As part of the Choosing Wisely campaign, the American Academy of Pediatrics released a list of five tests and treatments that should not be routinely done on newborns.
If your newborn ended up in a neonatal intensive care unit, would you question the medical advice given by your baby’s doctor?
Are those tests really necessary? Is that medication needed? Is there scientific evidence to show that they work?
While this may go against the old-school style of medicine, patient and parent involvement is at the heart of a new push to reduce waste in the healthcare system — one top five list at a time.
These top five lists are part of Choosing Wisely, a campaign launched by the ABIM Foundation in 2012.
Choosing Wisely calls on medical organizations such as the American Academy of Pediatrics (AAP) to come up with their own list of medical tests and treatments that may be unnecessary.
This week, the AAP released its second top five list in a paper published online today in the journal Pediatrics. The new list, which focuses on newborns, cautions against the routine use of the following tests and treatments:
- anti-reflux medications to treat acid reflux or apnea/desaturation in preterm infants
- use of antibiotics beyond 48 hours if there is no evidence of a bacterial infection
- pneumogram (breathing test) for assessment of ongoing or prolonged apnea (frequent pauses in breathing) in premature infants
- daily chest X-rays for infants with a breathing tube inserted when there is no indication for use of this test
- brain MRIs for screening in premature infants
Although routine use of these may be wasteful, there may be times when these tests and treatments are appropriate.
“It’s not that we’re saying: ‘Don’t do these at all,’” said study author Dr. Timmy Ho, a neonatologist at Beth Israel Deaconess Medical Center in Boston. “We’re just saying that if you’re going to do them, do it in a proper way that gives us the information we need to know whether or not this actually works.”
The neonatology top five started as a list of 2,870 suggestions made by more than 1,000 neonatologists, nurses, parents, and other healthcare professionals.
The survey asked respondents to identify interventions where the evidence showed they didn’t work, lacked evidence of their effectiveness, or were an unnecessary use of staff or resources.
This list was pared down through multiple committee meetings and a review of the scientific literature by a panel of experts.
For the first two items on the list — routine use of anti-reflux medication and antibiotics — the authors cited several studies showing that they may be harmful to infants. Overuse of antibiotics can also increase the risk of bacteria becoming resistant to these medications.
According to the authors, the last three items on the list don’t have enough evidence to support their use, although they may not be immediately harmful either.
“It’s not that there’s evidence saying that you shouldn’t do this,” said Ho. “There’s just not evidence supporting its benefit.”
These types of tests and treatments are ripe for further research. As more evidence is gathered, doctors can continue to refine how they practice medicine.
“Two years from now this top five list should be obsolete and there should be another list of wasteful things that we do that we can cut back on,” said Ho. “So that we keep improving what we do every day.”
In its efforts to reduce waste in the healthcare system, the Choosing Wisely campaign encourages greater involvement of patients.
“The Choosing Wisely program was started in the beginning to encourage conversations between patients and physicians around issues of overuse, which we saw as a problem that affected quality and safety and could cause potential harm of patients,” said Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, a nonprofit organization that supports the campaign.
In the case of children, this advocacy role falls to the parents. It includes talking to the doctor about the potential benefits and harms of tests and treatments, and whether there is strong enough scientific evidence to support their use.
“We’re interested in the public beginning to ask questions of their physicians,” said Wolfson, “and [having] conversations with them about whether this test is really needed.”
This is especially important for parents of newborns because neonatologists only care for infants for the first one to two months of their lives. After that, it falls on the parents to ensure that their child receives the best medical care.
“If we’ve done our job and we do what Choosing Wisely tells us to do, then these parents are going to take this message and carry it throughout their children’s lives,” said Ho.