Shared decision-making for pediatric acute otitis media in the United States: a randomized emergency department trial

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

Clinical trials number: NCT02872558 26/03/2017.

Keywords: Acute otitis media; Decision aid; Emergency medicine; Shared decision-making.

Fig. 1

Clinician and patient flow diagram