Choosing Wisely in Pediatric Hospital Medicine

Five Opportunities for Improved Healthcare Value

Ricardo A. Quinonez MD; Matthew D. Garber MD; Alan R. Schroeder MD; Brian K. Alverson MD; Wendy Nickel MPH; Jenna Goldstein MA; Jeffrey S. Bennett MD; Bryan R. Fine MD, MPH; Timothy H. Hartzog MD; Heather S. McLean MD; Vineeta Mittal MD; Rita M. Pappas MD; Jack M. Percelay MD, MPH; Shannon C. Phillips MD, MPH; Mark Shen MD; Shawn L. Ralston MD


Journal of Hospital Medicine. 2013;8(9):479-485. 

In This Article

Abstract and Introduction


Background Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric workgroup's results.

Methods A workgroup of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below.

Results The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

Conclusion We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.


Overuse in medicine is a significant and under-recognized problem. Don Berwick estimated that waste accounts for at least 20% of healthcare expenditures in the United States, with overtreatment as one of the largest categories.[1] A commentary by Schroeder et al. challenged pediatricians to incorporate this knowledge into our own patient safety and quality movement.[2] Recently published data suggest that we are far from achieving the patient safety goals set forth in the Institute of Medicine's landmark To Err is Human[3] report, despite more than a decade of national, local, and regional efforts.[4] One way to reduce waste and improve patient safety is to eliminate practices of unproven benefit. Therapies or tests that may initially seem promising are often proven to be not only unhelpful but actually harmful. The recommendation of the US Preventive Services Task Force against routine screening for prostate specific antigen is an example of how a common test initially thought of as lifesaving actually increases harm.[5]

The American Board of Internal Medicine Foundation (ABIM-F) recently announced the Choosing Wisely campaign. Through this campaign the Foundation encourages "physicians, patients and other healthcare stakeholders to think and talk about medical tests and procedures that may be unnecessary."[6] The primary output of this challenge is the development of a list of 5 tests and or therapies that physicians and patients should question. The ABIM-F approached different medical societies to develop these lists within their own specialties. The Society of Hospital Medicine (SHM) joined the Choosing Wisely campaign in April 2012, and agreed to develop a list of 5 therapies and tests for adult hospital medicine and pediatric hospital medicine. Here we present the contribution of the pediatric workgroup detailing the methodology and process for developing the list, as well as summarizing the evidence supporting each recommendation.