10 ways to eliminate wasteful medical tests and procedures

Unnecessary medical tests and procedures contribute to 20 percent of healthcare expenses but two new studies offer 10 suggestions for eliminating wasteful spending in pediatric and adult hospital medicine.

The studies, published in today's Journal of Hospital Medicine, endorse the 10 recommendations of the Society of Hospital Medicine's Choosing Wisely campaign. Study authors state these best practices--just a small part of a larger campaign that has already identified 90 overused and unnecessary treatments--will lower costs and increase patient care.

For pediatrics, experts recommend these five strategies:

1. Don't order chest radiographs for children with asthma or bronchiolitis because of its limited utility. The omission will reduce costs without compromising diagnostic accuracy and care.

2. Don't use bronchodilators in children with bronchiolitis because the agents have minimal or no treatment effects.

3. Don't treat children under two years of age with an uncomplicated lower respiratory tract infection with systemic corticosteroids. This treatment is potentially harmful and fails to demonstrate benefits.

4. Don't treat gaestroesophageal reflux in infants routinely with acid suppression therapy, such as proton pump inhibitors. Anti-reflux therapy does not reduce the symptoms of grastroesophageal disease in children.

5. Don't routinely order continuous pulse oximetry--a method for measuring oxygen saturation in the blood--in children with acute respiratory illness unless they are on supplemental oxygen. Continuous use of pulse oximetry has been associated with increased admission rates and length of stay.

Here are the five recommendations proposed for adult medicine:

1. Don't put or leave urinary catheters in place for incontinence or convenience or monitoring of output for non-critically ill patients. Misuse of urinary catheters can increase the likelihood of infection, morbidity, mortality, and higher healthcare costs.

2. Don't prescribe medications for stress ulcer prophylaxis to medical inpatients unless they are at high risk for gastrointestinal complications.

3. Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit threshold and in the absence of symptoms of active coronary disease, stroke or heart failure. Determine transfusion decisions based on multiple factors, including symptoms and hemoglobin concentration.

4. Don't order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation. Telemetric monitoring has limited utility; inappropriate use can increase cost of care and produce false positives.

5. In the face of clinical and lab stability, do not perform repetitive complete blood count and chemistry testing.

"These [pediatric and adult] lists are good starting points, and in fact many hospitalist groups, including our own, are using the Society of Hospital Medicine practices as a foundation for our waste reduction efforts," wrote Andrew Auerbach, M.D., M.P.H., and Robert Wachter, M.D., of the University of California, San Francisco, in an accompanying Journal of Hospital Medicine editorial. "The next challenge will be translating these recommendations into actionable measures and then clinical practice."

To learn more:
- here's the pediatric study abstract
- check out the adult study abstract
- read the editorial (subscription required)

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