Anticipatory guidance and a prescription for analgesic otic drops can reduce emergency department use
Article Outline
- McWilliams DB, Jacobson RM, Van Houten HK, Naessens JM, Ytterberg KL. A program of anticipatory guidance for the prevention of emergency department visits for ear pain. Arch Pediatr Adolesc Med 2008;162:151-6
- References
- Copyright
McWilliams DB, Jacobson RM, Van Houten HK, Naessens JM, Ytterberg KL. A program of anticipatory guidance for the prevention of emergency department visits for ear pain. Arch Pediatr Adolesc Med 2008;162:151-6
Question
Does anticipatory guidance provided during well-child care visits with a prescription for analgesic otic drops safely reduce emergency department (ED) visits, compared with no intervention?
Design
Retrospective analysis comparing an intervention site with control sites by using a “difference-in-differences” regression model.
Setting
Primary care practices at the Mayo Clinic, Rochester, Minnesota.
Participants
Children who attended a 15-month well-child care visit.
Intervention
Nurses provided standardized education and prescribed antipyrine-benzocaine otic drops at the 15-month well-child care visit. Education focused on controlling otalgia, recognizing signs of more serious illness, and decreasing the sense of medical urgency for uncomplicated ear pain.
Outcomes
Visit rates for ear pain during the ensuing year were compared in 4 retrospective cohorts: the intervention cohort (n = 191), a cohort from the same practice the preceding year (n = 168), and as controls, cohorts from these same years at other primary care sites not adopting this intervention (n = 133 and 126).
Results
After the intervention, ED visits for ear pain decreased 80%, urgent care visits decreased 40%, and primary care visits decreased 28%, with no significant change in the control sites' visit use during this time. Regression models incorporating patient characteristics and comparing the changes in sites across time supported the belief that the decline in ED use was significant (P = .009), with no significant change in urgent care (P = .33) or primary care (P = .14) use. On questionnaires, >80% of parents whose children had experienced subsequent ear pain responded that the program helped them avoid an ED or after-hours visit and strongly recommended continuing the education program.
Conclusions
Nurse-administered anticipatory guidance reduced ED visits for ear pain in toddlers and was supported by parents.
Comment
Targeting ear pain and acute otitis media (AOM) for innovative approaches to improving quality of care is reasonable because this condition is such a frequent cause of pediatric visits during early childhood and so often results in an antibiotic prescription. We can enhance quality by reducing excessive antibiotic use that contributes to rising rates of bacterial antibiotic resistance in the community, and more judicious antibiotic use may also reduce the frequency of AOM episodes. This study demonstrates that we can also reduce costs by avoiding unnecessary visits for ear pain to primary care offices during normal hours and after hours at EDs and urgent care centers. These visits are very common and are the largest component of the >$5 billion dollars spent annually on otitis media.1 The findings of this Mayo Clinic study are also consistent with work demonstrating the effectiveness of parental judgment and shared decision making for AOM management.2, 3 Efforts to change parental attitudes about judicious use of antibiotics and to implement shared decision making can be successful. A collaborative approach using a safety-net antibiotic prescription for treating AOM seems to have high rates of parental acceptance and satisfaction.4, 5 The success of efforts to educate parents and use of a shared decision-making approach to care contrasts with the difficulties experienced in trying to modify physician behavior. Although this data is compelling, this work should be validated with a randomized clinical trial in a more diverse socioeconomic and ethnic population. However, this study should encourage all of us to look for creative ways to empower parents and enhance value in pediatric practice.
References
- . Direct expenditures related to otitis media diagnoses: extrapolations from a pediatric Medicaid cohort. Pediatrics. 2000;105:e72–e78
- . Effectiveness of an educational intervention in modifying parental attitudes about antibiotic usage in children. Pediatrics. 2003;111:e548–e554
- . An assessment of the shared-decision model in parents of children with acute otitis media. Pediatrics. 2005;116:1267–1275
- Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics. 2003;112:527–531
- . Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care. Arch Pediatr Adolesc Med. 2005;159:679–684
PII: S0022-3476(08)00289-8
doi:10.1016/j.jpeds.2008.04.004
© 2008 Mosby, Inc. All rights reserved.
