Following watchful waiting guidelines for children with AOM cost-effective
CarlaKemp, Senior Editor
The appropriate use of watchful waiting for children with acute otitis media (AOM)
could reduce costs and improve health outcomes, a new study shows.
Watchful waiting involves observing children with uncomplicated AOM for 48 to 72 hours
to allow for spontaneous recovery without antibiotics. The 2004 AAP clinical practice guideline on diagnosis and management of AOM offered it as an option for children based on
age, diagnostic certainty, illness severity and likelihood of follow-up. The 2013
guidelines also recommend watchful waiting.
“While reducing the rate of antibiotic prescriptions may save on prescription costs
and antibiotic side effects, this must be balanced against costs to the parents, such
as time lost from work, cost of additional analgesic, and repeat office visits or
With these added costs, it is unclear if the WW (watchful waiting) approach would
be cost-effective to society, according to the authors of the study “Cost-Effectiveness
of Watchful Waiting in Acute Otitis Media” (Sun D, et al. Pediatrics. March 3, 2017, https://doi.org/10.1542/peds.2016-3086).
To determine how AOM is currently managed, researchers reviewed electronic health
record (EHR) data for 247 randomly selected patients diagnosed with AOM at a children’s
hospital emergency department from April 2014 to January 2015. They looked at discharge
instructions to see if patients received antibiotics or were instructed on watchful
waiting. They also identified how many patients qualified for watchful waiting based
on AAP guidelines.
Data from the EHR, Medicaid and hospital costs then were used to create a decision-analytic
model of a hypothetical cohort of 1,000 children with AOM. The model included direct
and indirect costs (i.e., antibiotics, analgesics, missed work days, office visits,
hospital stays) as well as disability-adjusted life years (DALYs).
Costs and DALYs were calculated for current practice and compared to costs and DALYs
if all patients who met the criteria for watchful waiting received such care.
Results showed 231 (93.5%) patients received an antibiotic prescription, even though
143 patients (57.9%) qualified for watchful waiting.
Using the decision-analytic model, the authors determined that costs would be lower
and there would be fewer DALYs if watchful waiting had been used for all who qualified
compared to current practice. For every 1,000 patients with AOM, there would be 514
fewer immediate antibiotic prescriptions and 205 fewer antibiotic courses overall.
In addition, about 14 DALYs would have been avoided and $5,573 would have been saved.
“This study demonstrates that implementing WW for AOM management when consistent with
the AAP guidelines is cost-effective from a societal perspective,” the authors concluded.
“This suggests that, though the WW approach requires additional patient follow-up,
and increasing utilization of this option would likely require additional provider
and parental education, appropriate use of this strategy could simultaneously reduce
health expenditures, improve health outcomes, and be cost-saving to society.”