Cerumen Impaction Removal in General Practices: A Comparison of Approved Standard Products.

BACKGROUND: Ear irrigation is a commonly used method for removing earwax in general practice. There is no firm evidence if no pre-treatment is as good as pre-treatment with various standard preparations. AIM: To assess the effectiveness of no pre-treatment compared to pre-treatment with commercially available cerumenolytics and to assess which preparation is best suited for pre-treatment. METHODS: This is a pragmatic observational study of patients with cerumen treated from a single GP with 3 different preparations or no preparation prior to standardized ear irrigation. Generalized linear mixed models with logit link function were performed to assess the effectiveness of pre-treatment with different preparations and no pre-treatment. The models were adjusted for age group (<70, ≥70) and sex. RESULTS: A total of 168 patients (298 ears, 58 % female, median age 65 years) consulted for obstructive cerumen, some of them several times. The cerumen was successfully removed in 70% (208/298). Comparing any preparation to no preparation (aggregated comparison), the odds ratio for complete clearance was 1.35 (95%confidence interval: 0.69-2.65). Comparing the preparations individually, the odds ratio of the docusate-sodium-based preparation was 1.87 (95% CI: 0.79-4.42) indicating a higher effectiveness. Although, not statistically significant. Ear irrigation was less successful for patients aged ≥ 70 years (OR = 0.48, 95% CI: 0.23-0.98). CONCLUSIONS: The aggregated comparison indicates a slight trend toward a higher effectiveness of any pre-treatment compared to no pre-treatment. The effect-size of docusate-sodium-based pre-treatment indicates a higher effectiveness of cerumen impaction removal. Nevertheless, superiority could not be shown conclusively according to the statistical significance given the restricted sample size.

[Removal of impacted cerumen by irrigation of the external auditory canal - Step-by-step]. / Spülung des äußeren Gehörgangs bei Cerumen obturans ­ Schritt-für-Schritt.

Cerumen impaction is a common consultation issue at general medical practices and causes symptoms like hearing loss, itching, pain or tinnitus. Without any indication of eardrum perforation, ear irrigation with warm water is a safe, effective and fast aid.

Quality of care in patients with atrial fibrillation in primary care: a cross-sectional study comparing clinical and claims data.

Objectives: Atrial fibrillation (AF) is a common cardiac arrhythmia with increased risk of thromboembolic stroke. Oral anticoagulation (OAC) reduces stroke risk by up to 68%. The aim of our study was to evaluate quality of care in patients with AF in a primary health care setting with a focus on physician guideline adherence for OAC prescription and heart rate- and rhythm management. In a second step we aimed to compare OAC rates based on primary care data with rates based on claims data. Methods: We included all GP practices in the region Vorpommern-Greifswald, Germany, which were willing to participate (N=29/182, response rate 16%). Claims data was derived from the regional association of statutory health insurance physicians. Patients with a documented AF diagnosis (ICD-10-GM-Code ICD I48.-) from 07/2011-06/2012 were identified using electronic medical records (EMR) and claims data. Stroke and bleeding risk were calculated using the CHA2DS2-VASc and HAS-BLED scores. We calculated crude treatment rates for OAC, rate and rhythm control medications and adjusted OAC treatment rates based on practice and claims data. Adjusted rates were calculated including the CHA2DS2-VASc and HAS-BLED scores and individual factors affecting guideline based treatment. Results: We identified 927 patients based on EMR and 1,247 patients based on claims data. The crude total OAC treatment rate was 69% based on EMR and 61% based on claims data. The adjusted OAC treatment rates were 90% for patients based on EMR and 63% based on claims data. 82% of the AF patients received a treatment for rate control and 12% a treatment for rhythm control. The most common reasons for non-prescription of OAC were an increased risk of falling, dementia and increased bleeding risk. Conclusion: Our results suggest that a high rate of AF patients receive a drug therapy according to guidelines. There is a large difference between crude and adjusted OAC treatment rates. This is due to individual contraindications and comorbidities which cannot be documented using ICD coding. Therefore, quality indicators based on crude EMR data or claims data would lead to a systematic underestimation of the quality of care. A possible overtreatment of low-risk patients cannot be ruled out.