Marcia Frellick

May 08, 2017

LAS VEGAS — Two popular practices make the list of things physicians "do for no reason," or at least for no good reason, attendees heard here at the Society of Hospital Medicine 2017 Annual Meeting.

One is prescribing antihypertensives for hypertensive urgency, commonly defined as a systolic blood pressure of at least 180 mm Hg or a diastolic pressure of at least 110 mm Hg. The other is the ordering of blood cultures when patients are taking antibiotics.

Physicians treat hypertensive urgency out of fear that something bad, such as stroke or acute myocardial infarction, will happen in the next few hours, said Tony Breu, MD, an instructor in medicine at Harvard Medical School and director of resident education at the Veterans Affairs Boston Healthcare System.

"If you have hypertensive urgency, there's no evidence that adverse events occur in the short term. This is a chronic disease; it takes time for these outcomes to occur," he explained.

In the heat of the moment, hospitalists might very well be paged by another provider to get a patient's blood pressure down, and lack of action might be viewed as bad medicine, he said. At some hospitals, the treatment of hypertensive urgency with antihypertensives is still the standard of care.

Asymptomatic Hypertension

A switch in nomenclature — from hypertensive urgency to acute asymptomatic severe hypertension — might curb the perceived need to respond immediately, Dr Breu suggested.

The practice of ordering blood cultures for patients taking antibiotics, even when previous cultures have been negative, is often just habit or related to institutional custom, he said.

There are two things to think about before ordering a blood culture, he explained: "What's the probability that we'll find a true positive, meaning not a contaminant? And how often is that true positive representing a new pathogen?"

If a previous culture was negative and the patient is taking antibiotics, any result will not be a true positive, he added. And false positives can extend hospital stays and lead to higher healthcare costs.

Just how widespread are these unnecessary practices?

"The treatment of hypertensive urgency is pretty pervasive," Dr Breu told Medscape Medical News. "As far as the blood cultures, I think it's prevalent, it happens, but it is dependent on the circumstance of the hospital. I don't think we have clear numbers on how frequent that is."

It's not clear how much of this asthmonia is real. If it exists, most of these kids do not have a bacterial infection.

A common practice in the field of pediatrics is the treatment of children with community-acquired pneumonia plus asthma, which is commonly referred to as "asthmonia," said Lenny Feldman, MD, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins Medicine in Baltimore.

"This happens all the time," he reported.

"Why are all these patients with asthma symptoms getting chest x-rays when the Choosing Wisely guidelines say don't order chest x-rays in children with uncomplicated asthma or bronchiolitis?" he asked.

The answer probably lies in the gray area of what is considered complicated, he acknowledged. Too often, though, something is seen on the x-ray and antibiotics are started.

"It's not clear how much of this asthmonia is real," Dr Feldman said. "If it exists, most of these kids do not have a bacterial infection."

He said he would never treat a young child for community-acquired pneumonia plus asthma. If he did offer treatment, it would be for a "child older than 5, probably the adolescent who has symptoms typical of mycoplasma along with it," he explained.

"My suggestion, if you're going to treat asthmonia, is only use the macrolide; do not give the beta lactam," he advised. "There is no evidence that typical bacteria are causing that asthmonia," he added.

However, macrolide resistance is increasing, he warned, so whether the child will benefit from treatment must be carefully considered.

These practices come from learned behaviors and the lack of transparency related to the cost of procedures and medications, Dr Feldman pointed out.

"We know that each one of these is not going to suddenly save our healthcare system a ton of money," he explained, "but if we can get folks thinking critically about what they do every day, we can come up with more cost-conscious, high-value care."

Dr Breu and Dr Feldman have disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2017 Annual Meeting. Presented May 3, 2017.

Follow Medscape Internal Medicine on Twitter @MedscapeIM and Marcia Frellick @mfrellick


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