Dysphonia Prevalence & Occupation in the US

ARTICLE IN PRESS
Prevalence and Occupation of Patients Presenting With
Dysphonia in the United States
*Michael S. Benninger, †Chantal E. Holy, *Paul C. Bryson, and *Claudio F. Milstein, *Cleveland, Ohio, and †Menlo Park,
California
Summary: Objective. Voice disorders are common conditions that may have a significant impact on patient quality
of life, yet their prevalence and epidemiology are poorly documented. In this study, we estimated the prevalence, demographics, and occupation of patients with dysphonia.
Methods. Using the Commercial and Medicare MarketScan databases of 146.7 million lives (2008–2012), the prevalence of dysphonia was estimated. Patient demographics and industry occupation were evaluated. Prevalence estimates
overall and by industry were made using Medical Expenditure Panel Survey. Industry estimates were compared with
US government employment statistics to assess differences between dysphonia and the general population.
Results. A gradual increase in the diagnosis of dysphonia was noted from 1.3% to 1.7% of the population from 2008
to 2012, with an associated increase in the diagnosis of acute laryngitis, the largest diagnostic category. A strong correlation was present between diagnosis and age, with acute laryngitis more common in the younger populations and
malignancies in older ages. Benign neoplasms were more prevalent in the service industry, with 2.6 times increased
likelihood compared with the general population, and malignancies were more prevalent in the manufacturing industry, with 1.4 times increased likelihood. Almost 3 million laryngoscopies and stroboscopies were performed with $900
million in costs.
Conclusion. Prevalence rates of the diagnosis of dysphonia are increasing and are associated with large healthcare
costs. Prevalence rates also differ somewhat between industries, and there appears to be a higher percentage of malignant neoplasms in the manufacturing industry and benign neoplasms in the service industry.
Key Words: Dysphonia–Prevalence–Etiology–Industry–Occupation.
INTRODUCTION
Voice disorders are relatively common and can have a significant impact on patient quality of life and healthcare costs1,2
Although there has been significant work within the voice care
community to evaluate quality of life and outcomes, there has
been a paucity of data related to general prevalence rates and
overall costs.2–6 With an estimated prevalence of approximately 1% in the US population, dysphonia’s most prevalent
manifestation is acute laryngitis, with a relatively small proportion of patients experiencing far more debilitating conditions such
as laryngeal malignancies.2 A telephone survey of 1326 patients in Iowa and Utah has shown that 29.9% of the population
has a lifetime history of dysphonia, with 6.6% of patients having
a current voice disorder.3 These prevalence estimates are not noted
in larger claims-based diagnostic prevalence rates. Utilizing the
2012 National Health Interview Survey, an estimated 17.9 million
adult patients reported a voice problem affecting approximately 1 in 13 US adults. Despite this, only 10% sought care from
a healthcare worker. Proper diagnosis and evaluation of the underlying causes of dysphonia often requires diagnosis and
Accepted for publication January 12, 2017.
Presented at the Annual Meeting of the Voice Foundation: Care of the Professional Voice,
Philadelphia, 2015.
Source of funding: License to access the MarketScan database was funded by Johnson
& Johnson.
Financial disclosures: CEH is a paid employee of Acclarent Inc.
From the *Head and Neck Institute, The Cleveland Clinic, Cleveland, Ohio; and the
†Johnson & Johnson, Menlo Park, California.
Address correspondence and reprint requests to Michael S. Benninger, Head and Neck
Institute, Lerner College of Medicine, The Cleveland Clinic, 9500 Euclid Avenue, A-71,
Cleveland, OH 44195. E-mail: [email protected]
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2017 Published by Elsevier Inc. on behalf of The Voice Foundation.
http://dx.doi.org/10.1016/j.jvoice.2017.01.011
management by an otolaryngologist. Recent studies have shown
that patient diagnoses often change as patients transition from
primary to subspecialty care, and increased time in nonspecialist care results in greater healthcare cost, potentially due to delays
in targeted treatments.7,8 Direct yearly expenditures for a voice
problem were $300 million.5
Despite these efforts to assess prevalence, impact, and cost,
there are notable limitations in the information available related
to dysphonia, in part due to limitations in the data and potentially in the methodology of the evaluations. In addition, there
has not been good data developed in relationship to different voice
disorder diagnoses or variations by age and sex. Because there
is an impact on work activity,3 a better understanding of prevalence and specific diagnosis based on the industry in which the
patient works would be expected to be valuable. The at-risk population for vocal disorders may significantly vary based on
etiology.
This preliminary study was thus designed to evaluate changes
in prevalence of dysphonia from 2008 to 2012, by etiology, and
evaluate demographic as well as occupational profiles of patients presenting with various conditions, to start understanding
the impact of various dysphonia diseases on patients. Because
of the large prevalence of disease in the >65-year-old population, both the Commercial and Medicare MarketScan databases
were queried, and a projection methodology was used to estimate nationwide counts of disease on a yearly basis.
METHODS
The study is a retrospective analysis of a large administrative
database designed to collect and pay for medical and drug claims
(aka claims-based analysis), with no identification of individual
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Journal of Voice, Vol. ■■, No. ■■, 2017
patients and therefore was exempt from the need to obtain an
institutional review board approval.
Databases
The Truven Health MarketScan Commercial Claims and Encounter Database (Truven Health Analytics, Ann Arbor, MI) as
well as the MarketScan Medicare database were queried. These
very large databases (in 2013: Commercial: 36.7 million; Medicare: 3.2 million) track patients longitudinally across all sites
of care over multiple years. Recently, Truven Health researchers developed a projection methodology to allow estimates of
US-wide frequencies of diagnoses or procedures from those obtained directly from the databases, making these databases
invaluable tools to estimate prevalence and incidence of disease
and procedures. These databases have recently been used for a
number of healthcare cost and epidemiology studies for dysphonia and other general otolaryngological conditions.2,8,9
Dysphonia disease identification
All patients with a primary or secondary diagnosis of dysphonia, in both outpatient and inpatient care, were identified from
2008 to 2012.
Projection methodology
Nationwide projections were obtained using a proprietary methodology developed by MarketScan. Briefly, the MarketScan
population was subdivided into 72 demographic cells linked to
similar subpopulations from the Medical Expenditure Panel
Survey (MEPS).10 Each cell within the MEPS survey includes
a number of people with similar characteristics. A weight factor
was assigned to each cell, such that the weight would be equal
to the ratio of the MEPS-estimated population for that particular cell, divided by the MarketScan sample size for that cell.
In our analyses, patients with 12 months of consecutive enrollment in MarketScan were included to avoid the potential of
statistical noise. Each calendar year was analyzed separately.
Unique patient diagnostic categories were counted only once in
a given calendar year, such that a patient with, for example, two
diagnoses of acute laryngitis only accounted for one count of
prevalence for acute laryngitis. Compounded annual growth rates
for each dysphonia disease type were estimated from 2008 to
2012.
Using the MEPS methodology allowed for projection of patient
counts to the entire population covered via Commercial or Medicare supplemental insurance. To further project to nationwide
estimates, all prevalence counts were further multiplied by the
respective ratios that accounted for all other patients. (For younger
than 65 years old, the additional ratio was equivalent to: (total
population under 65) / (MarketScan projected commercial population). For those older than 65 years old, the additional ratio
was equivalent to: (total population over 65) / (MarketScan projected Medicare population).
Cohort analyses
All patients identified in the prevalence analysis were further characterized by age, work status (employed vs not employed), and
industry affiliation. The ratio of patients with dysphonia by work
status and industry affiliation was compared with those obtained from the overall projected MarketScan population.
Statistical analyses
Continuous variables were shown as means and standard deviations. Proportions were calculated for all categorical variables
and presented as ratios with confidence intervals. To evaluate
statistical differences between proportions, t tests for unpaired
cohorts were conducted (α = 0.05). All statistical analyses were
performed using SAS EG 4.3 (SAS Institute, Inc., Cary, NC).
RESULTS
The total volume of covered lives in the MarketScan Commercial and Medicare databases increased from 36.8 million in 2008
to 56.1 million in 2012. Of these populations, 343,364 patients
in 2008 and 661,578 patients in 2012 presented with dysphonia. Using the projection methodology described above, the overall
prevalence for each dysphonia diagnosis was projected for the
US-wide population (304.3 million in 2008 and 313.8 million
in 2012). The results are shown in Table 1. Briefly, acute laryngitis represented approximately 54% of all cases of dysphonia,
followed by general “dysphonia” diagnoses (22%) and chronic
laryngitis (6%). All other diseases were fairly rare, accounting
for less than 200,000 patients per year and thus falling under
the “orphan disease” definition (according to US criteria, a disease
that affects fewer than 200,000 people).
TABLE 1.
Prevalence Estimates and Compound Annual Growth Rates (CAGR) for All Conditions From 2008 to 2012
Acute laryngitis
Dysphonia
Other
Chronic laryngitis
Malignant neoplasm of larynx
Edema of larynx
Vocal fold polyps
Paralysis
2008
2009
2010
2011
2012
CAGR (%)
2,206,593
760,265
341,549
248,846
104,009
78,142
74,177
69,390
2,604,168
951,775
389,834
293,151
97,814
92,839
77,137
76,452
2,530,288
1,068,905
437,986
310,972
103,084
113,531
83,030
81,167
2,650,974
1,134,977
489,226
325,397
105,131
123,482
85,104
88,945
2,754,056
1,247,471
565,490
342,601
108,209
130,184
88,694
94,418
5.7
13.2
13.4
8.3
1.0
13.6
4.6
8.0
The CAGR of the US population over the same time period was estimated at 0.8%.
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Michael S. Benninger, et al
Prevalence and Occupation of Patients With Dysphonia
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FIGURE 1. Prevalence of dysphonia in the United States, 2008–2012.
There was a gradual increase in prevalence rates of the diagnosis of dysphonia from 2008 (3.8 million) to 2012 (5.3
million), with an associated increase of percentage of the population from 1.3% to 1.7% (Figure 1). The average age of patients
in each diagnostic category was compared. Except for acute laryngitis, all dysphonia diseases affected a population with an
average age of >50, and for malignant disease the population
was >60 years old, as shown in Table 2. The distribution of the
specific diagnoses is noted in Figure 2, and the growth in the
prevalence of various diagnoses is shown in Figure 3. There was
a strong correlation of specific diagnoses by age, with acute laryngitis, laryngospasm, and benign lesions being more common
in the younger age groups, and malignancies, paralysis, and paresis
being more common in the older age groups (Figure 4). The procedures used to make or confirm the diagnosis are presented in
Figure 5, along with projections for 2018. Cost estimates are also
shown. A majority of patients had a flexible laryngoscopy performed, accounting for 2.2 million of the 2.7 million procedures
TABLE 2.
Average Age of Patients Presenting With Dysphonia
Diagnoses
Diagnosis
Malignant neoplasm of larynx
Paralysis
Paresis
Chronic laryngitis
Dysphonia
Benign neoplasm of larynx
Edema of larynx
Vocal fold polyps
Other diseases of vocal cords
Laryngeal spasm
Acute laryngitis
Average
Age
Standard
Deviation
66.16
58.97
58.58
54.92
54.82
53.86
53.10
52.38
50.05
42.58
19.53
11.72
19.41
18.58
17.96
20.06
17.78
18.87
17.13
21.44
24.68
23.63
performed. The overall estimated cost of diagnosis is $986 million.
Cost estimates were not obtained for cost of treatment (Figure 5).
Industry representation in the MarketScan database is shown
in Table 3 and Figure 6. Manufacturing (35%) and service (24%)
industries represent 59% of the patients. Significant differences
were identified between specific voice diagnoses and the industry
of the patient in comparison with the overall MarketScan population (Table 3 and Figure 7), with acute and chronic laryngitis
and benign neoplasms of the larynx higher in the service industry
(1.3 times more likely), and malignant neoplasms of the larynx
higher in the manufacturing industry (1.4 times more likely).
DISCUSSION
In this study, the total prevalence and compounded annual growth
rates of all dysphonia conditions were evaluated from 2008 to
2012. Our analysis suggested that approximately 1% of the overall
US population suffered from dysphonia on a yearly basis. Acute
laryngitis accounted for slightly more than half of all cases,
whereas more severe conditions were relatively rare (less than
200,000 per year). However, the growth of all conditions, except
malignant neoplasm of the larynx, was significantly larger than
that of the overall US population. The growth of all conditions
except acute laryngitis can be due to overall population trends,
such as aging. Growth in acute laryngitis, however, is unexplained and may be due to changes in the diagnostic practices
within the medical community. Another consideration is that there
is a growing recognition by both primary care and specialty providers that there may be a role for laryngopharyngeal reflux in
both acute and chronic laryngeal disorders and in the edema of
the larynx, which may play some role in the increases in these
diagnoses.
Industry representation was analyzed to further understand the
burden of disease on patient and society overall. Approximately 40% of patients with acute laryngitis and 32% of patients with
dysphonia were recorded as being full- or part-time employed.
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Journal of Voice, Vol. ■■, No. ■■, 2017
FIGURE 2. Distribution of specific diagnoses.
Nearly 30% of all patients with dysphonia were employed in
the service industry, which may place higher demands on voice.11
The direct economic health impact of a medical condition is
best estimated via claims data that incorporate all of the direct
costs of evaluation and treatment. Although the purpose of this
study was not to evaluate costs, and we did not evaluate all of
the subsequent treatment costs, the direct healthcare diagnostic
cost implications of dysphonia are substantial, nearing $1 billion
a year, well above prior estimates utilizing the same database.5
The indirect cost impact of dysphonia would also be expected
to be substantial, particularly if the more generous prevalence
estimates from surveys are taken into account.
This is the first in-depth evaluation of the industry distribution of patients with dysphonia and interesting relationships were
noted. It is not unexpected that the service industry would have
higher rates than the population as a whole, as service workers
will frequently be in occupations that require significant voice
use. Our study also identified a relatively high proportion of patients with malignant neoplasms of the larynx from the
manufacturing industry. This may in part be due to higher ex-
posures to carcinogenic chemicals12,13 and higher smoking rates
in manufacturing than other industries.14
Our study shows that 3% of patients presented with benign
neoplasms of the larynx. Laryngeal papillomas account for approximately 85% of benign laryngeal tumors, and although not
directly recorded there is no reason to expect that this distribution would not be the case in our study. Study estimates of the
prevalence of laryngeal papilloma have been largely restricted
to pediatric patients. Utilizing the Optum Clinformatics and
Truven MarketScan Medicaid databases, juvenile papilloma has
been estimated to be 0.51 per 100,000 in the Optum database
and 1.03 per 100,000 in the MarketScan Medicaid database.15
In this study, benign tumors are 1.3 times more likely in the
service industry than the entire cohort. Because specifics related
to the type of manufacturing or specific service industry are not
identifiable in this database, and given the large number of patients represented, the US government labor specific data were
used to estimate the possible relationships between diagnoses
and specific occupations. Healthcare workers comprise 11.7%
of the overall US labor market (http://www.bls.gov/ces/,
FIGURE 3. 2008–2012 growth of prevalence of patients with dysphonia diagnoses.
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Michael S. Benninger, et al
Prevalence and Occupation of Patients With Dysphonia
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FIGURE 4. Average age in relationship to specific diagnosis.
accessed December 14, 2015). If that distribution held true in
our population, then 49% of the service occupation subjects in
our trial would be in the healthcare sector. Based on this distribution, it could be estimated therefore that the risk of papilloma
would be even greater in the healthcare industry, possibly as high
as 2.65 times more likely than in the general worker population.
Estimating prevalence rates for dysphonia is complicated and
there is no perfect method to do so. Typically, prevalence rates
for the global population rely on large claims databases, which
provide information on a large enough group of patients to provide
assumptions related to the larger population. One caveat in the
use of claims data estimates of prevalence is that it relies on appropriate coding of the disorder. With improvements in coding
over time and as more groups try to access these databases, it
would be expected that data mining will provide better information. Another notable limitation is that claims databases only
give information related to people who actually seek out healthcare for their problem.
Other methods utilized to estimate prevalence of disease is
through surveys, with larger surveys having more validity than
smaller samples. Surveys will typically reveal higher prevalence rates, in that positive responses will occur in people who
do not feel that they require a visit to the healthcare system. These
are evident in the differences in prevalence rates of dysphonia
identified in this study (1.7%) in comparison with surveys that
have shown rates between 6% and 8%.3,8
Limitations of the present study include those inherent to all
database analyses, such as reliance on proper physician coding.
Additional limitations specific to this study include the fact that
the projection methodology developed by MarketScan does not
include uncertainty, and as such the results are presented as absolute values without error ranges. From an industry and
FIGURE 5. Diagnostic procedures performed.
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TABLE 3.
Industry Affiliation for Patients With Industry Data
MarketScan
All dysphonia
Acute laryngitis
Benign neoplasm of larynx
Chronic laryngitis
Dysphonia
Edema of larynx
Laryngeal spasm
Malignant neoplasm of larynx
Manufacturing
(%)
Services
(%)
Transportation,
Communications
and Utilities (%)
Finance,
Insurance, Real
Estate (%)
Retail
Trade (%)
Other
(%)
35
31
29
38
33
35
32
30
50
24
27
29
24
28
27
30
30
14
18
19
17
21
21
21
20
20
25
14
16
19
13
14
13
14
16
9
5
4
5
3
3
3
3
3
2
4
3
2
1
1
1
1
1
1
occupational standpoint, a key limitation is the fact that patients disclosed occupational or industry affiliation only in
approximately 50%–60% of cases. However, despite the fact that
not all patients provided this information, based on the signif-
icant size of patients included in the study, industry and
occupational information on 50%–60% patients can provide
meaningful information in terms of overall burden of disease and
potential associations.
FIGURE 6. Industry representation in the MarketScan database.
FIGURE 7. Differences in specific voice-related diagnoses in comparison with overall MarketScan population.
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Michael S. Benninger, et al
Prevalence and Occupation of Patients With Dysphonia
CONCLUSIONS
The diagnosis of dysphonia is increasing with prevalence rates
and current rates based on insurance claims evaluations being
approximately 1.7% of the population. There is a difference in
prevalence rates by age, with acute laryngitis being higher in
younger age groups and malignant neoplasms in older ages.
Prevalence rates also differ somewhat between industries, and
there appears to be a higher percentage of malignant neoplasms in the manufacturing industry and benign neoplasms in
the service industry. Overall prevalence rates are likely much
higher, as many patients with voice problems do not seek
medical care.
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