Overuse of medical care remains all too common in pediatric settings, according to the authors of a literature analysis published online January 3 in Pediatrics.
"Overused medical care is not just wasteful, it is potentially harmful," write Eric R. Coon, MD, from the Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine Primary Children's Hospital, Salt Lake City, and colleagues.
The authors note that whereas overuse of medical care has received significant attention in recent years, most studies and discussions have focused on adult patients.
To highlight the issue in pediatrics, the authors identified 10 of the most rigorous and relevant articles from 1445 articles published on the topic in 2015. They divided the findings into overdiagnosis, overuse, and overtreatment. Following are examples of the findings supported by the highest levels of evidence.
Overdiagnosis
Although clinicians have increasingly used pulse oximetry to measure oxygen saturation in infants with bronchiolitis, there are no data to support particular thresholds, the authors contend.
On the contrary, they found level 1B evidence (from an individual randomized controlled trial with narrow confidence intervals) that an oxygen saturation target of 90% is safe for infants hospitalized with bronchiolitis and results in less time spent on supplemental oxygen and reduced length of stay.
The trial compared the hypoxemia threshold of 90% recommended by the American Academy of Pediatrics with the 94% recommended by the NHS Scotland Quality Improvement. They found that time on supplemental oxygen was 22 hours shorter at the lower threshold and infants were discharged 10 hours earlier. No adverse outcomes were detected with the lower target.
More research is needed, Dr Coon and colleagues say, to see whether an even lower threshold would be safe and beneficial, and also whether any set threshold at all is necessary.
Alan Schroeder, MD, a coauthor of the literature review from the Department of Pediatrics at Stanford University in California, told Medscape Medical News, "Overdiagnosis is an underappreciated concept in medicine in general, and in particular pediatrics, both by families and by healthcare practitioners."
He added, "Finding abnormalities does not always benefit patients, and that's a really difficult concept for patients and physicians to grasp."
Overuse
Dr Coon and colleagues also found strong evidence that the frequency of head circumference screening should be reconsidered and that routine measurement may trigger unnecessary follow-up and parental stress.
"This one is going to be somewhat provocative because measurement of head size is at the core of what we do in our well-child visits. If we check things frequently, we find abnormalities that are of no major consequence to children and can lead to further investigations," Dr Schroeder said.
The American Academy of Pediatrics recommends the screening eight times before the child turns 2 years old; the World Health Organization recommends it only twice: once at birth and then at 8 weeks of age.
The team found level 2b evidence (from an individual cohort study) that head circumference screening "was neither sensitive nor specific for identifying neurocognitive disorders (NCD), defined as receipt of a neurodevelopmental diagnosis, classroom special education needs by age 11 years, or low Wechsler Intelligence Scale for Children IQ at age 8 years."
Overtreatment
The researchers found evidence, previously reported by Medscape Medical News, that two commonly used antidepressants for adolescents were no better than placebo and had potential harms not reported in the original study.
Reanalysis of a major 2001 study that had been funded by SmithKline Beecham found that neither paroxetine nor imipramine was better than placebo in Hamilton depression scores (the primary outcome) or in secondary outcomes, contrary to the study's original findings.
"The current widespread use of antidepressants in adolescents may have been driven in part by misleading results from the initial 2001 trial," Dr Coon and colleagues write.
The authors of the reanalysis also found new harms with the antidepressants, including their links to suicidal thoughts and behavior.
"That's very provocative," Dr Schroeder said. "This really gets at the importance of transparent reporting of data and how powerful the influence of industry can be. The first trial was ghost-written for the authors."
The review by Dr Coon and colleagues also found evidence that 3% hypertonic saline is not better than normal 0.9% nebulized saline for infants hospitalized with bronchiolitis.
Previous results were conflicting, and study designs limited generalizability to children in the United States. But a randomized, double-blind, controlled trial found that for infants younger than 1 year, there was no difference in length of stay (primary outcome) with either saline group.
"There was also no difference in clinical worsening (transfer to the pediatric [intensive care unit] or bronchospasm) or 7-day readmissions," the authors write.
"This study should give us pause when interpreting early results of therapeutic interventions in bronchiolitis," they conclude.
Dr Schroeder said that although readers are often drawn to articles and studies that show promise for a new drug or treatment, the message in this one is just as important: "to help physicians safely do less."
"Greater caution for providing more medical care should be exercised in the face of limited evidence," the authors write. "In addition to being more careful before advocating for poorly proven interventions, experts and medical societies might be well served to develop a mechanism to promptly revise recommended practices when more rigorous evidence emerges that undermines a recommendation. Guidelines tend to focus on practices that should be done; suggestions of practices to avoid in guidelines could be equally helpful."
The authors have disclosed no relevant financial relationships.
Pediatrics. Published online January 3, 2017. Abstract
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Cite this: Overdiagnosis, Overtreatment Too Common in Pediatric Care - Medscape - Jan 03, 2017.
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