Steroids and Antibiotics for OME

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Quality Improvement Opportunities. Rosenfeld RM,. Bellmunt. AM, . and Shin JJ. SUNY Downstate Medical Center, Brooklyn, NY, USA. Universitat. . Autònoma. de Barcelona, Barcelona, Spain. Harvard Medical School, Boston, MA, USA. ID: 599541 Download Presentation

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Steroids and Antibiotics for OME




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Slide1

Steroids and Antibiotics for OMEQuality Improvement Opportunities

Rosenfeld RM,Bellmunt AM, and Shin JJ

SUNY Downstate Medical Center, Brooklyn, NY, USAUniversitat Autònoma de Barcelona, Barcelona, SpainHarvard Medical School, Boston, MA, USA

Slide2

Rosenfeld RM and Post JC. Otolaryngol Head Neck Surg 1992; 106:378-86

Antibiotic therapy has a clinically and statistically significant impact

on resolution of otitis media with effusion (absolute RD, 22%)

Slide3

Neither guideline discussed topical intranasal steroids

Rosenfeld et al. Pediatrics &

Otolaryngol

HNS, 2004

Considered oral antibiotics and systemic steroids a reasonable option for managing OME

Recommended against “routine” use of antibiotics and steroids, but considered oral antibiotics an option prior to ear tube insertion

Stool et al. Publication

94-0622 Rockville: 1994

Slide4

Quality Measures for the Care ofChildren with Otitis Media with Effusion

Nineteen practices submitted data for 378 encounters71% did not get audiogram if OME >3m or if speech, language, or learning problems67% did not use pneumatic otoscopy or tympanometry for diagnosis13% inappropriately prescribed oral antibiotics3% inappropriately prescribed steroidsReliability and accuracy of records-based data extraction judged suboptimal by investigators

Lannon et al, Pediatrics 2011

Compliance with AMA performance measures for OME was assessed for children aged 2m-12y in 23 practices in 2 primary care networks

Pediatrics 2011; 127:e1490-7

Slide5

Rosenfeld RM, et al.

Otolaryngol

Head Neck

Surg

2016: February (Supplement)

Slide6

Antibiotics for OME

STATEMENT 8b. Clinicians should recommend against using systemic antibiotics for treating otitis media with effusion (OME). Strong recommendation based on systematic review of randomized, controlled trials and preponderance of harm over benefit.

Slide7

Antibiotics for OME in Children

Antibiotics increased OME resolution at 2-3m, RR=2.0, 95% CI 1.6-2.5 (6 trials, NNT benefit =5)Antibiotics increased diarrhea, vomiting, or skin rash, RR=2.2, 95% CI 1.3-3.6 (5 trials, NNT harm = 20)Conflicting results on hearing levels at 2-4w (2 trials)No change in rate of tube insertion or TM sequelaeConclude that adverse events of oral antibiotics exceed questionable benefits for OME

Venekamp et al, Cochrane Database 2016

Cochrane systematic review of 23 RCTs that compared antibiotics with placebo, no treatment, or ineffective therapy for treatment of OME

Cochrane Database Syst Rev 2016; 12:CD009163

Slide8

Steroids for OME

STATEMENT 8a. Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation based on systematic review of randomized, controlled trials and preponderance of harm over benefit.

Slide9

Efficacy of Intranasal Corticosteroids for Persistent Bilateral OME in Primary Care

Double-blind trial of 217 British children aged 4-11y with OM in past year and bilateral OME (B/B or B/C2) randomized to mometasone QD vs. placebo for 3m

Williamson et al, Health Technol Asses 2009

Health Technology Assessment

2009; 13 (www.hta.ac.uk)

P=NS

P=NS

P=NS

No change when adjusted for age, season, atopy or severity

7-22% of treatment group had nasal stinging, cough, epistaxis, and/or dry throat

80% of caregivers in both groups thought they had received active treatment

Slide10

Study Rationale

Despite national guidelines to the contrary, many clinicians in the US are still prescribing antibiotics or steroids for OME, especially topical intranasal steroidsThe specific usage rates of medical therapy for OME are largely unknown, but gaps in care are likely highly prevalentEven small gaps in care could have a large clinical impact because of the high prevalence of OME in childrenFindings in this study would help inform development of quality measures for a national otolaryngology data registry

Steroids and Antibiotics for OME

Slide11

The National Ambulatory Medical Care Survey (NAMCS) is based on a sample of visits to non-federally employed office-based physicians who are primarily engaged in direct patient care and, starting in 2006, a separate sample of visits to community health centers.The National Hospital Ambulatory Medical Care Survey (NHAMCS) is based on a national sample of visits to emergency departments, outpatient departments, and ambulatory surgery locations of noninstitutional general and short-stay hospitals.

Slide12

Oral Antibiotic Use for Otitis Media with Effusion: Ongoing QI Opportunities

32% of OME visits had oral antibiotics prescribed versus 13% of non-OME visits (adjusted odds ratio 4.31)Emergency department visits were 41% more likely to result in antibiotics (OR 1.41, 95% CI 1.29-1.54)Otolaryngology visits were 59% less likelyto result in antibiotics (OR 0.41,95% CI 0.29-0.57)

Roditi et al, Otolaryngol HNS 2016

Cross-sectional analysis of US National and Hospital Ambulatory Medical Care Surveys 2005-2010 for 1.4 million visits of OME without AOM

Otolaryngol Head Neck Surg 2016; 154:797-803

Slide13

Oral Steroid Use for Otitis Media with Effusion & Eustachian Tube Dysfunction

3.2% of OME/ETD visits had oral steroids prescribed versus 1.7% of other visits (P=.002)Adults, but not children, were more likely to get steroids for OME/ETD (odds ratio 3.50, P<.001)Patients seen by an otolaryngologist or inthe emergency room were less likely to receivesteroids than other settings

Bellmunt et al, Otolaryngol HNS 2016

Cross-sectional analysis of US National and Hospital AmbulatoryMedical Care Surveys 2005-2010 for 7.1 million OME or ETD visits

Otolaryngol Head Neck Surg 2016; 155:139-46

Slide14

Intranasal Steroid Use for Otitis Mediawith Effusion: Ongoing QI Opportunities

10.9% of OME visits had intranasal steroids (prescription and non-prescription) versus 3.5% of other visits (P<.001)Adjusted OR (age, sex, race/ethnicity, rhinitis, sinusitis) for intranasal steroids of 3.6 (95% CI, 1.6 to 8.0)Steroids used more in physician offices vs. hospital or ED (risk difference 6.6%)Significant QI opportunities exist

Wang et al, Otolaryngol HNS 2017

Cross-sectional analysis of nearly 2 million OME visits in the US National and Hospital Ambulatory Medical Care Surveys 2005-2012

Otolaryngol Head Neck Surg, May 2017; ePub.

Slide15

http://otojournal.org (May 2017, ePub ahead of print)

Slide16

Antibiotics (32%)

Nasal Steroids (11%)

Oral Steroids (3%)

Antireflux

Drugs (?)

Antihistamines (?)

Decongestants (?)

Slide17

Benjamin Franklin

Inventor, Author, and Diplomat, 1706-1790

He’s the bestphysician that knowsthe worthlessness of the most medicinesRosenfeld’s addendum: especially for OME


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