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Considering the full care pathway in regional variation in paediatric otitis media treatment in the Netherlands: an

Vera de Weerdt1,2, Christel van Dijk3, Jako Burgers4,5

  • 1Health Economics, Vrije Universiteit, Amsterdam, the Netherlands.

BMJ Open
|August 19, 2025
PubMed

Insights

Regional variation in paediatric otitis media (POM) treatment, including acute otitis media (AOM) and otitis media with effusion (OME), decreases when accounting for prior care steps. Adjusting for frequent AOM/persistent OME rates significantly reduces variation in referrals and surgeries.

Area of Science:

  • Otolaryngology
  • Health Services Research
  • Paediatric Medicine

Background:

  • Paediatric otitis media (POM) treatment, including ventilation tube insertion for acute otitis media (AOM) and otitis media with effusion (OME), has shown potential for unwarranted regional variation.
  • Quality improvement initiatives like Audit & Feedback (A&F) may overestimate variation by not considering the entire care pathway.

Purpose of the Study:

  • To assess regional variation across all steps of the POM care pathway: general practitioner (GP) contacts, referrals, and surgeries.
  • To investigate the impact of prior care steps on the observed regional variation in POM treatment.

Main Methods:

  • An observational study utilizing linked electronic health records from general practices and specialist claims data.
  • Analysis of 272,790 children aged 12 years or younger between 2017 and 2018.
  • Multilevel logistic regression was used to calculate the coefficient of variation (CV) for each care step and assess the effect of adjusting for prior care processes.

Main Results:

  • Regional variation increased progressively through the care pathway: GP contacts (CV 0.110), referrals (CV 0.179), and surgery (CV 0.239).
  • Higher rates of frequent AOM/persistent OME correlated with increased referral (OR 1.06) and surgical rates (OR 1.08).
  • Adjusting for regional frequent AOM/persistent OME prevalence significantly reduced variation in referrals (CV 0.103 vs 0.128) and surgery (CV 0.047 vs 0.059).

Conclusions:

  • Regional variation exists in GP contacts for POM and is more pronounced in subsequent referral and surgical steps.
  • Accounting for the prevalence of frequent AOM/persistent OME substantially mitigates regional treatment variation.
  • Future quality improvement efforts, including A&F, should incorporate prior care pathway data and develop targeted interventions for POM management.
Abstract

Keywords:
Paediatric otolaryngologyPrimary CareQuality Improvement

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