Otitis Media Prescriptions Differ by Race

Pam Harrison

November 17, 2014

Black children are 30% less likely to be diagnosed with otitis media than nonblack children, but when diagnosed, they are more likely to receive narrow-spectrum antibiotics, as recommended by current guidelines, than nonblack children, a multicenter study shows.

"Otitis media is a clinical diagnosis, and there is some subjectivity to it," Katherine Fleming-Dutra, MD, from Emory University School of Medicine, Atlanta, Georgia, told Medscape Medical News.

"But the fact that black children are more likely to receive guideline-recommended antibiotics raises the concern that the majority of US children may be receiving inappropriately broad-spectrum antibiotics for otitis media," she noted.

"Because the diagnosis of otitis media almost always results in an antibiotic prescription, our study reinforces the importance of using stringent criteria when diagnosing otitis media to reduce antibiotic overuse."

The study was published in the December issue of Pediatrics.

As Dr Fleming-Dutra observed, a recent study involving a single practice network in Philadelphia, Pennsylvania, showed that black children were less likely to be diagnosed with otitis media than white children.

Once diagnosed, however, they were also less likely to receive broad-spectrum antibiotics.

"Our objective was to see if this pattern was limited just to this practice network or if it existed nationally," Dr Fleming-Dutra noted.

Therefore, the investigators used the National Ambulatory Medical Care Survey, as well as the National Hospital Ambulatory Medical Care Survey, to examine visit rates for otitis media between 2008 and 2010 for children 14 years of age and younger.

They compared visits for otitis medical between black and nonblack children both as percentages of all outpatient visits and visit rates per 1000 children.

They also compared antibiotic prescribing by race as a percentage of otitis media visits during which either narrow-spectrum antibiotics or broader-spectrum antibiotics were prescribed.

Between 2008 and 2010, there were an estimated 19.2 million ambulatory visits by children aged 14 years and younger for otitis media, for an average of 6.4 million visits a year.

"Among these, 2.3 million (95% [confidence interval], 1.7–3.0 million) visits were by black children," the investigators observe.

Overall, the percentage of all visits that resulted in a diagnosis of otitis media for black children was significantly lower, at 7%, than for nonblack children, at 10% (P = .004).

The racial difference in diagnostic rates for otitis media was also seen across both younger and older children, at 10% vs 14% for children between 0 and 4 years of age and 4% vs 6% for those between 5 and 14 years of age (P = .004 and P = .02, respectively), the investigators add.

For all ages combined, visits per 1000 population leading to a diagnosis of otitis media trended lower for black children, but not significantly so.

In contrast, visits per 1000 population leading to a diagnosis of otitis media among children between 5 and 14 years of age were significantly lower among black children, at 89 per 1000 vs 143 per 1000 for nonblack children (P = .03).

Interestingly, the percentage of otitis media visits in which antibiotics were prescribed was similar among black and nonblack children, at 81% vs 76%, respectively.

However, broad-spectrum antibiotics were less likely to be prescribed for black children, at 42%, than for nonblack children, at 52% (P = .01).

Almost all narrow-spectrum antibiotics were penicillins or first-generation cephalosporins, with the sulfonamides being prescribed in less than 1% of visits.

No tetracyclines were prescribed in either group of children.

Provider Perception

Dr Fleming-Dutra noted that other studies have shown that when providers perceive that parents want antibiotics, "they are more likely to make bacterial diagnoses such as otitis media that justify antibiotic prescriptions and are more likely to prescribe antibiotics."

Other studies have also shown that race affects whether providers perceive that parents want antibiotics for their children.

"We think that race might influence interactions between parents and providers and whether providers perceive that parents want antibiotics," Dr Fleming-Dutra elaborated. "And these differences in perception could lead to racial differences in care for otitis media.

The study was funded by the Centers for Disease Control and Prevention. The authors have disclosed no relevant financial relationships.

Pediatrics. 2014;134:1059-1066.

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