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NEW ORLEANS – How did dehydration, an order for a peripherally inserted central catheter line, and the bright lights of the ward add up to a full-thickness burn on an infant?
The simple answer is a flashlight.
The more telling response is that the PICC line wasn’t needed in the first place – much less the 20 minutes spent trying to isolate a vein with a flashlight. The infant rebounded with intravenous fluids and by simply advancing feeding volumes, Dr. Alan R. Schroeder said at the Pediatric Hospital Medicine 2013 meeting.
"When we think about patient safety and errors, we spend an awful lot of time talking about how could we better optimize the PICC line process, but we don’t spend as much time on whether this PICC line was even necessary," he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Indeed, physicians are quite good at responding when asked to do more. A recent study of ambulatory health care utilization shows that six of nine quality indicators of underuse improved between 1999 and 2009, whereas only two of eleven overuse indicators got better (JAMA Intern. Med. 2013;173:142-8).
Still, the unnecessary care movement is picking up steam in recent years, insists Dr. Schroeder of the department of pediatrics, Santa Clara Valley Medical Center, San Jose, Calif.
Three medical meetings, including the Preventing Overdiagnosis Conference, were organized this year specifically on medical overutilization, with at least one article devoted each month to the topic in JAMA Internal Medicine.
The Image Wisely initiative has garnered 18,621 pledges to lower the amount of radiation used, while the Choosing Wisely campaign, challenging medical societies to identify five things physicians and patients should question, is bearing fruit.
The pediatric committee of the Society of Hospital Medicine was the first pediatric subspecialty group to respond to the challenge, with a panel of experts, including Schroeder, recently publishing the top five recommendations for pediatric hospital medicine (J. Hosp. Med. 2013 [doi:10.1002/jhm.2064]).
" ‘Less is more’ is almost becoming a trend," Dr. Schroeder said.
Widely publicized public health mistakes in adult medicine, like near-universal prostate-specific antigen testing in men and hormone therapy for menopausal women, coupled with a financially stressed health care system, have helped move the needle. But several barriers to safely doing less still remain, he observed.
Time pressures, malpractice concerns, and pressure from families and colleagues all push physicians to increase healthcare utilization. The case of 12-year-old Rory Staunton, who died last year from potentially preventable septic shock after being released from the emergency department, has prompted new measures nationwide to spot sepsis earlier and a slew of stories in the New York Times and other publications.
The response was quite different, however, when two other adolescents, Jenny Olenick and Ben Ellis, died during or within hours of routine wisdom teeth extraction, a procedure that has been suggested as unnecessary 60% of the time, Dr. Schroeder said.
"They were killed by health care," he said. "This is a commission error, yet this has had scant media coverage. This is the type of case that should really, really upset you."
He went on to say that the omission/commission philosophy has its roots in medical education school.
"A lot of you are doing noble jobs trying to change that, but traditionally we are taught from day one not to miss a diagnosis," he said. "You have to generate these very, very broad differential diagnoses. We don’t want to be the guy that misses a diagnosis on day one and someone else comes in and makes a diagnosis on day two."
Money as motive
Another powerful barrier to safely doing less is the financial motive. Some of the best work in this area was the 2009 watershed essay by surgeon Atul Gawande showing that the strong entrepreneurial spirit in McAllen, Texas, doubled Medicare spending, compared with nearby El Paso, without improving outcomes, Dr. Schroeder observed. Recent research also refuted the widely endorsed belief that PSA screening improves outcomes by picking up more cancers than diagnosing based on symptoms. It was a hard-fought battle with high financial stakes, with some 30 million men undergoing PSA testing each year at a cost of $3 billion.
"There’s not a billboard outside my hospital saying ‘Come see Dr. Schroeder because today he will do less for you,’ " he said. "I wish there were one, but it’s not going to bring patients in or help the hospital’s bottom line."
Dr. Schroeder called for financing reform to disconnect reimbursement from utilization by compensating physicians for how they do their job, not what they do. There was also a pitch for comparative-effectiveness research to confirm that existing therapies are of benefit and if not, should not be reimbursed. As role models, he cited an unfunded, randomized controlled study presented at the meeting on nebulized hypertonic saline, and a voluntary quality improvement collaborative of pediatric hospitalists that cut bronchodilator use by 46% among inpatients with bronchiolitis (J. Hosp. Med. 2013;8:25-30). Not surprising, one of the top five new recommendations for pediatric hospital medicine is: "Do not use bronchodilators in children with bronchiolitis."
Talk about ‘less’
Dr. Schroeder urged the audience of some 1,000 pediatric hospitalists to introduce "safely doing less" into the patient-safety dialogue. Clinicians should always remind their patients and trainees of unanticipated harms. Instead of saying, "It’s a straightforward procedure," try saying, "There isn’t a procedure out there that can’t make someone worse or cause harm."
When there’s an adverse event at your institution, he advised clinicians not to just focus on the details of the incident, but also on the necessity of the interventions that led up to the incident. This strategy was conspicuous in its absence during the recent meningitis outbreak from contaminated steroid injections for back and neuropathic pain, that prompted 749 cases of fungal infection, 63 deaths, and a massive, multistate investigation.
"Everyone wanted to know how this could have happened; where was the regulation behind the compounding pharmacy, which is a worthy question," he said. "But it took weeks before it came out that these epidural steroid injections aren’t evidence based, although they sure make a lot of money."
Finally, he suggested the audience redefine the term "conservative" care from its current definition of test and treat to watch and wait.
During a discussion immediately following the lecture, however, attendee and pediatric hospitalist Lynn Campbell, who is with Dell Children’s Medical Center of Central Texas, in Austin, pointed out that, unlike primary care providers or ED physicians, hospitalists come into the game midstream and thus don’t have the same trust level established with families when trying to take away unnecessary tests or therapies.
Dr. Schroeder said many families don’t want more therapies, like antibiotics, and just want to take their child home, but added, "There are no easy answers."
Dr. Schroeder reported having no financial disclosures.
NEW ORLEANS – How did dehydration, an order for a peripherally inserted central catheter line, and the bright lights of the ward add up to a full-thickness burn on an infant?
The simple answer is a flashlight.
The more telling response is that the PICC line wasn’t needed in the first place – much less the 20 minutes spent trying to isolate a vein with a flashlight. The infant rebounded with intravenous fluids and by simply advancing feeding volumes, Dr. Alan R. Schroeder said at the Pediatric Hospital Medicine 2013 meeting.
"When we think about patient safety and errors, we spend an awful lot of time talking about how could we better optimize the PICC line process, but we don’t spend as much time on whether this PICC line was even necessary," he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Indeed, physicians are quite good at responding when asked to do more. A recent study of ambulatory health care utilization shows that six of nine quality indicators of underuse improved between 1999 and 2009, whereas only two of eleven overuse indicators got better (JAMA Intern. Med. 2013;173:142-8).
Still, the unnecessary care movement is picking up steam in recent years, insists Dr. Schroeder of the department of pediatrics, Santa Clara Valley Medical Center, San Jose, Calif.
Three medical meetings, including the Preventing Overdiagnosis Conference, were organized this year specifically on medical overutilization, with at least one article devoted each month to the topic in JAMA Internal Medicine.
The Image Wisely initiative has garnered 18,621 pledges to lower the amount of radiation used, while the Choosing Wisely campaign, challenging medical societies to identify five things physicians and patients should question, is bearing fruit.
The pediatric committee of the Society of Hospital Medicine was the first pediatric subspecialty group to respond to the challenge, with a panel of experts, including Schroeder, recently publishing the top five recommendations for pediatric hospital medicine (J. Hosp. Med. 2013 [doi:10.1002/jhm.2064]).
" ‘Less is more’ is almost becoming a trend," Dr. Schroeder said.
Widely publicized public health mistakes in adult medicine, like near-universal prostate-specific antigen testing in men and hormone therapy for menopausal women, coupled with a financially stressed health care system, have helped move the needle. But several barriers to safely doing less still remain, he observed.
Time pressures, malpractice concerns, and pressure from families and colleagues all push physicians to increase healthcare utilization. The case of 12-year-old Rory Staunton, who died last year from potentially preventable septic shock after being released from the emergency department, has prompted new measures nationwide to spot sepsis earlier and a slew of stories in the New York Times and other publications.
The response was quite different, however, when two other adolescents, Jenny Olenick and Ben Ellis, died during or within hours of routine wisdom teeth extraction, a procedure that has been suggested as unnecessary 60% of the time, Dr. Schroeder said.
"They were killed by health care," he said. "This is a commission error, yet this has had scant media coverage. This is the type of case that should really, really upset you."
He went on to say that the omission/commission philosophy has its roots in medical education school.
"A lot of you are doing noble jobs trying to change that, but traditionally we are taught from day one not to miss a diagnosis," he said. "You have to generate these very, very broad differential diagnoses. We don’t want to be the guy that misses a diagnosis on day one and someone else comes in and makes a diagnosis on day two."
Money as motive
Another powerful barrier to safely doing less is the financial motive. Some of the best work in this area was the 2009 watershed essay by surgeon Atul Gawande showing that the strong entrepreneurial spirit in McAllen, Texas, doubled Medicare spending, compared with nearby El Paso, without improving outcomes, Dr. Schroeder observed. Recent research also refuted the widely endorsed belief that PSA screening improves outcomes by picking up more cancers than diagnosing based on symptoms. It was a hard-fought battle with high financial stakes, with some 30 million men undergoing PSA testing each year at a cost of $3 billion.
"There’s not a billboard outside my hospital saying ‘Come see Dr. Schroeder because today he will do less for you,’ " he said. "I wish there were one, but it’s not going to bring patients in or help the hospital’s bottom line."
Dr. Schroeder called for financing reform to disconnect reimbursement from utilization by compensating physicians for how they do their job, not what they do. There was also a pitch for comparative-effectiveness research to confirm that existing therapies are of benefit and if not, should not be reimbursed. As role models, he cited an unfunded, randomized controlled study presented at the meeting on nebulized hypertonic saline, and a voluntary quality improvement collaborative of pediatric hospitalists that cut bronchodilator use by 46% among inpatients with bronchiolitis (J. Hosp. Med. 2013;8:25-30). Not surprising, one of the top five new recommendations for pediatric hospital medicine is: "Do not use bronchodilators in children with bronchiolitis."
Talk about ‘less’
Dr. Schroeder urged the audience of some 1,000 pediatric hospitalists to introduce "safely doing less" into the patient-safety dialogue. Clinicians should always remind their patients and trainees of unanticipated harms. Instead of saying, "It’s a straightforward procedure," try saying, "There isn’t a procedure out there that can’t make someone worse or cause harm."
When there’s an adverse event at your institution, he advised clinicians not to just focus on the details of the incident, but also on the necessity of the interventions that led up to the incident. This strategy was conspicuous in its absence during the recent meningitis outbreak from contaminated steroid injections for back and neuropathic pain, that prompted 749 cases of fungal infection, 63 deaths, and a massive, multistate investigation.
"Everyone wanted to know how this could have happened; where was the regulation behind the compounding pharmacy, which is a worthy question," he said. "But it took weeks before it came out that these epidural steroid injections aren’t evidence based, although they sure make a lot of money."
Finally, he suggested the audience redefine the term "conservative" care from its current definition of test and treat to watch and wait.
During a discussion immediately following the lecture, however, attendee and pediatric hospitalist Lynn Campbell, who is with Dell Children’s Medical Center of Central Texas, in Austin, pointed out that, unlike primary care providers or ED physicians, hospitalists come into the game midstream and thus don’t have the same trust level established with families when trying to take away unnecessary tests or therapies.
Dr. Schroeder said many families don’t want more therapies, like antibiotics, and just want to take their child home, but added, "There are no easy answers."
Dr. Schroeder reported having no financial disclosures.
NEW ORLEANS – How did dehydration, an order for a peripherally inserted central catheter line, and the bright lights of the ward add up to a full-thickness burn on an infant?
The simple answer is a flashlight.
The more telling response is that the PICC line wasn’t needed in the first place – much less the 20 minutes spent trying to isolate a vein with a flashlight. The infant rebounded with intravenous fluids and by simply advancing feeding volumes, Dr. Alan R. Schroeder said at the Pediatric Hospital Medicine 2013 meeting.
"When we think about patient safety and errors, we spend an awful lot of time talking about how could we better optimize the PICC line process, but we don’t spend as much time on whether this PICC line was even necessary," he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Indeed, physicians are quite good at responding when asked to do more. A recent study of ambulatory health care utilization shows that six of nine quality indicators of underuse improved between 1999 and 2009, whereas only two of eleven overuse indicators got better (JAMA Intern. Med. 2013;173:142-8).
Still, the unnecessary care movement is picking up steam in recent years, insists Dr. Schroeder of the department of pediatrics, Santa Clara Valley Medical Center, San Jose, Calif.
Three medical meetings, including the Preventing Overdiagnosis Conference, were organized this year specifically on medical overutilization, with at least one article devoted each month to the topic in JAMA Internal Medicine.
The Image Wisely initiative has garnered 18,621 pledges to lower the amount of radiation used, while the Choosing Wisely campaign, challenging medical societies to identify five things physicians and patients should question, is bearing fruit.
The pediatric committee of the Society of Hospital Medicine was the first pediatric subspecialty group to respond to the challenge, with a panel of experts, including Schroeder, recently publishing the top five recommendations for pediatric hospital medicine (J. Hosp. Med. 2013 [doi:10.1002/jhm.2064]).
" ‘Less is more’ is almost becoming a trend," Dr. Schroeder said.
Widely publicized public health mistakes in adult medicine, like near-universal prostate-specific antigen testing in men and hormone therapy for menopausal women, coupled with a financially stressed health care system, have helped move the needle. But several barriers to safely doing less still remain, he observed.
Time pressures, malpractice concerns, and pressure from families and colleagues all push physicians to increase healthcare utilization. The case of 12-year-old Rory Staunton, who died last year from potentially preventable septic shock after being released from the emergency department, has prompted new measures nationwide to spot sepsis earlier and a slew of stories in the New York Times and other publications.
The response was quite different, however, when two other adolescents, Jenny Olenick and Ben Ellis, died during or within hours of routine wisdom teeth extraction, a procedure that has been suggested as unnecessary 60% of the time, Dr. Schroeder said.
"They were killed by health care," he said. "This is a commission error, yet this has had scant media coverage. This is the type of case that should really, really upset you."
He went on to say that the omission/commission philosophy has its roots in medical education school.
"A lot of you are doing noble jobs trying to change that, but traditionally we are taught from day one not to miss a diagnosis," he said. "You have to generate these very, very broad differential diagnoses. We don’t want to be the guy that misses a diagnosis on day one and someone else comes in and makes a diagnosis on day two."
Money as motive
Another powerful barrier to safely doing less is the financial motive. Some of the best work in this area was the 2009 watershed essay by surgeon Atul Gawande showing that the strong entrepreneurial spirit in McAllen, Texas, doubled Medicare spending, compared with nearby El Paso, without improving outcomes, Dr. Schroeder observed. Recent research also refuted the widely endorsed belief that PSA screening improves outcomes by picking up more cancers than diagnosing based on symptoms. It was a hard-fought battle with high financial stakes, with some 30 million men undergoing PSA testing each year at a cost of $3 billion.
"There’s not a billboard outside my hospital saying ‘Come see Dr. Schroeder because today he will do less for you,’ " he said. "I wish there were one, but it’s not going to bring patients in or help the hospital’s bottom line."
Dr. Schroeder called for financing reform to disconnect reimbursement from utilization by compensating physicians for how they do their job, not what they do. There was also a pitch for comparative-effectiveness research to confirm that existing therapies are of benefit and if not, should not be reimbursed. As role models, he cited an unfunded, randomized controlled study presented at the meeting on nebulized hypertonic saline, and a voluntary quality improvement collaborative of pediatric hospitalists that cut bronchodilator use by 46% among inpatients with bronchiolitis (J. Hosp. Med. 2013;8:25-30). Not surprising, one of the top five new recommendations for pediatric hospital medicine is: "Do not use bronchodilators in children with bronchiolitis."
Talk about ‘less’
Dr. Schroeder urged the audience of some 1,000 pediatric hospitalists to introduce "safely doing less" into the patient-safety dialogue. Clinicians should always remind their patients and trainees of unanticipated harms. Instead of saying, "It’s a straightforward procedure," try saying, "There isn’t a procedure out there that can’t make someone worse or cause harm."
When there’s an adverse event at your institution, he advised clinicians not to just focus on the details of the incident, but also on the necessity of the interventions that led up to the incident. This strategy was conspicuous in its absence during the recent meningitis outbreak from contaminated steroid injections for back and neuropathic pain, that prompted 749 cases of fungal infection, 63 deaths, and a massive, multistate investigation.
"Everyone wanted to know how this could have happened; where was the regulation behind the compounding pharmacy, which is a worthy question," he said. "But it took weeks before it came out that these epidural steroid injections aren’t evidence based, although they sure make a lot of money."
Finally, he suggested the audience redefine the term "conservative" care from its current definition of test and treat to watch and wait.
During a discussion immediately following the lecture, however, attendee and pediatric hospitalist Lynn Campbell, who is with Dell Children’s Medical Center of Central Texas, in Austin, pointed out that, unlike primary care providers or ED physicians, hospitalists come into the game midstream and thus don’t have the same trust level established with families when trying to take away unnecessary tests or therapies.
Dr. Schroeder said many families don’t want more therapies, like antibiotics, and just want to take their child home, but added, "There are no easy answers."
Dr. Schroeder reported having no financial disclosures.
EXPERT ANALYSIS FROM PEDIATRIC HOSPITAL MEDICINE 2013
