Only a minority of family physicians comply with guidelines on the management of acute otitis externa in adults, whether they be residents working at a training clinic or more experienced clinicians in private practice, according to recent, unpublished research. Physicians are so hesitant to prescribe systemic antibiotics in this population that they leave patients without the medication they need, according to the investigators.

The most effective way to increase compliance may be to include relevant questions in the electronic health record, according to Dr. Sampath Medepalli, one of the investigators and a second-year resident in family practice at the Wichita Falls (Tex.) Family Practice Residency Program.

“Ultimately it is the physician’s responsibility to follow the guidelines, but by tweaking the EHR, we can ensure compliance,” he added, noting that the idea for this research stemmed from the American Board of Internal Medicine’s Choosing Wisely campaign.

The research found that physicians were twice as likely to fail to prescribe systemic antibiotics when warranted than they were to prescribe systemic antibiotics when unwarranted.

The investigators assessed whether management of 236 patients presenting with suspected acute otitis externa (AOE) was carried out according to guidelines issued by the American Academy of Otolaryngology-Head and Neck Surgery Foundation. The guidelines were issued first in 2006 and updated in 2014 ( Otolaryngol Head Neck Surg. 2014 Feb;150[1] suppl. S1-S24. doi: 10.1177/0194599813517083 , Dr. Medepalli said in an interview. The guidelines advise against prescribing oral antibiotics to adults unless they have complicated AOE, such as a ruptured tympanic membrane or have compromised immunity, due to diabetes, pharmacological immune suppression, or other factors.

The study was designed to assess whether family physicians prescribed antibiotics and analgesic appropriately and provided substantial patient education. Chart reviews of 236 adults diagnosed with AOE between 2009 and 2015 were included; the investigators excluded anyone with complicated AOE.

Of the patients treated in the private practice family medicine practice, topical antibiotics only were given to 106 patients with noncompromised immune systems, which was consistent with the guidelines. Eight patients without a compromised immune system were given systemic antibiotics, for a 62% compliance rate. In comparison, topical antibiotics were given to 11 patients with compromised immunity, and only 3 received systemic antibiotics (44% compliance with the guidelines).

Of patients treated by residents at the residency run training clinic, only 3 of 19 patients received unnecessary systemic antibiotics, for 64% compliance. The other 16 were treated with topical agents. Of the five patients with compromised immunity, only two received the systemic antibiotics for which they were candidates, for a 50% compliance.

Looking at all patients regardless of whether they received care from the training clinic or private practice, compliance with the guidelines was achieved for 62% of those with noncompromised immunity and 46% of those with immunity shortcomings. Overall 15.42% of family physicians treated patients in accordance with the AOE guidelines.

The investigators also assessed physicians’ pain management and found that only 29% of patients treated at the residency-run outpatient clinic and 13% of those treated in private practice received either topical or systemic medication to lessen the pain associated with their AOE.

The guidelines call for physicians to educate their patients about water precautions, use of prophylactic drops, and addressing their immune compromise among other topics related to AOE. In most cases neither the residents nor the private practitioners documented that they provided such counseling.

The average age of patients cared for at the residency clinic was 43.86 years while those who received care from the privater practice averaged 21.3 years of age, a significant difference (P less than .001). There were significantly fewer minority patients in the private practice clinic than the resident clinic (2% vs. 19%; P less than .001),

This research won the Doctor’s Choice award at the 2015 meeting of the Texas Medical Association Congress in Austin. The Wichita Falls Family Practice Residency Program funded the study. Dr. Medepalli and his associates had no relevant financial conflicts of interest to declare.


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