Watchful waiting is cost-effective in acute otitis media

A recent study found that taking a watchful waiting approach when managing acute otitis media (AOM) in qualifying children proves to be the more cost-effective strategy to follow. The data not only underscore the underutilization of the novel management approach but also highlight the significant potential reduction in healthcare costs if implemented.

“This is a rare opportunity for a change in practice that is a win-win proposition. Our results suggest that increased use of a watchful waiting strategy would both reduce costs and improve patient outcomes,” says Danica Liberman, MD, MPH, FAAP, director of Patient Advocacy, Division of Emergency Transport Medicine, Children’s Hospital Los Angeles, California, and assistant professor of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles.

Liberman and fellow colleagues conducted a retrospective review of a random selection of 250 patients aged18 years and younger with AOM in the emergency department (ED) of a tertiary care children’s hospital. The data gathered were incorporated into a decision-analytic, cost-utility model comparing the cost-effectiveness of implementing a watchful waiting approach to current practice.

Among the 250 patients, chart review confirmed that 247 actually had AOM. Of these, 95.5% were prescribed antibiotics, 2.8% underwent watchful waiting, and 3.6% were sent home without an antibiotic prescription. Data showed that more than half of these patients (57.9%) were eligible for watchful waiting according to American Academy of Pediatrics (AAP) guidelines, while only 42.1% met conditions for immediate antibiotic intervention. For every 1000 patients with AOM in the modeled scenario, implementing watchful waiting resulted in 514 fewer immediate antibiotic prescriptions and 205 fewer antibiotic prescriptions used; a total of 14.3 disability-adjusted life-years were averted, with savings of $5,573.

According to the AAP guidelines for patients with AOM that include, age, signs, symptoms, and follow-up, watchful waiting is an appropriate management option in specific clinical scenarios.

“Though the AAP guidelines for AOM management were published several years ago in 2013, watchful waiting is clearly underutilized, as was seen in our study. Demonstrating to providers that watchful waiting is both more beneficial to patients and cost-saving to society should encourage more providers to use watchful waiting when appropriate,” Liberman says.

Although antibiotics may sometimes be a necessary therapeutic intervention in AOM, an optimal management of this very common pediatric condition appears to remain elusive, reflected in the current practices of antibiotics prescription. As such, clinicians should be prudent and exercise caution when considering appropriate antibiotic therapy in this patient population.

Families in general are very amenable to watchful waiting when their child qualifies, Liberman says. They appreciate the extra time and thought it takes the physician to explain to them why they recommend watchful waiting, why that option is the best one for their child, as well as the societal benefits. However, Liberman notes that physicians caring for pediatric populations must first be familiar themselves with the criteria for watchful waiting so that children aren’t inappropriately categorized, and then willing to apply these guidelines to their patients through education and follow-up.

Parents will likely universally expect antibiotics for AOM. However, that expectation likely started with a prescription from a provider, Liberman explains. Although it often seems faster and easier to simply write a prescription for amoxicillin, Liberman says that physicians have an obligation to do what’s best for their patients, and for many that is not immediately writing a prescription and instead educating a little about the disease process and the disadvantages of antibiotics.

“We believe the key message for both physicians and parents is that advocating for reduced reliance on immediate antibiotic prescriptions in favor of a watchful waiting strategy is not a matter of accepting a trade-off between costs and a patient’s well-being. It’s about doing what is in the patient’s best interest from a medical standpoint while at the same time conserving resources,” Liberman says.

Dr Petrou is a freelance medical writer based in Budapest, Hungary.