Antibiotics to CT scans
Academy joins Choosing Wisely campaign to reduce overtreatment
- Copyright © 2013, The American Academy of Pediatrics
A doctor routinely orders a computed tomography (CT) scan for a minor head injury. Another prescribes an antibiotic for a viral respiratory illness or suggests cough medicine for a toddler.
These physicians probably are not Choosing Wisely, according to a campaign to reduce unnecessary care that can drive up health care costs and, in some cases, harm patients.
On Feb. 21, the Academy became one of 35 medical and 13 consumer organizations participating in Choosing Wisely. AAP President Thomas K. McInerny, M.D., FAAP, appeared at a Washington, D.C., event marking the second phase of the campaign.
An initiative of the ABIM (American Board of Internal Medicine) Foundation, Choosing Wisely asks physicians and patients to question whether treatments, tests and procedures are supported by evidence, free from harm and truly necessary.
Improving care, reducing costs
“I think this is a very good idea because part of the Affordable Care Act is to do two things: improve the quality of care and reduce the expense of medical care. And oftentimes, those two things can be done simultaneously,” Dr. McInerny said. “Unfortunately, the public doesn’t always see it that way,” he added. “They always think, the more you do, the better your quality of care. That’s not always true.”
Each medical organization developed “5 things” that may be overused in that specialty (see Resources). Avoiding unnecessary use of antibiotics and cough and cold medications as well as reducing the routine use of CT scans in children made the Academy’s Top 5 list (see sidebar).
The campaign might prompt conversations about overtreatment, said Ricardo A. Quinonez, M.D., FAAP, chair of the AAP Section on Hospital Medicine Executive Committee.
“I think the issue of overuse is underappreciated in medicine in general but in pediatrics in particular,” said Dr. Quinonez, who coordinated the Society of Hospital Medicine’s Choosing Wisely list. He noted that many efforts — such as safety improvement in hospitals — are centered around what should be done rather than “things we could be doing less of.”
Started in 2011, the Choosing Wisely campaign was sparked by a 2010 article in New England Journal of Medicine in which Howard Brody, M.D., Ph.D., challenged physicians to do their part to cut health costs. He suggested medical societies develop Top 5 lists of commonly ordered, expensive tests or treatments not beneficial to major categories of patients. A program then was piloted by the National Physicians Alliance through an ABIM grant. Consumer Reports also joined the effort.
Last year, the ABIM Foundation released 45 tests and procedures “to think twice about” from the first group of partners. The items reflect concerns over safety and cost.
Cutting back on CT scanning to reduce radiation risk in children is reflected in three of the five AAP items. Dr. McInerny and others have pointed to these as most concerning. They prefer to see a greater emphasis on thorough physical exams and the use of ultrasonography over CT scans, where possible, particularly since many kids get minor head injuries or have abdominal pain. Half of children who go to emergency departments (EDs) with a head injury are given a CT scan, according to the Academy.
Jack Percelay, M.D., FAAP, chair of the AAP Committee on Hospital Care, said parents usually are receptive when he explains the risks of too many scans. “I’ve certainly told parents, ‘Why don’t we just wait and watch what happens with your child rather than go immediately to the CT scan because it’s a significant amount of radiation and it carries risk with it.’”
Another item on the AAP list addresses the need to stop prescribing antibiotics for viral respiratory illnesses. AAP District VII Chair Kenneth E. Matthews, M.D., FAAP, said the “vast overuse of antibiotics” is partly driven by some physicians’ desire to give families something to take home to care for their child. It’s worth the extra time it takes to reassure parents and educate them, he said.
The items on the AAP list “are things we’re trying to do right or trying to bring about for better care of children,” said Dr. Matthews. “I think if we work hard in trying to apply these, each time we think about prescribing an antibiotic, each time somebody recommends a cough-cold medicine, each time we order imaging studies, then we have to think: ‘What else could I do instead?’”
AAP Top 5
As part of the Choosing Wisely initiative, the Academy surveyed members to develop the following Top 5 list:
Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under 4 years of age.
Computed tomography (CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.
Neuroimaging (CT, MRI) is not necessary in a child with a simple febrile seizure.
CT scans are not necessary in the routine evaluation of abdominal pain.