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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Otitis Media: Right Answers, Wrong Questions, Wrong Conclusions
Routine treatment of otitis media with amoxicillin economically reasonable?
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Henry R. Bloom, MD, CCFP, ABFP, University Heights, OH, USA Clinical Associate Professor of Fam. Med, Case Medical School
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How would the assumptions of Coco's study (1) (percent of parents seeking care, willingness of physicians to observe, to give a prescription, or of parents to take one, now or if no improvement is seen in 48-72 hours, use of Amoxicillin or Amoxicillin-clavulinic acid as the only antibiotics, likelihood of patients returning with or without prescription, failure rate of antibiotics, number of complications, etc.) be changed if the physicians had probable cause to know the causative organism-viral or bacterial, and if bacterial, what the sensitivities were? We have previously demonstrated (2), in our study of 43 families, that the causative organisms of Otitis Media and related Upper Respiratory Tract Infections are passed throughout the Family. We showed that the combination of Clinical Judgment, with knowledge of cultures from other household members who were sick within the last 2 weeks, can significantly affect the accurate identification of a bacterial infection. In a child with Otitis Media, this could change the entire calculus of whether, when, and how to offer an antibiotic. Further, knowing sensitivities (a resistant Strep Pneumoniae, H Influenzae, or Staph Aureus (3,4), not sensitive to Amoxicillin) can allow for use of an antibiotic that is much more specific, efficacious, and with less side effects than Amoxicillin- clavulinic acid. Although Coco's study gives a highly sophisticated statistical/economic analysis, the initial focus of study, Otitis Media in the individual, may be missing the locus of infection, the means of diagnosis, and the target of treatment- the Family. We, as Family Physicians, should be the ones who can use all levels of analysis, microscopic, statistical, organ focused, etc, but also can step back and see the whole picture of the individual and the Family. We have to know how and where to focus our powerful analytic tools. Treatment of Otitis Media may be a case of losing that Family focus, and therefore getting the right answers, but to the wrong questions, and therefore coming to the wrong conclusions. 1. Coco AS. Cost effectiveness analysis of treatment options for acute Otitis Media. Ann Fam Med. 2007;5:29-38. 2. Bloom HR, Zyzanski SJ, Kelley L, Tapolyai A, Stange KC. Clinical Judgment predicts culture results in Upper Respiratory Tract Infections. J Am B Fam Pract. 2002;15:93-100. 3. Bloom HR. Sinuses, Staph, Strep, Patients and Families. Letter to the Editor. Pediatrics. 2002;109:557-8. 4. Andrade MA, Hoberman A, Glustein J, Paradise JL, Wald ER. Acute Otitis Media in children with Bronchiolitis. Pediatrics. 1998:101:617-20. Competing interests: None declared |
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Jan De Maeseneer MD PhD, Gent, Belgium Department of general practice and primary health care, University of Ghent, An De Sutter MD PhD
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We read the cost-effectiveness analysis of treatment options for acute otitis media with great interest. First of all we would like to inform the readers that a few months ago the Dutch guideline on otitis media has been adjusted (following the publication of an individual patient data meta-analysis of several placebo -controlled trials on children with otitis media (Lancet 2006; 368:1429- 35)). According to the new guidelines, indications for antibiotics are: children under 6 months, children between 6 mo and 2 years with bilateral otitis media, children with a runny ear due to spontaneous perforation of OMA, children with an abnormal illness course (increasing of general illness, pain or bad drinking after 3 days), children with Down syndrome, palatochisis or impaired immune response. In spite of these guidelines, which limit the use of antibiotics to a strict minimum, this study shows that amoxicilline has some beneficial effect: children with AOM routinely given amoxicilline for 7 to 10 days gain on average 3.5 hours of quality adjusted life compared with children receiving a delayed prescription. However, the extra cost for these 3.5 hours is 22.9 dollars or 311 million dollars in annual health care expenditure in the US. It is the responsibility of the society to decide whether this is worth the money, but obviously a dollar can only be spent once and choices have to be made. Three hundred and eleven million dollars could no doubt increase accessibility and quality of primary care for a lot of people and this would probably help many for more than 3,5 hours. This study shows that decreasing antibiotic prescriptions for OMA can be an important money -saver at little cost. Moreover, the largest benefit of less antibiotic prescribing is probably the decrease in antibiotic resistance. Decrease in resistance means at the very least a decreased need to prescribe the more expensive broad spectrum antibiotics for respiratory tract infections, (which in turn can also cause resistance and extend the problem). Including this benefit may change the balance. A study that calculates the current extra expenditure for prescribing and therapy failures caused by the increased resistance of the Streptococcus pneumoniae would be very interesting. We agree with the authors that this study shows us the quantifiable costs and benefits that must be accounted for when deciding about treatment of AOM. However, some costs or benefits that are difficult to quantify can be decisive, which makes this calculation incomplete and the conclusion uncertain. And ultimately, even if a treatment is beneficial, and costs are in line with the costs for similar benefits from other therapies, we still should consider the whole picture of the health care needs and ask: “Is this money well spent?” Competing interests: None declared |
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