Tonsillectomy in Maine: regulation versus education as modulators of medical care

The reduction in the rate of tonsillectomy, using the state of 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 the state of Maine was based on data covering a period of approximately 30 years. The data were based on direct contact with hospitals, in which we achieved the cooperation of virtually all of the hospitals of Maine, encompassing 98% of the hospital beds. These data were placed in context by information provided by the Maine Health Data Service, and by information for the northeastern United States, for the eastern United States, and for the entire United States, from the Department of Health, Education and Welfare. The operation of tonsillectomy and its variants, including adenoidectomy, has declined remarkably in the past 30 years, most drastically in the past eight years. 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 per thousand population per year, whereas it formerly was at a level of about 10.0. From this study, as well as from physicians in Maine, to whom an informal questionnaire was sent, it is clear that 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. In addition, there is a general 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 abcesses 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 the State of Maine, during the period under study. There were no alterations in payment, second 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. Evidence is presented to support the view that concentration of this operation in the hands of fewer, more highly trained surgical specialists has been positively associated with its sharper indications and declining frequency. The conclusion is offered that increased education of physicians, both specialists and general practitioners as well as family doctors, and of the public as a whole, is the most important single factor in producing this significant alteration in the behavior of the health care system in the State of 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).