Cost-effectiveness analysis of treatment options for acute otitis media

A Cost-Effectiveness Analysis of Population-Level Dental Caries Prevention Strategies in US Children

OBJECTIVE

To improve oral health disparities and outcomes among US children impacted by dental caries, there is a need to understand the cost-effectiveness of a targeted, risk-based versus universal-based approach for caries prevention.

METHODS

Health and economic outcomes were simulated in a cohort of 50,000 US children aged 1-18 years, comparing current practice (CP) to risk-based-prevention (RBP) and prevention-for-all (PFA) strategies using health care sector and limited societal perspectives. Prevention included biannual oral health exams and fluoride varnish application, and one-time dental sealant placement. The primary outcome is the cost-effectiveness ratio (ICER), defined as the additional cost per quality-adjusted life year (QALY) gained when comparing each strategy to the next least costly one.

RESULTS

For RBP compared to CP, the ICER was US$83,000/QALY from the health care sector perspective; for PFA compared to RBP the ICER was US$154,000/QALY. Using a limited societal perspective that includes caregiver time spent attending dental or medical setting visits, RBP compared to CP yielded a ratio of $119,000/QALY and PFA compared to RBP was $235,000/QALY. Results were most sensitive to changes in the probability of pain from an episode of dental caries, costs for prevention and restoration, and the loss in health-related quality of life due to dental caries pain. Scenario analyses evaluating a reduced intensity of prevention services yielded lower ICERs.

CONCLUSION

Using a risk-based approach that identifies and targets children at increased risk for dental caries to guide the delivery of prevention services represents an economic value similar to other pediatric prevention programs.

A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children

BACKGROUND

Antibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications.

METHODS

Our trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2-14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost.

RESULTS

DAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD.

CONCLUSIONS

When clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy.

TRIAL REGISTRATION

This trial has been registered at www.

CLINICALTRIALS

gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

Nasopharyngeal rapid diagnostic testing to reduce unnecessary antibiotic use and individualize management of acute otitis media

Background:

Acute otitis media (AOM) is the most common indication for antibiotics in children. The associated organism can influence the likelihood of antibiotic benefit and optimal treatment. Nasopharyngeal polymerase chain reaction can effectively exclude the presence of organisms in middle-ear fluid. We explored the potential cost-effectiveness and reduction in antibiotics with nasopharyngeal rapid diagnostic testing (RDT) to direct AOM management.

Methods:

We developed 2 algorithms for AOM management based on nasopharyngeal bacterial otopathogens. The algorithms provide recommendations on prescribing strategy (ie, immediate, delayed, or observation) and antimicrobial agent. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed as cost per quality-adjusted life day (QALD) gained. We used a decision-analytic model to evaluate the cost-effectiveness of the RDT algorithms compared to usual care from a societal perspective and the potential reduction in annual antibiotics used.

Results:

An RDT algorithm that used immediate prescribing, delayed prescribing, and observation based on pathogen (RDT-DP) had an ICER of $1,336.15 per QALD compared with usual care. At an RDT cost of $278.56, the ICER for RDT-DP exceeded the willingness to pay threshold; however, if the RDT cost was <$212.10, the ICER was below the threshold. The use of RDT was estimated to reduced annual antibiotic use, including broad-spectrum antimicrobial use, by 55.7% ($4.7 million for RDT vs $10.5 million for usual care).

Conclusion:

The use of a nasopharyngeal RDT for AOM could be cost-effective and substantially reduce unnecessary antibiotic use. These iterative algorithms could be modified to guide management of AOM as pathogen epidemiology and resistance evolve.

Cost-effectiveness Analysis of the Dental RECUR Pragmatic Randomized Controlled Trial: Evaluating a Goal-oriented Talking Intervention to Prevent Reoccurrence of Dental Caries in Children

BACKGROUND

The formation of dental caries is the most common chronic disease in children, and is preventable. The oral health-related quality of life has an immense impact on an individual's daily functioning, well-being or overall quality of life.

OBJECTIVES

This study aims to investigate the cost effectiveness of the Dental RECUR Brief Negotiated Interview for Oral Health (DR-BNI). This 30-minute therapeutic "talk" by a dental nurse with a parent/guardian was compared with a placebo-controlled intervention in preventing reoccurrence of dental caries in children who have had a primary tooth extracted.

METHODS

An economic model was developed to simulate the clinical progression of dental caries among children who have previously had a primary tooth extracted. The analysis was conducted using the UK NHS perspective. The main outcome was the incremental cost-effectiveness ratio (ICER) based on the quality-adjusted life years (QALYs). Estimates of costs and probabilities were obtained from the DR-BNI multicentre randomised controlled trial (RCT), while QALY values were obtained from published literature. Univariate and probabilistic sensitivity analyses were conducted to assess the uncertainty of the result and robustness of the model. Affordability and risk-aversion of the intervention were investigated to help decision makers make the best possible choices.

RESULTS

With an intervention cost of £6.47, the results from the RCT showed the healthcare cost for the DR-BNI intervention was £115.90 per child while the control had a healthcare cost of £119.46 per child. The QALYs gained for the prevention of reoccurrence of dental caries was higher in the DR-BNI intervention arm by 0.023 QALYs; thus, the DR-BNI was the dominant intervention. At willingness to pay threshold of £3500/QALY gained, a maximum probability of being cost effectiveness is achieved at 86%. The secondary analysis showed a cost-savings of £20.94 per participant for the prevention of at least one filling or extraction. Affordability results showed that the DR-BNI programme is affordable to the UK health system at a moderately low budget.

CONCLUSIONS

This study shows the proactive talking intervention to have a very moderate cost and to be effective in providing better health related quality-of-life gains. The intervention is cost savings with a dominant ICER even with a 200% increase in the cost of intervention. The NHS will be providing better oral health for children at a better net monetary benefit-to-risk ratio by adopting the DR-BNI intervention in preventing the reoccurrence of dental fillings and extractions for each participant.

TRIAL REGISTRATION

This trial was registered prospectively on 27th September 2013 with the trial registration number ISRCTN 24958829.

Effects of reactive oxygen species generation induced by Wonju City particulate matter on mitochondrial dysfunction in human middle ear cell

Atmospheric particulate matter (PM) contains different components that can elicit varying adverse health effects in humans and animals. Studies on PM toxicity and its underlying mechanisms in the middle ear are limited, and they generally use a PM standard. However, as PM composition varies temporally and geographically, it is crucial to identify the toxic PM constituents according to season and region and investigate their associated health effects. Thus, we sought to determine whether PM induces cytotoxicity and inflammatory factor and reactive oxygen species (ROS) generation in human middle ear epithelial cells obtained from patients with otitis media. The cells were treated with both standard urban PM and PM directly captured from the atmosphere in Wonju City. The association between mitochondrial dysfunction and PM was investigated. PM exposure significantly increased COX-2 and TNF-α mRNA expression, increased ROS generation, induced inflammatory responses, and caused abnormalities in mitochondrial motility and function. Furthermore, PM induced cell apoptosis, which consequently reduced cell survival, particularly at the concentration of 100 μg/mL. Overall, our study provides new insights into the toxic effects of standard and atmospheric PM on middle ear cell line.

RNA Sequencing and Pathways Analyses of Middle Ear Epithelia From Patients With Otitis Media

OBJECTIVES

Otitis media (OM) is the most common pediatric diagnosis in the United States. However, our understanding of the molecular pathogenesis of OM remains relatively poor. Investigation of molecular pathways involved in OM may improve the understanding of this disease process and elucidate novel therapeutic targets. In this study, RNA sequencing (RNA-Seq) was used to discern cellular changes associated with OME compared to healthy middle ear epithelium (MEE).

STUDY DESIGN

Ex vivo case-control translational.

METHODS

Middle ear epithelia was collected from five pediatric patients diagnosed with OME undergoing tympanostomy tube placement and five otherwise healthy pediatric patients undergoing cochlear implantation. Specimens underwent RNA-Seq and pathways analyses.

RESULTS

A total of 1,292 genes exhibited differential expression in MEE from OME patients compared to controls including genes involved in inflammation, immune response to bacterial OM pathogens, mucociliary clearance, regulation of proliferation and transformation, and auditory cell differentiation. Top networks identified in OME were organismal injury and abnormalities, cell morphology, and auditory disease. Top Ingenuity canonical pathways identified were axonal guidance signaling, which contains genes associated with auditory development and disease and nicotine degradation II and III pathways. Associated upstream regulators included β-estradiol, dexamethasone, and G-protein-coupled estrogen receptor-1 (GPER1), which are associated with otoprotection or inflammation during insult.

CONCLUSIONS

RNA-Seq demonstrates differential gene expression in MEE from patients with OME compared to healthy controls with important implications for infection susceptibility, hearing loss, and a role for tobacco exposure in the development and/or severity of OME in pediatric patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Pneumococcal Disease: A Systematic Review of Health Utilities, Resource Use, Costs, and Economic Evaluations of Interventions

BACKGROUND

Pneumococcal diseases cause substantial mortality, morbidity, and economic burden. Evidence on data inputs for economic evaluations of interventions targeting pneumococcal disease is critical.

OBJECTIVES

To summarize evidence on resource use, costs, health utilities, and cost-effectiveness for pneumococcal disease and associated interventions to inform future economic analyses.

METHODS

We searched MEDLINE, Embase, Web of Science, CINAHL, PsycINFO, EconLit, and Cochrane databases for peer-reviewed studies in English on pneumococcal disease that reported health utilities using direct or indirect valuation methods, resource use, costs, or cost-effectiveness of intervention programs, and summarized the evidence descriptively.

RESULTS

We included 383 studies: 9 reporting health utilities, 131 resource use, 160 economic costs of pneumococcal disease, 95 both resource use and costs, and 178 economic evaluations of pneumococcal intervention programs. Health state utility values ranged from 0 to 1 for both meningitis and otitis media and from 0.3 to 0.7 for both pneumonia and sepsis. Hospitalization was shortest for otitis media (range: 0.1-5 days) and longest for sepsis/septicemia (6-48). The main categories of costs reported were drugs, hospitalization, and household or employer costs. Resource use was reported in hospital length of stay and number of contacts with general practitioners. Costs and resource use significantly varied among population ages, disease conditions, and settings. Current vaccination programs for both adults and children, antibiotic use and outreach programs to promote vaccination, early disease detection, and educational programs are cost-effective in most countries.

CONCLUSION

This study has generated a comprehensive repository of health economic evidence on pneumococcal disease that can be used to inform future economic evaluations of pneumococcal disease intervention programs.

Antibiotic modulation of mucins in otitis media; should this change our approach to watchful waiting?

BACKGROUND

Gel-forming mucins (GFMs) play important roles in otitis media (OM) pathogenesis. Increased mucin expression is activated by pathogens and proinflammatory cytokines. Bacterial biofilms influence inflammation and resolution of OM and may contribute to prolonged mucin production. The influence of specific pathogens on mucin expression and development of chronic OM with effusion (OME) remains an area of significant knowledge deficit.

OBJECTIVES

To assess the relationship between GFM expression, specific pathogens, middle ear mucosal (MEM) changes, biofilm formation, and antibiotic utilization.

METHODS

Mixed gender chinchillas were inoculated with nontypeable Haemophilus influenzae (NTHi) strain 86028NP or Streptococcus pneumoniae (SP) strain TIGR4 via transbulla injection. Antibiotic was administered on day 3-5 post inoculation. GFM expression was measured by quantitative PCR. Biofilm formation was identified and middle ear histologic changes were measured.

RESULTS

SP infection resulted in higher incidence of biofilm and ME effusion compared with NTHi infection. However, NTHi persisted in the ME longer than SP with no substantive bacterial clearance detected on day 10 compared with complete bacterial clearance on day 10 for 50-60% of the SP-infected chinchillas. Both infections increased MEM inflammatory cell infiltration and thickening. NTHi upregulated the Muc5AC, Muc5B and Muc19 expression on day 10 (p = 0.0004, 0.003, and 0.002 respectively). SP-induced GFM upregulations were trended toward significant. In both NTHi and SP infections, the degree of GFM upregulation had a direct relationship to increased MEM hypertrophy, inflammatory cell infiltration and biofilm formation. Antibiotic treatment reduced the incidence of ME effusion and biofilm, limited the MEM changes and reversed the GFM upregulation. In NTHi infection, the rate of returning to baseline level of GFMs in treated chinchillas was quicker than those without treatment.

CONCLUSIONS

In an animal model of OM, GFM genes are upregulated in conjunction with MEM hypertrophy and biofilm formation. This upregulation is less robust and more quickly ameliorated to a significant degree in the NTHi infection with appropriate antibiotic therapy. These findings contribute to the understanding of pathogen specific influences on mucin expression during OM pathogenesis and provide new data which may have implications in clinical approach for OM treatment.

Family Spillover Effects in Pediatric Cost-Utility Analyses

BACKGROUND

Childhood illness can impose significant costs and health strains on family members, but these are not routinely captured by pediatric economic evaluations. This review investigated how family "spillover effects" related to costs and health outcomes are considered in pediatric cost-utility analyses (CUAs).

METHODS

We reviewed pediatric CUAs published between 2000 and 2015 using the Tufts Medical Center Cost-effectiveness Analysis (CEA) Registry and the Pediatric Economic Database Evaluation (PEDE) Registry. We selected studies conducted from the societal perspective and included in both registries. We investigated how frequently family spillover was incorporated into analyses, and how the inclusion of spillover health effects and costs changed CUA results.

RESULTS

We found 142 pediatric CUAs meeting inclusion criteria. Of those, 105 (72%) considered either family spillover costs (n = 98 time costs, n = 33 out-of-pocket costs, n = 2 caregiver healthcare costs) or health outcomes (n = 15). Twenty-four studies included 43 pairs of incremental cost-effectiveness ratios (ICERs) with and without spillover. In 19 pairs of ICERs, adding spillover changed the ICER enough to cross a common cost-effectiveness threshold (i.e., $50,000/QALY, $100,000/QALY, $150,000/QALY; values are in 2016 US$). Incorporating spillover generally made interventions more cost-effective (n = 18; 42%), or did not change CUA results enough to cross a threshold (n = 24; 56%). Including family spillover reduced ICERs by 31% ($40,000/QALY) on average.

CONCLUSION

Most pediatric CUAs conducted from a societal perspective include family costs but fewer include family health effects. Inclusion of family spillover effects tends to make CUA results more favorable. Future pediatric CUAs should aim to more fully incorporate the family burden of illness.

Otic drug delivery systems: formulation principles and recent developments

Disorders of the ear severely impact the quality of life of millions of people, but the treatment of these disorders is an ongoing, but often overlooked challenge particularly in terms of formulation design and product development. The prevalence of ear disorders has spurred significant efforts to develop new therapeutic agents, but perhaps less innovation has been applied to new drug delivery systems to improve the efficacy of ear disease treatments. This review provides a brief overview of physiology, major diseases, and current therapies used via the otic route of administration. The primary focuses are on the various administration routes and their formulation principles. The article also presents recent advances in otic drug deliveries as well as potential limitations. Otic drug delivery technology will likely evolve in the next decade and more efficient or specific treatments for ear disease will arise from the development of less invasive drug delivery methods, safe and highly controlled drug delivery systems, and biotechnology targeting therapies.

Optimisation of peptides that actively cross the tympanic membrane by random amino acid extension: a phage display study

Local treatment of middle ear (ME) disease currently requires surgical penetration of the tympanic membrane (TM). We previously discovered 12-mer peptides that are actively transported across the intact TM, a process that could be used for non-invasive drug delivery into the ME. To optimise transport and provide further understanding of the peptides transport mechanism, we extended two of the candidate peptides by six additional amino acids at random, and screened the resulting 18-mers libraries on TMs of rats with active bacterial otitis media (OM) for transport efficiency using phage display. Six identified peptides were individually tested in vivo for trans-TM transport to verify the tissue specificity. Three exhibited enhanced transport compared to their parent 12-mer scaffold, with the best showing an approximately nine-fold increase. Sequence analysis revealed anchor residues and structural features associated with enhanced transport. This included the prominent display of conserved sequence motifs at the extended free ends of the predicted peptide structures.

A Cost-Utility Analysis of 5 Strategies for the Management of Acute Otitis Media in Children

OBJECTIVE

To assess whether antimicrobial therapy in young children with acute otitis media reduces time to resolution of symptoms, overall symptom burden, and persistence of otoscopic evidence of infection. We used a cost-utility model to evaluate whether immediate antimicrobial treatment seems to be worthwhile, and if so, which antimicrobial agent is most cost effective.

STUDY DESIGN

We compared the cost per quality-adjusted life-day of 5 treatment regimens in children younger than 2 years of age with acute otitis media: immediate amoxicillin/clavulanate, immediate amoxicillin, immediate cefdinir, watchful waiting, and delayed prescription (DP) for antibiotic.

RESULTS

The 5 treatment regimens, listed in order from least effective to most effective were DP, watchful waiting, immediate cefdinir, immediate amoxicillin, and immediate amoxicillin/clavulanate. Listed in order from least costly to most costly, the regimens were DP, immediate amoxicillin, watchful waiting, immediate amoxicillin/clavulanate, and immediate cefdinir. The incremental cost-utility ratio of immediate amoxicillin compared with DP was $101.07 per quality-adjusted life-day gained. The incremental cost-utility ratio of immediate amoxicillin/clavulanate compared with amoxicillin was $2331.28 per quality-adjusted life-day gained.

CONCLUSIONS

In children younger than 2 years of age with acute otitis media and no recent antibiotic exposure, immediate amoxicillin seems to be the most cost-effective initial treatment.

Cost-Effectiveness of Watchful Waiting in Acute Otitis Media

BACKGROUND

American Academy of Pediatrics guidelines for acute otitis media (AOM) allow for children meeting certain criteria to undergo watchful waiting (WW). The cost-effectiveness of this policy has not been evaluated in the United States.

METHODS

A retrospective review of a random selection of 250 patients ≤18 years old with AOM in the emergency department of a tertiary care children's hospital was used to characterize current practice of AOM management. These data were incorporated into a decision-analytic cost-utility model comparing the cost-effectiveness of implementing WW to current practice. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed in 2015 USD per disability-adjusted life year (DALY) averted from a societal perspective. Multiple sensitivity analyses were conducted.

RESULTS

From this cohort, chart review confirmed 247 actually had AOM on physical examination. Of these, 231 (93.5%) were prescribed antibiotics, 7 (2.8%) underwent WW, and 9 (3.6%) were sent home without an antibiotic prescription. When American Academy of Pediatrics criteria for WW were applied to this population, 104 patients (42.1%) met conditions for immediate antibiotic prescription, and 143 patients (57.9%) qualified for WW. In our modeled scenario, for every 1000 patients with AOM, implementing WW yielded 514 fewer immediate antibiotic prescriptions and 205 fewer antibiotic prescriptions used, averting 14.3 DALYs, and saving $5573. The preferability of WW over current practice proved highly robust to sensitivity analysis.

CONCLUSIONS

WW for AOM management is cost-effective. Implementing WW may improve outcomes and reduce health care expenditures.

Value within otolaryngology: Assessment of the cost-utility analysis literature

Objective

To assess the characteristics and quality of cost utility analyses (CUA) related to otolaryngology within the CEA registry and to summarize their collective results.

Methods

All cost-utility analyses published between 1976 and 2011 contained in the Cost-Effectiveness Analysis Registry (CEA Registry) were evaluated. Topics that fall within the care of an otolaryngologist were included in the review regardless of the presence of an otolaryngologist author. Potential associations between various study characteristics and CEA registry quality scores were evaluated using the Pearson product moment correlation coefficient.

Results

Sixty-one of 2913 (2.1%) total CUA publications screened were related to otolaryngology. Eighteen of 61 (29.5%) publications included an otolaryngologist as an author. Fourteen studies agreed on the cost effectiveness of at least unilateral cochlear implantation and six of seven (85.7%) studies demonstrated the cost effectiveness of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA). Forty-six percent (28 of 61) of all manuscripts were published between 2008 and 2011. A more recent publication year was associated with a higher CEA registry quality score while the presence of an otolaryngologist author and journal impact factor had no significant correlation with the quality of the CUA.

Conclusion

Based on current evidence in the CEA registry, unilateral cochlear implantation for hearing loss and CPAP for OSA are both cost-effective therapeutic interventions. Although CUAs in otolaryngology have increased in quantity and improved in quality in more recent years, there is a relative lack of CUAs in otolaryngology in comparison to other subspecialties.

Delayed/back up antibiotic prescriptions: what do the public think?

OBJECTIVE

To describe the general public's understanding, acceptance and use of delayed antibiotics.

DESIGN

Face to face computer-assisted survey using an Ipsos MORI Capibus survey.

SETTING

Randomly selected households in England using multistage sampling.

RESPONDENTS

A representative sample of 1625 adults aged over 15 years and recruited from household visits in England, using age and gender quotas for each area.

DATA COLLECTION AND ANALYSIS

The survey was undertaken in January 2014. Weights based on gender, age, ethnicity, working status, social grade, housing tenure and Government Office Region corrected for selection biases, so that results are broadly representative of the population.

MAIN OUTCOMES MEASURES

Proportion of respondents; understanding the meaning of the term delayed antibiotic prescription and how the strategy is used in general practice; in favour of, or opposed to clinicians offering them a delayed antibiotic; reporting receipt, use and acceptability of delayed antibiotic prescriptions in the past year.

RESULTS

17% reported fully understanding the meaning of delayed antibiotic prescription and strategy use in general practice;72% were unaware of the term or strategy; 36-39% were in favour of, and 28-30% opposed to clinicians offering them a delayed antibiotic for throat, urine, ear or chest infections. Half of those who were fully aware of the term and practice were in favour of delayed antibiotics. Women, and older respondents, were more strongly opposed to delayed prescribing. Only 4% of all respondents, and 15% of those prescribed an antibiotic, reported being offered a delayed antibiotic in the last year.

CONCLUSIONS

Wider understanding and acceptance of delayed prescribing may facilitate increased uptake. Further research is needed to determine why groups are so strongly in favour or opposed to delayed prescribing.

Use of antibiotics in paediatric primary care settings in Serbia

OBJECTIVE

The aim of the study was to compare the quality of antibiotic use among children in primary settings with the internationally developed disease-specific quality indicators and with National Guidelines.

DESIGN

Prescriptions of systemic antibiotics to the paediatric population (<18 years) at the primary level of healthcare for the period between 2011 and 2013 were analysed by using the National Health Insurance Fund's outpatient reimbursement database.

RESULTS

The mean annual number of antibiotic prescriptions was 1.887.615, while the mean annual number of children receiving antibiotics was 728.285. The prescription rate slightly decreased by 10% from 1.516 antibiotic prescriptions per 1000 persons per year in 2011 to 1.365 in 2013. The highest percentage of prescribed antibiotics was observed in the group of children aged 2-23 months. The mean annual prevalence of antibiotic prescriptions was 54%. The percentage of patients prescribed an antibiotic for acute upper respiratory tract infections, acute tonsillitis and acute otitis media (AOM) was above the proposed range (≤ 20), 87% -96%. These three diagnoses represent more than 69% of all indications for prescribing antibiotics. The percentage of patients prescribed a recommended antibiotic was below the proposed range (≥ 80%), 1% -17%, while the adherence rate to National Guidelines was low, 19%-28%. The percentage of patients prescribed quinolones was above the proposed range for AOM (≤ 5%), 7%. There were no significant differences in indicators value at the regional level in Serbia.

CONCLUSIONS

Antibiotic use among children in Serbia is extremely high compared with that in most other European countries. Major problems are frequent use of antibiotics for indications that usually receive no benefit from this treatment and the use of broad-spectrum antibiotics.

Assessment of the light intensity of otoscopes utilized in teaching hospitals

INTRODUCTION

To attain an accurate otoscopic diagnosis, a functioning device with adequate capacity must be used.

OBJECTIVE

Evaluate the light intensity of otoscopes, comparing it utilizing the batteries present at the moment of calibration and after new batteries were supplied.

METHODS

Cross-sectional study of a historical cohort, which assessed 38 otoscopes, measuring the light intensity with the batteries present at the moment of assessment compared to the intensity with new batteries, as well as charge of the test batteries and the new batteries.

RESULTS

The mean of the sum of new batteries' charge was 3.19V, and of the test batteries was 2.70V, representing a decrease of 18.02% in charge. The mean luminosity with the new batteries was 366.89lumens, whereas in the test batteries it was 188.32lumens, representing a decrease of 83.75% in the light intensity. Student's t-test was applied for data comparison, showing a statistical difference between the light intensity with the original batteries and the new batteries (p=0.0001; CI=0.95).

CONCLUSION

There was a statistically significant difference between the proportions of light intensity in the otoscopes. A small variation in battery charge results in a great variation in light.

Are treatment guides and rational drug use policies adequately exploited in combating respiratory system diseases?

The aim of the present study was to increase awareness regarding the rational use of medicines. The data were obtained via the Material Resources Management System Module of the Ministry of Health. For the appropriateness of treatments, the Global Initiative for Asthma, the Global Initiative for Chronic Obstructive Lung Disease, and the guidelines for the rational use of medicines were used. We also investigated whether any de-escalation method or physical exercise was performed. Statistical analyses were performed using descriptive statistics to determine the mean, standard deviation, and frequency. The results showed that healthcare providers ignored potential drug reactions or adverse interactions, and reflecting the lack of adherence to the current treatment guides, 35.8% irrational use of medicines was recorded. Thus, de-escalation methods should be used to decrease costs or narrow the antibiotic spectrum, antibiotic selection should consider the resistance patterns, culturing methods should be analyzed, and monotherapy should be preferred over combination treatments.

Effect of urban particles on human middle ear epithelial cells

OBJECTIVES

The aim of this study was to examine the cytotoxic effect and inflammatory response of human middle ear epithelial cells (HMEECs) induced by urban particles (UP).

MATERIALS AND METHODS

Cell viability following UP exposure was assessed in HMEECs using the CCK 8 assay. The expression levels of the inflammation-related genes (COX-2 and MUC5AC) were analyzed using semi-quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and COX-2 production was analyzed using western blotting.

RESULTS

Treatment with UP decreased cell viability in HMEECs in a dose- and time-dependent manner. UP exposure induced the significantly increased expression of COX-2 and MUC5AC. Western blotting showed dose dependently increased expression of COX-2 production.

CONCLUSIONS

UP decreased cell viability, increased the inflammatory response, and increased mucin gene production in HMEECs. These findings indicate that exposure to UP can contribute to the development of otitis media.

Panel 7: Treatment and comparative effectiveness research

BACKGROUND AND OBJECTIVES

Otitis media (OM) is one of the most common reasons for antibiotic treatment in children. Controversies regarding antibiotic treatment for OM have accumulated in the past decade, and there seem to be more dilemmas than certainties. The objectives of this article are to provide the state-of-the art review on achievements in treatment of all different stages of OM, including acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media, and to outline the future research areas.

DATA SOURCES

PubMed, Ovid Medline, the Cochrane Database, and Clinical Evidence (BMJ Publishing).

REVIEW METHODS

All types of articles related to OM treatment published in English between January 2007 and June 2011 were identified. A total of 286 articles related to OM treatment were reviewed by the panel members; 114 relevant quality articles were identified and summarized.

RESULTS

New evidence emerged on beneficial results of antibiotic treatment, compared with observation of AOM in young children who were diagnosed based on stringent criteria. In OME, the main results were related to a nonsignificant benefit of adenoidectomy versus tympanostomy tube placement alone in the treatment of chronic OME in younger children. Other modalities of OM treatment were studied and described herein.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Significant progress has been made in advancing the knowledge on the treatment of OM. Areas of potential future research have been identified and outlined.

Reducing the costs of paediatric antibiotic prescribing in the community by implementing guideline recommendations

WHAT IS KNOWN AND OBJECTIVE

Italian children receive a high number of antibiotic prescriptions, and the use of second-choice antibiotics is common. A few studies in other countries have demonstrated that the implementation of international guidelines for the most common paediatric diseases may reduce the associated costs. A cost analysis of the expenditure for antibiotic prescriptions in outpatient children in the Lombardy region (Italy) and for each of the region's local health units (LHUs) was performed using a pharmacoepidemiological approach. The safety and cost impact associated with a quali-quantitative improvement in antibiotic prescribing was estimated.

METHODS

The data source was the Lombardy region's prescription database (year 2008) for outpatient children <14 years old. The average total expenditure for each package, and per capita, was calculated for each active substance considered and for each LHU. An estimate of the possible cost reduction was elaborated using, as a reference, the prescription profile of a group of paediatricians that has been involved in initiatives concerning care for years. The hospital admission rates for acute respiratory infections (ARI) and their major complications were evaluated at the regional level and in the group of children followed by the reference paediatricians.

RESULTS AND DISCUSSION

The cost reduction estimate reveals a possible decrease in antibiotic expenditure of about 3·6 million euros (-19·5%) in the Lombardy region. Large variability was observed between different LHUs (-33·3 to +9·2% of difference). The hospital admission rate was not different when comparing the group of children followed by the reference paediatricians to the rest of the study population, but the hospital admission rate for ARI was lower in the reference group (χ(2) = 16·4, P < 0·001).

WHAT IS NEW AND CONCLUSION

This is the first Italian study to evaluate the costs related to a specific prescription profile, which already exists in the real setting, hypothesizing its application in a large outpatient child population of the same geographical area. The results show that by improving prescribing appropriateness, it is possible to reduce the expenditure associated with antibiotic prescriptions to outpatient children in the Lombardy region by about one-fifth. The lower rate of hospital admissions for ARI suggests that the adopted profile is also beneficial to children's health.

Application of classic utilities to published pediatric cost-utility studies

OBJECTIVE

Economic analyses, such as cost-utility analyses (CUAs), are dependent on the quality of the data used. Our objective was to test how health utility values (measurements of patient preference) assessed by recommended methods (classic utilities) would impact the conclusions in published pediatric CUAs.

METHODS

Classic utilities for pediatric health states were obtained by recommended utility assessment methods, time trade-off, and standard gamble in 4016 parent interviews. To test the impact of these utilities on published studies, we obtained a sample of published pediatric CUAs by searching Medline, EMBASE, EconLit, Health Technology Assessment Database, Cochrane Database on Systematic Reviews, Database of Abstracts of Reviews of Effects, and the Cost Effective Analysis (CEA) Registry at Tufts Medical Center, using search terms for cost-utility analysis. Articles were included when results were presented as cost per quality adjusted life-years (QALYs), the interventions were for children <18 years of age and included at least one of the following health states: attention deficit hyperactivity disorder, asthma, gastroenteritis, hearing loss, mental retardation, otitis media, seizure disorder, or vision loss. Studies that did not include these or equivalent health states were excluded. For each CUA, we determined utilities (values for patient preference), the utility assessment method used, and presence of one-way sensitivity analyses (SAs) on utilities. When one-way SAs were conducted, we determined if using our classic utilities would change the result of the CUA. When an SA was not presented, we determined if using our classic utilities would tend to support or not support the published conclusions.

RESULTS

We evaluated 39 articles. Eighteen articles presented results of one-way SAs on utilities. Seven articles presented SAs over a range that included our classic utilities. In 4 of the 7, using classic utilities would change the conclusion of the study. For the 32 articles where no one-way SA were presented (n = 21), or where the classic utilities fell outside the range tested (n =11), a change to classic utility would tend against the study conclusion in 12 articles (31%).

CONCLUSIONS

More than a third of published CUA studies could change if pediatric utilities obtained by recommended, classic methods were used. One-way SAs on utilities are often not presented, making comparison between studies challenging.

Air pollution and emergency department visits for otitis media: a case-crossover study in Edmonton, Canada

BACKGROUND

Otitis media (OM) is one of the most common early childhood infections, resulting in an enormous economic burden to the health care system through unscheduled doctor visits and antibiotic prescriptions.

OBJECTIVES

The objective of this study was to investigate the potential association between ambient air pollution exposure and emergency department (ED) visits for OM.

MATERIALS AND METHODS

Ten years of ED data were obtained from Edmonton, Alberta, Canada, and linked to levels of air pollution: carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), sulfur dioxide, and particulate matter (PM) of median aerometric diameter < or = 10 and 2.5 pm (PM10 and PM2.5 respectively). A time-stratified case-crossover technique was applied to analyze the associations between ambient air pollution and health outcomes. Conditional logistic regression analysis with the subject's identification number as a stratum variable was used to obtain odds ratios (ORs) and their corresponding 95% confidence intervals after adjustment for meteorological factors.

RESULTS

We based the analysis on 14,527 ED visits for OM over 10 years in children 1-3 years of age. We observed statistically significant positive associations between ED visits for OM and interquartile increases in CO and NO2 levels after adjusting for ambient temperature and relative humidity. We observed the strongest associations (expressed by ORs) in the warmer months (April-September) in girls and all patients for exposure to CO and NO2, and in boys for exposure to CO, for 2 days before an OM ED visit.

CONCLUSIONS

These results support the hypothesis that ED visits for OM are associated with ambient air pollution.

Health Economics of Antibiotics

Antibiotics have made a significant contribution to improving patient health, but policy makers and health care payers are concerned about the costs of antibiotics in addition to their effectiveness. This paper aims to assess the value of antibiotics by examining incremental cost-utility ratios of antibiotics. Evidence was derived from cost-utility analyses of antibiotics included in the Tufts-New England Center Cost-Effectiveness Analysis Registry through September 2009. The analysis included 85 incremental cost-utility ratios from 23 cost-utility analyses. The findings showed that 38.8% of incremental cost-utility ratios related to dominant antibiotics (i.e., more effective and less costly than the comparator); 45.9% referred to antibiotics that improved effectiveness, but also increased costs; and 15.3% related to dominated antibiotics (i.e., less effective and more costly than the comparator). The median ratio was 748 € per quality-adjusted life year. Using threshold values of 20,000 € per quality-adjusted life year and 50,000 € per quality-adjusted life year, the probability that an antibiotic provides value for money was 64% and 67%, respectively. The current evidence base suggests that the majority of antibiotics provide value for money and that antibiotics can aid decision makers to attain further population health improvements, whilst containing pharmaceutical expenditures.

Ear discharge in children presenting with acute otitis media: observational study from UK general practice

BACKGROUND

National Institute for Health and Clinical Excellence (NICE) guidance to treat otitis media in older children immediately with antibiotics only if they have ear discharge is based on limited evidence.

AIM

To determine the clinical significance and outcome of ear discharge in children with acute otitis media, in routine clinical practice.

DESIGN OF STUDY

Observational cohort study of children with acute otitis media comparing those with and without ear discharge at presentation.

SETTING

Primary care in East Somerset.

METHOD

Two hundred and fifty-six children aged 6 months to 10 years were recruited from primary care. Clinical features and other characteristics were recorded at presentation. Follow-up was undertaken at 2 weeks and 3 months.

RESULTS

Children with otitis media who present with ear discharge are much more likely to be treated with antibiotics irrespective of age (adjusted odds ratio 15, 95% confidence interval [CI] = 3 to 66). Most with discharge have proven bacterial infection (58%, 95% CI = 42 to 72%). They have a more severe systemic illness, with higher axillary temperature (80% increase in odds of ear discharge for each additional degree centigrade, P = 0.02), pulse rate (9% increase in odds for each extra beat, P<0.001), and Yale score (mean 10.5 versus 9.0, P = 0.003). They may also have an increased likelihood of adverse outcome (adjusted odds ratio of pain at 1 week 2.9; further episodes of acute otitis media 3.3; hearing difficulty at 3 months 4.7; all P<0.10).

CONCLUSION

Ear discharge defines a group of children with otitis media who are sicker and may be at higher risk of adverse outcome. NICE guidance to treat them with antibiotics is supported.

Study of the impact of oseltamivir on the risk for pneumonia and other outcomes of influenza, 2000-2005

CONTEXT

Influenza results in large numbers of secondary complications and hospitalizations.

OBJECTIVE

To assess the impact of oseltamivir on influenza-related complications and hospitalizations by analyzing health insurance claims data for 6 influenza seasons.

DESIGN

A retrospective cohort study utilizing claims data from the 2000-2005 influenza seasons.

SETTING

Claims data were obtained from Thomson Healthcare MarketScan Research Databases.

PATIENTS

Patients prescribed oseltamivir within 1 day of influenza diagnosis were compared to those prescribed no antiviral therapy (controls).

OUTCOMES

Frequencies of pneumonia, other respiratory illnesses, and otitis media, and rates of hospitalization, were compared for the oseltamivir and no antiviral groups. Expenditure was also analyzed. Relative risk (RR) for each outcome was assessed using Cox proportional hazards regression.

RESULTS

Overall, 31,674 patients received oseltamivir and were propensity matched to patients with no antiviral prescription. Oseltamivir reduced the risk of diagnosis of pneumonia by 15% (RR 0.85, 95% confidence interval [CI] 0.73, 0.98), other respiratory illnesses by 20% (RR 0.80, 95% CI: 0.76, 0.83), and otitis media and its complications by 31% (RR 0.69, 95% CI: 0.61, 0.79). The greatest reductions in pneumonia risk, of 57% and 52%, were observed for children aged 6-12 years (RR 0.43, 95% CI: 0.26, 0.71) and 1-2 years (RR 0.48, 95% CI: 0.24, 0.99), respectively. Overall, hospitalization rates were reduced by 38% (RR 0.62, 95% CI: 0.52, 0.74) in the oseltamivir group compared with the no antiviral group. Total adjusted expenditures in the oseltamivir and no antiviral groups were not significantly different.

CONCLUSIONS

Oseltamivir reduced the relative risk of influenza-related complications and hospitalization when prescribed immediately upon presentation of influenza.

Age inconsistency in the American Academy of Pediatrics guidelines for acute otitis media

OBJECTIVE

The American Academy of Pediatrics acute otitis media guidelines could reduce antibiotic use. The objective was to compare strategies for diagnosing and treating otitis: (1) a commonly used, 2-criteria strategy, (2) the guidelines' 3-criteria algorithm, and (3) initially watching without antibiotics.

METHODS

A decision analysis was performed with literature-based parameter. The target population was children presenting to primary care physicians with possible otitis media. Main outcomes were antibiotic use, sick days, mild adverse drug events, and number needed to treat/avoided sick day.

RESULTS

For children 2 to <6 months of age, compared with the 2-criteria strategy, guideline use predicted 21% less antibiotic use, 13% more sick days, and 23% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.2 children per avoided sick day. For children 6 to <24 months of age, guideline use, compared with the 2-criteria strategy, predicted 26% less antibiotic use, 14% more sick days, and 28% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.4 children per avoided sick day. For children >2 years of age, guideline use, compared with the 2-criteria strategy, predicted 67% less antibiotic use, 4% more sick days, and 68% fewer adverse drug events. The number needed to treat for the guideline strategy versus the watch strategy was 6.3 children per avoided sick day; that for the 2-criteria strategy versus the guideline strategy was 12.3. Guideline use for children <2 years implies that our number needed to treat to avoid a sick day is <1.4; for children >2, guideline use implies we are willing to treat at least 6.3 children to avoid a sick day. Thus, the guidelines imply a greater willingness to treat older children, compared with younger children.

CONCLUSIONS

The American Academy of Pediatrics guidelines are inconsistent in their outcomes across age groups. Guideline implementation under age 2 reduces antibiotic use but at a relatively heavy cost of sick days and parental missed work days. This trade-off may be particularly unfavorable for working parents, who might reasonably prefer greater antibiotic use.