Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value

Quiñonez, Ricardo; Garber, Matthew; Schroeder, Alan R.; Alverson, Brian; Nickel, Wendy; Goldstein, Jenna; Bennett, Jeffrey S.; Fine, Bryan R.; Hartzog, Timothy H.; McLean, Heather; Mittal, Vineeta; Pappas, Rita; Percelay, Jack M.; Phillips, Shannon; Shen, Min; Ralston, Shawn L.

doi:10.1002/jhm.2064

Cited by 190 publications

(134 citation statements)

References 53 publications

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“…Our work is also, to our knowledge, the first published improvement project targeting the Pediatric Hospital Medicine Choosing Wisely recommendations. 12 Despite reduction in time spent on CPOx, there was no change in time until medically ready. Although an earlier study suggested CPOx prolonged LOS, our findings are consistent with preliminary results of a randomized trial comparing IPOx and CPOx, which did not show reduced LOS.…”

Section: Discussionmentioning

confidence: 99%

“…3 Studies in adults have also highlighted the contribution of CPOx to alarm counts on units, [4][5][6][7][8] which the Joint Commission has emphasized as a patient safety issue. 9,10 Despite evidence highlighting the limitations and lack of value, CPOx 12 emphasizing the lack of evidence and waste involved in its widespread use. In 2009, asthma and bronchiolitis accounted for ∼260 000 admissions and $3.2 million in hospital charges.…”

Section: Discussionmentioning

confidence: 99%

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Using Quality Improvement to Reduce Continuous Pulse Oximetry Use in Children With Wheezing

Schondelmeyer¹,

Simmons²,

Statile³

et al. 2015

Pediatrics

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BACKGROUND AND OBJECTIVES: Clinicians commonly use continuous pulse oximetry (CPOx) for hospitalized children with respiratory illnesses. The Choosing Wisely initiative recommended discontinuing CPOx for children on room air. We used quality improvement methods to reduce time on CPOx in patients with wheezing.METHODS: Our project took place on 1 unit of a children's hospital. We developed consensus-based criteria for CPOx discontinuation. Interventions included education, a checklist used during nurse handoff, and discontinuation criteria incorporated into order sets. We collected data on a second unit where we did not actively intervene to assess for secular trends and negative consequences of shorter monitoring. We followed time until medically ready, ICU transfers, hospital revisits, and medical emergency team calls on both units. We tracked the impact of interventions by using run charts and statistical process control charts.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Using Quality Improvement to Reduce Continuous Pulse Oximetry Use in Children With Wheezing

Schondelmeyer¹,

Simmons²,

Statile³

et al. 2015

Pediatrics

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“…26,27 Newborn medicine offers special challenges to the Choosing Wisely approach. Neonatal care is provided by an interprofessional team through which a family's influence has been somewhat indirect.…”

Section: Discussionmentioning

confidence: 99%

Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value

et al. 2015

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BACKGROUND: The use of unnecessary tests and treatments contributes to health care waste. The “Choosing Wisely” campaign charges medical societies with identifying such items. This report describes the identification of 5 tests and treatments in newborn medicine. METHODS: A national survey identified candidate tests and treatments. An expert panel of 51 individuals representing 28 perinatal care organizations narrowed the list over 3 rounds of a modified Delphi process. In the final round, the panel was provided with Grading of Recommendation, Assessment, Development and Evaluation (GRADE) literature summaries of the top 12 tests and treatments. RESULTS: A total of 1648 candidate tests and 1222 treatments were suggested by 1047 survey respondents. After 3 Delphi rounds, the expert panel achieved consensus on the following top 5 items: (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, and (5) avoid routine screening term-equivalent or discharge brain MRIs in preterm infants. CONCLUSIONS: The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost. This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.

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“…Specifically, the majority of the pediatric Choosing Wisely initiatives decrease opportunities for overdiagnosis, with recommendations that limit the use of CT scans, MRI, chest radiographs, apnea monitors, food allergy screening, and continuous pulse oximetry. 72,73 In general, guidelines that endorse testing can address the harms of overdiagnosis and support strong recommendations for testing with evidence that important outcomes for children are improved by diagnosis. Use of the US Preventive Services Task Force analytic framework, which considers both harms and benefits and clearly delineates pertinent outcomes, would help guideline panels in this endeavor.…”

Section: The Way Forwardmentioning

confidence: 99%

Overdiagnosis: How Our Compulsion for Diagnosis May Be Harming Children

et al. 2014

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Overdiagnosis occurs when a true abnormality is discovered, but detection of that abnormality does not benefit the patient. It should be distinguished from misdiagnosis, in which the diagnosis is inaccurate, and it is not synonymous with overtreatment or overuse, in which excess medication or procedures are provided to patients for both correct and incorrect diagnoses. Overdiagnosis for adult conditions has gained a great deal of recognition over the last few years, led by realizations that certain screening initiatives, such as those for breast and prostate cancer, may be harming the very people they were designed to protect. In the fall of 2014, the second international Preventing Overdiagnosis Conference will be held, and the British Medical Journal will produce an overdiagnosis-themed journal issue. However, overdiagnosis in children has been less well described. This special article seeks to raise awareness of the possibility of overdiagnosis in pediatrics, suggesting that overdiagnosis may affect commonly diagnosed conditions such as attention-deficit/hyperactivity disorder, bacteremia, food allergy, hyperbilirubinemia, obstructive sleep apnea, and urinary tract infection. Through these and other examples, we discuss why overdiagnosis occurs and how it may be harming children. Additionally, we consider research and education strategies, with the goal to better elucidate pediatric overdiagnosis and mitigate its influence.

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Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value

Cited by 190 publications

References 53 publications

Using Quality Improvement to Reduce Continuous Pulse Oximetry Use in Children With Wheezing

Using Quality Improvement to Reduce Continuous Pulse Oximetry Use in Children With Wheezing

Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value

Overdiagnosis: How Our Compulsion for Diagnosis May Be Harming Children

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