“Everything we do as physicians has downstream consequences and cost,” said Dr. Nathan Money, assistant professor of pediatrics at the University of Utah in Salt Lake City, as he and Dr. Danni Liang, assistant professor of pediatrics at the University of Cincinnati, began their talk on medical overuse. They highlighted the need to avoid unnecessary interventions to prevent negative outcomes and stressed the importance of considering the value of care, which can be seen as the balance between quality and cost. This includes looking at the various benefits for the patient and their family in comparison to the direct and indirect costs, such as lost wages and stress, as well as potential indirect harms.
Drs. Money and Liang highlighted three areas of medical overuse that we should consider for de-implementing wisely—the well-appearing hypothermic infant, antibiotic duration in urinary tract infections (UTIs), and post-hospital follow-up appointments.
Dr. Money looked to the literature to review the risks of serious bacterial infections (SBIs) in well-appearing infants who present with hypothermia. He cited research showing that well-appearing infants are at low risk for SBIs and may not warrant a full sepsis evaluation.1,2 Dr. Money’s own article further highlighted that younger and preterm infants were at lower risk for SBIs than older neonates, and though these infants were at risk for an SBI, it was less so than their febrile counterparts. While more studies are needed to be able to stratify risk for these patients, it is reasonable to observe certain well-appearing infants with isolated hypothermia.
How many days of antibiotics do you prescribe for an uncomplicated urinary tract infection? Dr. Liang reviewed the recent publication of the SCOUT trial results, looking at five days versus 10 days of antibiotic therapy and children two months to 10 years of age.3 Treatment failure rate was low, especially in those with afebrile versus febrile UTIs. It would be reasonable to consider a short course, five days of therapy, in children with early clinical improvement.
Most children hospitalized with bronchiolitis are otherwise well and can be expected to continue to improve after discharge from the hospital. Do all such patients require routine post-hospital follow-up with their outpatient providers? Dr. Money reviewed two articles that looked at routine post-hospitalization follow-up and post-emergency department follow-up for bronchiolitis.4,5 Both had similar results of routine follow-up versus as-needed follow-up regarding readmissions and time to symptom resolution. However, it was noted that those with routine follow-ups were more likely to have received prescriptions for albuterol, corticosteroids, and antibiotics than those with as-needed follow-ups; all are medications not generally indicated for treatment of bronchiolitis. It is reasonable to recommend as-needed follow-up to decrease healthcare utilization.
Dr. Liang discussed the importance of de-implementing low-value care wisely. As physicians and clinicians, we’re called to evaluate the quality of the evidence so that we can increase the quality of care while decreasing patient harm and the costs of care. We should be mindful of the well-documented disparities in the receipt of high- and low-value care services, disproportionally affecting socially disadvantaged groups, such as those whose language is other than English.
He gave literature-based examples6:
Consider early transition to oral antibiotics in patients with infections such as pyelonephritis, osteomyelitis, and complicated pneumonia.
Discharge well-appearing febrile infants once bacterial cultures are confirmed negative for 24 to 36 hours if adequate outpatient follow-up can be assured.
Do not start phototherapy in well-appearing infants with neonatal hyperbilirubinemia if their levels are below levels at which the American Academy of Pediatrics guidelines recommend treatment.
Use narrow-spectrum antibiotics, such as ampicillin or amoxicillin for children hospitalized with uncomplicated community-acquired pneumonia.
Do not start intravenous antibiotic therapy on well-appearing newborns with isolated risk factors for sepsis. Instead, use clinical tools, such as an evidence-based sepsis-risk calculator, to guide management.
Lastly, Drs. Money and Liang previewed a possible list of high-yield topics for future Choosing Wisely recommendations to decrease medical overuse of such treatments as melatonin; oseltamivir in hospitalized patients; viral testing; overmedicalization of tongue ties; unnecessary admission for stable patients with pneumothorax or pneumomediastinum; unnecessary gastrostomy-tube placement; routine two-day birth hospitalization; and the dangers of proton pump inhibitor use. There are many more opportunities to study, and many opportunities to increase value and decrease harm for our patients.
Key Takeaways
- Well-appearing infants with hypothermia are at low risk for SBI and may not warrant a full sepsis evaluation; it is reasonable to observe certain well-appearing infants with isolated hypothermia.
- In children with uncomplicated UTIs, it is reasonable to consider a shorter course of antibiotics for patients with early clinical improvement.
- Most children with acute bronchiolitis will continue to improve after hospital discharge and as-needed post-hospitalization follow-up may lead to decreased healthcare utilization.
Dr. McDaniel
Dr. McDaniel is a pediatric hospitalist and associate professor, head of pediatric hospital medicine, and medical director of acute pediatrics at the University of Virginia Children’s Hospital in Charlottesville, Va. She is chair of the SHM Pediatric Special Interest Group executive council.
References
- Jain SB, Anderson T, et al. Serious infections are rare in well-appearing neonates with hypothermia identified incidentally at routine visits. Am J Emerg Med. 2023;65:1-4. doi: 10.1016/j.ajem.2022.12.008.
- Money NM, Lo YHJ, et al. Predicting serious bacterial infections among hypothermic infants in the emergency department. Hosp Pediatr. 2024;14(3):153-62. doi: 10.1542/hpeds.2023-007356.
- Zaoutis T, Shaikh N, et al. Short-course therapy for urinary tract infections in children: the SCOUT randomized clinical trial. JAMA Pediatr. 2023;177(8):782-9. doi: 10.1001/jamapediatrics.2023.1979.
- Coon ER, Destino LA, et al. Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis: the bronchiolitis follow-up intervention trial (BeneFIT) randomized clinical trial. JAMA Pediatr. 2020;174(9):e201937. doi: 10.1001/jamapediatrics.2020.1937.
- Shapiro DJ, Bourgeois FT, et al. National patterns of outpatient follow-up visits after emergency care for acute bronchiolitis. JAMA Netw Open. 2023;6(10):e2340082. doi: 10.1001/jamanetworkopen.2023.40082.
- Tchou MJ, Schondelmeyer AC, et al. Choosing wisely in pediatric hospital medicine: 5 new recommendations to improve value. Hosp Pediatr. 2021;11(11):1179-90. doi: 10.1542/hpeds.2021-006037.