This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (20)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Medical Practice  • Medical Practice, Other  • Otolaryngology/ Head & Neck Surgery  • Middle/ External Ear Disorders  • Alert me on articles by topic  Social Bookmarking   What's this?

Peter C. Coyte, PhD; Ruth Croxford, MSc; Carl V. Asche, MSc; Teresa To, PhD; William Feldman, MD,FRCPC; Jacob Friedberg, MD,FRCSC

JAMA. 2001;286:2128-2135.

Context  Small-area variations in surgical rates raise concerns about access to care, treatment appropriateness, and the quality and cost of care.

Objective  To measure small-area variations in rates of myringotomy with insertion of tympanostomy tubes (TTs) and to identify determinants of rate variation.

Design and Setting  Retrospective analyses using hospital discharge data for patients who had undergone a myringotomy with insertion of TT by county in Ontario between April 1, 1996, and March 31, 1999. Information on possible determinants was taken from a survey of otolaryngologists and primary care physicians in 1996 and from the 1996 Canadian census and physician demographic databases for 1996-1999.

Participants  A total of 75 358 hospitalizations for TT placement of children and adolescents (aged 14 years).

Main Outcome Measure  Small-area variation in rates of TT.

Results  An almost 10-fold difference between the areas with the highest and lowest rates was found (extremal quotient, 9.6; 95% confidence interval [CI], 8.2-11.1; P<.001). Higher rates occurred in counties with higher percentages of high school graduates (parameter estimate, 0.01; 95% CI, 0-0.02; P = .049); and where referring physicians were more likely to be male (parameter estimate, 0.01; 95% CI, 0-0.02; P = .01), North American–trained (parameter estimate, 0.01; 95% CI, 0.01-0.02; P<.001), and have higher propensities to refer for surgery (parameter estimate, 0.40; 95% CI, 0.09-0.72; P = .02). Otolaryngologist opinion was not a significant predictor.

Conclusion  Substantial area variation in TT rates was observed. The opinion of primary care physicians was the dominant modifiable determinant, suggesting an area of research that may be important in reducing area variation in TT procedures.

Author Affiliations: Departments of Health Policy, Management, and Evaluation (Dr Coyte and Mr Asche), Otolaryngology (Dr Friedberg), Pediatrics (Dr Feldman), and Public Health Sciences (Dr To), and the Institute for Policy Analysis (Dr Coyte), University of Toronto, Toronto, Ontario; Institute for Clinical Evaluative Sciences, Toronto (Drs Coyte and To); Clinical Epidemiology Unit, Sunnybrook and Women's College Health Science Centre, Toronto (Ms Croxford); Department of Otolaryngology (Drs Coyte and Friedberg), Mount Sinai Hospital, Toronto; and the Departments of Otolaryngology (Dr Friedberg) and General Pediatrics (Dr Feldman), Hospital for Sick Children, Toronto. Mr Asche is now with Aventis Pharmaceuticals, Bridgewater, NJ.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort
Keyhani et al.
BMJ 2008;337:a1607-a1607.
ABSTRACT | FULL TEXT  

Decreasing rates of middle ear surgery in Western Australian children.
Spilsbury et al.
Arch Otolaryngol Head Neck Surg 2006;132:1216-1220.
ABSTRACT | FULL TEXT  

Geographical Variation in Surveillance Strategies After Curative-Intent Surgery for Upper Aerodigestive Tract Cancer
Johnson et al.
Ann. Surg. Oncol. 2006;13:1063-1071.
ABSTRACT | FULL TEXT  

The Ontario Asthma Regional Variation Study: emergency department visit rates and the relation to hospitalization rates.
Lougheed et al.
Chest 2006;129:909-917.
ABSTRACT | FULL TEXT  

Otitis Media With Effusion
American Academy of Family Physicians et al.
Pediatrics 2004;113:1412-1429.
ABSTRACT | FULL TEXT  

Patterns of Vision Care Among Medicaid-Enrolled Children
Kemper et al.
Pediatrics 2004;113:e190-196.
ABSTRACT | FULL TEXT  

Searching for El Dorado: the impossibility of finding the right rate
Frohlich and Roos
CMAJ 2002;167:880-881.
FULL TEXT  

Black-White Differences in Health Care Utilization Among US Children With Frequent Ear Infections
Park et al.
Pediatrics 2002;109:e84-84.
ABSTRACT | FULL TEXT