Ear and hearing care programs for First Nations children: a scoping review.

BACKGROUND: Ear and hearing care programs are critical to early detection and management of otitis media (or middle ear disease). Otitis media and associated hearing loss disproportionately impacts First Nations children. This affects speech and language development, social and cognitive development and, in turn, education and life outcomes. This scoping review aimed to better understand how ear and hearing care programs for First Nations children in high-income colonial-settler countries aimed to reduce the burden of otitis media and increase equitable access to care. Specifically, the review aimed to chart program strategies, map the focus of each program against 4 parts of a care pathway (prevention, detection, diagnosis/management, rehabilitation), and to identify the factors that indicated the longer-term sustainability and success of programs. METHOD: A database search was conducted in March 2021 using Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Programs were eligible or inclusion if they had either been developed or run at any time between January 2010 to March 2021. Search terms encompassed terms such as First Nations children, ear and hearing care, and health programs, initiatives, campaigns, and services. RESULTS: Twenty-seven articles met the criteria to be included in the review and described a total of twenty-one ear and hearing care programs. Programs employed strategies to: (i) connect patients to specialist services, (ii) improve cultural safety of services, and (iii) increase access to ear and hearing care services. However, program evaluation measures were limited to outputs or the evaluation of service-level outcome, rather than patient-based outcomes. Factors which contributed to program sustainability included funding and community involvement although these were limited in many cases. CONCLUSION: The result of this study highlighted that programs primarily operate at two points along the care pathway-detection and diagnosis/management, presumably where the greatest need lies. Targeted strategies were used to address these, some which were limited in their approach. The success of many programs are evaluated as outputs, and many programs rely on funding sources which can potentially limit longer-term sustainability. Finally, the involvement of First Nations people and communities typically only occurred during implementation rather than across the development of the program. Future programs should be embedded within a connected system of care and tied to existing policies and funding streams to ensure long term viability. Programs should be governed and evaluated by First Nations communities to further ensure programs are sustainable and are designed to meet community needs.

The impact of continuity of care on antibiotic prescribing in acute otitis media.

BACKGROUND: The rate of antibiotic prescribing for acute otitis media (AOM) remains high despite efforts to decrease inappropriate use. Studies have aimed to understand the prescribing patterns of providers to increase antibiotic stewardship. Watch and wait (WAW) prescriptions are effective at decreasing the number of antibiotic prescriptions being filled by patients. Additionally, poor continuity of care has been associated with higher cost and lower quality health care. OBJECTIVE: To understand the antibiotic prescribing habits for AOM in a largely Hispanic population. METHODS: A retrospective review was performed from 2016 to 2018 of all patients under 25 years old with a diagnosis of AOM seen at multiple outpatient primary care clinics of a single institution. Charts were reviewed for factors including race, ethnicity, gender, insurance status, presence of fever, primary care physician visit, and treatment choice. Data were collected and analyzed using STATA software with t-tests, ANOVA, and Pearson chi squared analysis. RESULTS: Antibiotics were prescribed 95.6% of the time with 3.8% being WAW prescriptions. There was no significant difference in antibiotic prescribing by race (p = 0.66), ethnicity (p = 0.38), gender (p = 0.34) or insurance status (p = 0.24). There was a difference between physicians, nurse practitioners, and physician's assistants and antibiotic prescribing rate (p < 0.01). Additionally, seen by their primary care provider were less likely to be prescribed antibiotics (85.8% vs 94.4%, p = 0.01). CONCLUSION: While a patient's race, ethnicity, gender, and insurance status did not influence the prescribing rate of physicians, continuity of care may play an important role in decreasing inappropriate antibiotic prescribing.

A multi-centre open-label randomised non-inferiority trial comparing watchful waiting to antibiotic treatment for acute otitis media without perforation in low-risk urban Aboriginal and Torres Strait Islander children (the WATCH trial): study protocol for a randomised controlled trial.

BACKGROUND: Treatment guidelines recommend watchful waiting for children older than 2 years with acute otitis media (AOM) without perforation, unless they are at high risk of complications. The high prevalence of chronic suppurative otitis media (CSOM) in remote Aboriginal and Torres Strait Islander communities leads these children to be classified as high risk. Urban Aboriginal and Torres Strait Islander children are at lower risk of complications, but evidence to support the subsequent recommendation for watchful waiting in this population is lacking. METHODS/DESIGN: This non-inferiority multi-centre randomised controlled trial will determine whether watchful waiting is non-inferior to immediate antibiotics for urban Aboriginal and Torres Strait Islander children with AOM without perforation. Children aged 2 - 16 years with AOM who are considered at low risk for complications will be recruited from six participating urban primary health care services across Australia. We will obtain informed consent from each participant or their guardian. The primary outcome is clinical resolution on day 7 (no pain, no fever of at least 38 °C, no bulging eardrum and no complications of AOM such as perforation or mastoiditis) as assessed by general practitioners or nurse practitioners. Participants and outcome assessors will not be blinded to treatment. With a sample size of 198 children in each arm, we have 80 % power to detect a non-inferiority margin of up to 10 % at a significance level of 5 %, assuming clinical improvement of at least 80 % in both groups. Allowing for a 20 % dropout rate, we aim to recruit 495 children. We will analyse both by intention-to-treat and per protocol. We will assess the cost- effectiveness of watchful waiting compared to immediate antibiotic prescription. We will also report on the implementation of the trial from the perspectives of parents/carers, health professionals and researchers. DISCUSSION: The trial will provide evidence for the safety and effectiveness of watchful waiting for the management of AOM in Aboriginal and Torres Strait Islander children living in urban settings who are considered to be at low risk of complications. TRIAL REGISTRATION: The trial is registered with Australia New Zealand Clinical Trials Registry ( ACTRN12613001068752 ). Date of registration: 24 September 2013.

Breastfeeding as a means to prevent infant morbidity and mortality in Aboriginal Canadians: A population prevented fraction analysis.

OBJECTIVES: Canadian Aboriginal infants experience poor health compared with other Canadian infants. Breastfeeding protects against many infant infections that Canadian Aboriginals disproportionately experience. The objective of our research was to estimate the proportion of select infant infection and mortality outcomes that could be prevented if all Canadian Aboriginal infants were breastfed. METHODS: We used Levin's formula to estimate the proportion of three infectious outcomes and one mortality outcome that could be prevented in infancy by breastfeeding. Estimates were calculated for First Nations (both on- and off-reserve), Métis and Inuit as well as all Canadian infants for comparison. We extracted prevalence estimates of breastfeeding practices from national population-based surveys. We extracted relative risk estimates from published meta-analyses. RESULTS: Between 5.1% and 10.6% of otitis media, 24.3% and 41.4% of gastrointestinal infection, 13.8% and 26.1% of hospitalizations from lower respiratory tract infections, and 12.9% and 24.6% of sudden infant death could be prevented in Aboriginal infants if they received any breastfeeding. CONCLUSION: Interventions that promote, protect and support breastfeeding may prevent a substantial proportion of infection and mortality in Canadian Aboriginal infants.

Ethnic differences in acute hospitalisations for otitis media and elective hospitalisations for ventilation tubes in New Zealand children aged 0-14 years.

AIMS: This paper describes ethnic differences in acute hospitalisations for otitis media (OM) and elective hospitalisations for ventilation tube insertion in New Zealand children aged 0-14 years. Ethnic differences in first attendances at Ear Nose and Throat (ENT) outpatient clinics are also described. METHOD: The analysis included all hospital admissions of children aged 0-14 years during 2002-2008 which met the following criteria: Acute admissions with an ICD-10-AM primary diagnosis code of otitis media; and elective admissions with a primary procedure code of ventilation tube insertion. First attendances at ENT outpatient clinics during 2007-2008 were also reviewed. Explanatory variables included ethnicity, gender, age, and NZ Deprivation Index decile. RESULTS: Among 0-4 year olds, Maori and Pacific children were more likely to be admitted acutely for otitis media than European children. In contrast, both Maori and Pacific children had lower rates of elective admissions for ventilation tube insertion, with ethnic differences being most marked for children from the most deprived areas. Maori and Pacific children aged 5-14 years also had higher acute otitis media admission rates than European children. In contrast to their younger counterparts however, they also had higher rates of ventilation tube insertion. Exploration of ENT outpatient data for children 0-4 years revealed similar first appointment rates for European and Maori children, but lower rates for Pacific and Asian children. For the 5-14 age group, first appointment rates were higher for Maori and Pacific children than for European children. However, Maori and Pacific children in both age groups had higher rates of non-attendance at their first ENT appointments than European children. CONCLUSION: This study highlights ethnic differences in access to ventilation tubes amongst New Zealand's 0-4 year olds, with the greatest inequalities being seen for Maori, Pacific and Asian children living in the most deprived areas. For Maori and Pacific children, such differences cannot be attributed to lower rates of AOM or OME compared to European children. The fact that similar patterns are not seen for children aged 5-14 years potentially suggests that routine Well Child hearing screening may be playing a role in identifying unmet need in this older age group. Such disparities also suggest that factors over and above OM prevalence may be influencing access to ventilation tubes. Further research is required to determine why Maori and Pacific children (0-4 years) have similar/lower ENT appointment rates than European children, despite a higher burden of middle ear disease, as well as higher non-attendance rates at outpatient clinics. Given the importance of early detection and treatment of OM for children's ongoing well-being and education, a greater understanding of the reasons for these inequalities is urgently required.

Race, otitis media, and antibiotic selection.

BACKGROUND AND OBJECTIVE: Previous research suggests that physicians may be less likely to diagnose otitis media (OM) and to prescribe broad-spectrum antibiotics for black versus nonblack children. Our objective was to determine whether race is associated with differences in OM diagnosis and antibiotic prescribing nationally. METHODS: We examined OM visit rates during 2008 to 2010 for children ≤14 years old using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. We compared OM visits between black and nonblack children, as percentages of all outpatient visits and visit rates per 1000. We compared antibiotic prescribing by race as the percentage of OM visits receiving narrow-spectrum (eg, amoxicillin) versus broader-spectrum antibiotics. We used multivariable logistic regression to examine whether race was independently associated with antibiotic selection for OM. RESULTS: The percentage of all visits resulting in OM diagnosis was 30% lower in black children compared with others (7% vs 10%, P = .004). However, OM visits per 1000 population were not different between black and nonblack children (253 vs 321, P = .12). When diagnosed with OM during visits in which antibiotics were prescribed, black children were less likely to receive broad-spectrum antibiotics than nonblack children (42% vs 52%, P = .01). In multivariable analysis, black race was negatively associated with broad-spectrum antibiotic prescribing (adjusted odds ratio 0.59; 95% confidence interval, 0.40-0.86). CONCLUSIONS: Differences in treatment choice for black children with OM may indicate race-based differences in physician practice patterns and parental preferences for children with OM.

Racial differences in antibiotic prescribing by primary care pediatricians.

OBJECTIVE: To determine whether racial differences exist in antibiotic prescribing among children treated by the same clinician. METHODS: Retrospective cohort study of 1,296,517 encounters by 208,015 children to 222 clinicians in 25 practices in 2009. Clinical, antibiotic prescribing, and demographic data were obtained from a shared electronic health record. We estimated within-clinician associations between patient race (black versus nonblack) and (1) antibiotic prescribing or (2) acute respiratory tract infection diagnosis after adjusting for potential patient-level confounders. RESULTS: Black children were less likely to receive an antibiotic prescription from the same clinician per acute visit (23.5% vs 29.0%, odds ratio [OR] 0.75; 95% confidence interval [CI]: 0.72-0.77) or per population (0.43 vs 0.67 prescriptions/child/year, incidence rate ratio 0.64; 95% CI 0.63-0.66), despite adjustment for age, gender, comorbid conditions, insurance, and stratification by practice. Black children were also less likely to receive diagnoses that justified antibiotic treatment, including acute otitis media (8.7% vs 10.7%, OR 0.79; 95% CI 0.75-0.82), acute sinusitis (3.6% vs 4.4%, OR 0.79; 95% CI 0.73-0.86), and group A streptococcal pharyngitis (2.3% vs 3.7%, OR 0.60; 95% CI 0.55-0.66). When an antibiotic was prescribed, black children were less likely to receive broad-spectrum antibiotics at any visit (34.0% vs 36.9%, OR 0.88; 95% CI 0.82-0.93) and for acute otitis media (31.7% vs 37.8%, OR 0.75; 95% CI 0.68-0.83). CONCLUSIONS: When treated by the same clinician, black children received fewer antibiotic prescriptions, fewer acute respiratory tract infection diagnoses, and a lower proportion of broad-spectrum antibiotic prescriptions than nonblack children. Reasons for these differences warrant further study.

Racial/ethnic and socioeconomic disparities in the prevalence and treatment of otitis media in children in the United States.

OBJECTIVES: Although racial/ethnic and socioeconomic disparities in child health are prevalent, little is known about them within common pediatric otolaryngic problems. Otitis media (OM) is a frequent diagnosis in children, and tympanostomy tube placement is the most common surgical treatment for OM. We sought to identify current knowledge regarding racial/ethnic and socioeconomic disparities in children with OM or tympanostomy tube placement. METHODS: Qualitative systematic review of MEDLINE database for U.S.-based articles reporting on racial/ethnic or socioeconomic disparities in diagnosis or surgical treatment of OM over the last 30 years. RESULTS: Of 428 abstracts identified, 15 met inclusion criteria. Articles addressed OM prevalence (12 of 15), risk factors (9 of 15), and tympanostomy tube insertion (4 of 15). Minority racial/ethnic groups studied were Black (11 of 15), Hispanic (6 of 15), American Indian/Alaska Native (2 of 15), and Asian (1 of 15). Predominant findings showed: 1) the most common identified risk factor for OM is socioeconomic status; 2) considerable variability exists concerning racial/ethnic disparities in disease prevalence; and 3) White children are more likely to undergo tympanostomy tube insertion compared to Black or Hispanic children. CONCLUSIONS: Racial/ethnic and socioeconomic disparities exist for the prevalence and treatment of children with OM. Socioeconomic deprivation increases the risk of OM in children. Despite the frequency of tympanostomy tube insertion in children in the United States, few studies have addressed inequalities in access or utilization of surgical therapy. Given the changing healthcare climate and the social and economic impact of OM in children, further investigation of racial/ethnic and socioeconomic disparities targeting access to surgical treatment of OM should take precedence in health services research.

Demographic disparities among children with frequent ear infections in the United States.

OBJECTIVES/HYPOTHESIS: To evaluate current racial/ethnic and socioeconomic disparities in the prevalence of frequent ear infections (FEI) among children in the United States. STUDY DESIGN: Cross-sectional study. METHODS: The National Health Interview Survey (years 1997 to 2006) was utilized to evaluate children who were reported by their parent/guardian to have "3 or more ear infections during the past 12 months." Demographic variables evaluated included age, sex, race/ethnicity, income level, and insurance status. Multivariate analyses determined the influence of demographic variables on the prevalence of FEI in children. RESULTS: Among an annualized population of 72.6 million children (average age, 8.55 +/- 0.19 years), 4.65 +/- 0.07 million children (6.6 +/- 0.1%) reported FEI. FEI was more commonly reported in white (7.0 +/- 0.1%) and Hispanic (6.2 +/- 0.2%) than in black (5.0 +/- 0.2%) and other race/ethnic groups (4.5 +/- 0.3%, P < .001). A larger portion of children in households below the poverty level reported FEI (8.0 +/- 0.3%, P < .001). Of children with no health insurance 5.4 +/- 0.3% had FEI. On multivariate analysis, black, Hispanic and other race/ethnic group had decreased odds ratio for FEI relative to white children (odds ratios: 0.63, 0.76, and 0.60, respectively, all P < .001). Income below poverty level also predicted FEI (odds ratio, 1.322, P < .001), whereas lack of insurance coverage did not (P = .181). CONCLUSIONS: Despite increasing awareness, there are still notable racial/ethnic and socioeconomic disparities among children with FEI. Further efforts to eliminate these disparities and improve the care of children with FEI are needed.

Otitis media in Aboriginal children: the discordance between burden of illness and access to services in rural/remote and urban Australia.

OBJECTIVE: To compare the burden of otitis media (OM) managed by Aboriginal Medical Service (AMS) practitioners and the availability of specialist ear health services in rural/remote versus urban Australian settings. DESIGN, SETTING AND PARTICIPANTS: We mailed questionnaires to all Australian AMS medical practitioners managing children in December 2006. Questions addressed the frequency of childhood OM cases seen, and the availability and waiting times for audiology; ear, nose and throat (ENT); and hearing-aid services. We compared rural/remote and urban practitioner's responses using the c2 test with clustering adjustments. RESULTS: Questionnaires were returned by 63/87 (72%) AMSs and by 131/238 (55%) eligible practitioners. Rural/Remote practitioners reported managing a greater number of children with OM per week than urban practitioners (1 df, P = 0.02) and a larger proportion of the children they managed having OM (1 df, P = 0.009). More rural/remote than urban practitioners reported relevant services were not available locally: audiology (11.1 vs. 0%, P = 0.038), ENT (33.3 vs. 3.9%, P = 0.0004) and hearing-aid provision (37.7 vs. 1.9%, P < 0.0001). More rural/remote practitioners reported audiology waiting times longer than the recommended 3 months (18.3 vs. 1.9%, P = 0.007). Equal proportions reported ENT waiting times longer than the recommended 6 months (13.9 vs. 11.3%, P = 0.7). CONCLUSIONS: Rural/Remote AMS practitioners manage a greater OM burden than urban AMS practitioners, but affected children have less access to specialist ear health services and longer waiting times. One in five rural/remote Aboriginal children wait longer than recommended for audiology testing, and one in eight Aboriginal children nationwide wait longer than recommended for ENT services.

Otitis media: health and social consequences for aboriginal youth in Canada's north.

OBJECTIVES: Otitis media is endemic among Inuit, First Nations and Métis children in northern Canada, with prevalence rates in some communities as high as 40 times that found in the urban south. Hearing impairment, much of it attributable to chronic otitis media, is the most common health problem in parts of the arctic, and conductive hearing loss among children may affect as many as two-thirds. STUDY DESIGN AND METHODS: There is a need for systematic data based on consistent disease definitions and measures, and taking account of cross-cultural methodological issues and sampling. RESULTS: Otitis media is most likely to develop in infancy. Susceptibility has been linked to immune defects and to a variety of environmental factors. Among the most significant are diet, the decline in initiation and maintenance of breastfeeding, and exposure to cigarette smoke. Hearing loss has been related to difficulties in language acquisition, and to subsequent issues with literacy and school achievement, including learning disabilities and attention deficits. The economic and social costs of otitis media are substantial. CONCLUSION: Approaches to treatment and prevention have enjoyed limited success. Public health and medical practice need to be informed by the traditional knowledge and practices of indigenous peoples.

Direct expenditures related to otitis media diagnoses: extrapolations from a pediatric medicaid cohort.

BACKGROUND: Treatment of otitis media in children is associated with substantial expenditures because of its high frequency during childhood. Vaccines against respiratory pathogens causing otitis media are now being developed. Information about otitis media-related medical expenditures will be needed to determine the cost-effectiveness of these preventive interventions. METHODS: This study used utilization data from claims to impute otitis media-related expenditures for medical visits, pharmaceuticals, and surgical procedures for 87 057 children 13 years of age and younger who were continuously enrolled in Colorado's fee-for-service Medicaid program during 1992. International Classification of Disease, Ninth Revision diagnostic codes were used to identify visits for otitis media. An antibiotic was considered to have been prescribed to treat otitis media if it was dispensed up to 24 hours before or within 48 hours after a physician encounter showing a diagnosis of otitis media. All tympanostomies, mastoidectomies, and adenoidectomies were assumed to be related to otitis media. Expenditures were imputed from utilization using a Medicaid fee schedule. National expenditures for 1992 to treat otitis media were extrapolated from Colorado's Medicaid data. We adjusted for differences between Colorado and the United States as a whole in terms of price, number, and intensity of services; for differences in reimbursement rates by service between Medicaid and private insurance; and for differences in utilization between Medicaid enrollees and the uninsured. To provide a more current expression of medical expenditures for otitis media, we inflated the 1992 expenditure estimates to 1998 dollars using the Consumer Price Index published by the US Bureau of Labor Statistics. RESULTS: Twenty-eight percent of children experienced at least 1 episode of diagnosed otitis media. The proportion of children with a diagnosis of otitis media was highest (42%-60%) in the 7-month to 36-month age range. The proportion was also higher among white (34.5%) and Hispanic (25.3%) children than among black children (18.5%), as well as among rural (34.5%) compared with urban children (27.2%). Children 19 to 24 months of age incurred the highest total annual expenditures per child with otitis media ($239.68). Expenditures for drugs, visits, and procedures were all highest for this group. The per-patient cost to Medicaid was greater for visits than for drugs or procedures across all age groups. Total per-patient expenditures were higher for males ($174.67) than for females ($154.47) and higher for white children ($176.59) than for Hispanic ($154.12) or black children ($134.44). The differences among the ethnic groups can be attributed almost entirely to differences in expenditures for procedures and drugs. Although mean expenditures per patient varied substantially by some patient characteristics (eg, race), these differences accounted for only a small fraction of the enormous variation in costs per patient. Including children with and without otitis media, age-specific estimated expenditures per child peaked among children 1 ($132.94) and 2 years of age ($88.72). Children 3 to 6 years of age incurred expenditures only one third as great as those incurred by children 1 year of age. Total national expenditures were estimated to have been approximately $4.1 billion in 1992 dollars and $5.3 billion in 1998 dollars. Over 40% of national expenditures to treat otitis media in children younger than 14 years of age were incurred for children between 1 and 3 years of age ($453 per capita in 1992 dollars over these 2 years vs $1027 for all years of age from 2 to 13). Nationally, expenditures for visits remained the largest component of expenditures. LIMITATIONS: This study assessed expenditures from the point of view of the health care system; that is, no social costs, such as lost work time, or expenditures not normally covered by insurance, such as those for transportation, we