van der Wild GJ, Rovers MM, Herberts ED, Zielhuis GA, van den Broek P; International Society of Technology Assessment in Health Care. Meeting.

Annu Meet Int Soc Technol Assess Health Care Int Soc Technol Assess Health Care Meet. 1997; 13: 99.

Department of Medical Informatics, Epidemiology and Bio-statistics, University of Nijmegen, the Netherlands.

OBJECTIVE: To assess current clinical management in the Netherlands of children who failed the Ewing hearing test and compare this with practice guidelines and outcomes of evaluation studies. METHODS: 600 out of 800 children were identified who failed a routine screening test for hearing impairment at the age of ca. 1 year in 1994 in a particular area in the Netherlands. Their parents were sent a questionnaire, asking about subsequent consultation of their GP, referral to the outpatient clinic, clinical managment by the ENT specialist, and current hearing status of their child. 33 of the GPs concerned and 22 of the ENT-specialists were then interviewed by telephone, asking them about their managment of these children, their reasons for preferred management and their commitment to practice guidelines. RESULTS: 427 of the 600 questionnaires were returned (response rate 71%). 76% had visited their GP in relation to the screening test. According to the parents, the GP reached the diagnosis of glue ear in 35%, established a hearing loss in 18%, and did not reach a diagnosis in 61% of the cases. 59% were referred to an ENT specialist, 1% was referred to an Audiological Centre, 3% got medication, 10% was invited for a return visit, and 19% was reassured and given the advice that no further action was required. Of the 250 children who visited an ENT specialist, 86% was diagnosed with glue ear and 0.4% with a perceptive hearing loss. 53% received grommets, 39% adenoidectomy, 3% tonsilectomy, and 9% medical treament. 6% were referred to an Audiological Centre, 1% was referred to a pediatrician, and 12% received no treatment. At the time of filling out the questionnaire, 70% of the parents rated the hearing status of their child as excellent, 7% was not entirely satisfied but had had no occasion to seek medical treatment, and 23% of the children was still under medical supervision. When asked to provide reasons for their decisions, GPs frequently cite the benign natural course of glue ear, doubts with respect to the specificity of the Ewing test and the presence of a clear explanation for the outcome of the hearing test such as distraction, cerumen or acute middle ear infection as reasons for not referring these children. Parents' anxiety about their child's development is frequently cited as a major reason for referral. When asked, most GPs consider themselves uncapable of establishing any deviation from normal speech and language development, a hearing loss, or glue ear in children at this age. Most GPs subscribe the guideline issued by the Dutch Society of General Practitioners in 1991, which recommends expectant management and referral only if indications exist that glue ear persists bilaterally during a period of at least 3 months after the onset of symptoms or the failed hearing test. ENT specialists use otoscopy as the major diagnostic tool in these children and use tympanometry only if the ear drum can not be evaluated in this way; audiometry is almost never used. As a major reason for inserting grommets ENT specialists cite the susceptiblity of these children to impaired language and speech development as the result of prolonged bilateral conductive hearing losses. They admit that they can not completely exclude a perceptive hearing loss, but they start treatment of the hearing loss as a conductive one; only if this proves to be ineffective, the possiblity of a perceptive hearing loss is further explored. No guideline for specialist treatment of this condition is available in the Netherlands. CONCLUSIONS: Hearing losses in children as the result of glue ear is very commonly seen in GPs' and ENT specialist practices. It has been the subject of many clinical evaluation studies, including randomized controlled trials. In spite of this, variation in medical practice persists, reflecting uncertainty about optimal management. Our study has shown which factors, other than outcomes from evaluation studies, determine clinical management. This certainly seems to challenge the objectives of Evidence Based Medicine. Whether this is always unjustified is still an open question.

Publication Types:

• Meeting Abstracts

Keywords:

• Acoustic Impedance Tests
• Audiometry
• Child
• Evidence-Based Medicine
• Hearing Loss
• Hearing Loss, Conductive
• Hearing Loss, Sensorineural
• Hearing Tests
• Humans
• Language Development
• Netherlands
• Otitis Media with Effusion
• Otolaryngology
• Parents
• Referral and Consultation
• diagnosis
• methods
• hsrmtgs

Other ID:

• HTX/98601612

UI: 102233153

From Meeting Abstracts