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Chen YL, Fang TY, Wang PC, Chen YH, Wang TC, Huang WT. National Quality Evaluation of Medication Use for Pediatric Otitis Media With Effusion. EAR, NOSE & THROAT JOURNAL 2023; 102:NP567-NP573. [PMID: 34082609 DOI: 10.1177/01455613211020531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Otitis media with effusion (OME) is characterized by the presence of fluid in the middle ear without the presentation of signs or symptoms of acute ear infection. The point prevalence of OME reaches as high as 60% in children younger than 2 years of age. We used the National Health Insurance Research Database (NHIRD) to investigate the use of medication in children with OME before receiving ventilation tube insertion (VTI). METHODS Data of pediatric patients (age ≤ 12 years) who had OME and received VTI from January 1, 2011, to December 30, 2012, were retrieved from the Taiwan NHIRD. We surveyed the use of 4 medications to understand whether health care providers achieved the standards of medication use recommended by clinical practice guidelines. RESULTS This study examines the factors affecting the use of medication for pediatric OME. Overall, according to the study's operational definitions, the use of systemic antibiotics was most common (59.9%), followed by systemic antihistamines (23.4%), systemic steroids (8.8%), and intranasal steroids (9.6%). Systemic antibiotics use was associated with 12 factors. Ten of the 12 factors increase the use of systemic antibiotics, including namely age (age > 2 years), comorbidities, teaching hospital, and community hospital. In contrast, namely catastrophic illness and watchful waiting are the 2 factors that decrease systemic antibiotics use. For the use of systemic antihistamines, systemic steroids, and intranasal steroids were related to 6, 5, and 2 factors, respectively. CONCLUSIONS The rate of drug use differs from the rate of use recommended by commonly used clinical practice guidelines. We found that the higher the number of factors that influenced the patients' drug use, the higher the rate of drug use. According to these results, drafting a treatment guideline for OME patients in accordance with current clinical practices in Taiwan is highly recommended.
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Affiliation(s)
- Yu-Lu Chen
- Department of Pharmacy, Cathay General Hospital, Taipei
| | - Te-Yung Fang
- Department of Otolaryngology, Cathay General Hospital, Taipei
- Fu-Jen Catholic University School of Medicine, New Taipei City
| | - Pa-Chun Wang
- Department of Otolaryngology, Cathay General Hospital, Taipei
- Fu-Jen Catholic University School of Medicine, New Taipei City
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung
| | - Ya-Hui Chen
- Department of Medical Research, Cathay General Hospital, Taipei
| | - Ting-Chuan Wang
- Department of Medical Research, Cathay General Hospital, Taipei
| | - Wan-Tsui Huang
- Department of Pharmacy, Cathay General Hospital, Taipei
- School of Pharmacy, Taipei Medical University, Taipei
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Abstract
PURPOSE OF REVIEW Otitis media (OM) is a disease with very high prevalence in infancy, substantial burden on healthcare resources, and relevant impact on the quality of life of families. The link between OM and allergy is controversial and still debated. However, a fundamental premise has to be placed before introducing this topic: there is the need to use clear and unambiguous terms. Literature abounds with misleading terms that significantly affect the methodology and consequently the outcomes. Moreover, it is essential to differentiate patients according to the OM type (i.e., acute OM, OM with effusion, and chronic suppurative OM), the allergic disease, and mainly the age. RECENT FINDINGS There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. To identify allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, to suspect allergy in OM patients could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of allergy in OM. As there are conflicting findings, a possible interpretation of pathophysiological events and a pragmatic approach are proposed.
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Ryan MA, Leu GR, Boss EF, Raynor EM, Walsh JM. Adherence to American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guidelines: A Systematic Review. Otolaryngol Head Neck Surg 2020; 163:626-644. [PMID: 32450772 DOI: 10.1177/0194599820922155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Clinical practice guidelines synthesize and disseminate the best available evidence to guide clinical decisions and increase high-quality care. Since 2004, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published 16 guidelines. The objective of this review was to evaluate clinicians' adherence to these guidelines' recommendations as measured in the literature. DATA SOURCES We searched PubMed, Embase, and Web of Science on August 29, 2019, for studies published after June 1, 2004. REVIEW METHODS We systematically identified peer-reviewed studies in English that reported clinician adherence to AAO-HNSF guideline recommendations. Two authors independently reviewed and abstracted study characteristics, including publication date, population, sample size, guideline adherence, and risk of bias. RESULTS The search yielded 385 studies. We excluded 331 studies during title/abstract screening and 32 more after full-text review. The remaining 22 studies evaluated recommendations from 8 of the 16 guidelines. The Otitis Media with Effusion, Polysomnography, Tonsillectomy, and Sinusitis guidelines were studied most. Study designs included retrospective chart reviews (7, 32%), clinician surveys (7, 32%), and health care database analyses (8, 36%). Studies reported adherence ranging from 0% to 99.8% with a mean of 56%. Adherence varied depending on the recommendation evaluated, type of recommendation, clinician type, and clinical setting. Adherence to the polysomnography recommendations was low (8%-65.3%). Adherence was higher for the otitis media with effusion (76%-90%) and tonsillectomy (43%-98.9%) recommendations. CONCLUSIONS Adherence to recommendations in the AAO-HNSF guidelines varies widely. These findings highlight areas for further guideline dissemination, research about guideline adoption, and quality improvement.
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Affiliation(s)
- Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Grace R Leu
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Eileen M Raynor
- Department of Head and Neck Surgery & Communication Sciences, Duke University Durham, North Carolina, USA
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Roditi RE, Caradonna DS, Shin JJ. The Proposed Usage of Intranasal Steroids and Antihistamines for Otitis Media with Effusion. Curr Allergy Asthma Rep 2019; 19:47. [PMID: 31486909 DOI: 10.1007/s11882-019-0879-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW To examine the role of allergy medications in the treatment of otitis media with effusion (OME), focusing on use of intranasal steroids and antihistamines. RECENT FINDINGS There has been ongoing controversy regarding the role of allergy in the development of OME. Treatment of OME with medications commonly used for allergic symptomatology has been studied. Proposed treatment options include decongestants, mucolytics, oral steroids, topical steroids, antihistamines, and antibiotics. We begin by evaluating the proposed association between allergy and OME, and then evaluate intranasal steroids and oral antihistamine therapy in the treatment of OME. The role of the adenoid and concurrent nasal symptomatology is also addressed. The preponderance of data suggests that neither intranasal steroids nor antihistamines improve the long-term clearance of isolated OME and are therefore not recommended. However, data are notably limited with regard to improvement rates in OME in patients specifically with concurrent allergy and/or adenoid hypertrophy. Future studies of medications for OME would ideally incorporate study designs controlling for both allergic rhinitis and adenoid hypertrophy, to better understand the impact of these medications on OME in these subgroups of patients.
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Affiliation(s)
- Rachel E Roditi
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham & Women's Hospital, 45 Francis Street ASB II, Boston, MA, 02115, USA
| | - David S Caradonna
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, 110 Francis Street, Suite 6E, Boston, MA, 02115, USA
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham & Women's Hospital, 45 Francis Street ASB II, Boston, MA, 02115, USA.
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Bellmunt AM, Roberts R, Lee WT, Schulz K, Pynnonen MA, Crowson MG, Witsell D, Parham K, Langman A, Vambutas A, Ryan SE, Shin JJ. Does an Otolaryngology-Specific Database Have Added Value? A Comparative Feasibility Analysis. Otolaryngol Head Neck Surg 2017; 155:56-64. [PMID: 27371627 DOI: 10.1177/0194599816651036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 05/02/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES There are multiple nationally representative databases that support epidemiologic and outcomes research, and it is unknown whether an otolaryngology-specific resource would prove indispensable or superfluous. Therefore, our objective was to determine the feasibility of analyses in the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) databases as compared with the otolaryngology-specific Creating Healthcare Excellence through Education and Research (CHEER) database. STUDY DESIGN Parallel analyses in 2 data sets. SETTING Ambulatory visits in the United States. SUBJECTS AND METHODS To test a fixed hypothesis that could be directly compared between data sets, we focused on a condition with expected prevalence high enough to substantiate availability in both. This query also encompassed a broad span of diagnoses to sample the breadth of available information. Specifically, we compared an assessment of suspected risk factors for sensorineural hearing loss in subjects 0 to 21 years of age, according to a predetermined protocol. We also assessed the feasibility of 6 additional diagnostic queries among all age groups. RESULTS In the NAMCS/NHAMCS data set, the number of measured observations was not sufficient to support reliable numeric conclusions (percentage standard error among risk factors: 38.6-92.1). Analysis of the CHEER database demonstrated that age, sex, meningitis, and cytomegalovirus were statistically significant factors associated with pediatric sensorineural hearing loss (P < .01). Among the 6 additional diagnostic queries assessed, NAMCS/NHAMCS usage was also infeasible; the CHEER database contained 1585 to 212,521 more observations per annum. CONCLUSION An otolaryngology-specific database has added utility when compared with already available national ambulatory databases.
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Affiliation(s)
- Angela M Bellmunt
- Ear Nose Throat Department, Hospital Universitari de la Vall d'Hebron, Barcelona, Spain
| | - Rhonda Roberts
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Walter T Lee
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Kris Schulz
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Melissa A Pynnonen
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew G Crowson
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - David Witsell
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Kourosh Parham
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Connecticut Health, Farmington, Connecticut, USA
| | - Alan Langman
- Puget Sound Hearing & Balance Group, Northwest Hospital, University of Washington, Seattle, Washington, USA
| | - Andrea Vambutas
- Department of Otolaryngology, Hofstra North Shore-LIJ School of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Sheila E Ryan
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer J Shin
- Division of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Roditi RE, Rosenfeld RM, Shin JJ. Otitis Media with Effusion: Our National Practice. Otolaryngol Head Neck Surg 2017; 157:171-172. [DOI: 10.1177/0194599817703056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Otitis media with effusion (OME) is the focus of an updated multidisciplinary clinical practice guideline published by the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) and the American Academy of Pediatrics (AAP). Based on data from clinical trials, the guideline recommends against using antihistamines, antibiotics, oral steroids, and intranasal steroids for OME. To understand practice patterns related to these guidelines, we assessed nationally representative data. Despite controlling for age, sex, race/ethnicity, and other potential confounders individualized for each medication class, an increased risk of antihistamine (odds ratio [OR], 3.53), antibiotic (OR, 4.31), and intranasal steroid administration (OR, 3.58) was seen when OME was diagnosed. These analyses have demonstrated opportunities for quality improvement in the care of patients with OME, quantifying gaps in practice relevant to proposed quality measures. Education targeted according to practice setting may facilitate appropriate therapy and/or referral for definitive intervention in children with OME.
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Affiliation(s)
- Rachel E. Roditi
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard M. Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Jennifer J. Shin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Wang DE, Lam DJ, Bellmunt AM, Rosenfeld RM, Ikeda AK, Shin JJ. Intranasal Steroid Use for Otitis Media with Effusion: Ongoing Opportunities for Quality Improvement. Otolaryngol Head Neck Surg 2017; 157:289-296. [PMID: 28535109 DOI: 10.1177/0194599817703046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Our objectives were (1) to assess patterns of intranasal steroid administration when otitis media with effusion (OME) has been diagnosed in children, (2) to investigate whether usage varies according to visit setting, and (3) to determine if practice gaps are such that quality improvement could be tracked. Study Design Cross-sectional analysis of an administrative database. Subjects and Methods National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005 to 2012; univariate, multivariate, and stratified analyses of intranasal steroid usage were performed. The primary outcome was intranasal steroid administration, and the primary predictor was a diagnosis of OME. The impact of location of service was also analyzed. Results Data representing 1,943,177,903 visits demonstrated that intranasal steroids were administered in 10.0% of visits in which OME was diagnosed, in comparison to 3.5% of visits in which OME was not diagnosed (univariate odds ratio, 3.07; 95% confidence interval [CI], 1.85-5.08; P < .001). After adjusting for age, sex, race/ethnicity, and other confounding conditions, multivariate analysis demonstrated that OME remained associated with an increase in intranasal steroid usage (odds ratio, 3.58; 95% CI, 1.60-8.01; P = .002). This practice pattern was more prevalent in the ambulatory office setting (risk difference 6.6%, P < .001) and less seen in a hospital-based office or emergency department. Conclusion Despite randomized controlled trials showing a lack of efficacy for isolated OME, nasal steroids continue to be used in treating children with OME in the United States. Related quality improvement opportunities to prevent usage of an ineffective treatment exist.
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Affiliation(s)
- David E Wang
- 1 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Derek J Lam
- 2 Department of Otolaryngology, Oregon Health and Science University, Portland, Oregon, USA
| | - Angela M Bellmunt
- 3 Department of Otolaryngology, Hospital Universitari de la Vall d'Hebron, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Richard M Rosenfeld
- 4 Department of Otolaryngology, SUNY Downstate Medical Center, New York, New York, USA
| | - Allison K Ikeda
- 5 School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Jennifer J Shin
- 1 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Vila PM, Thomas T, Liu C, Poe D, Shin JJ. The Burden and Epidemiology of Eustachian Tube Dysfunction in Adults. Otolaryngol Head Neck Surg 2017; 156:278-284. [DOI: 10.1177/0194599816683342] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Peter M. Vila
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Tom Thomas
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Carrie Liu
- Department of Otolaryngology, University of Calgary, Calgary, Canada
| | - Dennis Poe
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer J. Shin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Roditi RE, Ishman S, Lee S, Lin S, Shin JJ. Medications for Allergic Rhinitis. Otolaryngol Head Neck Surg 2016; 156:70-80. [PMID: 27576680 DOI: 10.1177/0194599816666064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objectives Adherence to the allergic rhinitis clinical practice guideline is being considered as a potential focus for national performance metrics. To help inform this discussion, we assessed patient- and clinician-reported medication administration among nationally representative populations of patients with allergic rhinitis. Study Design Cross-sectional analyses. Setting and Subjects Home health assessments, ambulatory visits. Methods Participants in the National Health and Nutrition Examination Survey and the National Ambulatory Medical Care Survey / National Hospital Ambulatory Medical Care Survey were assessed. The primary outcomes were the percentage of patients reporting receipt of antihistamines and/or nasal steroids among those with allergy-related symptoms and the percentage for whom a clinician administered these medications when diagnosing allergic rhinitis. Secondary outcomes included assessments of those with worse quality of life, confirmatory allergy testing, and leukotriene receptor antagonist use. Results Within the National Health and Nutrition Examination Survey, an estimated 29.2 million patients were diagnosed with "hay fever," while 92.2 million were diagnosed with "allergies." Patients with symptoms of allergic rhinitis reported that antihistamines or nasal steroids were prescribed in 21.1% to 24.0% of cases. Leukotriene receptor antagonists were given to 1.7% of those without asthma or use of other allergy medications. Within the National Ambulatory Medical Care Survey / National Hospital Ambulatory Medical Care Survey, observations representing 149.5 million visits for allergic rhinitis demonstrated that nasal steroids were administered in 29.6% of cases, while nonsedating and sedating antihistamines were given in 22.4% and 17.2%, respectively. Conclusions Despite a high prevalence of allergic rhinitis, per patient report and clinician entry, a substantial number of affected patients do not receive antihistamines and nasal steroids.
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Affiliation(s)
- Rachel E Roditi
- 1 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Stacey Ishman
- 2 Departments of Otolaryngology and Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stella Lee
- 3 University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sandra Lin
- 4 Department of Otolaryngology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer J Shin
- 1 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Bellmunt AM, Vila PM, Chen JX, Rosenfeld RM, Hackell JM, Shin JJ. Oral Steroid Usage for Otitis Media with Effusion, Eustachian Tube Dysfunction, and Tympanic Membrane Retraction. Otolaryngol Head Neck Surg 2016; 155:139-46. [PMID: 27026728 DOI: 10.1177/0194599816637845] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 02/17/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Avoiding oral steroids for otitis media with effusion (OME) is endorsed as a performance measure by the National Quality Foundation, but data regarding current gaps and practice patterns are lacking. Our objectives were to evaluate oral steroid use for OME and the related diagnoses of eustachian tube dysfunction (ETD) and tympanic membrane retraction (TMR), to assess variations by visit setting, and to identify opportunities for measurable performance improvement. STUDY DESIGN Cross-sectional analysis of a national database. SETTING Ambulatory visits in the United States. SUBJECTS Children and adults in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (2005-2010). METHODS Data were coded for patient demographic information, potential confounders (eg, concurrent conditions managed by oral steroids), and diagnosis of OME, ETD, or TMR (OME/ETD/TMR). The latter 2 diagnoses were included to meet minimum numbers for reliability of weighted estimates, but OME constituted the majority of cases. Multivariate regression was used to determine the variables associated with oral steroid use. RESULTS Among 590,772 observations representing 7,191,711,480 visits for OME/ETD/TMR, 3.2% resulted in a new prescription for oral steroid medication (2.3% for children, 7.0% for adults). Adults were more likely to receive steroids (odds ratio = 3.50, P < .001) than those with other diagnoses, but a similar association was not found for children. Patients seen by an otolaryngologist or in the emergency department were less likely to receive steroids than those seen in other settings. CONCLUSIONS OME/ETD/TMR is infrequently treated with oral steroids, particularly in children. Opportunities for performance improvement are limited.
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Affiliation(s)
- Angela M Bellmunt
- Ear Nose Throat Department, Hospital Universitari de la Vall d'Hebron, Barcelona, Spain
| | - Peter M Vila
- Department of Otolaryngology, Washington University in St Louis, St Louis, Missouri, USA
| | - Jenny X Chen
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | | | - Jennifer J Shin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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