Tonsillectomy in Maine

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Abstract
The reduction in the rate of tonsillectomy, using Maine as an example, and the causes thereof are addressed. Are federal and state regulations required to change the behavior of physicians and the public, or is education of greater importance? A study of tonsillectomy in Maine was based on data covering a period of .apprx. 30 yr. The data were based on direct contact with hospitals, in which the cooperation of virtually all the hospitals in Maine, encompassing 98% of the hospital beds, was achieved. These data were placed in context by information provided by the Maine Health Data Service, and by information for the northeastern USA, for the eastern USA, and for the entire USA, from the Department of Health, Education and Welfare. The operation of tonsillectomy and its variants, including adenoidectomy, has declined remarkably in the past 30 yr, most drastically in the past 8 yr. It now occupies only 4.5% of the total operative admissions for the state, where it formerly was 17%. It now has a populational incidence for the state of 3.3 operations/1000 population per year, whereas it formerly was at a level of .apprx. 10.0. From this study and from physicians in Maine to whom an informal questionnaire was sent, this reduction has come about largely because of education of physicians and the public. Increased awareness by the public, pediatricians and general practitioners of the limitations of this operation has been significant. There is a sense of improved general health of young people in Maine, with fewer chronic respiratory infections. Some negative opinions were expressed, including the possibility that peritonsillar abscesses may be more frequent in the future and that some pediatricians and general practitioners overuse antibiotics. Federal regulations, state regulations, Medicare, Medicaid, Blue Cross or Blue Shield regulations concerning tonsillectomy were not instituted at any point in Maine during the period under study. There were no alterations in payment, 2nd opinion programs or other restrictions or constraints placed on the operation at any level of official or hospital regulation. Formerly performed in large numbers by general practitioners, family practitioners and general surgeons, the operation(s) is now predominantly carried out by trained otolaryngologists, largely board certified. Concentration of this operation in the hands of fewer, more highly trained surgical specialists evidently has been positively associated with its sharper indications and declining frequency. Increased education of physicians, specialists, general practitioners and family doctors, and of the public as a whole, apparently is the most important single factor in producing this significant alteration in the behavior of the health care system in Maine. Effective limitation of the operation to specialists has been an important feature both of this educational process and of the more rational use of the operation(s).