Rewarding Restraint vs. Reality

Congratulations to Jeff Lewis, MD.  He has been selected from the Georgia Dept. of Public Health to receive the Maternal & Child Health Treating Children with Special Healthcare Needs Award.  This award will be presented at the Georgia- American Academy of Pediatrics Annual Awards Luncheon at Pediatric on the Perimeter on Friday Oct. 31, 2014 from Noon-1:30 pm.

Previously this blog noted the low usage of bronchiolitis guidelines (If a Guideline Falls in The Woods, and No One Hears It …) More information on this subject and why it is important has been published (J Pediatr 2014; 165: 786-92, ed 655-57).

Why this is important:

  1. Bronchiolitis is one area that has been well-studied and the evidence is strong regarding unnecessary medications and evaluations.
  2. Bronchiolitis is common.  It is the fourth most common reason for hospital care in US children’s hospitals.
  3. Four of five “Choose Wisely” targets in pediatrics focus on bronchiolitis care, including not routinely ordering chest xrays (in uncomplicated cases), avoiding bronchodilators, not using systemic corticosteroids, and not using pulse oximetry when off supplemental oxygen.

However, when one looks at Figure 1 (from the study) -resource utilization over time and Figure 2 – heat map for adjusted use by 42 separate hospitals –it is apparent that only about 5 of the hospitals are successful in at least 3 of 5 areas (albuterol, racemic epinephrine, steroids, chest radiographs, and antibiotics).  The data from these figures is derived from 64,994 hospitalizations that were analyzed.

Median hospital use of nonrecommended tests/treatments:

  • Albuterol 52.4% with range: 3.5% to 81%
  • Racemic epinephrine 20.1% with range: 0.6% to 78.8%
  • Corticosteroids 10.9% with range: 4.1% to 46.6%
  • Chest xray: 54.9% with range 24.1% to 76.6%
  • Antibiotics: 38.4% with range 27.1% to 50.1%

From editorial: “Many of us practice in environments that reward “doing more” as a sign of thoroughness and better clinical care.  Nowhere is this truer than in our acadmeic centers…we need a culture change in our training centers toward role modeling and rewarding restraint in testing and treatment as part of high value care efforts.”

Take-home message: If excessive testing and treatments is rampant for problems like bronchiolitis in which they have been proven to be of low value, what chance is there for restraint in more murky areas?

Related blog post: Trying to make Cents out of Value Care |

 

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