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Barriers and Facilitators to Implementing Watchful Waiting for Pediatric Acute Otitis Media
Deborah J Rinehart1, Aiden Gilbert2, Leisha Andersen3
1Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, CO; Division of General Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
Insights
Clinicians and parents are open to watchful waiting for acute otitis media (AOM), but implementation requires addressing workflow, trust, and communication barriers. Optimizing these factors can reduce unnecessary antibiotic use in children.
Area of Science:
- Pediatrics
- Infectious Diseases
- Health Services Research
Background:
- Acute otitis media (AOM) is a common childhood infection.
- The American Academy of Pediatrics recommends watchful waiting over immediate antibiotic initiation for nonsevere AOM.
- Antibiotic overuse contributes to antimicrobial resistance.
Purpose of the Study:
- To identify facilitators and barriers to implementing watchful waiting for nonsevere AOM.
- To understand perspectives of clinicians, administrators, and parents on watchful waiting.
- To inform strategies for reducing unnecessary antibiotic prescribing for AOM.
Main Methods:
- Qualitative study using semistructured interviews with clinicians/administrators and focus groups with parents.
- Purposeful and convenience sampling across three healthcare systems.
- Analysis guided by the Practical Robust Implementation and Sustainability Model and Rapid Assessment Process.
Main Results:
- Barriers include lack of standard workflows, time constraints, trust issues, unclear parental guidance, fear of complications, and misconceptions about antibiotics.
- Patient-level barriers involve social factors like transportation, communication, and finances.
- Facilitators include a strong stewardship culture, clinician-family rapport, and parental desire for shared decision-making.
Conclusions:
- Clinicians, administrators, and parents are receptive to watchful waiting for AOM management.
- Modifiable factors can be leveraged to support watchful waiting adoption.
- Successful implementation can decrease unneeded antibiotic use in children with AOM.
Objective:
To assess facilitators and barriers to watchful waiting for nonsevere acute otitis media (AOM), as recommended by the American Academy of Pediatrics, rather than immediate antibiotic initiation.
Study Design:
In a qualitative study, purposeful sampling was used in to recruit clinicians and clinician administrators from three health care systems for semistructured interviews and convenience sampling was used to recruit parents of children aged 6 months or older with a recent diagnosis of AOM for focus groups. The Practical Robust Implementation and Sustainability Model guided the study. Interviews were analyzed using the Rapid Assessment Process.
Results:
Forty-four participants (23 clinicians/administrators and 21 parents) engaged in interviews and focus groups. Barriers to watchful waiting included lack of standard workflows and systems to support the process, time constraints, bidirectional trust, unclear instructions and processes for parents, fear of complications, parental misconceptions about antibiotics, and parental concerns about pain management. Patient-level obstacles included social factors, such as access to transportation, communication limitations, and finances. Facilitators included a strong stewardship culture, family/clinician rapport, and parent desire to participate in decision-making.
Conclusions:
Our findings suggest clinicians, administrators, and parents are receptive to watchful waiting for management of AOM in children. Several modifiable factors were identified that could support the utilization of watchful waiting and reduce unneeded antibiotic use among children.
Trial Registration:
NCT06034080.
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