"Choosing wisely" -- a reconsideration of risk and benefit in clinical decision making

First-ever Dartmouth Atlas report on pediatric health care finds wide variation in hospital and outpatient care for children across Northern New England.  Press release, Lebanon, N.H. December 11, 2013. 

Whether children are receiving recommended care or are subjected to potentially unneeded treatments varies widely depending on where they live, according to the Dartmouth Atlas Project’s first report on health care provided to children and infants, which examines care in Maine, New Hampshire, and Vermont.

The new report shows that children in Dover, N.H., had almost twice as many emergency room visits as those living in Burlington, Vt., and children in Lebanon, N.H., were more than twice as likely to have their tonsils removed as children in Bangor, Maine. The study also finds that children in Lewiston, Maine, and Manchester, N.H., are 50 percent more likely to receive head CT scans, exposing them to radiation, than children in the areas served by the region’s three major children’s hospitals: Portland, Maine; Lebanon, N.H.; and Burlington, Vt. 

Since the original reports by Wennberg and Fischer more than a decade ago, overuse of diagnostic modalities and treatments has been documented for almost every patient population and clinical condition.   "But wait," you say.  "This press release doesn't prove anything about overuse.  This merely points out variation in care."  And this is entirely true. However, in the US (and the answer would presumably be different in Haiti or Guatemala) every systematic study has found either no difference or improved outcomes in low-utilizing regions.  The harsh reality is that we expose patients to risk in excess of benefit.  Routinely. 

Recognizing this, many physician leaders and national organizations are now turning their attention to this previously-neglected dimension of quality.  Consider the Choosing Wisely campaign of the ABIM Foundation, which has collected examples of over-used interventions from more than three dozen professional societies, and developed education materials that urge patients and families to ask about the necessity for these tests and treatments. 

In discussions with our physician leaders, I am seeing examples of strong work already done, but also many opportunities to improve our practice.  In our ICU, for example, sedation vacations are routine.  There have been inroads into the appropriate use of thoracic CT in the diagnosis of pulmonary embolism in the ED setting.  We are in discussions at the Dolan Center to measure & increase guideline adherence to reduce antibiotic overuse for acute otitis media and sinusitis in children.  

More serious attention to "appropriate use" will have many benefits.  Our hospitalists spend hundreds of hours a month "reconciling" medication lists at admission and discharge.  How many of these medications can we safely eliminate?  How many drug interactions and outpatient med errors can we prevent?  

The use of advanced imaging for Emergency and inpatients has increased dramatically and it has been estimated that overall population-level exposure to diagnostic irradiation has increased 600 fold in the past twenty years (1). In many cases increased imaging has been observed without improvement in disease detection or outcome.  At the same time, there is growing concern about the increased risk of imaging-associated malignancy.  It has been estimated that as much as 1.5% of all new cancers  result from medical radiation exposure.  We should be concerned about this, especially in the young although recent data suggest that this complication is also a significant factor for the adult population.  

The marked increase in advanced imaging also challenges the clinical community to followup findings of uncertain significance.  One prospective study (2) identified that factitious lesions occurred in up to 50% of such images, often occasioning further images (and radiation), invasive investigations, patient risk, anxiety and cost.  

Finally, I want to share a thought about over-use and "standardization" of care.  It seems to me that clinical excellence is very much about knowing when to default to check-lists and lock-step standards.  These can help reduce illogical variation, simplify care, improve teamwork and keep us from forgetting important steps.  But true excellence is also about knowing when NOT to standardize - when, instead, to individualize care based on this patient's particular clinical presentation.  Much overuse grows from the adoption of pseudo-protocols - the shortness of breath work up…the abdominal pain work up…the headache workup.  The protocol for each of these should include an incisive history and a thorough physical exam.  Everything else…depends.  

What do you think?  Is there overuse in your department?  Can we do better, and if so, how do we start?  Write a reply.  Let's talk.

1. National Council on Radiation Protection and Measurements. Ionizing radiation exposure of the population of the United States. NCRP report no. 160. Bethesda, Md.: National Council on Radiation Protection and Measurements; 2009.

2. Swensen SJ, Jett JR, Hartman TE, et al. CT screening for lung cancer: five-year prospective experience. Radiology. 2005;235(1):259–265.