Ambulatory Care Quality Improvement Research Articles

Specialty-Based Ambulatory Quality Improvement Program: A Specialty-Specific Ambulatory Metric Project.

Healthcare is increasingly being delivered in the outpatient setting, but robust quality improvement programs and performance metrics are lacking in ambulatory care, particularly specialty-based ambulatory care. To promote quality improvement in ambulatory care, we developed an infrastructure to create specialty-specific quality measures and dashboards that could be used to display providers' performance across relevant measures to individual providers and institutional leaders. The products of this program include a governance and infrastructure for specialty-specific ambulatory quality metrics as well as two distinct dashboards for data display. One dashboard is provider-facing, displaying provider's performance on specialty-specific measures as compared to institutional standards. The second dashboard is a leadership dashboard that provides overall and provider-level information on performance across measures. The Specialty-based Ambulatory Quality program reflects a systematic, institutionally-supported quality improvement framework that can be applied across diverse ambulatory specialties. As next steps, we plan to evaluate the program's impact on provider performance across measures and expand this program to other specialties practicing in the outpatient setting.

Promoting Patient and Family Partnerships in Ambulatory Care Improvement: A Narrative Review and Focus Group Findings.

IntroductionAmbulatory practices that actively partner with patients and families in quality improvement (QI) report benefits such as better patient/family interactions with physicians and staff, and patient empowerment. However, creating effective patient/family partnerships for ambulatory care improvement is not yet routine. The objective of this paper is to provide practices with concrete evidence about meaningfully involving patients and families in QI activities.MethodsReview of literature published from 2000–2015 and a focus group conducted in 2014 with practice advisors.ResultsThirty articles discussed 26 studies or examples of patient/family partnerships in ambulatory care QI. Patient and family partnership mechanisms included QI committees and advisory councils. Facilitators included process transparency, mechanisms for acting on patient/family input, and compensation. Challenges for practices included uncertainty about how best to involve patients and families in QI. Several studies found that patient/family partnership was a catalyst for improvement and reported that partnerships resulted in process improvements. Focus group results were concordant.ConclusionThis paper describes emergent mechanisms and processes that ambulatory care practices use to partner with patients and families in QI including outcomes, facilitators, and challenges.FundingGordon and Betty Moore Foundation.Electronic supplementary materialThe online version of this article (doi:10.1007/s12325-016-0364-z) contains supplementary material, which is available to authorized users.

The influence of hospitalization or intensive care unit admission on declines in health-related quality of life.

Survivors of critical illness report impaired health-related quality of life (HRQoL) after hospital discharge, but the degree to which these impairments are attributable to critical illness is unknown. We sought to examine changes in HRQoL associated with an intensive care unit (ICU) stay and the differential association of type of hospitalization (critical illness versus noncritical illness) on changes in HRQoL. We identified 11,243 participants in the Ambulatory Care Quality Improvement Project (a multicenter randomized trial of Veterans conducted March 1997 to August 2000) completing at least two Medical Outcomes Study Short-Form 36 questionnaires over 2 years, and categorized patients by hospitalization status during the interval between measures. We used multiple linear regression with generalized estimating equations for analysis. Our primary outcome was change in the Physical Component Summary score. Participants requiring hospitalization or ICU admission had significantly worse baseline HRQoL than those not hospitalized (P < 0.001). Compared with patients who were not hospitalized, follow-up Physical Component Summary scores were lower among non-ICU hospitalized patients and ICU patients (adjusted β-coefficient = -1.40 [95% confidence interval, -1.81, -0.99] and adjusted β-coefficient = -1.53 [95% confidence interval, -2.11, -0.95], respectively), with no difference between the two groups (P value = 0.80). Similar results were seen for the Mental Component Summary score and each of the Medical Outcomes Study Short-Form 36 subdomains. Prehospital HRQoL is a significant determinant of HRQoL after hospitalization or ICU admission. Hospitalization is associated with increased risk of impairment in HRQoL after discharge, yet the overall magnitude of this reduction is small and similar between non-ICU hospitalized and critically ill patients.

Regional Variation in Health Status among Chronic Obstructive Pulmonary Disease Patients

Background: Little is known about geographic differences in health status among patients with chronic obstructive pulmonary disease (COPD). Objectives: The aim of this study was to examine regional variations in self-reported health status of COPD patients at 7 Veterans Affairs clinics. Methods: The Ambulatory Care Quality Improvement Project was a multicenter, randomized trial conducted from 1997 to 2000 that evaluated a quality improvement intervention in the primary care setting. Four thousand and nine participants with COPD (age ≧45 years) completed the Seattle Obstructive Lung Disease Questionnaire (SOLDQ) and 2,991 also completed the Medical Outcomes Study 36-item short form (SF-36). The unadjusted maximal difference in health status scores is reported as the ratio of the highest and lowest site prevalence. We report the maximal site difference in mean health status scores after adjusting for demographics, comorbidities, utilization, medication use and clinic factors. Results: Subjects were predominantly older (66.5 ± 9.2 years) Caucasian (83.2%) men (97.9%). After adjustment, the maximal site difference for each health status score was significant (p < 0.01) but larger for the SOLDQ (physical 11.2, emotional 9.7, coping skills 7.6) than for the SF-36 (physical component summary 4.7, mental component summary 2.6). Most of the health status variation was explained by individual or clinic level factors, not clinic site. Conclusions: Our models explained <30% of variation in health status measures; therefore, future studies should consider additional predictors of health status such as physical performance, social determinants of health, COPD treatment and environmental factors. Despite its limitations, this study suggests a need to consider regional differences in health status when comparing COPD health outcomes in diverse geographic areas.

Experience with a trigger tool for identifying adverse drug events among older adults in ambulatory primary care

Objective:To evaluate the performance of a trigger tool for identifying adverse drug events (ADEs) among older adults in ambulatory primary care practices.Methods:Manual 12-month retrospective chart review at six practices using...

Functional status and patient satisfaction a comparison of ischemic heart disease, obstructive lung disease, and diabetes mellitus

To determine the extent to which chronic illness and disease severity affect patient satisfaction with their primary care provider in general internal medicine clinics. Cross-sectional mailed questionnaire study. Primary care clinics at 7 Veterans Affairs medical centers. Of 62,487 patients participating in the Ambulatory Care Quality Improvement Project, 35,383 (57%) returned an initial screening questionnaire and were subsequently sent a satisfaction questionnaire. Patients (N=21,689; 61%) who returned the Seattle Outpatient Satisfaction Survey (SOSQ) were included in the final analysis, representing 34% of the original sample. The organizational score of the SOSQ measures satisfaction with health care services in the internal medicine clinic, and the humanistic scale measures patient satisfaction with the communication skills and humanistic qualities of the primary care physician. For ischemic heart disease (IHD), chronic obstructive pulmonary disease (COPD), and diabetes, patient ability to cope with their disease was more strongly associated with patient satisfaction than disease severity. Among IHD patients, improvement in ability to cope emotionally with their angina was associated with higher SOSQ organizational scores (standardized beta=0.18; P<.001) but self-reported physical limitation due to angina was not (beta=0.01; P=.65). Similarly, in COPD, improved ability to cope with dyspnea was associated with greater organizational scores (beta=0.11; P<.001) but physical function was not (beta=-0.03; P=.27). For diabetes, increased education was associated with improved organizational scores (beta=0.31; P<.001) but improvement in symptom burden was not (beta=0.03; P=.14). Similar results were seen with prediction of SOSQ humanistic scores. Patient education and ability to cope with chronic conditions are more strongly associated with satisfaction with their primary care provider than disease severity. Further improvements in patient education and self-management may lead to improved satisfaction and quality of care.

Continuity of care and other determinants of patient satisfaction with primary care

The patient-clinician relationship is a central feature of primary care, and recent developments in the delivery of health care have tended to limit continuity of care. The objective of this study was to evaluate the extent to which continuity of care and other factors are related to patient satisfaction. Cross-sectional, mailed questionnaire study. Primary care clinics at 7 Veterans Affairs medical centers. Patients (N=21,689) participating in the Ambulatory Care Quality Improvement Project who returned the baseline Seattle Outpatient Satisfaction Questionnaire (SOSQ). We evaluated the association between self-reported continuity and satisfaction, after adjusting for characteristics of patients, clinics, and providers. The humanistic scale of the SOSQ measures patient satisfaction with communication skills and humanistic qualities of providers, whereas the organizational scale measures satisfaction with delivery of health care services. The mean adjusted humanistic score for patients who reported always seeing the same provider was 17.3 (95% confidence interval [CI], 15.5 to 19.1) points higher than for those who rarely saw the same provider. Similarly, the mean adjusted organizational score was 16.3 (95% CI, 14.5 to 18.1) points higher for patients who always saw the same provider compared to rarely. Demographic factors, socioeconomic status, health status, clinic site, and patient utilization of services were all associated with both the adjusted humanistic and organizational scores of the SOSQ. Self-reported continuity of care is strongly associated with higher patient satisfaction. This suggests that improving continuity of care may improve patient satisfaction with providers as well as with their health care organization.

Outpatient Quality Improvement in Academic Faculty Practice Plans: Does it Exist?

The purpose of this study was to (a) investigate the extent to which academic faculty practice plans (FPPs) are currently involved in ambulatory care quality improvement (QI), (b) describe the structure of QI initiatives at outpatient FPPs, and (c) delineate facilitators and barriers to development of FPP outpatient QI initiatives. Members of the Steering Committee of the Group Practice Council of the University HealthSystem Consortium (UHC), representing the leadership of 88 FPPs, were asked to respond to a 38-item Web-based questionnaire during February and March 2003. The survey elicited information on the organizational characteristics of FPPs, their current degree of engagement in outpatient QI activities, and factors driving interest and barriers impeding efforts to conduct outpatient QI initiatives. Descriptive statistics for all variables of interest were performed. Responses were received from 33 participants believed to represent at least 28 of the total 88 FPP members of the UHC. Nearly all respondents indicated that some types of outpatient QI initiatives were currently taking place in their FPP. However, only 12% of respondents met 4 or more of the 6 criteria deemed to be essential to having a robust outpatient QI program. Among key QI indicators, one third of respondents reported that their FPP had a separate and distinct outpatient quality committee, and some one fifth had a budget for outpatient QI or financial incentives for outpatient clinics to engage in QI (or both). The majority of respondents stated that at least some departments in their FPP were collecting quality data. Most respondents reported that patient safety and external demand for outpatient QI were the "more important" factors driving QI efforts, whereas lack of human resources and other resources were the "more significant" barriers hindering QI initiatives. The results of the study suggest that, although FPPs showed a strong interest in outpatient QI initiatives, FPPs' efforts are still in an infancy phase and lag far behind inpatient performance measurement activities. Without appropriate resources, it appears unlikely that FPPs will be able to move the agenda forward to develop a quality culture and robust program of self-assessment and improvement in the outpatient setting.

Association of body weight with condition-specific quality of life in male veterans

We hypothesized that obese adults with coronary heart disease, obstructive lung disease, or depression would report greater impairments in health-related quality of life owing to their angina, dyspnea, or depressive symptoms as compared with persons with normal body weight. We analyzed cross-sectional data from the Ambulatory Care Quality Improvement Project, a multicenter study of veterans enrolled in general internal medicine clinics. Health-related quality of life was assessed using the Medical Outcomes Study Short Form-36, the Seattle Angina Questionnaire, the Seattle Obstructive Lung Disease Questionnaire, and the Hopkins Symptom Checklist for Depression. Compared with patients of normal weight (body mass index: 18.5 to 24.9 kg/m2), underweight patients (body mass index <18.5 kg/m2) reported health-related quality-of-life scores that were at least 5% lower (worse) in all 15 quality-of-life domains examined. Patients with class III obesity (body mass index > or =40 kg/m2) reported quality-of-life scores that were at least 5% lower than those of normal weight patients in eight domains. Scores of overweight patients (body mass index: 25 to 29.9 kg/m2) were higher (better) than those of normal weight patients in 11 domains. Body mass index was strongly associated with generic- and condition-specific health-related quality of life. Our results suggest that, when considering health-related quality-of-life outcomes among veterans, the optimal body mass index may be above the "normal" range. Further research should test the validity of the 1998 National Institutes of Health body mass index categories as predictors of health outcomes among veterans.

Association between chronic heart failure and inhaled β-2-adrenoceptor agonists

Background Recent reports suggest an association between β-agonists and the risk of incident chronic heart failure (CHF). We sought to examine the association between inhaled β-agonists and risk of incident and nonincident heart failure. Methods We performed a nested case-control study within the Ambulatory Care Quality Improvement Project (ACQUIP). Case subjects were defined as having had a hospitalization with a primary discharge diagnosis of CHF. Controls were randomly selected from the ACQUIP cohort. The exposure was the number of β-agonist canisters filled in the 90 days before an index date. Results After adjusting for potentially confounding factors, there appeared to be no association between the use of inhaled β-agonists and the risk of heart failure (1–2 canisters per month, OR 1.3 [95% CI 0.9, 1.8], ≥3 canisters per month, 1.1 [95% CI 0.8, 1.6]). However, among the cohort that had a history of CHF, there appeared to be a dose-response association between the number of inhaled β-agonists and the risk of hospitalization for chronic heart failure (1–2 canisters per month, adjusted OR 1.8 [95% CI 1.1, 3.0], ≥3 canisters per month, adjusted OR 2.1 [95% CI 1.2, 3.8]). Conclusion β-Agonists did not appear to be associated with incident heart failure but were associated with risk of CHF hospitalization among those subjects with a previous CHF diagnosis. Although a causal relationship cannot be inferred from these findings, further research is warranted to determine the safety and effectiveness of inhaled β-agonists for patients with CHF.

Cardiovascular risk factor control among veterans with diabetes: the ambulatory care quality improvement project.

To describe the extent to which hyperglycemia, hypertension, and dyslipidemia are currently detected, treated, and controlled in U.S. veterans with diabetes with and without ischemic heart disease (IHD). A cohort of 3,769 veterans who self-reported diabetes and who received all health care from the Veterans Administration (VA) medical centers were selected from subjects enrolled in the Ambulatory Care Quality Improvement Project, a randomized health services intervention at seven VA primary care clinics. IHD was defined by a self-reported history of myocardial ischemia, infarction, or revascularization. Mean values of HbA(1c), blood pressure, and cholesterol subfractions were collected from computerized laboratory databases. Medication data were collected from computerized pharmacy databases. Mean HbA(1c) and optimal control (HbA(1c) <7%) did not differ for those without and with IHD: 8.1 vs. 8.0%, and 26 vs. 24%, respectively. Veterans with IHD were more likely to have hypertension (73 vs. 64%), to be treated (88 vs. 78%), and to have optimal blood pressure control (19 vs. 10%) compared with veterans without IHD (all P values <0.01). Veterans with IHD were more likely to have dyslipidemia (81 vs. 53%), were equally likely to be treated (54 vs. 50%), and were more likely to have optimal LDL levels (30 vs. 16%) compared with veterans without IHD, all P values <0.01. Optimal cardiovascular risk factor control was the exception in this cohort of diabetic veterans attending primary care clinics. More aggressive management of cardiovascular risk factors in veterans with diabetes may be warranted, especially among those without prevalent IHD.

Intraindividual change in SF-36 in ambulatory clinic primary care patients predicted mortality and hospitalizations

Objective We sought to determine whether change in SF-36 scores over time is associated with the risk of adverse outcomes. Study Design and Setting 7,702 participants in the Ambulatory Care Quality Improvement Project who completed a baseline and 1-year SF-36. Using logistic regression methods we estimated the 1-year risk of hospitalization and death based on previous 1-year changes in the physical (PCS) and mental (MCS) component summary scores. Results After adjusting for baseline PCS scores, age, VA hospital site, distance to VA, and comorbidity, a >10-point decrease in PCS score was associated with an increased risk of death (OR 2.3, 95% CI 1.6–3.4) and hospitalization (OR 1.8, 1.4–2.2). An increased risk was also seen with a >10-point decrease in the MCS (OR for death, 1.6, 1.1–2.3; OR for hospitalization 1.5, 1.2–1.8). Conclusion Change in SF-36 PCS and MCS scores is associated with mortality and hospitalizations, and provides important prognostic information over baseline scores alone.

Construction and implementation of nursing actions in the gastroenterology outclinic

The reorganization of the Schistosomiasis Sector of Gastroenterology at UNIFESP started in 1998, when the Nursing Service was implanted. to develop administrative nursing actions, systematization of care and orientation program for the schistosomic patient. a descriptive study carried out at the Gastroenterology Outclinic, which attends schistosomic patients of different clinical types. the reorganization of activities in this Sector resulted in the creation of an organizational structure and the implantation of the nursing visit; creation and distribution of explanatory leaflets and development of the Schistosomiasis Education Program; beginning of the database pilot project with all outpatients and an electronic register of the collection of biologic material. this initiative opens up a new opportunity for nursing actions and contributes to quality improvement in ambulatory care.

Using Quality of Life to Predict Hospitalization and Mortality in Patients With Obstructive Lung Diseases

Condition-specific measures of quality of life (QOL) for patients with COPD have been demonstrated to be highly reliable and valid, but they have not conclusively been shown to predict hospitalization or death. We sought to determine whether a brief, self-administered, COPD-specific QOL measure, the Seattle Obstructive Lung Disease Questionnaire (SOLDQ), could accurately predict hospitalizations and death. Prospective cohort study. Patients enrolled in the primary care clinics at seven Department of Veterans Affairs (VA) medical centers participating in the Ambulatory Care Quality Improvement Project. Of 24,458 patients who completed a health inventory, 5,503 reported having chronic lung disease. The 3,282 patients who completed the baseline SOLDQ were followed for 12 months. Hospitalization and all-cause mortality during the 1-year follow-up period. During the follow-up period, 601 patients (18.3%) were hospitalized, 141 (4.3%) for COPD exacerbations, and 167 patients (5.1%) died. After adjusting for age, VA hospital site, distance to the VA hospital, employment status, and smoking status, the relative risk of any hospitalization among patients with scores on the emotional, physical, and coping skills scales of the SOLDQ that were in the lowest quartile, when compared to the highest quartile, were 2.0 (95% confidence interval [CI], 1.5 to 2.6), 2.5 (95% CI, 1.9 to 3.4), and 1.9 (95% CI, 1.5 to 2.5), respectively. When hospitalizations were restricted to those specifically for COPD, the odds ratio (OR) for the lowest quartile of physical function was 6.0 (95% CI, 3.1 to 11.5). Similarly, patients in the lowest quartile of physical function also had an increased risk of death (OR, 6.8; 95% CI, 3.3 to 13.8). When adjusted for comorbidity (OR, 0.8; 95% CI, 0.5 to 1.2), long-term steroid use (OR, 2.8; 95% CI, 1.6 to 4.9), and prior hospitalization for COPD (OR, 4.5; 95% CI, 2.2 to 9.2), patients having baseline SOLDQ physical function scores in the lowest quartile had an odds of hospitalization for COPD that was fivefold higher than patients with scores in the highest quartile (OR, 5.0; 95% CI, 2.6 to 9.7). Lower QOL is a powerful predictor of hospitalization and all-cause mortality. Brief, self-administered instruments such as the SOLDQ may provide an opportunity to identify patients who could benefit from preventive interventions.

Validation of case-mix measures derived from self-reports of diagnoses and health

Self-reported chronic diseases and health status are associated with resource use. However, few data exist regarding their ability to predict mortality or hospitalizations. We sought to determine whether self-reported chronic medical conditions and the SF-36 could be used individually or in combination to assess co-morbidity in the outpatient setting. The study was designed as a prospective cohort study. Patients were enrolled in the primary care clinics at seven Veterans Affairs (VA) medical centers participating in the Ambulatory Care Quality Improvement Project (ACQUIP). 10,947 patients, ⩾ 50 years of age, enrolled in general internal medicine clinics who returned both a baseline health inventory checklist and the baseline SF-36 who were followed for a mean of 722.5 (±84.3) days. The primary outcome was all-cause mortality, with a secondary outcome of hospitalization within the VA system. Using a Cox proportional hazards model in a development set of 5,469 patients, a co-morbidity index [Seattle Index of Co-morbidity (SIC)] was constructed using information about age, smoking status and seven of 25 self-reported medical conditions that were associated with increased mortality. In the validation set of 5,478 patients, the SIC was predictive of both mortality and hospitalizations within the VA system. A separate model was constructed in which only age and the PCS and MCS scores of the SF-36 were entered to predict mortality. The SF-36 component scores and the SIC had comparable discriminatory ability (AUC for discrimination of death within 2 y 0.71 for both models). When combined, the SIC and SF-36 together had improved discrimination for mortality (AUC = 0.74, p-value for difference in AUC < 0.005). A new outpatient co-morbidity score developed using self-identified chronic medical conditions on a baseline health inventory checklist was predictive of 2-y mortality and hospitalization within the VA system in general internal medicine patients.

The association between depressive symptoms and health status in patients with chronic pulmonary disease

This study evaluated the association between depressive symptoms and health related quality of life (HRQoL) in patients with chronic pulmonary disease using both general and disease-specific HRQoL measures. A cross-sectional analysis of HRQoL measures completed by patients enrolled in the Department of Veteran Affairs Ambulatory Care Quality Improvement Project. 1252 patients with chronic pulmonary disease screened positive for emotional distress and returned the Hopkins Symptom Checklist-20 (SCL-20). 733 of 1252 had a score of 1.75 or greater on the SCL-20 indicating significant depressive symptoms. Depressive symptoms were associated with statistically significantly worse general and pulmonary health as reflected by lower scores on all sub-scales of both the Medical Outcomes Short Form-36 and the Seattle Obstructive Lung Disease Questionnaire. In fact, 11% to 18% of the variance in physical function sub-scales was attributed to depressive symptoms alone. Patients with chronic pulmonary disease and depressive symptoms reported significantly more impaired functioning and worse health status when compared to those patients without depressive symptoms. Because there are highly effective treatments for depression, selective screening of patients with chronic pulmonary disease for depression may identify a group that could potentially benefit from treatment interventions.

Improving patient follow-up through implementation of an ambulatory care quality improvement program.

Nurse practitioners in ambulatory care settings must begin using quality improvement strategies to enhance patient outcomes and to improve patient follow-up. The article highlights the development and beginning stages of implementation of one such quality improvement program and discusses the actions that were taken to increase timeliness of key patient processes. An example of a quality improvement educational program, outlines of the plan, and scope of services are also provided.

Quality Improvement Activity Directed at the National Level

Quality improvement projects coordinated by the Health Care Financing Administration (HCFA) are currently underway to improve the care provided to Medicare beneficiaries. We describe five national quality improvement projects, the End Stage Renal Disease Core Indicators Project, the National Anemia Cooperative Project, the Ambulatory Care Quality Improvement Project, and the Cooperative Cardiovascular Project. We outline the types of intervention strategies employed and compare the approaches used for fee-for-service sites and for managed care plans.

Quality Improvement: An ACQIP Exercise on the Management of Otitis Media

As part of Pediatrics in Review's ongoing focus on quality improvement, we present a self-assessment exercise taken from the American Academy of Pediatrics' Ambulatory Care Quality Improvement Program (ACQIP). Tabulated responses of pediatricians who completed this exercise as part of the ACQIP program are presented on pages 253 to 254, allowing readers to see how their own answers compare and providing material for thought and discussion. Readers are encouraged to participate in the ACQIP program. Additional information can be obtained by calling or writing the Division of Quality Care, American Academy of Pediatrics, Box 927, Elk Grove Village, IL 60009-0927. Monitoring Otitis Media EDUCATIONAL OBJECTIVES This exercise and the follow-up materials should help you identify areas of improvement in how your practice monitors and documents information for children with acute or chronic otitis. INSTRUCTIONS Beginning with tomorrow's appointments, answer the questions below for the most recent, but not the current episode of otitis media in the first 10 patients you see who are younger than 4 years of age and experiencing at least their second episode of otitis. You will need to review charts to answer the questions. Put a check in each box in which you find the information in your medical record listed.

Quality Improvement: An ACQIP Exercise on the Management of Otitis Media

As part of Pediatrics in Review9s ongoing focus on quality improvement, we present a self-assessment exercise taken from the American Academy of Pediatrics9 Ambulatory Care Quality Improvement Program (ACQIP). Tabulated responses of pediatricians who completed this exercise as part of the ACQIP program are presented on pages 253 to 254, allowing readers to see how their own answers compare and providing material for thought and discussion. Readers are encouraged to participate in the ACQIP program. Additional information can be obtained by calling or writing the Division of Quality Care, American Academy of Pediatrics, Box 927, Elk Grove Village, IL 60009-0927. Monitoring Otitis Media EDUCATIONAL OBJECTIVES This exercise and the follow-up materials should help you identify areas of improvement in how your practice monitors and documents information for children with acute or chronic otitis. INSTRUCTIONS Beginning with tomorrow9s appointments, answer the questions below for the most recent, but not the current episode of otitis media in the first 10 patients you see who are younger than 4 years of age and experiencing at least their second episode of otitis. You will need to review charts to answer the questions. Put a check in each box in which you find the information in your medical record listed.