Finkelstein Jonathan A, Stille Christopher J, Rifas-Shiman Sheryl L, Goldmann Donald
Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA.
Pediatrics. 2005 Jun;115(6):1466-73. doi: 10.1542/peds.2004-1473.
To assess the current use of initial observation ("watchful waiting") of acute otitis media among community physicians and the acceptability of this option to parents of young children.
Sixteen nonoverlapping Massachusetts communities enrolled in a community intervention study on appropriate antibiotic use.
Pediatricians, family physicians, and a random sample of parents of children <6 years old were surveyed. Parents predicted what their satisfaction would be with initial observation of an ear infection without antibiotics if suggested by their physician and concerns they would have regarding this watchful-waiting approach. Physicians reported the frequency with which they use this approach in children > or =2 years and those <2 years old. Separate multivariable models identified factors independently associated with parental satisfaction and with frequency of self-reported use by physicians. All models accounted for clustering of responses within communities.
Two thousand fifty-four (40%) parents and 160 (58%) physicians responded. Of the parents, 34% would be somewhat or extremely satisfied if initial observation was recommended, another 26% would be neutral, and the remaining 40% would be somewhat or extremely dissatisfied. The multivariable model showed lower parental education (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.35, 0.71, for high school education or less compared with college graduation) and Medicaid enrollment (OR: 0.77; CI: 0.57, 1.0) was associated with lower predicted satisfaction. Higher antibiotic-related knowledge (OR: 1.2; CI: 1.1, 1.3, per question correct), belief that antibiotic resistance is a serious problem (OR: 2.3; CI: 1.8, 2.8), and reporting feeling included in medical decisions (OR: 1.4; CI: 1.1, 1.7) all were independently associated with higher predicted satisfaction. Thirty-eight percent of physicians treating children > or =2 years old never or almost never reported using initial observation, 39% reported use occasionally, 17% sometimes, and 6% most of the time. In a multivariable model, only more years in practice (OR: 0.96; CI: 0.93, 0.99) was associated with a decreased likelihood of occasional or more-frequent use of watchful waiting (compared with those who never use initial observation). However, a secondary model that combined occasional users with nonusers (compared with those reporting use sometimes or more often) identified several correlates of use of observation: years in practice (OR: 0.95; CI: 0.91, 0.99), family medicine specialization (OR: 4.5; CI: 1.9, 11), belief that antibiotic resistance is a significant problem (OR: 4.3; CI: 1.3, 14.5), and practice in a community receiving a judicious antibiotic-use intervention (OR: 3.5; CI: 1.3, 9.1).
A majority of physicians reported at least occasionally using initial observation, but few use it frequently. Many parents have concerns regarding this option, but acceptability is increased among those with more education and those who feel included in medical decisions. Substantial change in both parental and provider views would be needed to make initial observation a widely used alternative for acute otitis media.
评估社区医生目前对急性中耳炎采用初始观察（“密切观察等待”）的情况以及幼儿家长对该选择的接受程度。
马萨诸塞州16个不重叠的社区参与了一项关于合理使用抗生素的社区干预研究。
对儿科医生、家庭医生以及随机抽取的6岁以下儿童的家长进行了调查。家长们预测如果医生建议对耳部感染进行不使用抗生素的初始观察，他们的满意度如何，以及他们对这种密切观察等待方法的担忧。医生报告了他们在2岁及以上和2岁以下儿童中使用这种方法的频率。分别采用多变量模型确定与家长满意度以及医生自我报告的使用频率独立相关的因素。所有模型都考虑了社区内回答的聚类情况。
2554名（40%）家长和160名（58%）医生做出了回应。在家长中，如果建议进行初始观察，34%会有点满意或非常满意，另外26%会持中立态度，其余40%会有点不满意或非常不满意。多变量模型显示，家长教育程度较低（高中及以下学历与大学毕业相比，优势比[OR]：0.50；95%置信区间[CI]：0.35，0.71）和参加医疗补助计划（OR：0.77；CI：0.57，1.0）与较低的预测满意度相关。抗生素相关知识较高（每个正确回答的问题，OR：1.2；CI：1.1，1.3）、认为抗生素耐药性是一个严重问题（OR：2.3；CI：1.8，2.8）以及报告感觉参与了医疗决策（OR：1.4；CI：1.1，1.7）均与较高的预测满意度独立相关。在治疗2岁及以上儿童的医生中，38%从未或几乎从未报告使用初始观察，39%报告偶尔使用，17%有时使用，6%大部分时间使用。在多变量模型中，只有执业年限更长（OR：0.96；CI：0.93，0.99）与偶尔或更频繁使用密切观察等待的可能性降低相关（与那些从未使用初始观察的医生相比）。然而，一个将偶尔使用者与非使用者合并的二级模型（与那些报告有时或更频繁使用的医生相比）确定了观察使用的几个相关因素：执业年限（OR：0.95；CI：0.91，0.99）、家庭医学专业（OR：4.5；CI：1.9，11）、认为抗生素耐药性是一个重大问题（OR：4.3；CI：1.3，14.5）以及在接受明智抗生素使用干预的社区执业（OR：3.5；CI：1.3，9.1）。
大多数医生报告至少偶尔使用初始观察，但很少有人经常使用。许多家长对该选择存在担忧，但在受教育程度较高以及感觉参与了医疗决策的家长中，接受程度有所提高。要使初始观察成为急性中耳炎广泛使用的替代方法，家长和医疗服务提供者的观点都需要有实质性改变。
