square tests were performed to assess if the percentage of patients receiving testing was statistically significant across clinics. A logistic regression model was used to examine the association between receipt of testing and being tested on initial visit., Results: A total of 12,468 patients diagnosed with dizziness and/or a vestibular disorder were identified from 7 community and 5 academic CHEER network clinics across the country. One-fifth of these patients had at least 1 vestibular function test. The percentage of patients tested varied widely by site, from 3% to 72%; academic clinics were twice as likely to test. Initial visit vestibular testing also varied, from 0% to 96% of dizzy patients, and was 15 times more likely in academic clinics., Conclusion: There is significant variation in use and timing of vestibular diagnostic testing across otolaryngology clinics. The CHEER network research database does not contain outcome data. These results illustrate the critical need for research that examines outcomes as related to vestibular testing., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objectives: (1) To evaluate the probability of antibiotic administration associated with ICD-9 diagnosis of otitis media with effusion (OME) in the absence of acute otitis media, (2) to determine whether usage varies according to visit setting, and (3) to ascertain if practice gaps are such that future practice changes might be measured., Study Design: Cross-sectional analysis of an administrative database., Setting: Ambulatory visits in the United States., Subjects and Methods: National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005-2010; univariate, multivariate, and stratified analyses of antibiotic usage were performed. The study population was restricted to children without acute or unspecified otitis media. The primary outcome was the probability of oral antibiotic administration when OME was diagnosed. The impact of the location of service and subspecialty care was also analyzed., Results: Data from 1,390,404,196 pediatric visits demonstrated that oral antibiotics were administered for 32% of visits with an OME diagnosis, even in the absence of acute otitis media (odds ratio, 4.31; 95% confidence interval: 2.88-6.44; P < .001). The highest antibiotic administration was seen in the emergency department (risk difference, 37.1%; number needed to harm, 3). No significant increased risk of antibiotic usage was seen during otolaryngology visits. Diagnoses of infections at nonotologic sites were associated with a 1.98 to 26.60 increase in odds of oral antibiotic administration., Conclusion: Oral antibiotics continue to be administered in children with OME in the absence of acute infection, with risk varying by location of service. There is a potential opportunity for quality improvement through reducing antibiotic administration for pediatric OME., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objective: To characterize factors that surgeons perceive as affecting selection of procedures designed to treat hypopharyngeal obstruction in adults with obstructive sleep apnea (OSA) and to compare those factors among 2 groups of American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) member surgeons., Study Design: Cross-sectional online survey., Subjects and Methods: AAO-HNS members with a self-identified subspecialty interest either in sleep medicine or general otolaryngology were asked to complete an online survey, each respondent rated (5-point Likert scale) the perceived quality of their education and training and the role of specific factors in selection, both for procedure categories (eg, all hypopharyngeal) and individual procedures. Responses were examined for the entire group and for subgroups., Results: Response rate was 27% (163/610). Sixty-five percent of respondents rated their surgical OSA education and training during postgraduate continuing medical education (CME) courses as of high quality, compared with 39% for residency/fellowship and 4% for medical school (P < 0.01). For individual hypopharyngeal procedures, over 40% of respondents reported limited training (except for tongue radiofrequency), and over 30% raised concerns about scientific evidence and reimbursement. Surgeon personal experience suggested treatment benefits without clearly favoring individual procedures. Respondents noted that patients were reluctant to undergo procedures, despite treatment recommendations, particularly maxillomandibular advancement. The sleep medicine subgroup reported higher ratings for education and training quality, research evidence, and personal experience with hypopharyngeal procedures. Concerns about adequate education and training, the quality of research evidence, and reimbursement issues were major factors in procedure selection., Conclusion: Multiple factors affect procedure selection. Surgeons identify concerns regarding education and training and research evidence.