Five tests for newborns to avoid

Some treatments usually aren’t worth the time and cost, a panel of experts determines

While some medical practices are overdone, good ones pay off. Here, Nurse Kristi Hommberg checks Kash Livengood, 7 months, as he sits with dad Matt Livengood, of Crestline, Ohio, in the neonatal ICU at Nationwide Children’s Hospital. Kash, who was 1 pound, 7 ounces at birth, now weighs more than 15 pounds. Neonatology leaders at Children’s bemoan unnecessary tests.

Every day, doctors order tests and prescribe treatments that are a waste. They don’t help the patient, and some cause harm.

As part of an ongoing effort to name what shouldn’t be happening — at least not regularly — a list of five generally useless interventions done on sick newborns appears in today’s issue of the journal Pediatrics.
The list of things to avoid as a matter of routine:

• Anti-reflux medications. The science doesn’t show they help, and they’ve been associated with dangerous infections, hemorrhage and death.
• Antibiotics beyond 48 hours for babies without symptoms or other evidence of infection. Like anti-reflux medications, antibiotics that aren’t serving a documented purpose can do more harm than good and have been associated with an intestinal disease called necrotizing enterocolitis in small babies.
• Pneumograms. These are tests that monitor the breathing rate and heart rate and the amount of oxygen that gets into the blood. They haven’t been shown to reduce life-threatening heart and lung problems with routine use.
• Daily chest scans in babies with chest tubes. There’s no evidence they reduce complications, and they increase radiation exposure.
• Screening MRIs of the brain.
The list is based on a multistep vetting process that included advice from more than 1,000 people, including 776 neonatologists. The list started with 2,870 potential tests and treatments and was narrowed and debated by a panel of 51 experts.

How often the interventions are happening and where is unclear. The researchers hope to get a better handle on that in coming months and to better quantify how much money could be saved if doctors stopped ordering the tests and treatments.

Dr. Timmy Ho, the lead author of the paper, stresses that the calling out of these five items is designed to make a bigger point: Hospitals need to examine what they’re doing and why. If it isn’t good for the patient, they should stop.

A 2011 estimate found that 34 percent of health-care spending, or $2.7 trillion, could be attributed to overuse and waste.

That year, the American Board of Internal Medicine Foundation started a campaign called “ Choosing Wisely” and urged medical groups to generate top-five lists such as this one.

Money likely plays less of a role in poor decision-making than inertia and a lack of awareness about evidence that goes against the practice, said Ho, a neonatologist at Beth Israel Deaconess Medical Center in Boston who also teaches at Harvard Medical School.

“They practice a certain way and stick to what they know,” he said. “There’s a certain comfort level in doing things like we were taught to.”

And — particularly in an area of medicine that requires a fair amount of guesswork — doctors might make decisions in the interest of being better safe than sorry, Ho said.

Neonatology leaders at children’s hospitals in Columbus, Akron and Cincinnati said they’ve already abandoned the list of five because science didn’t support use of those tests and treatments. But they said there’s no doubt these things are still happening, particularly at community hospitals without a close relationship with an academic institution.

The list shared today “could easily be 50 things,” said Dr. Anand Kantak, who directs neonatology and oversees the neonatal intensive-care unit at Akron Children’s Hospital. “This is where medicine needs to go and is going to go.”

Not only are the tests and treatments cited in the paper wasteful and costly, they often prompt more unnecessary interventions, Kantak said.

He guessed that the item happening most often in medicine today is use of anti-reflux medication, but he said all of the five things are occurring to some degree.

Kantak said doctors can be seduced by technology, such as brain MRIs. While they can, and do, see changes in the brain when they examine it, the more important question is whether seeing that makes any difference in the child’s life. If the answer is “no,” then the MRI should not happen, he said.

“It’s very, very expensive. It’s nice to have it. But nice to have it for who? For the patient or for you? If it’s for you, that’s research,” he said.

Dr. Edward Shepherd, chief of neonatology at Nationwide Children’s Hospital, said the five tests and treatments are “significant sources of annoyance for me.”

“I could never understand why people wanted to do these things,” he said. “We want to get rid of things that might cause more harm than good.”

Shepherd said he doesn’t think doctors who continue to order the tests and treatments have their paychecks in mind. “I think all of these things occur because people for a while thought that they were really good ideas.”

Dr. Beth Haberman, senior medical director of neonatal services and medical director of the newborn intensive-care unit at Cincinnati Children’s Hospital, agreed that money is not the primary driver.
“I think it’s more drive to please the families,” she said.

Haberman said it’s tough to tell families, such as those whose preemies have apnea and are spitting up regularly, that there’s nothing to do, that waiting it out is better than giving them reflux medication.
“It’s like antibiotics for viral illnesses,” Haberman said. “Families aren’t satisfied when they leave the emergency department and they don’t have a medication.”

She and Shepherd said the list can act as a road map for doctors and as evidence that they’re sometimes doing the best thing when they do nothing.

“There will be people who say, ‘I’ve been doing it this way my whole life, and it works, and I don’t care what some ivory-tower academic says,’ but there are many fewer of those kind of people now,” Shepherd said.

Ho and his colleagues write in today’s paper that the list should not be interpreted as a “do not do” list. Good medicine depends on individualized decision-making.

“There are going to be times when these tests and treatments are absolutely indicated, and it would be almost criminal not to do them,” Ho said last week.
Source : dispatch


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