Most physicians are not adhering to recommendations on otitis media management, according to a new report from the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF).
In a commentary reviewing practice patterns related to the treatment of otitis media with effusion (OME) and how well they match recommendations published by the AAO-HNSF and the American Academy of Pediatrics (AAP), Rachel E. Roditi, MD, Richard M. Rosenfeld, MD, MPH, and Jennifer J. Shin, MD, SM, outline what types of practices are following the recommendations and which aren’t, as well as what types of medications are being administered outside the recommendations.
Roditi, a surgeon at Brigham and Women’s Hospital, Boston, Massachusetts, specializing in otolaryngology, professor of Otology and Laryngology at Harvard Medical School, Boston, and lead author of the commentary, says she hopes the commentary will remind pediatricians to be thoughtful in their approach to managing OME by considering the guidelines’ recommendations to avoid unnecessary prescriptions where possible and seek specialty care as needed.
“We also hope that reflecting on individual practice patterns will allow for continued quality improvement across specialties as we continue to educate our colleagues and trainees about evidence-based approaches to disease management,” Roditi says.
The report aimed at providing an analysis of large national databases to compare current practices with the published guidelines.
“Guidelines provide recommendations based on the published evidence regarding a particular condition, and typically represent best practice,” Roditi says. “Analyzing adherence to the guideline recommendations was meant to promote introspection about individual practice patterns as well as to help identify opportunities for quality improvement.”
The most recent AAO-HNSF guidelines recommend against the use of antihistamines, antibiotics, oral steroids, and intranasal steroids for the treatment of OME, according to the report, and an earlier recommendation from AAO-HNSF and the AAP recommended against all these medications except for intranasal steroids.
The review analyzed data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. The researchers found that excessive antihistamine use occurred in nearly 116,000 visits per year, and that 413,600 visits resulted in a prescription for antibiotics for the child. Oral steroids were not often used, but intranasal steroids were administered to more than 134,000 patients in a year.
“These children were therefore exposed to potential adverse effects from steroids, antibiotics, and antihistamines while gaining no benefits in hearing, risk of future surgery, or long-term OME resolution,” the commentary states.
To put it into perspective, the commentary outlines that antihistamines were given in 4.1% of OME cases, instead of the baseline risk of 2.1%. In terms of antibiotic use, there was an 18.8% increased risk of administering antibiotics to a child diagnosed with OME but without acute otitis media (AOM). This means that every sixth visit for OME could result in an unnecessary antibiotic prescription, the authors note.
The commentary also reveals that although children weren’t often treated with oral steroids, adults with OME, eustachian tube dysfunction, or tympanic membrane retraction were more likely to be given oral steroids than adults without these ear-related diagnoses. Intranasal steroids, on the other hand, were given in 10% of OME cases compared with just 3.5% of visits in which OME was not diagnosed.
These patterns varied based on the practice setting, with antihistamines and antibiotics given most often in the emergency department (ED). According to the commentary, every third visit to the ED for OME resulted in an antibiotic being administered. Antihistamine and antibiotic use were also excessive in other settings, but not as much as in the ED. What was higher in nonemergency settings, however, was the use of oral and intranasal steroids.
One setting where the recommendations were followed, however, with no increase in antihistamine or steroid administration and a lower incidence of antibiotic use was the otolaryngologist office, leading the authors to conclude that there might not be a need for a change in behaviors within this specialty but moreso among general practitioners.
“While there are definitely several conditions in which antibiotics should be considered for otitis media, many different forms of otitis media exist,” Roditi says. “We hope that this article will encourage clinicians to differentiate between the variations of otitis media in order to clarify when antibiotics are truly recommended. In particular, for OME without concurrent AOM, antibiotics are not indicated. It is our hope that this can lead to fewer unnecessary prescriptions and earlier referral for definitive therapy when applicable.”
The authors suggest that education on adhering to the recommended guidelines be tailored by practice type, targeting education efforts on particular medications to avoid, such as antibiotic and antihistamine use in the ED. The commentary, according to its authors, demonstrates significant gaps in care and illustrates opportunities for quality improvement.