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# Don't You Think We'd Have Ear Infections Figured Out By Now?:

January 23, 2018

This is an intriguing article, though you might believe it's a hard way to lend support to what you're already doing for young children with acute otitis media.

This is an intriguing article, though you might believe it's a hard way to lend support to what you're already doing for young children with acute otitis media.

Source: Shaikh N, Dando EE, Dunleavy ML, et al. A cost-utility analysis of 5 strategies for the management of acute otitis media in children. J Pediatr.2017;189:54-60.e3; doi:10.1016/j.jpeds.2017.05.047. See AAP Grand Rounds commentary by Dr. Benjamin Doolittle (subscription required).

This was a pure "dry lab" study, meaning that it was all on paper, or in modern terms, it was in the silicon chips. No patients were touched in this study, including no chart reviews.

The authors used modeling techniques, taking baseline assumptions from the medical literature, to try to decide the "best" strategy for treating acute otitis media (AOM) in children younger than 2 years of age. They compared 5 potential strategies: 1) immediate treatment with 10 days of high dose amoxicillin/clavulanate (AC); 2) immediate treatment with 10 days of high dose amoxicillin (AM); 3) immediate treatment with 10 days of cefdinir (CD); 4) watchful waiting (WW), involving no treatment for 48-72 hours to see if symptoms improve; and 5) delayed prescription (DP), a sort of safety net strategy where parents are given a prescription at the initial visit but asked to fill it only if the child does not improve in 72 hours. AM was the narrow winner in their modeling that included sensitivity analyses that varied the estimates of all the baseline variables, within reasonable clinical likelihood. So, this study mostly concurs with current AOM management guidelines. In his commentary, Dr. Doolittle notes very importantly that the overall differences in benefit in quality-adjusted life days (QALDs) across all 5 interventions was pretty small; for example, the QALD benefit of AM over DP was only about 1/3 of a day, at a cost of about $100 more to the family. Some families might not consider that a worthwhile use of their$100.

I was intrigued that this study used a cost-utility analysis (CUA) method, something that is being seen increasingly in the literature. It should not be confused with more common terms like cost-effectiveness (CEA) or cost-benefit analysis (CBA), which are subtly different. In fact, the authors used both CUA and CEA almost interchangeably. Without being too tedious, CUA is a more likely to be helpful in making resource allocation decisions for large populations, such as for countries with single-payer systems for healthcare, or in the US for large HMOs. These analyses can look at costs over a range of very different outcomes, arriving at an incremental cost-effectiveness ratio (ICER; getting more confused?). ICER is calculated as the difference in the cost of 2 interventions, divided by the difference in the expected QALD or similar metric. Holders of the purse strings can decide on a threshold ICER, and interventions that fall below the threshold presumably would be funded or permitted.

I searched long and hard for a straightforward, calculus-free explanation of different types of economic analyses, and I think the best is part of the National Library of Medicine's National Information Center on Health Services Research and Health Care Technology (NICHSR). Among many other features, the site has a learning module on health economics, and Module 4 is all about understanding health economic studies. The first screen will give you the basics, but the several screens following are very worthwhile if you have the time and interest.

The editorial accompanying this Journal of Pediatrics article is probably a more satisfying read for pediatric providers than is the main article, which is very heavy on methodology. Dr. Christopher Harrison, an experienced (i.e. around my age) pediatric infectious diseases physician at Children's Mercy Hospital in Kansas City provides a wonderful overview of the history of AOM research that will inform your practice. For example, I shake my head in astonishment every time I see a child being treated with cefdinir for AOM. Read Dr. Harrison's short editorial and you'll know why.

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