Anderson Jana L, Oliveira J E Silva Lucas, Hess Erik P, Vanmeter Derek E, Mullan Aidan, Brito Juan P, Hargraves Ian G, Bellolio Fernanda
Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.
Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil.
BMC Emerg Med. 2025 Aug 2;25(1):146. doi: 10.1186/s12873-025-01305-w.
Shared decision-making is increasingly utilized when multiple reasonable options exist. In the emergency department, however, several perceived barriers-such as time constraints, illness complexity, and varying levels of acceptance-limit its use. In cases of acute otitis media (AOM) in children, parental expectations for immediate antibiotic treatment often conflict with national guidelines recommending a trial of analgesics for 48 to 72 h prior to initiating antibiotics. As a result, antibiotic prescribing rates in the emergency department remain high, reaching up to 96%. Our aim was to measure the impact of the ear pain decision aid on parental knowledge, engagement and antibiotic use.
We conducted a randomized trial in the Emergency Department and affiliated Urgent Care setting comparing shared decision-making with a web-based decision aid (earpaindecisionaid.org) to usual care for parents of children aged 6 months and older with non-severe AOM. Outcomes included parental knowledge of AOM, clinician/parent engagement, interaction time, and antibiotic use.
One hundred-one parents were enrolled; 42 participated in the Ear Pain Decision Aid (EPDA) arm using shared decision-making, while 59 received usual care (UC). Fifty-one interactions were videotaped. Parents in the EPDA arm scored greater in knowledge: EPDA 6.1 (1.74) vs. UC 5.1 (1.79), mean difference 1.0 (95% CI 0.3, 1.7), p = 0.004. They also scored high in decision-making: EPDA 14.7 (2.86) vs. UC 8.75 (3.68), mean difference 6.0 (95% CI 1.9, 10.0), p = 0.005. There was no significant difference in interaction time: EPDA 4.2 min (3.2, 5.6) vs. UC 3.0 min (2.4, 4.4), p = 0.059. No difference was detected in immediate antibiotic prescriptions: EPDA 36% vs. UC 42%, odds ratio 0.76 (95% CI 0.33, 1.71), p = 0.50. Similarly, no significant difference was found in wait-and-see prescription use: EPDA 64% vs. UC 6a8%, odds ratio 1.32 (95% CI 0.59, 2.99), p = 0.50.
Shared decision-making with the Ear Pain Decision Aid (EPDA) improved parental knowledge and engagement without significantly increasing interaction time in the emergency department. Although no significant reduction in antibiotic prescribing was observed, this may be due to the study's limited sample size, which increases the risk of Type II error. These findings support the feasibility of integrating shared decision-making tools into emergency care. Larger, multicenter studies are needed to further evaluate the EPDA's effectiveness in promoting antibiotic stewardship for pediatric acute otitis media.
NCT02872558 26/03/2017.
当存在多种合理选择时，共同决策的应用越来越广泛。然而在急诊科，一些可感知的障碍，如时间限制、病情复杂性和不同程度的接受度，限制了其使用。在儿童急性中耳炎（AOM）病例中，家长对抗生素立即治疗的期望往往与国家指南相冲突，国家指南建议在开始使用抗生素前先试用48至72小时的镇痛药。因此，急诊科的抗生素处方率仍然很高，高达96%。我们的目的是评估耳部疼痛决策辅助工具对家长知识、参与度和抗生素使用的影响。
我们在急诊科及附属紧急护理机构进行了一项随机试验，将共同决策与基于网络的决策辅助工具（earpaindecisionaid.org）相比较，用于6个月及以上非重症AOM儿童的家长的常规护理。结果包括家长对AOM的知识、临床医生/家长的参与度、互动时间和抗生素使用情况。
共招募了101名家长；42名家长参与了使用共同决策的耳部疼痛决策辅助工具（EPDA）组，59名家长接受常规护理（UC）。录制了51次互动过程。EPDA组家长在知识方面得分更高：EPDA组为6.1（1.74），UC组为5.1（1.79），平均差异为1.0（95%可信区间0.3，1.7），p = 0.004。他们在决策方面得分也更高：EPDA组为14.7（2.86），UC组为8.75（3.68），平均差异为6.0（95%可信区间1.9，10.0），p = 0.005。互动时间没有显著差异：EPDA组为4.2分钟（3.2，5.6），UC组为3.0分钟（2.4，4.4），p = 0.059。即时抗生素处方方面未发现差异：EPDA组为36%，UC组为42%，比值比为0.76（95%可信区间0.33，1.71），p = 0.50。同样，在观察等待处方使用方面也未发现显著差异：EPDA组为64%，UC组为68%，比值比为1.32（95%可信区间0.59，2.99），p = 0.50。
使用耳部疼痛决策辅助工具（EPDA）的共同决策提高了家长的知识和参与度，且在急诊科没有显著增加互动时间。虽然未观察到抗生素处方有显著减少，但这可能是由于研究样本量有限，增加了II类错误的风险。这些发现支持了将共同决策工具整合到急诊护理中的可行性。需要更大规模的多中心研究来进一步评估EPDA在促进儿童急性中耳炎抗生素管理方面的有效性。
NCT02872558 2017年3月26日
