Acute Otitis Media Guidelines, Antibiotic Use, and Shared Medical Decision-Making
- Robert M. Siegel, MD
Acute otitis media (AOM) continues to be the most common reason practitioners prescribe antibiotics for children.1 Concern over emerging resistance of the common pathogens that cause AOM has led to efforts for more judicious use of antibiotics by being more careful in making the diagnosis, selecting narrow-spectrum antibiotics, and using analgesics instead of antibiotics unless the infection fails to clear on its own.2,3 In 2004, the American Academy of Family Physicians and the American Academy of Pediatrics jointly issued guidelines with criteria for making the diagnosis, endorsing an observation option for those without severe disease, and advocating more aggressive pain management.4
With their study in this month's issue of Pediatrics, Coco et al5 report on how the guidelines have altered physicians' prescribing habits when treating AOM. In their insightful examination of the enormous National Ambulatory Medical Care Survey (NAMCS) database, the authors demonstrate that the use of analgesics and the narrow-spectrum antibiotic amoxicillin by pediatricians has increased. This is noteworthy, because guidelines historically have had little impact on physician behavior.6 In addition, those who reported not using an antibiotic initially showed a short-lived rise in frequency, but there was ultimately no significant difference by the end of the study period. In an earlier study, Halasa et al7 examined the NAMCS and National Hospital Ambulatory Medical Care Survey databases and showed that there had already been a dramatic decline in antibiotic use for AOM from 1994 to 2000. This finding suggests that efforts to decrease antibiotic use in general may have taken hold and had a maximal effect before the new AOM guidelines. Given that there was a similar decline in both the diagnosis and number of antibiotic prescriptions in the Halasa et al study, the decrease was most likely a result of greater accuracy in diagnosis rather than intentional watchful waiting. Also, the American Academy of Pediatrics/American Academy of Family Physicians guidelines only reinforce that watchful waiting is an option, not a preferred treatment plan. Further reduction in antibiotic use may require a more forceful endorsement of watchful waiting, more active training of physicians, and efforts to educate parents on observation without antibiotics.8
Observation without antibiotic therapy remains controversial, although the benefits of early treatment are limited at best.9,10 Coco et al suggest that practitioners may be hesitant not to prescribe antibiotics because of perceived parental reluctance to accept this strategy. Although this reluctance is certainly at work in some families, how often do doctors ask their patients' parents whether this is actually the case?11 The reluctance of physicians to share decision-making should also be addressed.
Historically, physicians have assumed a dominant and paternalistic role in medical decision-making. This model is based on the assumption that physicians are knowledgeable about the best treatment options and are the best at evaluating the pros and cons of treatment options.12 Yet, the benefits of parental involvement in antibiotic decision-making for AOM has been well described.13 Efforts to educate parents on the benefits and risks of antibiotics and to participate in the decision of when to use antibiotics leads to decreased antibiotic use and better satisfaction with their children's care.14
Several groups have examined watchful waiting for AOM with a rescue or safety-net antibiotic prescription if symptoms do not resolve.15,–,17 In office and emergency department settings, more than 60% of parents chose not to fill an antibiotic prescription when the child was given adequate pain control.16,17 This safety-net strategy has the advantage of actively involving parents in the decision to use antibiotics and also gives the security of having antibiotics available if they prove to be necessary.
Parents and doctors seem to have similar concerns about antibiotic use. In a survey of parental and physician attitudes on watchful waiting, Finkelstein et al18 demonstrated that 34% of parents would be satisfied with watchful waiting, 26% would be neutral, and 40% would be dissatisfied with the approach. The majority of parents, however, were concerned about prolonged pain or fever and progression to serious infection. Of physicians who never use watchful waiting, common concerns were treatment failure, longer duration of symptoms, reduced patient satisfaction, and the risk of serious complications. Similarly, the parents' concerns about using antibiotics included increased antibiotic resistance, allergic reactions, and adverse effects.
If use of antibiotics is to be decreased when treating AOM, physicians must immediately address the main concern and reason for the visit: ear pain. The results of Coco et al suggest that this is happening. Educating and involving the patients and families with regards to antibiotic use and ensuring that their children's ear pain is adequately managed will lead to decreased antibiotic use and better patient satisfaction. Today's patients and families are more medically sophisticated than the last generation, because they have greater access to information through the Internet and its educational resources such as wikis and blogs.19 Health care providers should embrace and encourage this empowerment and involve patients in shared decision-making regarding whether to use antibiotics for otitis media. With the assurance of a pediatrician that prescribed analgesics will probably remove their child's pain, patients will appreciate being asked to participate in the decision as to when to fill an antibiotic prescription for AOM.
Footnotes
- Accepted November 24, 2009.
- Address correspondence to Robert M. Siegel, MD, Cincinnati Children's, Department of Pediatrics, 3333 Burnet Ave, Cincinnati, OH 45229. E-mail: bob.siegel{at}cchmc.org
-
FINANCIAL DISCLOSURE: Dr Siegel is a member of the Scientific Advisory Board of Atkins Nutritionals, Inc.
-
- AOM =
- acute otitis media •
- NAMCS =
- National Ambulatory Medical Care Survey
REFERENCES
The Necktie: Is It Flu's Best Friend? While looking professional is always expected of physician, does the fact that neckties may be harboring germs make the risk of wearing them outweigh the benefits? According to a recent article in The Wall Street Journal (Smith R, November 19, 2009), several hospitals are considering banning these garments due to the risk that they are responsible for spreading germs from patient to patient. Of note, the British Medical Association recommended that neckties not be worn by physicians in 2006, and the AMA considered a similar resolution this past year (but is seeking scientific evidence that wearing a necktie does lead to spread of germs before it brings the resolution to a vote). The question is whether this movement to remove ties is based on scientific fact or has occurred because physicians now prefer to dress more casually on a daily basis. The data that has been published on physician dress suggests that patients don't care whether doctors wear ties or not—so for the moment—the evidence-seeking jury, like a necktie, remains knotted with more data to be forthcoming in the future.
Noted by JFL, MD
- Copyright © 2010 by the American Academy of Pediatrics
