Nov 17, 2014

Interview Transcript

Interviewer: A study finds disparities in how ear infections are treated in children of different races, up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The science and research show is on the scope.

Interviewer: I'm talking with Dr. Adam Hersh, assistant professor of pediatrics at the University of Utah. He's led a research study published in the Journal of Pediatrics with some thought-provoking statistics that give clues as to why antibiotics are over prescribed for the treatment of ear infections in children. Dr. Hersh, what were the main results of your study?

Dr. Hersh: There are two main results here. First, we found that there was a difference in the rate at which ear infections were diagnosed for children between black children and non-black children. We found that non-black children were more likely to be diagnosed with ear infections when they were seen in a doctor's office for respiratory symptoms.
Second, we found that once the diagnosis of an ear infection was made, we found differences in the types of antibiotics that were chosen by doctors between black children and non-black children. More specifically, what we found is that non-black children were more likely to get broad-spectrum antibiotics, antibiotics that are actually not indicated in most circumstances for this specific infection.

Interviewer: First of all, maybe we should define what does non-black children mean?

Dr. Hersh: For the purposes of this study, we did use two different groups, black and non-black. This was largely to be consistent with previous research in this area that used similar groups. Ninety-five percent of the group of children that are categorized as non-black are Caucasian.

Interviewer: What kind of differences are we talking about?

Dr. Hersh: These differences are pretty big. In terms of the rate of diagnosis of an ear infection, it appears that black children are about 30% less likely to be diagnosed with an ear infection than non-black children. In terms of the antibiotics that are chosen, black children are about 20 to 30% less likely to get a broad spectrum antibiotic than non-black children. These differences are of pretty significant magnitude.

Interviewer: These differences are because of access to care, you think?

Dr. Hersh: That's an important question to think about. We found that the rate at which black children and non-black children are seen nationwide for respiratory tract infections. In fact, for care in general is actually the same.

Interviewer: An interesting point is that black children are actually receiving the preferred treatment. Can you explain that?

Dr. Hersh: At least in terms of the antibiotics that are chosen for black children as compared to non-black children, that's absolutely correct. Black children are more frequently and more likely receiving the preferred, first-line recommended antibiotics. Again, that's important, not just because of the concerns about killing off more of the good bacteria and leading to antibiotic resistance, but also because some of these broader spectrum antibiotics actually are more likely to cause harm to the child. For instance, some of the board spectrum antibiotics that are more frequently prescribed for non-black children are those that are most frequently linked to certain types of antibiotic associated diarrhea, something called clostridium difficile.

Interviewer: How was this study done?

Dr. Hersh: This study was done using a database that's collected and maintained by the Center for Disease Control. It's a nationally representative database of outpatient health care encounters that's conducted annually. What we understand, what we know from these databases is that somewhere between 30 and 40% of all diagnoses for children, at the doctor's office, are related to respiratory tract infections. We know from these databases, from this work, that about one in five times that a child is seen in a doctor's office, they'll leave with an antibiotic prescription in hand. An ear infection is the single most frequent diagnosis that leads to an antibiotic prescription.

Interviewer: This wasn't exactly addressed by your study, but can you help us understand some of the reasons that might lead to differences in care?

Dr. Hersh: We know that in many cases, physicians perceive that patients want an antibiotic. That perception is one of the strongest drivers of an antibiotic prescriptions. Particularity in circumstances where it's kind of a gray area, when it's not clear cut. If the physician perceives that this parent wants an antibiotic for their child and they're not going to be satisfied any other way, there's a much greater likelihood that they'll prescribe an antibiotic than if they didn't have that same perception.

Interviewer: I think you can look at the other way as well, that there could be an under-diagnosis or an under-treatment of black children.

Dr. Hersh: That's a really important point. There really are two potential ways to interpret this. Over-diagnosis and over-treatment, or under-diagnosis and under-treatment. Historically, in a lot of other areas of medicine, there have been well-identified health care disparities where patients of black race get less care. In some cases, lower quality care. That may not be what's going on here.

Interviewer: It seems like understanding those causes will be important for addressing this problem.

Dr. Hersh: That's absolutely right. I think that why this is occurring is a much more complicated research question.

Interviewer: Yeah. Absolutely. What's the take home message from all of this?

Dr. Hersh: I think there's really two take home messages. The first is that all of us, patients, parents, physicians, anyone that works in the health care environment, we need to remind ourselves that we do bring stereotypes and biases into the exam rooms with us. We need to think about how these biases may ultimately influence the care that children receive.
Second, this study really reinforces and reemphasizes a critical point about the diagnosis and treatment of upper respiratory tract infections. That's that physicians need to use really stringent criteria to diagnose respiratory tract infections that justify antibiotics and only prescribe antibiotics when those stringent critical criteria are met. I think a message for parents is that they should ask their doctor when the diagnosis is being made.
For instance, of an ear infection, they should ask their doctor how certain the doctor is about the diagnosis. If there's some uncertainty, they should ask whether or not it's possible that maybe watching and waiting would be a reasonable approach rather than taking the antibiotic when there still remains some uncertainty about what the diagnosis is. I think that's a really key thing for parents to understand, that the vast majority of upper respiratory tract infections that kids have are caused by viruses and helped at all by antibiotics.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.


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