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New Hampshire children far more likely to receive surgery, drugs than Vermont, Maine

Where children live in northern New England has dramatic influence over how much and what types of medical care they receive, according to a first-of-its-kind report from researchers at Dartmouth College.

For example, children living in Berlin were almost four times as likely to have tubes surgically inserted in their ears to manage ear infections than children living in Bangor, Maine, according to the data.

Children in Manchester and Dover also underwent the procedure at a rate more than double that of children in most areas of Maine, despite inconclusive evidence that the tubes improve long-term outcomes better than “watchful waiting,” according to the study’s authors, led by David Goodman, a professor of pediatrics at Dartmouth’s Geisel School of Medicine.

Laconia ranked seventh out of 70 northern New England communities in CT scan utilization for both head and abdomen – with each scan exposing children to the same radiation as more than 200 X-rays.

In Concord, the utilization rates for several diagnostic imaging tests were also above the regional average. Out of every 1,000 children in Concord:

∎ 14.1 received a head CT scan, 2.1 more than average.

∎ 9.8 received an abdominal CT scan, one more than average.

∎ 8.6 received a head MRI, 1.5 more than average.

∎ 90.9 received a chest X-ray, 19.4 more than average.

∎ 30.6 received an abdominal X-ray, 8.4 more than average.

Children in New Hampshire are more likely than their peers in Maine or Vermont to be prescribed medications of all kinds, with more than 451 prescriptions filled for every 100 children in the state, compared with 429.9 in Maine and 418.9 in Vermont.

The report is the first by the Dartmouth Atlas to examine pediatric care. The Atlas project has spent 20 years documenting variations in utilization by Medicare patients, about whom much more data is available, Goodman said yesterday.

“Children are a much larger population than Medicare, and they may be less expensive and receive less treatment overall, but they represent the future of our society and everyone would see children’s health care as something we should improve,” he said.

“I hope the report stimulates interest in measuring the care of children and the development of data we badly need to improve care of children in the United States.”

The researchers looked at data collected by the states of Maine, New Hampshire and Vermont between 2007 and 2010. They then broke the states into smaller segments based on where residents received their medical care, and compared the rates at which children in each area received certain types of care – from surgical procedures such as ear tubes to annual physicals and follow-up visits.

Information about particular physicians was not available, Goodman said.

No one state or community performed consistently on all measures; however, many trends did emerge from the data.

For medical care such as annual physicals, where known benefits outweigh side effects and risks of harm, the best rate of utilization is 100 percent.

Berlin, Plymouth, North Conway, Wolfeboro, Manchester and Portsmouth were all in the top 10 communities where children visited a physician at least once annually, with at least 89.5 percent utilization.

Concord’s annual office visit rate was 88 percent.

Children in Maine, who had the lowest rate of annual office visits, were more likely to visit the emergency room.

Physicians in all three states did not frequently follow up with children after prescribing ADHD medication. No community in northern New England had a rate above 70 percent for that care.

Berlin had the highest rate of low-income children under 2 who were screened for lead poisoning (86.4 percent), and the highest rate of adolescents receiving annual physicals (64.5 percent).

However, Berlin also had the highest rate of both ear tube insertions (also called tympanostomies) and tonsillectomies.

Overall, New Hampshire children were much more likely to have their tonsils removed than children in Vermont and Maine.

Concord had the lowest tonsillectomy rate in the state, at 5.9 procedures per 1,000 children. That rate was still higher than all communities in Maine and Vermont except one. With a rate of 2.7 tonsillectomies per 1,000 children, Bangor, Maine, had the lowest rate in northern New England.

The study cites an earlier piece of research of pediatric medical records in Britain in the 1930s. At the time, many doctors believed removing children’s tonsils would prevent ear infections and other problems.

Looking at health records, the research found that when one school district instated a new health officer, the rate of tonsillectomies dropped 90 percent. No increase in infections occurred.

The wide variation in the rate of tonsillectomies across northern New England may be due as much to underutilization in some regions as to overutilization in others, Goodman said.

The best rate of use is hard to define, he said, “but no region probably has the right rate reflecting effective use for properly diagnosed children.”

(Sarah Palermo can be reached at 369-3322 or or on Twitter @SPalermoNews.)

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