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As part of the Choosing Wisely campaign, the American Academy of Pediatrics worked with a team of neonatologists at Beth Israel Deaconess Medical Center in Boston to devise a list of the top 5 tests and treatments that can be left out of routine newborn care because of cost or lack of efficacy.
As part of the Choosing Wisely campaign, the American Academy of Pediatrics (AAP) worked with a team of neonatologists at Beth Israel Deaconess Medical Center (BIDMC) in Boston to devise a list of the top 5 tests and treatments that can be left out of routine newborn care because of cost or lack of efficacy.
To pull together the list, the neonatologists at BIDMC solicited more than 1,000 physicians for their input on the most overused tests or procedures that are unnecessary because of cost, efficacy, or safety. More than 1600 tests and 1200 treatments were pitched, and a 51-expert panel reviewed all the suggestions.
The end result is a recommendation from AAP that 5 tests or treatments be left off pediatricians’ list of suggested procedures as part of the Choosing Wisely campaign, launched by the American Board of Internal Medicine Foundation (ABIM) in 2011 to promote “care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.”
Of the tests that were suggested as wasteful or unnecessary, 71% were screening tests (primarily laboratory-based or imaging), 23% were diagnostic tests (laboratory and imaging tests), and 6% were monitoring studies (pneumograms and oximetry monitoring).
Of the treatments recommended in the survey, 56% were “overused” medications. The top 4 medications deemed overused were for gastroesophageal reflux, antimicrobial agents, diuretics, and patent ductus arteriosus prophylaxis and treatment. The next most commonly recommended treatments to add to the wasteful list included certain respiratory procedures, some surgical procedures, and nutritional interventions.
At first, a list of 22 tests and treatments was compiled from the survey, and that number was reduced eventually to 5.
Those 5 recommendations are as follows:
1. Avoid routine use of antireflux medications for the treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants.
The investigators say that gastroesophageal reflux is normal in infants, and there is little evidence to show that reflux can cause apnea or desaturation. There is also little evidence-based support for the use of H2 antagonists, proton-pump inhibitors, and motility agents as treatments. In fact, the study notes that some research has shown adverse physiologic effects in addition to necrotizing enterocolitis, infections, intraventricular hemorrhage, and mortality. A companion paper to the main study adds that there was not enough evidence to support the safety and efficacy of the use of proton pump inhibitors in older children or of metoclopramide in children aged older than 2 years.
2. Avoid routine continuation ofantibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection.
In light of today’s blood culturing systems, a majority of pathologic organisms can be identified in less than 48 hours. Use of prophylactic antibiotic therapy in asymptomatic patients or other instances of prolonged antibiotic use may be associated with necrotizing enterocolitis or death in extremely low-birth-weight infants, the report notes.
3. Avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity.
Preterm, and even full-term, infants commonly face cardiorespiratory problems. Pneumograms-also known as cardiorespiratory scans, pneumocardiograms, or simply sleep studies-are sometimes used to monitor these issues by recording breathing effort, heart rate, oxygen levels, and air flow from the lungs while the infant sleeps. Despite being useful in some cases in which the etiology of a problem remains in doubt, the study found that pneumograms did not reduce the frequency of acute life-threatening events or mortality.
4. Avoid routine daily chest radiographs without an indication for intubated infants.
Performing chest radiographs, or chest X-rays, intermittently can sometimes produce unexpected findings, according to the study. Daily X-rays, however, were not shown to reduce adverse outcomes but did increase radiation exposure, according to the study.
5. Avoid routine screening term-equivalent or discharge brain magnetic resonance imaging (MRI) in preterm infants.
Insufficient evidence exists to support the use of term-equivalent or discharge screening MRIs. Although this costly test correlates with neurodevelopmental outcomes later in the child’s life, it may not lead to improved long-term outcomes.
Waste in the healthcare system costs an estimated $2.7 trillion each year through failure of care delivery or care coordination, overtreatment, administrative problems, or pricing failures. The study, published in Pediatrics, notes that waste accounts for 34% of all healthcare spending in the United States. Overtreatment alone was estimated to have contributed $158 billion to $226 billion to healthcare costs in 2011, the same year Choosing Wisely was launched. The AAP joined the Choosing Wisely campaign in 2013 and, like other member medical societies, the academy is challenged to create “top 5” lists that support the initiative of the campaign.
Although many of the recommendations apply more to neonatal physicians, lead author Timmy Ho, MD, FAAP, a neonatologist at BIDMC, says general pediatricians must still be aware of the recommendations and be prepared to address concerns from parents.
“It is critical that they pursue the same value-based approach that starts in the well-baby nursery, may or may not go to the [neonatal intensive care unit (NICU)], then continues in the pediatrician’s office,” Ho says.
Dealing with parents who are concerned about overtesting beyond the recommendations and ask about opting out of more essential tests is not covered specifically in this study, but Ho says having a conversation about what tests are needed and why is a critical component of the pediatrician-parent relationship and a hallmark of the Choosing Wisely program.
“Pediatricians are well trained to take the time to have discussions with parents about why a particular test or treatment is necessary and understand their patients' parents' perspectives to understand why there is concern or fear of essential testing,” Ho says.
“Unfortunately, in the current structure of healthcare in the [United States], clinicians often don't have the time to delve into the belief and value structures of every parent to understand why they are thinking the way they are,” Ho says. “The most important piece of advice would be to take the time to have those conversations, even though they may be difficult and time-consuming.
Ho and his colleagues say that providers should offer neonate parents more opportunities to participate in clinical decision making that includes the use of routine tests and noninvasive treatments. This list is not an all-inclusive recommendation of procedures that can be removed from the patient’s care plan, but rather a catalyst for more shared decisions.
Although not all the tests and treatments that made the list are expensive, Ho notes that they all have cost implications because of the use of staff times, volume, and other related costs.
“Consider that the elimination of even one radiograph, assuming even a conservative price of $100 per film, for each very low-birth-weight infant in a NICU with 200 such admissions per year would represent savings of $20,000,” the researchers write. “Moreover, the elimination of multiple low-price ineffective therapies might cumulatively impact efficiency at a national level.”
Ho and his colleagues also recognize that each hospital and NICU is different.
“In applying the results, we would encourage centers to first measure incidence of use. Certain items may be prioritized for reduction or elimination,” the study team writes. “Once high reliability has been achieved in the top 5 items, such self-examination will reveal other areas of overuse and waste on which value improvement efforts ought to focus.”
Ho gives an example of National Institutes of Health recommendations against the use of nitric oxide in preterm infants that was left off the top 5 list. “Nitric oxide use may not be an issue in the large majority of centers, but reduction in its overuse will have a substantial cost impact in certain outliers,” the study notes.
Ho also stresses that although the team repeatedly references “routine” in its report, there may be times when the tests are appropriate and should be indicated. “Standardization of ‘best practice’ never should override clinician judgment based on the newborn’s clinical presentation,” the researchers note. “However, as part of a learning healthcare system, if tests and treatments on the Top 5 list are ordered, the clinician should specify why the order was justified. Variance from standard practice should be systematically examined to ascertain under which circumstances deviation may be justifiable or preferred.”