ACEP recently published their own “Choosing Wisely” campaign contribution – a list of five changes to Emergency Medicine practice that ought be encouraged in the interests of increasing cost-effective care. While most would agree the ACEP version is reasonable, I think many clinicians hoped for something a little more earth-shattering.
Something like the Pediatric Hospital Medicine list for Choosing Wisely.
These authors specifically looked at the top 10 inpatient diagnoses in terms of volume and aggregate costs, and specifically evaluated components of treatment as candidates for recommendations. And, even speaking as someone who makes an effort to minimize testing – I find these recommendations take an impressive step in terms of aggressive reduction in resource utilization.
The highlights:
Do not order chest radiographs in children with asthma or bronchiolitis.
Do not use bronchodilators in children with bronchiolitis.
Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection.
How often do you get radiographs in patients with respiratory disease – that get discharged? How about admitted? The authors estimate 60% of admitted patients receive radiographs, with fewer than 2% affecting clinical management.
Or, routine bronchodilator therapy – which, frankly, is ordered for a lot of children simply due to a sense we ought to do something. Both beta-agonist and racemic epinephrine fall under this recommendation, as they’ve not been shown to confer any reliable, clinically meaningful, patient-oriented outcome in bronchiolitis.
Finally – corticosteroids. Young children, even with albuterol-responsive wheezing, showed no benefit when corticosteroids were added. These are not harmless interventions, particularly for growing infants, and seems to pre-dispose some folks to subsequent readmission.
With pediatric respiratory season on the horizon, I challenge all of you to use this document as a tool share with colleagues and consultants to decrease unnecessary testing and therapy.
“Choosing Wisely in Pediatric Hospital Medicine: Five Opportunities for Improved Healthcare Value”
http://www.ncbi.nlm.nih.gov/pubmed/23955837