Cost-Effectiveness Analysis of Treatment Options for Acute Otitis Media

Andrew S. Coco

doi:10.1370/afm.626

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Figure 1.
Decision tree for treatment strategies for acute otitis media.
AOM = acute otitis media.

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Table 1.

Baseline Estimates for a Cost-Effectiveness Analysis of 4 Treatment Strategies for Acute Otitis Media

Variable	Baseline	Low Sensitivity	High Sensitivity	Reference(s)
WW=watchful waiting; DP=delayed prescription; GI=gastrointestinal; IV=intravenous; AOM=acute otitis media.
Clinical factors
Probability of mastoiditis—WW/DP	0.000019	0.000	0.000038	1, 34
Probability of mastoiditis—routine amoxicillin	0.000010	0.000	0.000020	1, 34
Probability of nonattendance—WW	0.203	0.173	0.233	35
Probability of nonattendance—DP	0.37	0.292	0.448	23
Probability of nonattendance—routine amoxicillin	0.06	0.044	0.076	27
Probability of clinical failure with nonattendance—any strategy	0.077	0.053	0.101	28
Probability of clinical failure; prescription for amoxicillin redeemed—DP	0.24	0.172	0.308	21
Probability of clinical failure—WW	0.175	0.147	0.203	27
Probability of clinical failure—routine amoxicillin	0.061	0.044	0.078	28
Probability of GI adverse effects	0.099	0.042	0.156	21, 30, 31
Probability of dermatologic adverse effects	0.02	0.000	0.04	32
Costs, $
Amoxicillin	9.40	7.74	14.95	36
Amoxicillin-clavulanate	47.80	31.22	71.70	36
Hospitalization for mastoiditis	5,340.00	2,670.00	10,680.00	33
Home IV antibiotics for mastoiditis (includes home nurse visits)	305.00	178.00	545.00	36, 37
Office consultation	34.23	17.12	68.46	37, 38
Non–health care	15.08	7.54	30.16	39
Work loss	91.00	46.00	182.00	39
Utilities
Day of AOM	0.79	0.713	0.867	40
Day of treatment success	0.96	0.942	0.978	40
Day of treatment failure	0.72	0.646	0.794	40
GI adverse effects from antibiotics	0.70	0.608	0.792	40
Rash from antibiotics	0.77	0.694	0.846	40

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Table 2.

Calculation of Quality-Adjusted Life-Days Lost in Event Pathways for Decision Model of Treatment Strategies for Acute Otitis Media

Pathway	A Days of AOM*	B Days of Treatment Success*	C Days of Treatment Failure*	*D Days of GI Adverse Effects^†**	*E Days of Rash^‡**	Total QALDs Lost^§ (95% CI)
AOM = acute otitis media; GI = gastrointestinal; QALDs = quality-adjusted life-days; CI = confidence interval.
Notes: Clinical failure = continuation of symptoms after 2.7 days of observation and subsequent resolution with 7 to 10 days of amoxicillin. Clinical failure with amoxicillin = continuation of symptoms after 2.7 days of amoxicillin and subsequent resolution with 10 days of amoxicillin-clavulanate.
* Baseline utilities were used: 0.79 utility per day for days of AOM; 0.96 for days of treatment success, 0.72 for days of treatment failure, 0.70 for days of GI adverse effects, and 0.77 for days of rash.
† Children receiving amoxicillin had a 9.9% chance of having 2 days of GI adverse effects. Children receiving amoxicillin and then amoxicillin-clavulanate had a 9.9% chance of having 4 days of GI adverse effects.
‡ Children receiving amoxicillin had a 2% chance of having 2 days of rash. Children receiving amoxicillin and then amoxicillin-clavulanate had a 2% chance of having 4 days of rash.
§ QALDs lost were calculated by subtracting the sum of columns A through E from the study time frame of 30 days.
Resolution with observation	2.7 × 0.79 = 2.1330	27.3 × 0.96 = 26.2080	0	0	0	1.6590 (0.7686–2.3583)
Clinical failure	2.7 × 0.79 = 2.1330	20.062 × 0.96 = 19.2595	7 × 0.72 = 5.0400	0.198 × 0.7 = 0.1386	0.04 × 0.77 = 0.0308	3.3981 (2.2898–4.5063)
Resolution with amoxicillin	2.7 × 0.79 = 2.1330	27.062 × 0.96 = 25.9795	0	0.198 × 0.7 = 0.1386	0.04 × 0.77 = 0.0308	1.7181 (1.0018–2.4344)
Clinical failure with amoxicillin	2.7 × 0.79 = 2.1330	19.824 × 0.96 = 19.0310	7 × 0.72 = 5.0400	0.396 × 0.7 = 0.2772	0.08 × 0.77 = 0.0616	3.4572 (2.3319–4.5824)

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Table 3.

Costs, Utilities, and Incremental Cost-Effectiveness of Treatment Strategies for Acute Otitis Media

Variable	Delayed Prescription	Watchful Waiting	7 to 10 Days of Amoxicillin	5 Days of Amoxicillin
QALYs = quality-adjusted life-years.
Notes: Each column was compared with the one to its left. The incremental cost utility ratio of 7 to 10 days of amoxicillin was compared with delayed prescription.
* Watchful waiting was dominated by blend of delayed prescription and 7 to 10 days of amoxicillin.
† This option cost more and had less utility.
Cost, $
Non–health care	12.78	14.52	15.10	15.47
Work loss	95.31	98.43	94.70	97.34
Office consultation	22.52	31.47	33.83	34.61
Antibiotic	1.68	1.47	11.61	9.42
Mastoiditis	0.11	0.11	0.06	0.06
Total	132.40	146.00	155.30	156.90
Incremental cost, $	–	13.60	9.30	1.60
Effectiveness, QALYs	0.99460	0.99472	0.99501	0.99487
Incremental effectiveness, QALYs	–	0.00012	0.00029	–0.00014
Cost-effectiveness, $ per QALY	133.12	146.77	156.08	157.71
Incremental cost utility ratio, $ per QALY	–	Extended dominance*	55,853	Dominated^†

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Table 4.

One-Way Sensitivity Analyses for a Cost-Effectiveness Analysis of Treatment Strategies for Acute Otitis Media: 7 to 10 Days of Amoxicillin Compared With Delayed Prescription

Variable	Variable Range	Effect on ICUR
ICUR = incremental cost utility ratio (cost-effectiveness ratio in dollars per quality-adjusted life-year); GI = gastrointestinal; DP = delayed prescription.
* Dominant: option was more effective and less costly than comparative option.
Amoxicillin cost, $	7.74–14.95	54,200–68,000
Non–health care cost, $	7.54–30.16	54,500–62,200
Office consultation cost, $	17.12–68.46	43,300–85,600
Work loss cost, $	46–182	58,100–56,000
Probability of clinical failure—routine amoxicillin	0.044–0.078	42,000–80,300
Probability of GI adverse effects from antibiotic	0.042–0.156	49,200–68,900
Probability of nonattendance—routine amoxicillin	0–0.076	71,600–53,600
Probability of nonattendance—DP	0–0.448	Dominant* if probability is <0.23; 33,000–89,400 if probability is >0.23
Probability of prescription redemption—DP	0.172–0.308	142,000–33,000
Utility of a day of treatment failure	0.646–0.794	40,500–98,600

The Article in Brief

Cost-Effectiveness Analysis of Treatment Options for Acute Otitis Media

Andrew S. Coco, MD, MS

Background In the United States, there are 13.6 million doctor visits per year for children with acute otitis media, or inflammation of the middle ear. In 1995, these visits cost an estimated $2.98 billion. This study compares the costs and effectiveness of 4 approaches to treating children with acute otitis media: (1) watchful waiting (waiting 72 hours to see whether symptoms settle before starting the patient on amoxicillin (an antibiotic)); (2) delayed prescription (parents return to the office for a prescription of amoxicillin if symptoms continue for 48-72 hours); (3) 5 days of amoxicillin treatment; and (4) 7 to 10 days of amoxicillin treatment.

What This Study Found Children with acute otitis media would receive the most benefit by taking routine amoxicillin for 7 to 10 days; however, this approach is costly. Delayed prescription is the least costly option and would have the added benefit of reducing resistance to antibiotics, which occurs with frequent antibiotic use.

Implications

From an economic perspective, it is reasonable to treat acute otitis media with either an initial period of observation or routine amoxicillin.
The effectiveness of antibiotics in reducing several hours of symptoms of acute otitis media comes at considerable financial cost.
This study supports recent guidelines from the American Academy of Pediatrics and American Academy of Family Physicians, which offer the option of observing lower risk children with acute otitis media for 48 to 72 hours, providing relief of symptoms rather than antibiotic treatment.