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Original Investigation |

Trends in Otitis Media–Related Health Care Use in the United States, 2001-2011

Tal Marom, MD1; Alai Tan, MD, PhD2; Gregg S. Wilkinson, PhD2; Karen S. Pierson, MA2; Jean L. Freeman, PhD2; Tasnee Chonmaitree, MD1,3
[+] Author Affiliations
1Division of Pediatric Infectious Diseases, Department of Pediatrics, The University of Texas Medical Branch, Galveston
2Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston
3Department of Pathology, The University of Texas Medical Branch, Galveston
JAMA Pediatr. 2014;168(1):68-75. doi:10.1001/jamapediatrics.2013.3924.
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Importance  Otitis media (OM) is a leading cause of pediatric health care visits and the most frequent reason children consume antibiotics or undergo surgery. During recent years, several interventions have been introduced aiming to decrease OM burden.

Objective  To study the trend in OM-related health care use in the United States during the pneumococcal conjugate vaccine (PCV) era (2001-2011).

Design, Setting, and Participants  An analysis of an insurance claims database of a large, nationwide managed health care plan was conducted. Enrolled children aged 6 years or younger with OM visits were identified.

Main Outcomes and Measures  Annual OM visit rates, OM-related complications, and surgical interventions were analyzed.

Results  Overall, 7.82 million unique children (5.51 million child-years) contributed 6.21 million primary OM visits; 52% were boys and 48% were younger than 2 years. There was a downward trend in OM visit rates from 2004 to 2011, with a significant drop that coincided with the advent of the 13-valent vaccine (PCV-13) in 2010. The observed OM visit rates in 2010 (1.00/child-year) and 2011 (0.81/child-year) were lower than the projected rates based on the 2005-2009 trend had there been no intervention (P < .001). Recurrent OM (≥3 OM visits within 6-month look-back) rates decreased at 0.003/child-year (95% CI, 0.002-0.004/child-year) in 2001-2009 and at 0.018/child-year (95% CI, 0.008-0.028/child-year) in 2010-2011. In the PCV-13 premarket years, there was a stable rate ratio (RR) between OM visit rates in children younger than 2 years and in those aged 2 to 6 years (RR, 1.38; 95% CI, 1.38-1.39); the RR decreased significantly (P < .001) during the transition year 2010 (RR 1.32; 95% CI, 1.31-1.33) and the postmarket year 2011 (RR 1.01; 95% CI, 1.00-1.02). Tympanic membrane perforation/otorrhea rates gradually increased (from 3721 per 100 000 OM child-years in 2001 to 4542 per 100 000 OM child-years in 2011; P < .001); the increase was significant only in the older children group. Mastoiditis rates substantially decreased (from 61 per 100 000 child-years in 2008 to 37 per 100 000 child-years in 2011; P < .001). Ventilating tube insertion rate decreased by 19% from 2010 to 2011 (P = .03).

Conclusions and Relevance  There was an overall downward trend in OM-related health care use from 2001 to 2011. The significant reduction in OM visit rates in 2010-2011 in children younger than 2 years coincided with the advent of PCV-13. Although tympanic membrane perforation/otorrhea rates steadily increased during that period, mastoiditis and ventilating tube insertion rates decreased in the last years of the study.

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Figure 1.
Trends of Otitis Media (OM) Visits Among Children From Birth to 6 years, 2001-2011

A, Overall OM visit rates for children from birth to 6 years. Joinpoint analysis detected 3 segments (2001-2003, 2004-2009, and 2010-2011) that had significant changes in OM visit rate trends. OM visit rates increased at 0.04/child-year annually in 2001-2003, decreased at 0.02/child-year annually in 2004-2009, and decreased at 0.14/child-year annually in 2010-2011. The overall trend for children aged 0-6 years was more influenced by those aged 2-6 years because of their higher proportion in the study population. During 2010-2011 (after 13-valent pneumococcal conjugate vaccine [PCV-13] licensure), children younger than 2 years had a significantly greater decrease in OM visit rates than did children aged 2 to 6 years (0.27/child-year vs 0.09/child-year decrease, respectively; P < .001). B, Otitis media visit rates for children aged 2 to 6 years. Joinpoint analysis detected 3 segments (2001-2003, 2004-2009 and 2010-2011) that had significant changes in OM visit rate trends. In 2001-2003, OM visit rate increased at 0.06/child-year annually; in 2004-2009, OM visit rate decreased at 0.02/child-year annually; and in 2010-2011, OM visit rate decreased at 0.09/child-year annually (P < .001). C, Otitis media visit rates for children younger than 2 years. The OM visit rate trends during 2001-2009 and 2010-2011 were significantly different: they decreased at 0.03/child-year annually in 2001-2009, and they dropped at 0.27/child-year annually in 2010-2011 (P < .001). The projected rates of OM visits for 2004-2011 were derived from a Poisson regression model based on the observed rates in 2004-2009 (dashed line). The observed OM visit rates (solid line) in 2010-2011 (1.00/child-year [95% CI, 1.00-1.00] and 0.81/child-year [0.81-0.82], respectively) were significantly lower than the projected rates (1.09/child-year [1.09-1.09] and 1.07/child-year [1.07-1.07], respectively). American Academy of Pediatrics (AAP) guidelines for OM diagnosis and treatment were published in 200418; influenza vaccine (Inf Vac) recommendations were made to vaccinate children by age group: 6 to 23 months (2004)19; 6 to 60 months (2007)20; and 6 months to 18 years (2008)21; recommendation to routinely vaccine children with PCV-13 occurred in 2010.13

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Figure 2.
Otitis Media (OM) Complications and Surgical Interventions, 2001-2011

A, Tympanic membrane perforation/otorrhea cases within 21 days after an OM primary visit. B, Mastoiditis cases within 21 days after an OM primary visit. C, Other rare complications within 21 days after an OM primary visit. These complications included meningitis, facial nerve palsy, sigmoid vein thrombosis, and intracranial abscess. D, Myringotomy and/or ventilating tube insertion. The solid line represents the linear fit across the studied years.

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Figure 3.
Otitis Media (OM) Visit Rates in Children Younger Than 2 Years vs Those Aged 2 to 6 Years, 2005-2011

During 2005-2009, there was a stable difference between OM visit rates in children younger than 2 years and those aged 2 to 6 years (rate ratio [RR], 1.38 [95% CI, 1.38-1.39]). The differences between the 2 age groups were decreased significantly (P < .001) during 2010-2011 (RR, 1.32 [95% CI, 1.31-1.33] in 2010 and 1.01 [1.00-1.02] in 2011). Because of the large sample size in our study, the differences between the rates and their 95% CIs were ≤0.01/child-year. Such differences were too small to be visible in the Figure. A recommendation to use the 13-valent pneumococcal conjugate vaccine (PCV-13) was issued in 2010.

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