title: Delayed otolaryngology referral for voice disorders increases health care costs.
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, 9(th) 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.
authors.affiliation: Duke Voice Care Center, Division of Otolaryngology-Head & Neck Surgery, Duke University Medical Center, Durham, NC. Electronic address: seth.cohen@duke.edu.
authors.forename: Seth M
authors.initials: SM
authors.lastname: Cohen
authors.affiliation: Division of Public Health & Study Design and Biostatistics Center, University of Utah, Salt Lake City.
authors.forename: Jaewhan
authors.initials: J
authors.lastname: Kim
authors.affiliation: Department of Communication Sciences and Disorders, Division of Otolaryngology-Head & Neck Surgery (Adjunct), University of Utah, Salt Lake City.
authors.forename: Nelson
authors.initials: N
authors.lastname: Roy
authors.affiliation: Department of Otolaryngology-Head & Neck Surgery, University of California - San Francisco.
authors.forename: Mark
authors.initials: M
authors.lastname: Courey
mesh_terms: D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000191:economics; D003362:Cost-Benefit Analysis; D057210:Delayed Diagnosis / Q000191:economics*; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D007818:Laryngeal Diseases / Q000150:complications / Q000175:diagnosis* / Q000191:economics*; D007828:Laryngoscopy / Q000191:economics*; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D010036:Otolaryngology / Q000191:economics*; D058007:Physicians, Primary Care / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000191:economics*; D011320:Primary Health Care / Q000191:economics / Q000592:standards; D012017:Referral and Consultation / Q000191:economics / Q000592:standards; D012189:Retrospective Studies; D013997:Time Factors; D014481:United States; D014832:Voice Disorders / Q000191:economics* / Q000209:etiology*
keywords: Cost; Larynx; Otolaryngology; Primary care; Referral; Voice