Adherence to treatment guidelines for acute otitis media in children. The necessity of an effective strategy of guideline implementation

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Abstract

Objectives

Acute otitis media is the single diagnosis responsible for most prescriptions of antibiotics in Sweden and the USA. The treatment of acute otitis media has significant impact on child health, healthcare costs, and the development of anti-microbial resistance. In the Swedish national guidelines from the year 2000, watchful waiting was recommended for most children over 2 years of age. The aims of the present study were to assess the degree of adherence to acute otitis media guidelines at a busy pediatric emergency department of a university hospital and to determine whether an information campaign changed the result.

Methods

Audit of 91 patient records before and 80 patient records after an information campaign consisting of an oral presentation, posting of flow charts, and sending of educational material to prescribing physicians. Four endpoints were studied: choosing to use antibiotics, choice of antibiotic, dosage of antibiotic, and duration of treatment.

Results

Before the information campaign, adherence to guidelines was between 70% (dosage) and around 90% (duration). No significant change was seen after the information campaign. The endpoint choosing to use antibiotics showed a large divergence in adherence in children under 2 years (96%) compared to older children (39%).

Conclusions

Overall adherence to recommendations was 70–90% but adherence to watchful waiting was poor. Information did not improve adherence, suggesting insufficient educational power or the existence of barriers other than lack of knowledge. Specific barriers should be identified, and implementation and follow-up should be part of producing guidelines in order to achieve the desired results.

Section snippets

Background

Our knowledge of how to treat diseases in the most beneficial way is always improving. Guidelines based on evidence and produced by expert panels are important means of achieving good medical quality. The difficulty in applying evidence-based conclusions to clinical practice and patient outcome is well acknowledged [1]. Acute otitis media (AOM) is the second-most common infectious diagnosis in children and the single diagnosis responsible for most prescriptions of antibiotics in children in

Methods

We first conducted a retrospective analysis of patient records from the pediatric emergency department at the Queen Silvia Children’s Hospital in Gothenburg, Sweden between January 1, 2009 and June 30, 2009. This was followed by an information campaign on the recommended principles of treatment of AOM in January and February 2010. The study was completed with a renewed retrospective analysis of patient records on visits from March 1, 2010 until June 30, 2010, and differences in management of

Results

Ninety-one patients were included in the first investigation of patient records, from a total of 1041 for the period (Fig. 1). The characteristics of the patients are given in Table 2. The adherence differed between our four endpoints, from 70% for dosage of antibiotics to 90% for duration of treatment (Table 3).

The second investigation of patient records included 80 of the 652 AOM diagnoses over the period (Table 2 and Fig. 2). No significant improvement was found in any of the four endpoints

Discussion

The objective of the study was to assess the adherence to national guidelines regarding the treatment of AOM in a hospital setting, and to determine whether a short but intense information campaign with different educational tools could modify the result. Considerable deviation from current recommendations – especially regarding the new aspects of WW – has been reported in Sweden [7]. Our hypothesis was that these deviations from recommendations were a result of lack of knowledge and that a

Conflicts of interest

The authors declare that they have no conflicts of interest.

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