{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,31]],"date-time":"2025-12-31T14:58:52Z","timestamp":1767193132146,"version":"3.48.0"},"reference-count":45,"publisher":"BMJ","issue":"8","license":[{"start":{"date-parts":[[2025,8,19]],"date-time":"2025-08-19T00:00:00Z","timestamp":1755561600000},"content-version":"unspecified","delay-in-days":18,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100010763","name":"National Health Care Institute","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100010763","id-type":"DOI","asserted-by":"crossref"}]},{"name":"Consortium Quality of Care of the Netherlands Federation of University Medical Centres"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,7,11]]},"published-print":{"date-parts":[[2025,8]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Ventilation tube insertion for paediatric otitis media (POM), including acute otitis media (AOM) and otitis media with effusion (OME), has been signalled in the past for potential unwarranted treatment variation. Quality improvement initiatives, like Audit &amp; Feedback (A&amp;F), often ignore the care pathway when identifying such variation, possibly overestimating variation at a specific care step. To gain more insight into the effect of prior care steps, this study examined (1) the degree of regional variation in each step of the care pathway (general practitioner (GP) contacts, referrals and surgeries) and (2) investigated the effect of adjusting for prior care steps.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Observational study using general practice electronic health record data linked to specialist claims data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>272 790 children \u226412 years with and without POM registered in 320 GP practices between 2017 and 2018.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary and secondary outcomes<\/jats:title>\n                    <jats:p>Using multilevel logistic regression, the degree of regional variation in each step of the POM care pathway was assessed by calculating the coefficient of variation (CV).<\/jats:p>\n                    <jats:p>The effect of adjusting for prior care steps was determined by estimating correlations between subsequent care steps and analysing the impact on the CV.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Regional variation in POM treatment was larger in each subsequent step in the care pathway (CV POM GP contacts 0.110; referral 0.179; surgery 0.239). In regions with a higher proportion of children with frequent AOM\/persistent OME, referral rates were higher (POM: OR: 1.06; 95%\u2009CI: 1.02 to 1.11) and surgical rates were higher (for OME only: OR: 1.08; 95%\u2009CI: 1.02 to 1.15). Regional variation in referrals and surgery decreased after adjusting for the regional frequent AOM\/persistent OME rate (CV referrals POM 0.103 vs 0.128; CV surgery OME 0.047 vs 0.059).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Regional variation is observed in GP contact rates for POM and is larger in referrals and surgeries. Adjusting for the proportion of frequent AOM\/persistent OME significantly reduces regional variation in POM treatment. Future A&amp;F should adjust for prior care processes and develop tailored interventions for quality improvement.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-101692","type":"journal-article","created":{"date-parts":[[2025,8,19]],"date-time":"2025-08-19T15:15:53Z","timestamp":1755616553000},"page":"e101692","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Considering the full care pathway in regional variation in paediatric otitis media treatment in the Netherlands: an observational study"],"prefix":"10.1136","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3644-620X","authenticated-orcid":false,"given":"Vera","family":"de Weerdt","sequence":"first","affiliation":[{"name":"Health Economics, Vrije Universiteit, Amsterdam, the Netherlands"},{"name":"Amsterdam University Medical Centers, Amsterdam, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christel","family":"van Dijk","sequence":"additional","affiliation":[{"name":"National Healthcare Institute Diemen Netherlands, Diemen, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6040-4221","authenticated-orcid":false,"given":"Jako","family":"Burgers","sequence":"additional","affiliation":[{"name":"Nederlands Huisartsen Genootschap, Utrecht, Utrecht, the Netherlands"},{"name":"Maastricht University CAPHRI School for Public Health and Primary Care, Maastricht, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kati","family":"Gaspar","sequence":"additional","affiliation":[{"name":"CPB Netherlands Bureau for Economic Policy Analysis, the Hague, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karin","family":"Hek","sequence":"additional","affiliation":[{"name":"NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Raphael J","family":"Hemler","sequence":"additional","affiliation":[{"name":"Otholaringology, Gelre Hospitals, Apeldoorn, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sjoerd","family":"Repping","sequence":"additional","affiliation":[{"name":"University of Amsterdam, Amsterdam, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert A","family":"Verheij","sequence":"additional","affiliation":[{"name":"NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands"},{"name":"NIVEL, Utrecht, the Netherlands"},{"name":"Tilburg University Tilburg School of Social and Behavioral Sciences, Tilburg, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hanna C","family":"Willems","sequence":"additional","affiliation":[{"name":"Amsterdam University Medical Centers, Amsterdam, the Netherlands"},{"name":"Department of Internal Medicine and Geriatrics, University of Amsterdam, Amsterdam, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3359-2711","authenticated-orcid":false,"given":"Eric J E","family":"van der Hijden","sequence":"additional","affiliation":[{"name":"Health Economics, Vrije Universiteit, Amsterdam, the Netherlands"},{"name":"Zilveren Kruis Health Insurance, Leiden, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xander","family":"Koolman","sequence":"additional","affiliation":[{"name":"Health Economics, Vrije Universiteit, Amsterdam, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,8,19]]},"reference":[{"key":"2025123106470172000_15.8.e101692.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijporl.2007.03.010"},{"key":"2025123106470172000_15.8.e101692.2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijporl.2014.06.034"},{"key":"2025123106470172000_15.8.e101692.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijporl.2003.09.002"},{"key":"2025123106470172000_15.8.e101692.4","doi-asserted-by":"crossref","DOI":"10.1186\/s40463-021-00533-x","article-title":"Choosing Wisely Canada - pediatric otolaryngology recommendations","volume":"50","author":"McDonough","year":"2021","journal-title":"J Otolaryngol Head Neck Surg"},{"key":"2025123106470172000_15.8.e101692.5","unstructured":"Federatie Medisch Specialisten . 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