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Shared decision-making for pediatric acute otitis media in the United States: a randomized emergency department trial
Jana L Anderson1, Lucas Oliveira J E Silva2, Erik P Hess3
1Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA. Anderson.Jana@mayo.edu.
Insights
The Ear Pain Decision Aid (EPDA) improved parental knowledge and engagement for acute otitis media (AOM) in children. While not reducing antibiotic use in this study, it shows promise for shared decision-making in emergency care.
Area of Science:
- Pediatric Emergency Medicine
- Health Informatics
- Clinical Decision Support
Background:
- Shared decision-making (SDM) faces barriers in emergency departments (EDs), including time constraints and complexity.
- Parental expectations for antibiotics in acute otitis media (AOM) often conflict with guidelines, leading to high prescribing rates (up to 96%) in the ED.
- The study addresses the need to improve parental understanding and engagement in AOM management.
Purpose of the Study:
- To measure the impact of a web-based decision aid on parental knowledge, engagement, and antibiotic use for pediatric AOM in the ED.
- To evaluate the feasibility of implementing SDM tools in the emergency care setting for AOM.
Main Methods:
- A randomized trial compared a web-based decision aid (earpaindecisionaid.org) for SDM to usual care (UC) for parents of children (≥6 months) with non-severe AOM.
- Outcomes included parental knowledge, clinician/parent engagement, interaction time, and antibiotic prescribing rates.
- 101 parents were enrolled; 42 in the EPDA arm and 59 in the UC arm.
Main Results:
- Parents using the EPDA showed significantly higher scores in knowledge (mean difference 1.0, p=0.004) and decision-making engagement (mean difference 6.0, p=0.005).
- No significant difference was found in interaction time (p=0.059).
- Immediate antibiotic prescriptions were similar between groups (EPDA 36% vs. UC 42%, p=0.50), as was wait-and-see prescription use (EPDA 64% vs. UC 68%, p=0.50).
Conclusions:
- SDM with the EPDA effectively improved parental knowledge and engagement for pediatric AOM without increasing ED visit duration.
- The study did not find a significant reduction in antibiotic prescribing, possibly due to limited sample size (risk of Type II error).
- Findings support the integration of SDM tools in emergency care, with larger studies recommended to confirm effectiveness in antibiotic stewardship.
Background:
Shared decision-making is increasingly utilized when multiple reasonable options exist. In the emergency department, however, several perceived barriers-such as time constraints, illness complexity, and varying levels of acceptance-limit its use. In cases of acute otitis media (AOM) in children, parental expectations for immediate antibiotic treatment often conflict with national guidelines recommending a trial of analgesics for 48 to 72 h prior to initiating antibiotics. As a result, antibiotic prescribing rates in the emergency department remain high, reaching up to 96%. Our aim was to measure the impact of the ear pain decision aid on parental knowledge, engagement and antibiotic use.
Methods:
We conducted a randomized trial in the Emergency Department and affiliated Urgent Care setting comparing shared decision-making with a web-based decision aid (earpaindecisionaid.org) to usual care for parents of children aged 6 months and older with non-severe AOM. Outcomes included parental knowledge of AOM, clinician/parent engagement, interaction time, and antibiotic use.
Results:
One hundred-one parents were enrolled; 42 participated in the Ear Pain Decision Aid (EPDA) arm using shared decision-making, while 59 received usual care (UC). Fifty-one interactions were videotaped. Parents in the EPDA arm scored greater in knowledge: EPDA 6.1 (1.74) vs. UC 5.1 (1.79), mean difference 1.0 (95% CI 0.3, 1.7), p = 0.004. They also scored high in decision-making: EPDA 14.7 (2.86) vs. UC 8.75 (3.68), mean difference 6.0 (95% CI 1.9, 10.0), p = 0.005. There was no significant difference in interaction time: EPDA 4.2 min (3.2, 5.6) vs. UC 3.0 min (2.4, 4.4), p = 0.059. No difference was detected in immediate antibiotic prescriptions: EPDA 36% vs. UC 42%, odds ratio 0.76 (95% CI 0.33, 1.71), p = 0.50. Similarly, no significant difference was found in wait-and-see prescription use: EPDA 64% vs. UC 6a8%, odds ratio 1.32 (95% CI 0.59, 2.99), p = 0.50.
Conclusion:
Shared decision-making with the Ear Pain Decision Aid (EPDA) improved parental knowledge and engagement without significantly increasing interaction time in the emergency department. Although no significant reduction in antibiotic prescribing was observed, this may be due to the study's limited sample size, which increases the risk of Type II error. These findings support the feasibility of integrating shared decision-making tools into emergency care. Larger, multicenter studies are needed to further evaluate the EPDA's effectiveness in promoting antibiotic stewardship for pediatric acute otitis media.
Clinical Trials Number:
NCT02872558 26/03/2017.
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