Right-Sizing Care: Lessons for Pediatrics

Laurie Scudder, DNP, NP

Disclosures

June 01, 2016

Editor's Note:
Unnecessary use of diagnostic tests and treatment strategies is a serious concern and a major driver of healthcare spending in the United States. And the issue extends to the care of children. The Lown Institute launched the Right Care Alliance in 2013 to promote access to safe, affordable, and effective healthcare. The fourth annual conference, held in April 2016, featured sessions discussing the latest evidence on overuse—both the impact of overuse and strategies to right-size use of specific tests and treatments. Medscape spoke with Ricardo Quinonez, MD, chief of pediatric hospital medicine, Children's Hospital of San Antonio, San Antonio, Texas, and Alan Schroeder, MD, associate chief for research, Pediatric Hospital Medicine, Lucile Packard Children's Hospital Stanford, Palo Alto, California, about the specific lessons for pediatrics they gleaned from the meeting.

Medscape: Are there particular procedures, diagnostic tests, and pharmacologic agents that present the most concern for overuse in children?

Dr Schroeder: Worthy targets include procedures, tests, or drugs that are used frequently for a large number of children. That includes such things as CT for evaluation of minor head injuries and abdominal pain, pharmacologic agents and monitoring devices in bronchiolitis, cough/cold medicines for upper respiratory tract infections, and imaging in children with urinary tract infection. These are all conditions that are common in children, and for which there is evidence of variability in care. Many of these interventions are wasteful and potentially harmful.

Dr Quinonez: One additional issue that continues to offer significant challenges and has gained renewed attention lately is the incredible rates of inadequate, inappropriate antibiotic use. That is probably just as much a problem in pediatrics as it is in adults.

Medscape: What were some of the key drivers of overuse in kids?

Dr Schroeder: Researchers from the Children's Hospital of Colorado presented results from a study that used focus groups to try to identify drivers of increased utilization for febrile seizures and overuse. In those groups, they identified the following:

  • Intolerance of uncertainty;

  • Parental expectations to "do something";

  • Influences from past experiences; and

  • Testing to satisfy a perceived desire on the part of future medical providers.[1]

In most discussions involving overuse, we tend to hear about the same proposed drivers: fee-for-service reimbursement, fear of malpractice, and patient/parental demands or perceived demands. We also hear a lot about the fear of missing something—a discomfort with uncertainty in a general culture where omission errors tend to be judged more harshly than commission errors.

But the interesting thing is that although there may be some degree of agreement that these factors drive overuse, there have been very few studies exploring this. I think that we probably do need better data to better understand why we do the things we do, so that we can then have more targeted interventions to combat overuse. The data are hard to tease out because even if you ask physicians, in real time, why, say, they're giving ceftriaxone to a kid with a cold, they may not be able to give you an exact answer. Or, they may say "I don't want to get sued," because that seems to be a justifiable rationale, even if the drivers happen to be more complex than that.

Dr Quinonez: I completely agree. We need further study to determine whether the drivers that we believe are to blame for overuse really are the issues. The one example I always throw out is the fact that in both adult medicine and pediatrics, we tend to blame patients and highlight them and their requests as drivers of overuse.

But when that actually has been studied, both in adults and kids, the conclusion has been that it is probably a very minimal driver. In reality, the issue arises when the physician and the patient are not on the same page and don't understand each other and have different expectations of each other's goals. It's not really that patients are demanding inappropriate care, although we like to think that's true. Studies in pediatrics in both the clinic setting and the emergency department have shown this to be the case. [Editor's note: Dr Quinonez discusses this research in more detail in a guest commentary on Ellipsis.]

Medscape: Can you describe some of the data presented that examined harms resulting from overuse?

Dr Schroeder: I can speak to the data we presented around trends in CT scanning in children with isolated head injury. Several prior investigations have described a reduction in CT over the past few years, at least in children's hospitals, which is encouraging. First and foremost, by doing less scanning, you're saving kids from excessive exposure to ionizing radiation—with obvious benefits related to the association with malignancy, especially in children.

But the other question to consider is: Does excessive imaging lead to overdiagnosis? What we found, looking at the Pediatric Health Information System database, was that the decrease in scanning has been associated with decreased detection of intracranial bleeding and skull fractures.[2] And that decrease, in turn, has actually been associated with a reduction in hospitalizations.

These findings get at the idea that unnecessary tests not only have direct harms (ie, radiation from CT), but may also cause harm because of the downstream interventions that follow when things are detected that may not have real clinical significance.

There are other examples. Randomized trials of infants with bronchiolitis have conclusively demonstrated that detection of hypoxemia drives hospitalization, but does not improve outcomes.

Here's another. Does detection of bacteremia in infants with urinary tract infections affect the management of those patients? What we have found is that if you detect bacteremia in a urinary tract infection, it increases the duration of intravenous antibiotics and hospitalization considerably, but it's not clear that that prolongation of hospitalization is benefiting infants.[3,4] So it may be that detecting bacteremia in an infant with a urinary tract infection (who will therefore receive antibiotics, regardless) may be actually more harmful than beneficial.

Medscape: Given that harms from interventions, diagnostics, and pharmacologic therapies are specific to that situation, is there any way to measure aggregate harm from overuse?

Dr Quinonez: It often depends on the type of intervention that is being studied. Some have more clear and direct harm. For example, studies of screening for cancer have found very little evidence that early cancer detection has done much to improve mortality in adults. There is at least some suggestion that screening in asymptomatic adults, such as early cancer detection, has really failed to produce much benefit, and perhaps have resulted in significant harm.[5]

Prostate cancer screening, mammography—these interventions have clear and demonstrated harms from overdetection and overdiagnosis of indolent disease that probably would not have had any consequence had they gone undetected.

Dr Schroeder: In an analysis of US healthcare spending,[6] Don Berwick and Andrew Hackbarth estimated that at least 20% of costs were the result of waste owing to several factors, including overtreatment. There have been some quantitative efforts, by the Institute of Medicine and others, to try to examine this issue from a cost perspective. There have also been reports looking at how often medical errors cause deaths, including a recent, controversial paper in the BMJ that described medical errors as the third leading cause of hospital deaths.[7] And a good portion of those medical errors may occur from care that's unnecessary.

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