Educational program reduces ED visits for otitis.

An educational program for anticipating and managing ear pain, presented by nurses to parents at the 15-month well-child visit, significantly cut health care costs over the following year, especially for emergency department visits.

Parents and physicians alike gave high marks to the program, which reduced visits to the emergency department (ED) for acute otitis media (AOM) by 80% and yielded a net savings of about $50 per child, Dr. Deborah B. McWilliams and her colleagues at the Mayo Clinic, Rochester, Minn., wrote (Arch. Pediatr. Adolesc. Med. 2008;162:151-6).

In an editorial in the same issue, Dr. Stephen Berman of the Children's Hospital, Denver, wrote that the program "demonstrates one of the small steps that can be taken to shift our emphasis to parental empowerment and shared decision making" to improve performance in pediatric practice while also reducing costs to maximize the value of health care services (Arch. Pediatr. Adolesc. Med. 2008; 162:186-8).

In the controlled study that was conducted during a 3-month period in 2003, nurses gave 5- to 10-minute structured PowerPoint presentations to the parents of 191 children who were being seen for their 15-month well-child visit. The investigators also recruited a control cohort of 133 children at any of the other Mayo Clinic practices at the time of the interventions. Children with tympanostomy tubes were not allowed into the study.

The presentation reviewed how to recognize ear pain, how to safely relieve pain (including the use of antipyrine-benzocaine analgesic ear drops as well as dosing instructions for ibuprofen and acetaminophen), and how to recognize the danger signs that require urgent medical attention. The nurses also explained why it would be beneficial to schedule an appointment with the child's pediatrician on the following day for possible AOM, rather than going to the ED after hours.

Compared with the previous year, ED visits declined by 80%, urgent care visits dropped by 40%, and regular-hours primary care office visits decreased by 28% in the intervention group. The control arm saw no significant decrease in visits to these venues.

Of 88 parent responses to survey questions at the 24-month well-child visit, 42% said that their child had experienced ear pain since the 15-month well-child visit. In that subgroup of parents, 86% thought that the educational program had helped them to avoid an ED or after-hours visit. Nearly 90% of these respondents thought that the prescription for antipyrine-benzocaine otic drops that each parent was given at the 15-month well-child visit also had helped them to avoid an ED or after-hours visit.

"Because total visits for ear pain also decreased significantly, there must have been not only a potential shift from after-hours visits to primary care but also a realization by parents that much of the ear pain is controllable and transient, not always requiring a medical appointment," Dr. Berman wrote.

Parental support for the intervention was very high among the 97 survey respondents at the 15-month well-child visit, and also among the 88 respondents at the 24-month visit.

A 3-year review of medical records since the intervention revealed no cases of mastoiditis or otolaryngologic, ED, or hospital visits that could be attributed to a delay in medical attention or antibiotic therapy.

The estimated costs of the project would have totaled $12,040 per 1,000 patients, saving at least $65,779 per 1,000 patients based on the cost of ED, urgent care center, and regular hours primary care visits at the Mayo Clinic. This translated into a net savings of about $50 per child.

Other than an absence of randomization, the study was limited by a reliance on control data from other local clinic sites, a lack of information on parent education levels in the groups, and a lack of data on how many patients used or filled the prescription.

BY JEFF EVANS

Senior Writer