Five Unnecessary Tests for Newborns: Choosing Wisely

Lara C. Pullen, PhD

July 20, 2015

The Choosing Wisely campaign has identified the top five newborn medicine tests and treatments that cannot be justified on the basis of efficacy, safety, or cost. Timmy Ho, MD, from Beth Israel Deaconess Medical Center in Boston, Massachusetts, and colleagues published the results of their extensive selection process online July 20 in Pediatrics.

The top five for newborn medicine are:

  1. Avoid routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants.

  2. Avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection.

  3. Avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity.

  4. Avoid routine daily chest radiographs without an indication for intubated infants.

  5. Avoid routine screening term-equivalent or discharge brain magnetic resonance imaging scans in preterm infants.

The authors draw attention to the use of the word "routine," explaining there may be specific instances in which these tests or treatments are appropriate.

The Process

The Choosing Wisely campaign creates lists for each specialty. The lists are intended as a first step in the improvement of clinical outcomes and resource use.

"Unlike purely consensus-driven guidelines, our study benefits from multiple methods that ensure both internal validity and generalizability,” the authors write. “The initial survey was administered to a multidisciplinary group of >1000 frontline practitioners and parents. As with the Top Five list from the Pediatric Choosing Wisely Committee of the Society of Hospital Medicine, the newborn medicine list also uses the Rand/UCLA appropriateness method, or modified Delphi method, to build consensus."

The 2-year process thus involved a broad coalition of stakeholders and included a systematic literature review. The authors analyzed surveys from 1047 respondents and initially identified 1648 candidate tests and 1222 candidate treatments. They performed three rounds of the modified Delphi process, after which the expert panel achieved consensus on the top five items.

Increasing Value

The authors note that most of the items on the list are not associated with high prices. They are, however, frequently performed.

The authors believe that efforts in waste reduction in the neonatal intensive care unit (NICU) may be particularly effective because of the team-based care structure.

Moreover, previous studies have documented a great deal of variability in practice between NICUs. The authors suggest that each NICU measure how often it performs each of the items on the list. Each individual NICU can then prioritize the items for reduction or elimination according to the frequency of occurrence in a given NICU.

The newborn medicine list is the latest in an extensive effort that has been made by 63 medical societies in the United States and several organizations in at least 12 countries. The Top Five lists are meant to advance the goal of increasing value in care delivery.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online July 20, 2015. Abstract

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