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Setting the Record Straight

Charles D. Bluestone, MD; Jerome O. Klein, MD; George A. Gates, MD

Arch Otolaryngol Head Neck Surg. 1994;120(10):1051-1053.

Abstract
In a recent article published in the Journal of the American Medical Association (JAMA). Kleinman and colleagues¹ described their analysis of data on children who were insured by companies that used Value Health Sciences (VHS) for utilization review and who were proposed to have tympanostomy tube placement by their physicians. The analysis by employees of VHS determined that 27% of the procedures for tympanostomy tubes were "inappropriate" indications and 32% had "equivocal" indications; only 41% of the procedures had "appropriate" indications. As members of the expert panel who were invited by VHS to develop criteria for indications for tube insertion, we are not only concerned about many aspects of that publication, but also about the process that was used to arrive at the criteria, the aftermath of our involvement, and the potential implications these methods have on the future of delivery of health care in this country. The following is our attempt to describe the method, point out flaws in the process, and identify the obvious problems in the article by Kleinman and his colleagues, so that other physicians can benefit from our experience as participants in a utilization review by a for-profit company. To set the record straight, we present our current recommendation for tympanostomy tube insertion for the most frequently encountered conditions, recurrent acute otitis media and chronic otitis media with effusion, based on our analysis of results of randomized clinical trials.

Author Affiliations
From the Department of Otolaryngology, University of Pittsburgh (Pa) School of Medicine and Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh (Dr Bluestone); Boston (Mass) University School of Medicine, and Division of Pediatric Infectious Diseases, Boston (Mass) City Hospital (Dr Klein); and Department of Otolaryngology–Head and Neck Surgery, University of Washington and Virginia Merrill Bloedel Hearing Research Center, Seattle, (Dr Gates).

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