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Otitis media, the most common medical problem in U.S. children, is a pain in the pocketbook as well as the ear. Ambulatory care costs (not including the $240 million spent on outpatient antibiotics) run about $1 billion per year.
Yet wide variations in treatment exist, says W. Cyrus Jordan, MD, MPH, medical director for the Vermont Program for Quality Health Care (VPQHC), a private, not-for-profit corporation that exits to improve the quality and efficiency of Vermont's health care system.
"There are significant uncertainties regarding the best management of otitis media and significant variation in how physicians treat the condition. As a result, it's unclear to many physicians and parents what constituted the best care. So some children are undertreated, and some are overtreated," he explains.
In Vermont, for example, an analysis of claims from July 1, 1993, to June 30, 1993, of three major health care plans showed that the majority of children under the age of 2 had at least one otitis media-related claim. The analysis also confirmed treatment variation. "Depending on the source of payment, there was a significant difference in the use of surgical treatment. Medicaid patients underwent surgery at a higher rate than those who were covered by private insurers," he says.
That's why VPQHC convened a group of local experts to work toward decreasing variations in care and establish best practices for treating middle-ear infections. The 12-member study group included representatives from Medicaid; private insurers; pediatricians; family practitioners; a pediatric ear, nose, and throat surgeon; an audiologist; and researchers from the family practice department at the University of Vermont.
First the team reviewed research, current scientific literature, and a national practice guideline by the Agency for Health Care Policy and Research. "However, this work was limited in scope because it addressed only children between 1 and 3 with just one form of otitis," Jordan says. His group wanted to create a practice guideline to reduce costs while addressing a comprehensive set of best practices among differing circumstances. Here are some of the issues it addresses:
1. More accurate physical examinations. An examination technique called pneumatic otoscopy can increase the accuracy of diagnosing middle-year infections, enabling the physician to differentiate between children who need treatment and those who do not. "The presence of fluid in the middle ear is the key finding necessary for a diagnosis," he says. "In addition to inspecting the eardrum, the physician should move the eardrum by pushing air against it. If the fluid is present, the eardrum will not move normally."
2. Increased testing for hearing loss. "Because too few practitioners test for hearing loss, some children who require more aggressive treatment are not identified. Conversely, some are treated too aggressively despite the fact that their hearing has not been affected," he says.
3. Use of lower-cost antibiotics. Traditional narrow-spectrum antibiotics are much less expensive (and just as effective) than broad-spectrum ones. For example, a course of amoxicillin costs about $5, while Ceclor cost from $60 to $120. "Recent studies show that broad-spectrum offer no advantages except when others have failed and infections are recurrent," he explains. Using the new broad-spectrum antibiotics also will develop resistant organisms, which only compound the difficulties in treating middle-ear infections.
4. Reduced use of antibiotics for children with persistent fluid. The guideline discourages using antibiotics if there are no signs of active infection because they increase the rate of resolution by 14%. This relatively small improvement needs to be weighed against potential side effects, costs, and development of antimicrobial resistance.
5. Appropriate timing for surgical evaluation. The guidelines offer clear recommendations about when children with persistent fluid need surgical evaluation. "Timing of referral can result in premature surgery for some children, while others are referred too late and suffer unnecessary discomfort and hearing loss," he says.
6. Reduced follow-up. Instead of scheduling a follow-up exam two weeks after antibiotic treatment begins, a four-week exam is recommended.
VPQHC also created three products through which to disseminate the guideline. "We designed a report that outlined the collaborative process to develop the guidelines and included an easy-to-read flowchart for a reference," he says.
The report, as well as an exam room poster that highlighted key aspects of the guideline, was distributed to hundreds of physicians in the state. "The poster helps physicians explains otitis media and its treatment to parents," he says.
More than 200 physicians also attended 12 educational forums sponsored by VPQHC on how to incorporate the guideline in to their practices. The study group developed a family education brochure outlining key aspects of treating middle-ear infections that was distributed through school and public health nurses. It includes such information as when to seek professional help, whom to call, what treatment to expect, and what records to keep regarding their child's health history.
Finally, the group developed an evaluation and monitoring of claims data so state officials can determine whether physicians actually changed their practices as a result of the project.
[For more details or a copy of the guidelines, contact Vermont Program for Quality in Health Care, 136 Main St., Montpelier, VT 05602. Phone: (802) 229-2152.]n