title: Watchful waiting for acute otitis media: are parents and physicians ready?
abstract: OBJECTIVE
  To assess the current use of initial observation ("watchful waiting") of acute otitis media among community physicians and the acceptability of this option to parents of young children.
  
  
  METHODS
  Sixteen nonoverlapping Massachusetts communities enrolled in a community intervention study on appropriate antibiotic use.
  
  
  METHODS
  Pediatricians, family physicians, and a random sample of parents of children <6 years old were surveyed. Parents predicted what their satisfaction would be with initial observation of an ear infection without antibiotics if suggested by their physician and concerns they would have regarding this watchful-waiting approach. Physicians reported the frequency with which they use this approach in children > or =2 years and those <2 years old. Separate multivariable models identified factors independently associated with parental satisfaction and with frequency of self-reported use by physicians. All models accounted for clustering of responses within communities.
  
  
  RESULTS
  Two thousand fifty-four (40%) parents and 160 (58%) physicians responded. Of the parents, 34% would be somewhat or extremely satisfied if initial observation was recommended, another 26% would be neutral, and the remaining 40% would be somewhat or extremely dissatisfied. The multivariable model showed lower parental education (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.35, 0.71, for high school education or less compared with college graduation) and Medicaid enrollment (OR: 0.77; CI: 0.57, 1.0) was associated with lower predicted satisfaction. Higher antibiotic-related knowledge (OR: 1.2; CI: 1.1, 1.3, per question correct), belief that antibiotic resistance is a serious problem (OR: 2.3; CI: 1.8, 2.8), and reporting feeling included in medical decisions (OR: 1.4; CI: 1.1, 1.7) all were independently associated with higher predicted satisfaction. Thirty-eight percent of physicians treating children > or =2 years old never or almost never reported using initial observation, 39% reported use occasionally, 17% sometimes, and 6% most of the time. In a multivariable model, only more years in practice (OR: 0.96; CI: 0.93, 0.99) was associated with a decreased likelihood of occasional or more-frequent use of watchful waiting (compared with those who never use initial observation). However, a secondary model that combined occasional users with nonusers (compared with those reporting use sometimes or more often) identified several correlates of use of observation: years in practice (OR: 0.95; CI: 0.91, 0.99), family medicine specialization (OR: 4.5; CI: 1.9, 11), belief that antibiotic resistance is a significant problem (OR: 4.3; CI: 1.3, 14.5), and practice in a community receiving a judicious antibiotic-use intervention (OR: 3.5; CI: 1.3, 9.1).
  
  
  CONCLUSIONS
  A majority of physicians reported at least occasionally using initial observation, but few use it frequently. Many parents have concerns regarding this option, but acceptability is increased among those with more education and those who feel included in medical decisions. Substantial change in both parental and provider views would be needed to make initial observation a widely used alternative for acute otitis media.
authors.affiliation: Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA. jonathan_finkelstein@harvardpilgrim.org
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Finkelstein
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Stille
authors.forename: Sheryl L
authors.initials: SL
authors.lastname: Rifas-Shiman
authors.forename: Donald
authors.initials: D
authors.lastname: Goldmann
mesh_terms: D000208:Acute Disease; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D019090:Case Management; D002648:Child; D002675:Child, Preschool; D003469:Culture; D003625:Data Collection; D003657:Decision Making; D004351:Drug Resistance; D005194:Family Practice; D006801:Humans; D007223:Infant; D008404:Massachusetts; D009035:Mothers / Q000523:psychology; D010033:Otitis Media / Q000188:drug therapy / Q000628:therapy*; D010290:Parents / Q000523:psychology*; D010342:Patient Acceptance of Health Care; D010353:Patient Education as Topic; D010372:Pediatrics; D010549:Personal Satisfaction; D010820:Physicians / Q000523:psychology*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012494:Sampling Studies
chemical_list: D000900:Anti-Bacterial Agents