Trends in otitis media-related health care use in the United States, 2001-2011

Abstract

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.

Figure 1

Trends of otitis media visits among children aged 0-6 years, 2001-2011 Overall otitis media visit rates for children 0-6 years of age. Joinpoint analysis detected 3 segments (2001-2003, 2003-2009 and 2009-2011) 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 2003-2009, and decreased at 0.14/child-year annually in 2009-2011. The overall trend for children aged 0-6 years was more influenced by those aged 2-6 years due to their higher proportion in the study population. During 2010-2011 (post PCV-13 licensure), children aged <2 years had significant greater decrease in OM visit rates than children of 2-6 years (0.27/child-year vs. 0.09 decrease, respectively, P<0.001). Otitis media visit rates for children 2-6 years of age. Joinpoint analysis detected 3 segments (2001-2003, 2003-2009 and 2009-2011) that had significant changes in OM visit rate trends. In 2001-2003, OM visit rate increased at 0.06/child-year annually, in 2003-2009, OM visit rate decreased at 0.02/child-year annually and in 2009-2011, OM visit rate decreased at 0.09/child-year annually (P<0.001). Otitis media visit rates for children <2 years of age. OM visit rates trends during 2001-2009 and 2009-2011 were significantly different: while they have decreased at 0.03/child-year annually in 2001-2009, they dropped at 0.27/child-year annually in 2009-2011 (P<0.001). The projected rates of OM visits for 2005-2011 were derived from a Poisson regression model based on the observed rates in 2005-2009 (red dashed line). The observed OM visit rates (blue line) in 2010-2011 (1.00/child-year, 95% CI: 1.00-1.00 and 0.81, 95% CI: 0.81-0.82, respectively) were significantly lower than the projected rates (1.09/child-year, 95% CI: 1.09-1.09 and 1.07, 95% CI: 1.07-1.07, respectively). Interventions: AAP guideline, publication of the American Academy of Pediatric guidelines for otitis media diagnosis and treatment (2004); Inf.Vac. (6-23), recommendation to vaccinate all children aged 6-23 months with influenza vaccine (2004); Inf.Vac. (6-60), recommendation to vaccinate all children aged 6-60 months with influenza vaccine (2006); Inf.Vac. (all children), recommendation to vaccinate all children aged 6 months to 18 years with influenza vaccine (2008); PCV-13 licensure, recommendation to routinely vaccine children with PCV-13 (2010).

Figure 2

Otitis media complications and surgical interventions, 2001-2011. Tympanic membrane perforation/otorrhea cases, within 21 days after OM primary visit, per 100,000 otitis media child-years. Mastoiditis cases, within 21 days after OM primary visit, per 100,000 otitis media child-years. Other rare complications, within 21 days after OM primary visit, per 100,000 otitis media child-years. These complications include meningitis, facial nerve palsy, sigmoid vein thrombosis and intra-cranial abscess. Myringotomy and/or ventilating tubes insertion, per 100,000 child-years.

Figure 2

Otitis media complications and surgical interventions, 2001-2011. Tympanic membrane perforation/otorrhea cases, within 21 days after OM primary visit, per 100,000 otitis media child-years. Mastoiditis cases, within 21 days after OM primary visit, per 100,000 otitis media child-years. Other rare complications, within 21 days after OM primary visit, per 100,000 otitis media child-years. These complications include meningitis, facial nerve palsy, sigmoid vein thrombosis and intra-cranial abscess. Myringotomy and/or ventilating tubes insertion, per 100,000 child-years.

Figure 2

Otitis media complications and surgical interventions, 2001-2011. Tympanic membrane perforation/otorrhea cases, within 21 days after OM primary visit, per 100,000 otitis media child-years. Mastoiditis cases, within 21 days after OM primary visit, per 100,000 otitis media child-years. Other rare complications, within 21 days after OM primary visit, per 100,000 otitis media child-years. These complications include meningitis, facial nerve palsy, sigmoid vein thrombosis and intra-cranial abscess. Myringotomy and/or ventilating tubes insertion, per 100,000 child-years.

Figure 2

Otitis media complications and surgical interventions, 2001-2011. Tympanic membrane perforation/otorrhea cases, within 21 days after OM primary visit, per 100,000 otitis media child-years. Mastoiditis cases, within 21 days after OM primary visit, per 100,000 otitis media child-years. Other rare complications, within 21 days after OM primary visit, per 100,000 otitis media child-years. These complications include meningitis, facial nerve palsy, sigmoid vein thrombosis and intra-cranial abscess. Myringotomy and/or ventilating tubes insertion, per 100,000 child-years.

Figure 3

Otitis media visit rates in children <2 years old vs. 2-6 years old, 2005-2011 During 2005-2009, there was a stable difference between OM visit rates in children aged <2 years and of those aged 2-6 years (Rate ratio [RR] =1.38, 95% CI=1.38-1.39). The differences between the two age groups were decreased significantly (P<0.001) during 2010-2011 (RRs were 1.32 [95% CI: 1.31-1.33] in 2010 and 1.01 [95% CI: 1.01-1.02] 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 small differences were too small to be visible in the figure. Intervention: PCV-13, recommendation to immunize children with PCV-13 (2010).