Impact of a Quality Improvement Intervention on Antibiotic Prescribing for Children with Acute Otitis Media in Emergency and Urgent Care Settings

Abstract Corresponding Author: Joana Dimo, DO, Department of Pediatrics, Division of Infectious Diseases, University of Colorado, 13123 East 16th Avenue, Box 055, Aurora, CO 80045, USA. 216-210-4687. [email protected] Alternate Corresponding Author: Nicole M. Poole, MD, Department of Pediatrics, Division of Infectious Diseases, University of Colorado, 13123 East 16th Avenue, Box 055, Aurora, CO 80045, USA. (720) 777-7507. [email protected] Funding: None No conflicts of interest Background Acute otitis media (AOM), the most common indication for pediatric antibiotics in the US, self-resolves without antibiotics in 60-75% of cases. This study evaluates the impact of a quality improvement intervention on antibiotic prescribing rate, first-line antibiotic choice, and treatment duration for pediatric AOM. Methods A bundled intervention for AOM management included (1) an electronic health record (EHR) order set that preselected a 5-day duration for children 24 months and older prescribed an antibiotic for AOM (April 2021) and (2) creation of a local clinical care pathway (CCP) for AOM (December 2022). The pathway encouraged observation and pain management in children 24 months and older with non- severe AOM, as well as children 6-23 months with unilateral, non-severe AOM. Non-severe AOM was defined as lack of severe otalgia following pain medication, temperature greater than 39☐C, and tympanic membrane perforation. A retrospective review of pediatric patients 61 days to 18 years old presenting to emergency and urgent care centers between January 2019 through September 2023 was conducted. Outcomes were (1) rates of antibiotic prescribing (oral or intramuscular formulations) over total AOM encounters in patients 61 days to 18 years old, (2) treatment duration of less than or equal to 5 days over all antibiotics prescribed (excluding azithromycin courses) in patients 24 months to 18 years old, and (3) first line antibiotic choice defined as amoxicillin over all antibiotics prescribed in patients 61 days to 18 years old. Statistical process control charts with upper and lower control limits and identified “special cause” variation by standard definitions were used to analyze outcomes. Results A total of 34,324 patients were included in the study. Rates of antibiotic prescribing remained high throughout the study time period (88 to 93%), with special cause variation detected (Figure 1). After EMR order-set development, a significant increase in compliance with recommended duration of less than or equal to 5 days was observed (3% to 83%), with special cause variation over the study period (Figure 2). Rates of amoxicillin prescribing versus non-first line antibiotic decreased throughout the study time (77 to 74%), with special cause decrease throughout the study (Figure 3). Conclusion Implementation of an EMR order set resulted in substantial increase in shorter durations for AOM in patients older than 24 months. Antibiotic prescribing rates increased, and amoxicillin prescribing decreased throughout study period. The effect of the amoxicillin shortage, which started in October 2022, likely played a role in amoxicillin prescribing rates, though increased use of amoxicillin with increasing supply has not yet been observed. This project indicated that further dissemination of the new AOM guideline and de-implementation of previous practices is needed to achieve improvement in antibiotic prescribing and first line antibiotic use. Figure 1: Proportion of antibiotics prescribed per all AOM diagnoses in patients 61 days to 18 years old. Figure 2: Proportion of patients with duration of 5 or fewer days compared to all duration in patients 2 years to 18 years old. Figure 3: Proportion of amoxicillin prescribed per all antibiotics in patients 61 days to 18 years old.