Top Five neonatal tests and treatments that shouldn't be routine

Last Updated: 2015-07-21

By Will Boggs MD

NEW YORK (Reuters Health) - An expert panel of 51 perinatal specialists has identified the Choosing Wisely Top Five tests and treatments that cannot be justified as part of routine newborn care.

"We need to approach care with greater thought as to the value - and potential harm - of the testing or treatment under consideration," Dr. DeWayne M. Pursley from Beth Israel Deaconess Medical Center in Boston told Reuters Health by email. "The main purpose of the study is to call attention to the practices that neonatal clinicians may perform routinely and to encourage them to reflect on whether these practices have value and to eliminate them when they don't."

The American Board of Internal Medicine Foundation launched the Choosing Wisely campaign in 2011 to encourage discussion of medical tests and procedures that may not be necessary. Establishing Top Five lists is part of that campaign.

Dr. Pursley and colleagues in the American Academy of Pediatrics Section on Perinatal Pediatrics identified an expert panel that sorted through 2870 suggestions for candidate tests and treatments to arrive at a consensus list of five Choosing Wisely practices.

"We did formal literature reviews on the top 12," Dr. Pursley said. "These tests and treatments were described in specific clinical contexts, and any of those could easily have been considered a Top Five item. In our first round, we started with a list of 22 tests and treatments without specific contexts (indications), and I suspect that many of those are used in ways that, with a rigorous review, would be considered of low value."

The ultimate Top Five are listed in the July 20 Pediatrics online report:

- Avoid routine use of antireflux medications for symptomatic gastroesophageal reflux disease (GERD) or for apnea and desaturation in preterm infants.

- Avoid routine continuation of antibiotics beyond 48 hours for initially asymptomatic preterm infants without evidence of bacterial infection.

- Avoid routine pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity.

- Avoid routine daily chest x-rays without an indication in intubated infants.

- Avoid routine use of term-equivalent or discharge screening brain MRIs in preterm infants.

"The literature shows evidence of harm for two of these five items (antireflux medications and antibiotic therapy beyond 48 hours), whereas the remaining three items (pneumograms, daily chest radiographs, and term-equivalent brain MRIs) lack sufficient evidence of efficacy," the researchers noted.

"The word 'routine' is included in each item," Dr. Pursley said. "This is important because each of the Top Five tests and treatments might actually be very important and have great value in certain contexts. Communication with the physician and care team is really important."

"We have presented our study at several national conferences, and it's common for neonatologists to state that they don't engage in one, two, or even all of these practices," Dr. Pursley said. "We are currently working to determine how often (and at what cost) these practices are occurring in hospitals around the country. The opportunity is for hospitals to closely examine their own practices to seek out and eliminate those tests and treatments that have low value."

"Interestingly, with the exception of term-equivalent brain MRIs, most of the items on the list are not associated with high prices," the authors concluded. "However, even low-priced tests and treatments can have significant cost implications due to volume, use of staff time, or triggering of subsequent testing and therapies and might therefore represent appropriate targets for a value-focused approach."

Dr. Joseph Schulman, director of NICU Quality Measurement and Improvement for the California Department of Health Care Services in Sacramento, told Reuters Health by email, "This ranking reflects priority and consensus ranking by an expert panel, and not data on actual incidence. The authors encourage centers to 'first measure incidence of use...' and further point out that the 'Top Five list serves as a starting point.'"

"Thus," he added, "a NICU in which none of the Top Five practices occurs is not necessarily one that provides no unnecessary tests/treatments. Moreover, without incidence data, the magnitude of the overuse/waste among NICUs applying Top Five practices remains unknown."

"To build upon this excellent starting point, future research and quality collaborative efforts could collect data describing the current wide array of potential unnecessary practices and measure their local incidence and variation across hospitals," Dr. Schulman said.

He concluded, "It would be fascinating to conduct a follow-up survey of study respondents, asking: Has the unnecessary test or treatment you identified been routinely applied at your own institution? If so, why has it persisted despite your identifying it as unnecessary? If it has not been routinely applied at your own institution, how have you come to know about such practices?"

SOURCE: http://bit.ly/1CNdlTf

Pediatrics 2015.