CLINICAL RESEARCH STUDY
Delayed Otolaryngology Referral for Voice Disorders Increases Health Care Costs Seth M. Cohen, MD, MPH,a Jaewhan Kim, PhD,b Nelson Roy, PhD, CCC-SLP,c Mark Courey, MDd a Duke Voice Care Center, Division of OtolaryngologyeHead & Neck Surgery, Duke University Medical Center, Durham, NC; bDivision of Public Health & Study Design and Biostatistics Center and cDepartment of Communication Sciences and Disorders, Division of OtolaryngologyeHead & Neck Surgery (Adjunct), University of Utah, Salt Lake City; dDepartment of OtolaryngologyeHead & Neck Surgery, University of California - San Francisco.
ABSTRACT BACKGROUND: Despite the accepted role of laryngoscopy in assessing patients with laryngeal/voice disorders, controversy surrounds its timing. This study sought to determine how increased time from first primary care to first otolaryngology outpatient visit affected the health care costs of patients with laryngeal/ voice disorders. METHODS: Retrospective analysis of a large, national administrative claims database was performed. Patients had an International Classification of Diseases, 9th Revision-coded diagnosis of a laryngeal/voice disorder; initially saw a primary care physician and, subsequently, an otolaryngologist as outpatients; and provided 6 months of follow-up data after the first otolaryngology evaluation. The outpatient health care costs accrued from the first primary care outpatient visit through the 6 months after the first otolaryngology outpatient visit were determined. RESULTS: There were 260,095 unique patients who saw a primary care physician as an outpatient for a laryngeal/voice disorder, with 8999 (3.5%) subsequently seeing an otolaryngologist and with 6 months postotolaryngology follow-up data. A generalized linear regression model revealed that, compared with patients who saw an otolaryngologist 1 month after the first primary care visit, patients in the >1-month and 3-months and >3-months time periods had relative mean cost increases of $271.34 (95% confidence interval $115.95-$426.73) and $711.38 (95% confidence interval $428.43-$993.34), respectively. CONCLUSIONS: Increased time from first primary care to first otolaryngology evaluation is associated with increased outpatient health care costs. Earlier otolaryngology examination may reduce health care expenditures in the evaluation and management of patients with laryngeal/voice disorders. Ó 2015 Elsevier Inc. All rights reserved. The American Journal of Medicine (2015) 128, 426.e11-426.e18 KEYWORDS: Cost; Larynx; Otolaryngology; Primary care; Referral; Voice
As many otolaryngologic disorders are evaluated initially by primary care physicians, decisions for otolaryngology referral may have important implications for the health care system. From 1999 to 2009, among primary care visits,
ear/nose/throat complaints grew from 4.5% to 8.5%, with a corresponding increase in otolaryngology referral rates from 3.8% to 7.5%.1 With otolaryngologists being the third most common specialty to which family medicine physicians
Funding: This study was funded by the American Academy of Otolaryngology-Head and Neck Surgery (SC). The funding source did not have any role in the design, conduct; collection, management, analysis, and interpretation of data; preparation, review or approval of the manuscript; nor decision to submit manuscript for publication. Conflict of Interest: SMC has funding from the American Academy of Otolaryngology Head Neck Surgery and National Institutes on Deafness and Other Communication Disorders Outcome Supplements. JK and NR have no conflicts of interest. MC has received financial payment for medical record review.
Authorship: All authors had access to the data and took part in conception and design of study, analysis and interpretation of data, drafting and revising of the work, final approval, and agreement for accountability for all aspects of the work. Requests for reprints should be addressed to Seth Cohen, MD, MPH, Division of OtolaryngologyeHead & Neck Surgery, Duke University Medical Center, DUMC Box 3805, Durham, NC 27710. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.10.040
Cohen et al
Otolaryngology Referral and Cost
426.e12
referred patients, over- or under-referral may affect health large, national administrative US claims database, was care costs.2 retrospectively analyzed for January 1, 2004 to December Laryngeal/voice disorders represent a unique group of 31, 2008. The MarketScan databases (Truven Health Anadisease states common to primary care physicians and lytics, Ann Arbor, MI) contained the annual health care otolaryngologists, with a point prevalence of 1 in 13 among claims of approximately 55 million individuals during this primary care patients.3,4 Laryngeal/voice disorders are time period, including employees 1 and 3 months, >3 visual examination of the larynx, cation of Diseases, 9th Revision, months. the absence of which is associated Clinical Modification (ICD-9-CM) Outpatient treatment costs were tabuwith extremely poor diagnostic codes (Table 1), seen initially by a lated for each referral time group. accuracy.8 Delaying referral or not primary care physician and subsequently an otolaryngologist, referring to a specialist trained in Primary care to otolaryngology evaluaboth as outpatients, from January laryngoscopy (ie, an otolaryngoltion of 1 month was associated with 1, 2004 to December 31, 2008 ogist) could lead to delayed diaglowest costs. were included. Because patients nosis, inappropriate treatment, and Incremental higher costs occurred with with a brainstem stroke may have progression of disease with delayed otolaryngology evaluation a disordered voice from nucleus adverse effects on patient outambiguous involvement, codes comes and health care costs. times. 438.10 and 438.19 (late effects of Yet, controversy surrounds the cerebrovascular disease) were timing of laryngoscopy with recincluded. To have sufficient cost data and allow time for ommendations for laryngoscopy in cases of dysphonia of 2 multiple evaluation and treatment trials after the weeks duration and a recent clinical practice guideline otolaryngology evaluation, patients had to have at least extending the need for laryngoscopy or referral for laryn6 months follow-up after the initial outpatient otolaryngoscopy to a maximum of 3 months in patients with gology encounter. Patients who did not initially see a persistent hoarseness/dysphonia.9-11 This guideline stateprimary care physician and subsequently an otolaryngoloment has been subsequently criticized due to the potential gist as an outpatient for a laryngeal/voice disorder, and with impact of delayed otolaryngology evaluation with resulting 1 to 3 conditions, and urban vs rural status (based on employment months, and >3 months) affects the outpatient costs in a metropolitan statistical area), and time to otolaryngolincurred during the evaluation and treatment of laryngeal/ ogist (the time from the first outpatient primary care to the voice disorders. Our hypothesis is that early evaluation, the first outpatient otolaryngology encounter) were collected. 1-month group, will be associated with the lowest costs. Primary care physicians were classified as urgent care, medical doctor (not elsewhere classified), osteopathic METHODS medicine, internal medicine, multispecialty group, emergency medicine, hospitalist, family practice, geriatric medThis study was approved by the Duke University Medical icine, preventive medicine, pediatrician, nurse practitioner, Center Institutional Review Board. The MarketScan or physician assistant; otolaryngologists were classified as Commercial Claims and Encounters dataset and Medicare otolaryngology, pediatric otolaryngology, or head & neck Supplemental and Coordination of Benefits dataset, a
426.e13 Table 1 Codes
The American Journal of Medicine, Vol 128, No 4, April 2015 Laryngeal/Voice Disorder-related ICD-9 and CPT
Aggregated Diagnostic Category Vocal fold paralysis Bilateral vocal fold paralysis Vocal fold paresis Nonspecific dysphonia Acute laryngitis Benign laryngeal/ vocal fold pathology Other larynx/vagus Chronic laryngitis Laryngeal cancer Laryngeal spasm Late effect cerebrovascular disease, other speech deficits
ICD-9 Codes 478.30, 478.32 478.34 478.31, 478.33 784.49, 784.42, 784.40, 784.41 464, 464.01, 464.20, 464.21 478.4, 478.5, 478.6, 478.71, 478.79, 212.1 478.70, 352.3 476.0, 476.1 161.0, 161.1, 161.2, 161.3, 161.8, 161.9 478.75 438.10, 438.19
Procedure Category
CPT Codes
Radiology
71010, 71050, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 70450, 70460, 70470, 70490, 70491, 70492, 71520, 71260, 71270, 70551, 70552, 70553, 70540, 70542, 70543 74210, 74220, 74230, 92610, 92611, 92612, 92613, 92614, 92615, 92616, 92617 92526 92506, 92507, 92508, 92520
Swallow study
Swallow therapy Voice evaluation/ therapy Laryngoscopy Stroboscopy Surgery
Chemodenervation Laryngeal electromyography Reflux testing/ evaluation Radiation therapy
31505, 31575 31579 31300, 31320, 31360, 31365, 31367, 31368, 31370, 31375, 31380, 31382, 31390, 31395, 31400, 31420, 31500, 31502, 31510, 31511, 31512, 31513, 31515, 31520, 31525, 31526, 31527, 31528, 31529, 31530, 31531, 31536, 31540, 31541, 31545, 31546, 31560, 31561, 31570, 31571, 31576, 31577, 31578, 31580, 31582, 31584, 31587, 31588, 31590, 31595, 31599, 64716, 64886 64613, 95874 95865 91010, 91011, 91012, 91020, 91030, 91034, 91035, 91037, 91038 77263, 77014, 77295, 77290, 77334, 77338, 77300, 77413, 77427, 77336, 774214, 77470, 77301, 77280, 77418
ICD-9 ¼ International Classification of Diseases, 9th Revision; CPT ¼ Current Procedural Terminology.
surgery based on the MarketScan database dictionary. The presence of common comorbid conditions: sinusitis (461.x, 473.x), asthma (493.x), chronic obstructive pulmonary disease (490, 491.xx, 492), gastroesophageal reflux (530.81), acute pharyngitis (462), acute bronchitis (466.xx), acute upper respiratory illness (465.x), pneumonia (481, 482.xx, 483.x, 486), and allergic rhinitis (477.x) were tabulated.4 Costs from outpatient encounters, pharmacy claims, and procedures incurred from the first primary care outpatient visit to 6 months after the first outpatient otolaryngology visit were calculated. Because 97.8% of physician encounters for laryngeal/voice disorders in the MarketScan dataset were in the outpatient setting, costs from inpatient and emergency department settings were not included.4 Pharmacy claims for proton pump inhibitors, antibiotics, antihistamines, oral and inhaled steroids, and histamine 2 antagonists, which accounted for 84.1% of medication-related costs, were collected.7 The therapeutic drug classes and generic identification numbers according to the MarketScan database dictionary were used to identify these medications. A pharmacy claim was determined to be related to a laryngeal/voice disorder if the pharmacy claim was within 2 weeks of an outpatient encounter, new or return, with a laryngeal/voice disorder, and there was no pharmacy claim for the medication in the 3 months before the index date. Procedures related to the evaluation and management of laryngeal/voice disorders were identified by CPT codes (Table 1). For calculating costs from radiation therapy, the specific CPT codes were included only if related to laryngeal cancer ICD-9 codes to minimize the chances of incorporating costs due to other nonlaryngeal malignancies coexisting with other laryngeal/ voice ICD-9 codes. Costs for medical encounters and procedures were the gross payment to the provider, which was the amount eligible for payment under the medical plan. Medication costs were the ingredient cost, which is the discount below the average wholesale price, plus the dispensing fee. Costs were adjusted to 2008 utilizing the Consumer Price Index. Costs were calculated for: 1) the first primary care outpatient visit up to but not including the first outpatient otolaryngology visit (preotolaryngology costs), 2) the first outpatient otolaryngology visit to 6 months after the index otolaryngology visit (postotolaryngology costs), and 3) total costs (pre- þ postotolaryngology costs). All MarketScan database management and statistical analyses were performed with Stata Version 11.1 (Stata Corp, College Station, TX). The impact of the time to otolaryngologist on total costs was assessed using multivariate techniques. Possible differences in case mix severity (ie, severity of the laryngeal/voice disorder) among patients with different times from first primary care to first otolaryngology evaluation could influence cost outcomes. To help adjust for case mix selection bias, age and sex, which are both associated with more costly and debilitating diseases of laryngeal cancer and vocal fold paralysis, and number of comorbid conditions, also associated with costs in the evaluation and treatment
Cohen et al
Otolaryngology Referral and Cost
426.e14 outpatient primary care to first outpatient otolaryngology visit. Because preotolaryngology costs may be related to postotolaryngology costs, the instrumental variable analysis also controlled for patient-related differences in preotolaryngology costs as they may reflect differences in treatment and severity of the laryngeal/voice disorder.
of laryngeal/voice disorders, were included in the models.4,13 Because laryngeal diagnoses may change during evaluation and management, the number of aggregate diagnoses rendered by otolaryngologists during the 6-month follow-up period was also included in the models.14 This variable was considered as a possible surrogate measure of the complexity of the voice problem. The number of primary care and otolaryngology visits may similarly denote the chronicity and severity of the patients’ conditions and thus were also included. Other variables known to affect the costs of the evaluation and treatment of laryngeal/voice disorders, such as geographic region, were part of the models.13 A generalized linear regression with gamma distribution, a statistical model for outcome variables with skewed distributions, such as health care costs, or for data that can only take on positive values, was used.15 The robustness of the results from the generalized linear regression was confirmed by 2 more statistical methods: a median regression and an instrumental variables regression. For the instrumental variable analysis, the dependent variable was postotolaryngology costs, and independent variable of interest was time from first
Table 2
RESULTS There were 54,600,465 unique patients in the MarketScan databases during January 1, 2004 to December 31, 2008, with 536,943 (1%) unique patients having a diagnosis of laryngeal/voice disorder. There were 260,095 unique patients that saw a primary care physician as an outpatient for a laryngeal/voice disorder, with 9833 (3.9%) referred by a primary care physician or self-referred to an otolaryngologist as an outpatient and with 6 months of postotolaryngology follow-up data. The demographic data of the cohort reflecting the time from first primary care to first outpatient otolaryngology visit is shown in Table 2. There were 834 patients excluded from the >3-months group as they did not have 6 months of postotolaryngology
Patient Characteristics by Time from First Primary Care Outpatient Encounter to First Outpatient Otolaryngology Encounter 1 Month
Number of patients 6164 Age, years (%) 1 Month and 3 Months
>3 Months
Excluded Patients
1959
850
834
P-Value* .17
7.45 10.41 59.88 22.26
4.47 10.59 54.47 30.47
4.56 9.35 50.6 35.49
39.31 60.69
38.82 61.18
43.17 56.83
9.85 29.91 43.95 15.62 0.66
8.59 32.82 43.41 15.06 0.12
8.75 40.29 37.89 12.35 0.72
17.29 82.71 2.64 (2.06)
18.35 81.65
(2.16)
17.82 82.18 2.77 (2.05)
(0.61)
1.32 (0.57)
1.27 (0.52)
.07
3-month group.
46.35 37.06 11.53 5.06
48.2 32.61 14.03 5.16
.07
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The American Journal of Medicine, Vol 128, No 4, April 2015
follow-up data. Compared with the >3-months group, the 834 excluded patients had different geographic distribution and longer time between the first primary care and first otolaryngology outpatient visits (Table 2). As the time from first primary care to first otolaryngologist encounter increased, the unadjusted mean and median overall costs increased with an increase in the proportion of overall costs related to medications and a decrease in the proportion of costs related to outpatient visits and procedures (Table 3). Further analysis of the costs revealed that medications accounted for roughly two-thirds of primary care costs, and medication and procedure-related costs varied inversely at the 3 time points of otolaryngology evaluation (Table 3). A generalized linear regression model with gamma distribution examined the impact of time from first primary care to first otolaryngologist outpatient visit on adjusted overall costs (Table 4). The adjusted mean total costs per person increased for each time interval and was greatest for the >3-month interval (Table 5; Wald statistic, P < .05). Similarly, a median regression analysis with outcome the natural log of total cost found increasing adjusted median total costs per person with coefficients of 0.14 (95% confidence interval 0.09-0.19) for >1 to 3 months and 0.33 (95% confidence interval 0.26-0.40) for >3-months vs 1-month time period compared with the
1-month group. In the instrument variable analysis, compared with seeing an otolaryngologist 1 month after the first primary care visit, a 10% and 29% increase in postotolaryngology costs was noted for patients seeing an otolaryngologist >1 to 3 months and >3 months after the first outpatient primary care visit, respectively (Table 5).
DISCUSSION The timing of otolaryngology evaluation for laryngeal/voice disorders has important consequences for patients and the health care system. Our results demonstrate that reduced health care costs were associated with an earlier time between the first primary care and first otolaryngology outpatient visits for patients with laryngeal/voice disorders. These data further suggest that the clinical practice guideline recommendation for laryngoscopy or referral for laryngoscopy by a maximum of 3 months needs reconsideration.11 Previous reports for other disease processes have presented conflicting results regarding specialist care and the impact on patient outcomes and costs. For instance, early referral for physical therapy for low back pain resulted in lower health care costs, and early orthopedic referral for common musculoskeletal diseases also led to lower costs.16,17 Yet, community-acquired pneumonia treatment
Table 3 Mean and Median Annual Outpatient Costs per Person Involved in the Evaluation and Management of Laryngeal/Voice Disordered Patients by Time from First Primary Care Outpatient Visit to First Outpatient Otolaryngology Visit 1 Month Preotolaryngology costs* Mean (SD) Median 25th percentile 75th percentile % Medication costs % Outpatient visit costs % Procedure costs Postotolaryngology costs* Mean (SD) Median 25th percentile 75th percentile % Medication costs % Outpatient visit costs % Procedure costs Total costs* Mean (SD) Median 25th percentile 75th percentile % Medication costs % Outpatient visit costs % Procedure costs
224.20 (489.47) 79.37 54.96 69.74 69.7% 30.3% 0%
>1 Month and 3 Months 274.94 (611.00) 92.63 59.95 68.90 68.9% 31.1% 0%
> 3 Months 333.55 (846.84) 84.27 57.57 71.56 71.6% 28.4% 0%
1598.11 (3714.62) 729.63 378.50 1592.92 19.7% 26.4% 53.9%
1950.97 (4550.59) 842.84 417.01 1882.46 22.7% 20.4% 46.0%
2379.64 (5183.15) 1015.90 424.14 2358.04 51.8% 14.9% 33.3%
1822.31 (3821.93) 906.72 470.57 1918.00 25.8% 26.9% 47.3%
2225.92 (4725.28) 1037.58 537.00 2237.79 38.01% 21.7% 40.3%
2713.19 (5544.95) 1263.16 611.67 2684.44 54.3% 16.6% 29.2%
*Preotolaryngology costs ¼ costs incurred from first primary care outpatient visit up to but not including the first otolaryngology outpatient visit. Postotolaryngology costs ¼ costs incurred from first otolaryngology outpatient visit through 6 months after this visit. Total costs ¼ preotolaryngology þ postotolaryngology costs.
Cohen et al
Otolaryngology Referral and Cost
426.e16
Table 4 Generalized Linear Regression Model for Total Outpatient Costs Involved in the Evaluation and Management of Patients with Laryngeal/Voice Disorders Covariate Time to otolaryngologist 1 month >1 month and 3 months >3 months Age, years 65 Sex Male Female Region Northeast North Central South West Number of comorbid conditions 0 1 2 3 Metropolitan statistical area No Yes Year 2004 2005 2006 2007 2008 Referral type PCP referred Self-referred # Otolaryngology-given diagnoses over 6 months after first otolaryngology visit # Outpatient visits to PCP before otolaryngology evaluation # Outpatient otolaryngology visits over 6 months after first otolaryngology visit
Coefficient 95% Confidence ($)* Interval ($)
Reference 271.34 115.95-426.73 711.38
429.43-993.34
P-Value
.001
Delayed Otolaryngology Referral for Voice Disorders Increases Health Care Costs Seth M. Cohen, MD, MPH,a Jaewhan Kim, PhD,b Nelson Roy, PhD, CCC-SLP,c Mark Courey, MDd a Duke Voice Care Center, Division of OtolaryngologyeHead & Neck Surgery, Duke University Medical Center, Durham, NC; bDivision of Public Health & Study Design and Biostatistics Center and cDepartment of Communication Sciences and Disorders, Division of OtolaryngologyeHead & Neck Surgery (Adjunct), University of Utah, Salt Lake City; dDepartment of OtolaryngologyeHead & Neck Surgery, University of California - San Francisco.
ABSTRACT BACKGROUND: Despite the accepted role of laryngoscopy in assessing patients with laryngeal/voice disorders, controversy surrounds its timing. This study sought to determine how increased time from first primary care to first otolaryngology outpatient visit affected the health care costs of patients with laryngeal/ voice disorders. METHODS: Retrospective analysis of a large, national administrative claims database was performed. Patients had an International Classification of Diseases, 9th Revision-coded diagnosis of a laryngeal/voice disorder; initially saw a primary care physician and, subsequently, an otolaryngologist as outpatients; and provided 6 months of follow-up data after the first otolaryngology evaluation. The outpatient health care costs accrued from the first primary care outpatient visit through the 6 months after the first otolaryngology outpatient visit were determined. RESULTS: There were 260,095 unique patients who saw a primary care physician as an outpatient for a laryngeal/voice disorder, with 8999 (3.5%) subsequently seeing an otolaryngologist and with 6 months postotolaryngology follow-up data. A generalized linear regression model revealed that, compared with patients who saw an otolaryngologist 1 month after the first primary care visit, patients in the >1-month and 3-months and >3-months time periods had relative mean cost increases of $271.34 (95% confidence interval $115.95-$426.73) and $711.38 (95% confidence interval $428.43-$993.34), respectively. CONCLUSIONS: Increased time from first primary care to first otolaryngology evaluation is associated with increased outpatient health care costs. Earlier otolaryngology examination may reduce health care expenditures in the evaluation and management of patients with laryngeal/voice disorders. Ó 2015 Elsevier Inc. All rights reserved. The American Journal of Medicine (2015) 128, 426.e11-426.e18 KEYWORDS: Cost; Larynx; Otolaryngology; Primary care; Referral; Voice
As many otolaryngologic disorders are evaluated initially by primary care physicians, decisions for otolaryngology referral may have important implications for the health care system. From 1999 to 2009, among primary care visits,
ear/nose/throat complaints grew from 4.5% to 8.5%, with a corresponding increase in otolaryngology referral rates from 3.8% to 7.5%.1 With otolaryngologists being the third most common specialty to which family medicine physicians
Funding: This study was funded by the American Academy of Otolaryngology-Head and Neck Surgery (SC). The funding source did not have any role in the design, conduct; collection, management, analysis, and interpretation of data; preparation, review or approval of the manuscript; nor decision to submit manuscript for publication. Conflict of Interest: SMC has funding from the American Academy of Otolaryngology Head Neck Surgery and National Institutes on Deafness and Other Communication Disorders Outcome Supplements. JK and NR have no conflicts of interest. MC has received financial payment for medical record review.
Authorship: All authors had access to the data and took part in conception and design of study, analysis and interpretation of data, drafting and revising of the work, final approval, and agreement for accountability for all aspects of the work. Requests for reprints should be addressed to Seth Cohen, MD, MPH, Division of OtolaryngologyeHead & Neck Surgery, Duke University Medical Center, DUMC Box 3805, Durham, NC 27710. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.10.040
Cohen et al
Otolaryngology Referral and Cost
426.e12
referred patients, over- or under-referral may affect health large, national administrative US claims database, was care costs.2 retrospectively analyzed for January 1, 2004 to December Laryngeal/voice disorders represent a unique group of 31, 2008. The MarketScan databases (Truven Health Anadisease states common to primary care physicians and lytics, Ann Arbor, MI) contained the annual health care otolaryngologists, with a point prevalence of 1 in 13 among claims of approximately 55 million individuals during this primary care patients.3,4 Laryngeal/voice disorders are time period, including employees 1 and 3 months, >3 visual examination of the larynx, cation of Diseases, 9th Revision, months. the absence of which is associated Clinical Modification (ICD-9-CM) Outpatient treatment costs were tabuwith extremely poor diagnostic codes (Table 1), seen initially by a lated for each referral time group. accuracy.8 Delaying referral or not primary care physician and subsequently an otolaryngologist, referring to a specialist trained in Primary care to otolaryngology evaluaboth as outpatients, from January laryngoscopy (ie, an otolaryngoltion of 1 month was associated with 1, 2004 to December 31, 2008 ogist) could lead to delayed diaglowest costs. were included. Because patients nosis, inappropriate treatment, and Incremental higher costs occurred with with a brainstem stroke may have progression of disease with delayed otolaryngology evaluation a disordered voice from nucleus adverse effects on patient outambiguous involvement, codes comes and health care costs. times. 438.10 and 438.19 (late effects of Yet, controversy surrounds the cerebrovascular disease) were timing of laryngoscopy with recincluded. To have sufficient cost data and allow time for ommendations for laryngoscopy in cases of dysphonia of 2 multiple evaluation and treatment trials after the weeks duration and a recent clinical practice guideline otolaryngology evaluation, patients had to have at least extending the need for laryngoscopy or referral for laryn6 months follow-up after the initial outpatient otolaryngoscopy to a maximum of 3 months in patients with gology encounter. Patients who did not initially see a persistent hoarseness/dysphonia.9-11 This guideline stateprimary care physician and subsequently an otolaryngoloment has been subsequently criticized due to the potential gist as an outpatient for a laryngeal/voice disorder, and with impact of delayed otolaryngology evaluation with resulting 1 to 3 conditions, and urban vs rural status (based on employment months, and >3 months) affects the outpatient costs in a metropolitan statistical area), and time to otolaryngolincurred during the evaluation and treatment of laryngeal/ ogist (the time from the first outpatient primary care to the voice disorders. Our hypothesis is that early evaluation, the first outpatient otolaryngology encounter) were collected. 1-month group, will be associated with the lowest costs. Primary care physicians were classified as urgent care, medical doctor (not elsewhere classified), osteopathic METHODS medicine, internal medicine, multispecialty group, emergency medicine, hospitalist, family practice, geriatric medThis study was approved by the Duke University Medical icine, preventive medicine, pediatrician, nurse practitioner, Center Institutional Review Board. The MarketScan or physician assistant; otolaryngologists were classified as Commercial Claims and Encounters dataset and Medicare otolaryngology, pediatric otolaryngology, or head & neck Supplemental and Coordination of Benefits dataset, a
426.e13 Table 1 Codes
The American Journal of Medicine, Vol 128, No 4, April 2015 Laryngeal/Voice Disorder-related ICD-9 and CPT
Aggregated Diagnostic Category Vocal fold paralysis Bilateral vocal fold paralysis Vocal fold paresis Nonspecific dysphonia Acute laryngitis Benign laryngeal/ vocal fold pathology Other larynx/vagus Chronic laryngitis Laryngeal cancer Laryngeal spasm Late effect cerebrovascular disease, other speech deficits
ICD-9 Codes 478.30, 478.32 478.34 478.31, 478.33 784.49, 784.42, 784.40, 784.41 464, 464.01, 464.20, 464.21 478.4, 478.5, 478.6, 478.71, 478.79, 212.1 478.70, 352.3 476.0, 476.1 161.0, 161.1, 161.2, 161.3, 161.8, 161.9 478.75 438.10, 438.19
Procedure Category
CPT Codes
Radiology
71010, 71050, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 70450, 70460, 70470, 70490, 70491, 70492, 71520, 71260, 71270, 70551, 70552, 70553, 70540, 70542, 70543 74210, 74220, 74230, 92610, 92611, 92612, 92613, 92614, 92615, 92616, 92617 92526 92506, 92507, 92508, 92520
Swallow study
Swallow therapy Voice evaluation/ therapy Laryngoscopy Stroboscopy Surgery
Chemodenervation Laryngeal electromyography Reflux testing/ evaluation Radiation therapy
31505, 31575 31579 31300, 31320, 31360, 31365, 31367, 31368, 31370, 31375, 31380, 31382, 31390, 31395, 31400, 31420, 31500, 31502, 31510, 31511, 31512, 31513, 31515, 31520, 31525, 31526, 31527, 31528, 31529, 31530, 31531, 31536, 31540, 31541, 31545, 31546, 31560, 31561, 31570, 31571, 31576, 31577, 31578, 31580, 31582, 31584, 31587, 31588, 31590, 31595, 31599, 64716, 64886 64613, 95874 95865 91010, 91011, 91012, 91020, 91030, 91034, 91035, 91037, 91038 77263, 77014, 77295, 77290, 77334, 77338, 77300, 77413, 77427, 77336, 774214, 77470, 77301, 77280, 77418
ICD-9 ¼ International Classification of Diseases, 9th Revision; CPT ¼ Current Procedural Terminology.
surgery based on the MarketScan database dictionary. The presence of common comorbid conditions: sinusitis (461.x, 473.x), asthma (493.x), chronic obstructive pulmonary disease (490, 491.xx, 492), gastroesophageal reflux (530.81), acute pharyngitis (462), acute bronchitis (466.xx), acute upper respiratory illness (465.x), pneumonia (481, 482.xx, 483.x, 486), and allergic rhinitis (477.x) were tabulated.4 Costs from outpatient encounters, pharmacy claims, and procedures incurred from the first primary care outpatient visit to 6 months after the first outpatient otolaryngology visit were calculated. Because 97.8% of physician encounters for laryngeal/voice disorders in the MarketScan dataset were in the outpatient setting, costs from inpatient and emergency department settings were not included.4 Pharmacy claims for proton pump inhibitors, antibiotics, antihistamines, oral and inhaled steroids, and histamine 2 antagonists, which accounted for 84.1% of medication-related costs, were collected.7 The therapeutic drug classes and generic identification numbers according to the MarketScan database dictionary were used to identify these medications. A pharmacy claim was determined to be related to a laryngeal/voice disorder if the pharmacy claim was within 2 weeks of an outpatient encounter, new or return, with a laryngeal/voice disorder, and there was no pharmacy claim for the medication in the 3 months before the index date. Procedures related to the evaluation and management of laryngeal/voice disorders were identified by CPT codes (Table 1). For calculating costs from radiation therapy, the specific CPT codes were included only if related to laryngeal cancer ICD-9 codes to minimize the chances of incorporating costs due to other nonlaryngeal malignancies coexisting with other laryngeal/ voice ICD-9 codes. Costs for medical encounters and procedures were the gross payment to the provider, which was the amount eligible for payment under the medical plan. Medication costs were the ingredient cost, which is the discount below the average wholesale price, plus the dispensing fee. Costs were adjusted to 2008 utilizing the Consumer Price Index. Costs were calculated for: 1) the first primary care outpatient visit up to but not including the first outpatient otolaryngology visit (preotolaryngology costs), 2) the first outpatient otolaryngology visit to 6 months after the index otolaryngology visit (postotolaryngology costs), and 3) total costs (pre- þ postotolaryngology costs). All MarketScan database management and statistical analyses were performed with Stata Version 11.1 (Stata Corp, College Station, TX). The impact of the time to otolaryngologist on total costs was assessed using multivariate techniques. Possible differences in case mix severity (ie, severity of the laryngeal/voice disorder) among patients with different times from first primary care to first otolaryngology evaluation could influence cost outcomes. To help adjust for case mix selection bias, age and sex, which are both associated with more costly and debilitating diseases of laryngeal cancer and vocal fold paralysis, and number of comorbid conditions, also associated with costs in the evaluation and treatment
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426.e14 outpatient primary care to first outpatient otolaryngology visit. Because preotolaryngology costs may be related to postotolaryngology costs, the instrumental variable analysis also controlled for patient-related differences in preotolaryngology costs as they may reflect differences in treatment and severity of the laryngeal/voice disorder.
of laryngeal/voice disorders, were included in the models.4,13 Because laryngeal diagnoses may change during evaluation and management, the number of aggregate diagnoses rendered by otolaryngologists during the 6-month follow-up period was also included in the models.14 This variable was considered as a possible surrogate measure of the complexity of the voice problem. The number of primary care and otolaryngology visits may similarly denote the chronicity and severity of the patients’ conditions and thus were also included. Other variables known to affect the costs of the evaluation and treatment of laryngeal/voice disorders, such as geographic region, were part of the models.13 A generalized linear regression with gamma distribution, a statistical model for outcome variables with skewed distributions, such as health care costs, or for data that can only take on positive values, was used.15 The robustness of the results from the generalized linear regression was confirmed by 2 more statistical methods: a median regression and an instrumental variables regression. For the instrumental variable analysis, the dependent variable was postotolaryngology costs, and independent variable of interest was time from first
Table 2
RESULTS There were 54,600,465 unique patients in the MarketScan databases during January 1, 2004 to December 31, 2008, with 536,943 (1%) unique patients having a diagnosis of laryngeal/voice disorder. There were 260,095 unique patients that saw a primary care physician as an outpatient for a laryngeal/voice disorder, with 9833 (3.9%) referred by a primary care physician or self-referred to an otolaryngologist as an outpatient and with 6 months of postotolaryngology follow-up data. The demographic data of the cohort reflecting the time from first primary care to first outpatient otolaryngology visit is shown in Table 2. There were 834 patients excluded from the >3-months group as they did not have 6 months of postotolaryngology
Patient Characteristics by Time from First Primary Care Outpatient Encounter to First Outpatient Otolaryngology Encounter 1 Month
Number of patients 6164 Age, years (%) 1 Month and 3 Months
>3 Months
Excluded Patients
1959
850
834
P-Value* .17
7.45 10.41 59.88 22.26
4.47 10.59 54.47 30.47
4.56 9.35 50.6 35.49
39.31 60.69
38.82 61.18
43.17 56.83
9.85 29.91 43.95 15.62 0.66
8.59 32.82 43.41 15.06 0.12
8.75 40.29 37.89 12.35 0.72
17.29 82.71 2.64 (2.06)
18.35 81.65
(2.16)
17.82 82.18 2.77 (2.05)
(0.61)
1.32 (0.57)
1.27 (0.52)
.07
3-month group.
46.35 37.06 11.53 5.06
48.2 32.61 14.03 5.16
.07
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The American Journal of Medicine, Vol 128, No 4, April 2015
follow-up data. Compared with the >3-months group, the 834 excluded patients had different geographic distribution and longer time between the first primary care and first otolaryngology outpatient visits (Table 2). As the time from first primary care to first otolaryngologist encounter increased, the unadjusted mean and median overall costs increased with an increase in the proportion of overall costs related to medications and a decrease in the proportion of costs related to outpatient visits and procedures (Table 3). Further analysis of the costs revealed that medications accounted for roughly two-thirds of primary care costs, and medication and procedure-related costs varied inversely at the 3 time points of otolaryngology evaluation (Table 3). A generalized linear regression model with gamma distribution examined the impact of time from first primary care to first otolaryngologist outpatient visit on adjusted overall costs (Table 4). The adjusted mean total costs per person increased for each time interval and was greatest for the >3-month interval (Table 5; Wald statistic, P < .05). Similarly, a median regression analysis with outcome the natural log of total cost found increasing adjusted median total costs per person with coefficients of 0.14 (95% confidence interval 0.09-0.19) for >1 to 3 months and 0.33 (95% confidence interval 0.26-0.40) for >3-months vs 1-month time period compared with the
1-month group. In the instrument variable analysis, compared with seeing an otolaryngologist 1 month after the first primary care visit, a 10% and 29% increase in postotolaryngology costs was noted for patients seeing an otolaryngologist >1 to 3 months and >3 months after the first outpatient primary care visit, respectively (Table 5).
DISCUSSION The timing of otolaryngology evaluation for laryngeal/voice disorders has important consequences for patients and the health care system. Our results demonstrate that reduced health care costs were associated with an earlier time between the first primary care and first otolaryngology outpatient visits for patients with laryngeal/voice disorders. These data further suggest that the clinical practice guideline recommendation for laryngoscopy or referral for laryngoscopy by a maximum of 3 months needs reconsideration.11 Previous reports for other disease processes have presented conflicting results regarding specialist care and the impact on patient outcomes and costs. For instance, early referral for physical therapy for low back pain resulted in lower health care costs, and early orthopedic referral for common musculoskeletal diseases also led to lower costs.16,17 Yet, community-acquired pneumonia treatment
Table 3 Mean and Median Annual Outpatient Costs per Person Involved in the Evaluation and Management of Laryngeal/Voice Disordered Patients by Time from First Primary Care Outpatient Visit to First Outpatient Otolaryngology Visit 1 Month Preotolaryngology costs* Mean (SD) Median 25th percentile 75th percentile % Medication costs % Outpatient visit costs % Procedure costs Postotolaryngology costs* Mean (SD) Median 25th percentile 75th percentile % Medication costs % Outpatient visit costs % Procedure costs Total costs* Mean (SD) Median 25th percentile 75th percentile % Medication costs % Outpatient visit costs % Procedure costs
224.20 (489.47) 79.37 54.96 69.74 69.7% 30.3% 0%
>1 Month and 3 Months 274.94 (611.00) 92.63 59.95 68.90 68.9% 31.1% 0%
> 3 Months 333.55 (846.84) 84.27 57.57 71.56 71.6% 28.4% 0%
1598.11 (3714.62) 729.63 378.50 1592.92 19.7% 26.4% 53.9%
1950.97 (4550.59) 842.84 417.01 1882.46 22.7% 20.4% 46.0%
2379.64 (5183.15) 1015.90 424.14 2358.04 51.8% 14.9% 33.3%
1822.31 (3821.93) 906.72 470.57 1918.00 25.8% 26.9% 47.3%
2225.92 (4725.28) 1037.58 537.00 2237.79 38.01% 21.7% 40.3%
2713.19 (5544.95) 1263.16 611.67 2684.44 54.3% 16.6% 29.2%
*Preotolaryngology costs ¼ costs incurred from first primary care outpatient visit up to but not including the first otolaryngology outpatient visit. Postotolaryngology costs ¼ costs incurred from first otolaryngology outpatient visit through 6 months after this visit. Total costs ¼ preotolaryngology þ postotolaryngology costs.
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426.e16
Table 4 Generalized Linear Regression Model for Total Outpatient Costs Involved in the Evaluation and Management of Patients with Laryngeal/Voice Disorders Covariate Time to otolaryngologist 1 month >1 month and 3 months >3 months Age, years 65 Sex Male Female Region Northeast North Central South West Number of comorbid conditions 0 1 2 3 Metropolitan statistical area No Yes Year 2004 2005 2006 2007 2008 Referral type PCP referred Self-referred # Otolaryngology-given diagnoses over 6 months after first otolaryngology visit # Outpatient visits to PCP before otolaryngology evaluation # Outpatient otolaryngology visits over 6 months after first otolaryngology visit
Coefficient 95% Confidence ($)* Interval ($)
Reference 271.34 115.95-426.73 711.38
429.43-993.34
P-Value
.001
