|Year : 2019 | Volume
| Issue : 1 | Page : 127-132
Adherence to Egyptian pediatric acute otitis media guideline in Egypt
Ahmed Ragab1, Hala M Elmoselhy Shaheen2, Nagwa N Hegazy2, Alaa A. A. El-Sweedy3
1 Department of ENT, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Family Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Family Medicine, Benha Family Health Centre, Benha, Egypt
|Date of Submission||20-Jun-2016|
|Date of Acceptance||03-Jul-2016|
|Date of Web Publication||17-Apr-2019|
Alaa A. A. El-Sweedy
Department of Family Medicine, Benha Family Health Centre, Benha
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess the adherence of different specialties (family physicians, pediatricians, and otolaryngologists) to Egyptian clinical practice guideline dealing with pediatric acute otitis media (AOM) in Egypt.
Egyptian clinical practice guideline for AOM has been promoted as a strategy to measure and improve the quality of patient care. However, more efforts have been expended on creating guidelines than implementing them.
Patients and methods
It was a cross-sectional descriptive study. Participants from different specialties, such as family physicians, pediatricians, and otolaryngologists were selected by systematic random techniques from the list of participants in the conferences. A self-administered questionnaire with 26 items that covered all the aspects of management of Egyptian clinical practice guideline for AOM was distributed to the participants to assess their adherence to the Egyptian guideline of AOM.
Poor adherence to the Egyptian guideline of AOM was detected in all specialties without significant differences (92.5% of family physicians, 100% of otolaryngologists, and 100% of pediatricians). A physician's age, sex, scientific degree, and experience did not significantly affect the adherence.
Poor adherence of different specialties to the Egyptian guideline of AOM in Egypt was observed. Resolving this challenge will require comprehensive policy appraisal and harmonized actions at different AOM health care providers. Mere dissemination of evidence and promotion of guidelines will not help.
Keywords: adherence, diagnosis, guideline, otitis media, treatment and child
|How to cite this article:|
Ragab A, Elmoselhy Shaheen HM, Hegazy NN, El-Sweedy AA. Adherence to Egyptian pediatric acute otitis media guideline in Egypt. Menoufia Med J 2019;32:127-32
|How to cite this URL:|
Ragab A, Elmoselhy Shaheen HM, Hegazy NN, El-Sweedy AA. Adherence to Egyptian pediatric acute otitis media guideline in Egypt. Menoufia Med J [serial online] 2019 [cited 2019 May 27];32:127-32. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/127/256101
| Introduction|| |
The WHO and UNICEF developed integrated management of childhood illnesses (IMCI) in 1990 to reduce morbidity and mortality . IMCI was developed in settings where child mortality was high and where simple and inexpensive solutions were needed . IMCI is an evidence-based strategy that comprised of strengthening the skills of health workers, the health system, and family and community health practices. More than 100 countries have adopted the components of IMCI for the management of common child diseases including acute otitis media (AOM) . IMCI is the main source of the Egyptian guideline concerning AOM in children.
AOM is an inflammation of the middle ear cleft, with or without intact tympanic membrane . AOM is one of the most common reasons for children under 5 years of age to present to a doctor and to be prescribed antibiotics . AOM is generally self-limiting but its recurrence and frequency entail high direct health care costs and indirect costs for parents , as well as a burden on family affecting the quality of life. Despite a superficial familiarity, AOM still poses many challenges of definition, assessment, and indications for the treatment ,.
The Egyptian guidelines depends mainly in diagnosis of AOM on recent acute otorrhea of mucopurulant discharge or acute ear pain . The Egyptian guideline (2010) (IMCI) recommends the treatment of pain by giving paracetamol 120 mg/5 ml every 6 h until the pain or fever subsides, as shown in [Table 1] .
|Table 1: Paracetamol for ear pain according to the Egyptian guideline (2010)|
Click here to view
]There are other guidelines that recommend topical agent like benzocaine, naturopathic agents, homeopathic agents, narcotic analgesia with codeine or analogs, and tympanostomy or myringotomy in cases of severe pain of AOM ,,.
The Egyptian guideline (IMCI) recommends amoxicillin as a first-line antibiotic in managing AOM for 10 days. The doses of amoxicillin is 20 to 40 milligrams (mg) per kilogram (kg) of body weight per day, divided and given every 8 hours. There are other recommended guidelines of AOM observation policy before starting with antibiotics. The Egyptian guideline (2010) (IMCI) recommends amoxicillin as a first-line antibiotic for 10 days for treating AOM.
The Egyptian guideline (IMCI) recommends cotrimoxazole (40 mg trimethoprim +200 mg sulphamethoxazole per 5 ml for 10 days) as a second-line antibiotic in managing . Others guidelines recommend amoxicillin–clavulanate as a second-line antibiotics therapy ,,. The Egyptian guideline (IMCI) recommends frequent breastfeeding and for longer durations .
So the aim of the present study was to assess the adherence of different specialties (family physicians, pediatricians, and otolaryngologists) to Egyptian (IMCI) dealing with pediatric AOM in Egypt. This will allow coordinated actions to solve different AOM health care problems.
| Patients and Methods|| |
The present study is a descriptive analytical study aiming for assessing the adherence of different specialties (family physicians, pediatricians, and otolaryngologists) dealing with AOM. The target population was all physicians specialty dealing with cases of AOM (family medicine, pediatrician, and otolaryngologists). Ethical considerations were followed during the study, with total confidentiality of any obtained data. The study was approved by the Ethical Committee of the Faculty of Medicine, Menoufia University; an official permission letter was obtained and directed to the administrators in selected departments' congresses. Informed consent was obtained from all the participants after a simple and clear explanation of the research objectives. Participants were recruited during Menoufia department's congresses. They were selected by systematic random techniques. Every third person from the list was selected. The total number of physicians registered in the list of attendance included, respectively, 200 family physicians, 160 otolaryngologists, and 170 pediatricians. Participants who were selected to participate in the study were 66 family physicians, 56 pediatricians, and 60 otolaryngologists. Some of the study samples were excluded from participation due to their incomplete submitted questionnaire or because they did not submit their questionnaire to the researcher. Therefore, the final sample of the study included 53 family physician, 48 otolaryngologists, and 51 pediatricians. All participants were subjected to a self-administered designed questionnaire to assess guidelines adherence. It was collected on the spot after being filled. Data were collected from June 2014 to the first of May 2015.
The questionnaire had enclosed six sections; the first included 10 questions to assess the sociodemographic characters of the studied participants, the second section was about the frequency of AOM in the participant practice, the third section contained four questions for AOM diagnosis, and the fourth section had four questions for the plane of management of AOM that reflected the different aspects of the guideline. The fifth section had six questions about drugs recommended and not recommended in AOM. The sixth section had five questions about the prevention of AOM. If 50% or more of the participants' responses reflected Egyptian guideline, the participant himself/herself can be classified as adhered to that guideline. The questionnaire consisted of six different parts. The questionnaire was validated. Data were collected from June 2014 to the first of May 2015.
The results were collected, tabulated, and analyzed statistically using Microsoft Excel and SPSS, version 17 software programs (SPSS Inc., Chicago, Illinois, USA). The Student t test was used as a test of significance for comparison between two quantitative variables. χ2 tests were used to compare categorical outcomes. A P value less than 0.05 was considered statistically significant.
| Results|| |
The present result showed that there was a statistically significant difference between the physicians who adhered and not adhered to the Egyptian guideline as 92% of the family physicians, 100% of the otolaryngologists, and 100% of the pediatricians poorly adhered to the Egyptian guideline [Table 2].
|Table 2: Adherence to different specialties as per the Egyptian guideline|
Click here to view
The age, sex, and years of experience of family physicians, pediatricians, and otolaryngologists had no effect on their adherence to Egyptian AOM guideline [Table 3].
In this study, there was a statistically significant difference between different specialties concerning their adherence in diagnosing AOM, treating otalgia, treatment of mild bilateral AOM, and treatment recurrent AOM as P value is less than 0.05 and, therefore, is significant [Table 4].
|Table 4: The effect of age, experience, degree, and sex on adherence to the Egyptian guideline while dealing with acute otitis media|
Click here to view
| Discussion|| |
Comparing physicians who adhered and those who did not adhere to the Egyptian guideline in general, in the present study, revealed that there was a statistically significant difference between family physicians, pediatricians, and otolaryngologists regarding their adherence to the AOM guideline. The study indicated that about 100% of the otolaryngologists, 92.2% of the family physicians, and 100% of the pediatricians poorly adhered to the Egyptian AOM guideline. These results were in agreement with the study, which reported that otolaryngologists had the lowest adherence to the guideline than other physicians dealing with AOM; and that their antibiotic choices are mainly cefprozil and clarithromycin, which are not recommended . Another study revealed that 46.4% of the pediatricians adhered to the guideline of otitis media while it was only 19% of the family physicians who adhered to the same . These results are in contrast to the Danhauer's  study conducted in the United States, which reported that the pediatricians (94%) adhered to the American guideline rather than other guidelines dealing with otitis media. Another study urged that (a) most otolaryngologists (70%) were influenced by evidence-based guidelines, (b) 62% stated that evidence-based guidelines supported their clinical practice, (c) 32% stated that these guidelines directed their clinical practice, (d) the mean confidence in the evidence or recommendations stated in the guidelines was 77%, and (e) the mean percentage of nonadherence to the guideline recommendations was 45% . In contrast, other studies were in agreement with the results of the present study that revealed that the awareness of the otitis media guidelines was about 34%, which could be considered as a low percentage. However, about 44% reported a change in their patient management as a result of these guidelines . Another study on otitis media and otitis media with effusion documented that the clinical practices of clinicians remained unchanged even after the release of the American guideline (2004) and the percentage of their adherence to this guideline was low .
Why the majority of the clinicians did not adhere to the guidelines is explained by Haggard . He stated that this might be due to physicians' inertia and culture; lack of appropriate incentives; lack of detailed knowledge because of poor dissemination; conflicts of interest; parental pressure; insufficient use of appropriate analgesia; uncertain diagnosis; and concerns over possible complication for not treating the infection . While Lugtenberg et al.  argued that 68% of the causes for nonadherence to the guidelines was due disagreements with the guideline recommendations. A similar study revealed that a physician's adherence to the guidelines varies with different types of patient and also with the duration of the clinical experience .
Moreover, the present study's results reflected the age and experience as a variable that affects the adherence of different specialties to the Egyptian AOM guideline. Other studies confirmed the same results without differences in adherence to the AOM guideline with respect to age, sex, or experience. Other researchers identified age as an important determinant factor leading to significant differences regarding the implementation of the guidelines. This study revealed that about 59% who graduated after 1986 preferred using evidence-based medical guidelines while 39% of those graduated before 1986 did not prefer using them. This indicated that the younger the physicians are, the more they are inclined to use these medical guidelines .
One study urged that because many physicians receive little or no comparative feedback on their performance; they tend to rely on their own judgment and personal experience to determine whether or not they are doing the right thing for the patients. Their experience is influenced by their culture, beliefs, and habits. In contrast to Kenefick's study and in obvious consistency with the previous results related to age, the present study indicated that experience as a variable did not significantly affect the adherence of different specialties to different guidelines . These results were in contrast with Baback's (2012) study in which the recently graduated physicians adhered to the guidelines more compared to those who have more experience in practice .
In this study, there was a statistically significant difference between different specialties concerning their adherence to the Egyptian AOM guideline in diagnosing AOM. This difference was in favor of the pediatricians' adherence (25.7%) to the Egyptian guideline (IMCI) while only 3.9% of the family physicians and 3.9% of the otolaryngologists adhered to it. This was in agreement with the Babak's (2012) studies who indicated that more than 75% of the pediatricians adhered in their diagnosis of AOM to the American guideline than other physicians . Most of the primary care physicians incorrectly diagnosed AOM due to their crowded works, uncooperative toddler, and anxious parents .
Pediatricians' adherence to the Egyptian guideline may be due to the simple procedure stated in the Egyptian guideline (only the presence of ear pain and/or otorrhea) in their diagnosis of AOM. Other guidelines call for several procedures, such as examination of the tympanic membrane, which may be more time-consuming. Second, pediatricians often feel that ear diseases do not belong to their specialization and are more connected to the otolaryngologists. These results were in contrast with the study conducted in United States, which revealed that 87% of the pediatricians diagnosed AOM by both otoscopic examination of the tympanic membrane and symptoms of the patient .
The study also revealed that there was a statistically significant difference between different specialties concerning their adherence to different guidelines in treating otalgia. About 23.7% of the family physicians, 3.9% of the pediatricians, and 2.6% of the otolaryngologists adhered to the Egyptian AOM guideline. Timmer's study stated that the family physicians did not commonly use topical analgesia, decongestion, or antihistamine because the existing evidence was insufficient on their effectiveness; specifically for early cure rates, symptom resolution, prevention of surgery, or other complications; and this, in turn, resulted in an increased risk of other side effects .
This study revealed that about 4.6% of the family physicians, 3.3% of the otolaryngologists, and 4.6% of the pediatricians really used an observation policy in treating the mild unilateral AOM in children. This was in agreement with Timmer M study, which reported that 78.8% of the cases diagnosed as AOM received antibiotics and this means that 21.2% of all the cases would have been managed using initial observation .
| Conclusion|| |
Poor adherence to the Egyptian guideline of AOM was detected in all specialties without significant differences. The present study's results reflected that the age and experience as a variable dose do not significantly affect the adherence of different specialties to the Egyptian AOM guideline. Poor adherence to the Egyptian AOM guideline calls for more developmental research studies on the influence of such guideline. In addition, resolving this challenge may require comprehensive policy appraisal and harmonized actions at different AOM healthcare centers. Mere dissemination of evidence and promotion of the guidelines will not help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pradhan N, Rizvi N, Sami N, Gul X. Insight into implementation of facility-based integrated management of childhood illness strategy in a rural district of Sindh, Pakistan. Glob Health Action 2013; 6
Nguyen T, Leung K, Ghali W, Sauve R. Does integrated management of childhood illness (IMCI) training improve the skills of health workers? PLoS One 2013; 8
Gyssens C. International guidelines for infectious diseases: a practical guide. Neth J Med 2005; 1
Ragab A, Mohammed A, Abdel-Fattah A, Afifi A. Prevalence of complications associated with tympanostomy tube insertion. Menouf Med J 2015; 28
Wood J. Diagnosis and management acute otitis media in young children. Med Today J 2014; 15
Maharjan M, Bhandari S, Mishra S. Prevalence of otitis media in school going children in Eastern Nepal. Kathmandu Univ Med J 2006; 4
Greenberg D, Bilenko N, Liss Z. The burden of acute otitis media on the patient and the family. Eur J Pediatr 2003; 162
Frcse A, Rhonda A, Berryhil W, Ramakrishnan K. Diagnosis and treatment of otitis media. Am Fam Physician 2007; 76
Lieberthal A, Wald E, Ganiats T, Culpepper L, Mahoney M, Miller D, et al
. The American Academy of Pediatrics for diagnosis and management of acute otitis media. Pediatrics J 2014; 113:969–999.
Forgie S, Zhanel G, Robinson J. Canadian Pediatric Society Infectious Diseases and Immunization Committee. Paediatr Child Health
Subcommittee of Clinical Practice Guideline for Diagnosis and Management of Acute Otitis Media in Children (Japan Otological Society, Japan Society for Pediatric Otorhinolaryngology, Japan Society for Infectious Diseases in Otolaryngology), Clinical practice guidelines for the diagnosis and management of acute otitis media (AOM) in children in Japan, Auris Nasus Larynx 2012; 39
Marchisio P, Bellussi L, Mauro G, Doria M, Felisati G, Longhi R, et al
. Otitis media guideline summary. Int J Pediatr Otorhinolaryngol 2010; 74
Jeong H, Park S, Choi K, Park E, Kim H. Korean clinical practice guidelines: otitis media in children. Korean Med 2012; 27
Quach C, Paul Collet J, LeLorier J. Acute otitis media in children: a retrospective analysis of physician prescribing patterns. Br J Clin Pharmacol 2004; 57
Walter E, Yang H, Rowena J. Low rates of adherence to 1999 acute otitis media treatment guidelines across pediatric and family practices. JCOM 2007; 14
Danhauer J. National survey of pediatricians' opinions about and practices for acute otitis media. J Am Acad Audiol 2010;21
Cabana M. Analysis of published trials examining methods to change provider prescribing behavior and child health outcomes. J Pediatrics 2003; 16
Lugtenberg M, Schaick J, Westert G, Burgers J. Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. BioMed Central J 2009; 10
Mark J, Heijden G, Siegers C, Grolman W, Rovers M. Awareness of, opinions about and adherence to evidence-based guidelines in otorhinolaryngology. Otolaryngol Head Neck Surg 2012; 138
Haggard M. Poor adherence to antibiotic prescribing guidelines in acute otitis media—obstacles, implications, and possible solutions. Eur J Pediatr 2011; 170
Mckinlay J, Link C, Freund K, Marceau L, Donnell A, Lutfey K. Sources of variation in physician adherence with clinical guidelines: results from a factorial experiment.JGIM 2007; 5
Ahmed S. Assessment of health services provided for children by rural health units of Assiut governorate. J Am Sci 2013; 9
Wolf R, Sharp L, Wang R. Family physicians opinions and attitudes to three clinical practical guidelines. JABFP 2004; 17
Kamraval K, Jalessil M, Asgharil A, Farhadi M, Ahmadvand A, Ghalehbaghi B, et al
. Have guidelines affected ear, nose, and throat specialists' diagnoses and the prescription of antibiotics for acute otitis media. Iran J Otorhinolaryngol 2012; 24
Kenefick H, Lee J, Fleishman V. Improving physician adherence to clinical practice guidelines: barriers and strategies for change [unpublished Master thesis]. Cambridge, England: New England Healthcare Institute.
Babak Ghalehbaghi B, Mohammadi N, Asghari A, Ahmadvand A, Moradi Y, Kamrava K, et al.
Evaluation of Iranian pediatric specialists' attitude and knowledge regarding approach to patients with acute otitis media. Med J Islam Repub Iran 2012; 2
Miser W. To treat or not to treat otitis media. J Am Board Fam 2001; 14
Timmer M. Management of acute otitis media: Update. Evid Rep Technol Assess 2007; 198
[Table 1], [Table 2], [Table 3], [Table 4]