Published online August 1, 2007
PEDIATRICS Vol. 120 No. 2 August 2007, pp. 281-287 (doi:10.1542/peds.2006-3601)
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ARTICLE

Management of Acute Otitis Media by Primary Care Physicians: Trends Since the Release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline

Louis Vernacchio, MD, MSc, Richard M. Vezina, MPH and Allen A. Mitchell, MD

Slone Epidemiology Center at Boston University, Boston, Massachusetts


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVES. In 2004, the American Academy of Pediatrics and the American Academy of Family Physicians released a clinical practice guideline on the management of acute otitis media that included endorsement of an observation option for selected cases and recommendations of specific antibiotics. We sought to describe primary care physicians' current management of acute otitis media to compare it with the guideline's recommendations and describe trends since 2004.

DESIGN. We used a mail survey from March through June 2006 within the Slone Center Office-Based Research Network, a national practice-based pediatric research network.

RESULTS. The response rate was 299 (62.7%) of 477. The observation option was considered reasonable by 83.3%, compared with 88.0% in 2004, and was used in a median of 15% of acute otitis media cases over the previous 3 months. The most common physician-identified barriers to the use of the observation option were parental reluctance (83.5%) and the cost and difficulty of follow-up of children who do not improve (30.9%). In terms of antibiotic choices for acute otitis media, agreement with the guideline's antibiotic recommendation for 4 common clinical scenarios was as follows: high-dose amoxicillin for acute otitis media with nonsevere symptoms (57.2%), high-dose amoxicillin-clavulanate for acute otitis media with severe symptoms (12.7%), high-dose amoxicillin-clavulanate for cases that failed to respond to amoxicillin (42.8%), and intramuscular ceftriaxone for cases that failed to respond to treatment with amoxicillin-clavulanate (16.7%). Each of these proportions declined from 2004.

CONCLUSIONS. Most primary care physicians accept the concept of an observation option for acute otitis media but use it only occasionally. Antibiotics prescribed for acute otitis media differ markedly from the guideline's recommendations, and the difference has increased since 2004.

Key Words: otitis media • antibiotics • clinical practice guidelines • primary care

Abbreviations: AOM—acute otitis media • AAP—American Academy of Pediatrics • AAFP—American Academy of Family Physicians • SCOR—Slone Center Office-Based Research

Despite being one of the most common illnesses for which children are brought to physicians, acute otitis media (AOM) remains a management challenge for primary care providers. This is especially true given 2 important trends in AOM management. First, the concept of initial observation without antibiotic treatment has been adopted as standard practice in some parts of the world1 and has begun to achieve acceptance in the United States as well.2–6 Second, the widespread emergence of antimicrobial resistance has increased the urgency to reduce antibiotic use and, when antibiotic treatment is chosen, has made the choice of antibiotic more difficult.

In May 2004, in response to these issues, the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) jointly issued a clinical practice guideline entitled "Diagnosis and Management of Acute Otitis Media."7 The guideline endorsed an observation option for selected children with AOM, specifically considering it an option for those ≥2 years old with nonsevere symptoms or an uncertain diagnosis and for those 6 months to 2 years old with both nonsevere symptoms and an uncertain diagnosis. The guideline also made specific antibiotic recommendations for various common AOM scenarios, including high-dose amoxicillin as first-line treatment for most children, high-dose amoxicillin-clavulanate as first-line treatment for children with severe symptoms (moderate-to-severe otalgia or fever of ≥39°C), and various specific antibiotics for those whose conditions failed to respond to first-line treatment.

In October 2004, we surveyed the physician-members of the Slone Center Office-Based Research (SCOR) Network to determine their familiarity with the guideline and to compare their practices with the guideline's recommendations in several key areas.8 We now describe follow-up survey data from the same group of physicians collected ~2 years after the publication of the guideline and 18 months after our initial survey.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The SCOR Network is a national practice-based, primary care pediatric research network coordinated by investigators at the Slone Epidemiology Center at Boston University. In March 2006, we mailed surveys to all active physician-members of the network inquiring about their opinions and practices regarding the observation option for AOM and about their preferred choices of antibiotics for 4 common AOM scenarios. The AOM scenarios included the following: AOM with nonsevere symptoms, AOM with severe symptoms, AOM that failed treatment with amoxicillin at 80 to 90 mg/kg per day, and AOM that failed treatment with amoxicillin-clavulanate at 80 to 90 mg/kg per day. (The survey also contained a section on screening practices for type 2 diabetes mellitus in children, the results of which are not presented here.) Approximately 6 weeks later, we sent a second survey to nonresponders, half by mail and half by fax, determined randomly. After another ~6 weeks, we called the office of each nonresponder to verify the contact information and faxed a third survey to the office.

To analyze open-ended responses about barriers to the use of the observation option, 1 investigator (Dr Vernacchio) reviewed the responses and created categories to which he assigned each response; a second investigator (Dr Mitchell) independently assigned each response to a category. When the investigators did not agree or when there were <5 responses in a category, the response was coded as "other." Proportions were calculated as the number of each given response divided by the total number of valid responses. Comparisons of proportions between groups were performed by {chi}2 analysis or, when the analysis was limited to responders to both the 2004 and 2006 surveys, by McNemar's test for paired observations. Comparison between 2004 and 2006 of the median proportion of cases in which physicians used the observation option was performed by using Wilcoxon signed ranks test. SAS 9 (SAS Institute, Inc, Cary, NC) software was used for all analyses. The study was approved by the Boston University Medical Campus Institutional Review Board.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Four hundred eighty-nine surveys were mailed; 7 were undeliverable because the physician had relocated and a current address could not be determined, 3 physicians were no longer practicing primary care, and 2 others had retired. Two hundred ninety-nine completed surveys were received, for a response rate of 62.7%. Among the 299 respondents, 207 also responded to our 2004 survey. Nonresponders did not differ significantly from responders by gender, practice setting, region, or specialty (data not shown). The demographics of the responders are shown in Table 1.


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  		TABLE 1 Characteristics of 299 Physicians Who Responded to the Survey

 
Overall, 249 (83.3%) believed the observation option was reasonable for some children with AOM, whereas 50 (16.7%) did not. The proportion who accepted the observation option did not differ significantly by the physician's gender, region, or membership in AAP and/or AAFP, but it was higher among pediatricians (compared with family physicians), suburban and urban non–inner-city practices, and younger physicians (Table 2).


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  		TABLE 2 Acceptance of the Observation Option According to Physician Characteristics

 
Compared with 2004, the overall proportion who accepted the observation option among this group of providers declined somewhat, from 88.0% in 2004 to 83.3% in 2006, although the difference was not statistically significant (P = .1). Among the 204 physicians who responded to this question on both the 2004 and 2006 surveys, the proportion declined from 90.2% to 84.3% (162 accepted the observation option at both time points, 10 did not accept the observation option at both time points, 10 did not accept the observation option in 2004 but accepted it in 2006, and 22 accepted the observation option in 2004 but did not accept it in 2006; P = .03).

During the 3 months before completing the survey, the physicians reported by using the observation option in a median of 15% of the AOM cases they diagnosed (range: 0%–95%; 25th, 75th percentiles: 5%, 30%). For those physicians responding to both surveys, the proportion of cases in which they used the observation option did not significantly change from 2004 to 2006 (median: 15% in both surveys; P = .4). In 2006, 10.7% of the responding physicians used the observation option in half or more of their recent AOM cases. Their preferences for follow-up strategies for children treated with observation are shown in Table 3.


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  		TABLE 3 Physicians' Preferred Follow-up Strategies for Children With AOM Treated With the Observation Option

 
We asked 249 responding physicians who accepted the observation option to identify in an open-ended fashion up to 3 barriers to its use in their practices. A total of 161 (64.7%) listed parents' reluctance, demand for antibiotics, and/or anxiety about observation as the most important barrier, and 208 (83.5%) listed it as 1 of the 3 most important barriers. Other reported barriers to the use of the observation option are shown in Table 4.


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  		TABLE 4 Physician-Identified Barriers to the Use of the Observation Option for AOM

 
For 4 common clinical AOM scenarios for which the AAP/AAFP guideline makes specific antibiotic recommendations, the surveyed physicians were asked which antibiotic they would prescribe; the results, compared with responses from 2004, are shown in the Figure 1. From 2004 to 2006, physicians' adherence with the recommended antibiotic choices declined for all 4 scenarios presented.


Figure 1
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  		FIGURE 1 Antibiotic choices of physicians in 2004 and 2006 for 4 common AOM scenarios. A, AOM with nonsevere symptoms (a P = .01 for comparison of 2004 to 2006). B, AOM with severe symptoms (a P = .1 for comparison of 2004 to 2006). C, AOM that failed treatment with amoxicillin at 80 to 90 mg/kg per day (a P = .05 for comparison of 2004 to 2006). D, AOM that failed treatment with amoxicillin-clavulanate at 80 to 90 mg/kg per day (a P = .05 for comparison of 2004 to 2006). The antibiotics shown in bold type are recommended by the 2004 AAP/AAFP guideline on AOM.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This survey of a group of US pediatric primary care physicians offers a portrait of the office-based management of AOM in 2006 and relates it to the recommendations of the 2004 AAP/AAFP AOM clinical practice guideline. In addition, we compared the current survey's responses with those from a similar survey of the same group of providers fielded in late 2004, ~6 months after the release of the AOM guideline.

The current survey, and the 2004 survey to which its results are compared, were performed within the SCOR Network, a national, practice-based, pediatric research network consisting of nearly 500 pediatricians and family physicians. Members of the SCOR Network may not be representative of all US pediatric primary care providers in that they have chosen to be involved in research. However, they do represent a diverse group of office-based physicians from 42 US states and a variety of practice and community settings, and thus can provide valuable insights into how the AOM guideline's recommendations are being implemented and which of them are most problematic for primary care providers. As for the possibility of response bias in the survey, the fact that the demographics of responders did not differ significantly from those of nonresponders is reassuring. Yet, other unmeasured biases could have been associated with response. For example, we consider it likely that physicians who are more familiar with the guideline and/or more inclined to follow its recommendations would also have been more likely to complete the survey. This possibility, combined with the fact that SCOR Network physicians have all agreed to be involved in practice-based research, suggests that our results likely represent a "best case" scenario in terms of familiarity with and adherence to the guideline's recommendations.

In this survey, we found that most of these physicians accept the concept of an observation option for selected children with AOM, but the proportion who accept it has not increased since 2004 and may have decreased slightly. Those who are most accepting of the observation option include pediatricians (as opposed to family physicians), younger physicians, and those practicing in suburban and urban non–inner-city locations. Overall, the responding physicians currently use the observation option in ~15% of the AOM cases they diagnose, approximately the same proportion as in 2004, but just over 1 in 10 of them are enthusiastic early adopters of observation, using it with at least half of their diagnosed AOM cases.

When questioned in an open-ended fashion about barriers to the use of the observation option in their practices, these physicians overwhelmingly pointed to parental reluctance to accept this approach. There is, however, growing evidence that many US parents will accept observation when this option is presented in an appropriate context,5,6,9–12 thus there is a disconnect between what studies show parents will accept and what physicians think parents will accept. About one third of physicians also cited the time, cost, and general difficulty associated with follow-up for children managed initially with observation who do not improve within an acceptable time frame as an important barrier. This concern may be ameliorated somewhat by the use of a backup antibiotic prescription given to the parent at the time of initial AOM diagnosis, a follow-up strategy demonstrated to be practical in several clinical trials6,9,13,14 and favored by a majority of the responding physicians. This strategy does, however, place more decision-making responsibility in the parent's hands and may not be welcomed by or appropriate for all families.

This survey also demonstrates significant discrepancies between the recommendations of the AAP/AAFP guideline and physicians' choices of antibiotics to treat AOM. For AOM with nonsevere symptoms, slightly more than half chose the recommended high-dose amoxicillin. Nearly one third opt for standard-dose amoxicillin, a significant increase from 2004. This trend back to standard-dose amoxicillin for nonsevere disease may represent an awareness of recent data that widespread use of the heptavalent pneumococcal conjugate vaccine has reduced the circulation of penicillin-resistant Streptococcus pneumoniae in some communities.15,16

For AOM with severe symptoms, only 1 of 8 physicians agreed with the recommendation for high-dose amoxicillin-clavulanate, whereas a much larger number chose high-dose amoxicillin. The widespread nonadherence with this recommendation may reflect a feeling that the guideline strayed from the evidence that AOM with severe symptoms is more likely because of S pneumoniae (for which the addition of clavulanate is not helpful) than nontypeable Haemophilus influenzae and Moraxella catarrhalis.17,18 Alternatively, initially prescribing amoxicillin-clavulanate for children with AOM and severe symptoms may leave physicians feeling that they do not have a comfortable second-line option (ie, switching to a different oral antibiotic with no better microbiologic coverage for the likely organisms or giving a painful and expensive daily intramuscular injection of ceftriaxone for 3 consecutive days, as the guideline recommends).

For children whose treatment with amoxicillin failed, just under half of the responding physicians chose the recommended amoxicillin-clavulanate, with a substantial and increasing number choosing cefdinir instead. Cefdinir's rise as a second-line agent at the expense of amoxicillin-clavulanate may reflect heavy marketing of the drug, more convenient dosing options, and/or a lower risk of diarrhea.19

Finally, for children whose treatment with amoxicillin-clavulanate failed, the majority chose an oral antibiotic alternative (primarily cefdinir or azithromycin, which have inferior or at best equivalent microbiologic coverage to amoxicillin-clavulanate for the likely organisms), whereas only 1 in 6 chose the recommended intramuscular ceftriaxone, suggesting a strong preference for oral over intramuscular administration.

We did not ask the surveyed physicians to provide a rationale for their antibiotic choices, thus we can only speculate as to their reasons for not following the guideline's recommendations. In addition to the possible reasons cited above, one general possibility for nonadherence is that the physicians are not familiar with the guideline's antibiotic recommendations. However, the widespread dissemination of the AAP/AAFP guideline to the pediatric primary care community after its publication, as well as data from our 2004 survey indicating that >90% read the guideline or summaries of it, argue against this conclusion.8 Nonetheless, previous research demonstrated that casual familiarity with a clinical practice guideline does not necessarily result in putting its specific recommendations into practice, and that may be the case here.20 Also, other pressures, such as pharmaceutical company advertising, office stockpiling of free antibiotic samples, and/or parental preferences, may drive antibiotic choices as much or more than expert guidelines, although there is little research to quantify the effects of these influences.

Interestingly, we found that agreement with the guideline on antibiotic choices declined from 2004 to 2006 for all 4 of the survey's AOM scenarios. This fact, combined with the lack of increase in acceptance and use of the observation option from 2004 to 2006, suggests that the impact of the AAP/AAFP guideline has declined, at least among this group of providers. This trend, if real, may reflect a waning of the intense publicity (eg, review articles, news reports) that the AOM guideline initially received. It may also represent "clinical practice guideline fatigue" resulting from a potentially overwhelming number of guidelines directed to pediatric primary care providers in recent years.21,22 Finally, it may signal increasing disillusionment with the recommendations themselves.

Based on the results of this survey, what might be done to improve the quality of care for children with AOM? First, for those who advocate increased use of the observation option, the overwhelming perception among physicians that parents are not willing to accept this approach will have to be overcome. Recent success in substantially reducing antibiotic use for uncomplicated upper respiratory infections suggests that such a goal can be achieved through coordinated educational efforts directed at both physicians and the public.23,24 Second, for those concerned about the appropriateness of physicians' antibiotic choices for AOM, additional research will be needed to explain the large and increasing gap between physicians' choices and the guideline's recommendations. Depending on the results of such research, efforts should be undertaken either to more effectively educate practicing physicians or to modify the guideline's antibiotic recommendations to make them more responsive to new data and to the realities of primary care practice.

In the end, even the best evidence-based recommendations serve to improve care only if the clinicians charged with their implementation find them both scientifically convincing and clinically practical. In the case of the 2004 AAP/AAFP AOM guideline, the experts still face the substantial challenge of convincing pediatric practitioners that the recommendations represent the best interpretation of the data and of assisting those practitioners in overcoming barriers to their implementation.


   ACKNOWLEDGMENTS
 
We thank the physician-members of the SCOR Network for participation in the survey.


   FOOTNOTES
 
Accepted Mar 22, 2007.

Address correspondence to Louis Vernacchio, MD, MSc, Slone Epidemiology Center, 1010 Commonwealth Ave, Boston, MA 02215. E-mail: lvernacchio{at}slone.bu.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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