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Bullseye on Overuse: Fewer Interventions for Better Care


 

The overuse of tests, treatments, and procedures is getting increased attention as a patient safety issue.

The Joint Commission, along with the American Medical Association–convened Physician Consortium for Performance Improvement, recently held a summit to look at how to cut back on the overuse of certain medical interventions being performed even though they are not medically necessary and could cause harm.

The summit was centered on five common treatments and procedures:

• Percutaneous coronary intervention (PCI).

• Blood transfusions.

• Tympanostomy tubes for brief periods of fluid behind the eardrum.

Dr. Donna E. Sweet

• Antibiotics to treat viral upper respiratory infections.

• Early induction of labor without medical need.

"We have come to believe in American medicine that everything we do is beneficial," said Dr. Donna E. Sweet, an internist and professor of medicine at the University of Kansas, Wichita, who headed up the work group looking at antibiotic overuse for upper respiratory tract viral infections. "There’s always a downside."

Antibiotic Overuse

In the case of viral upper respiratory infections, commonly prescribed antibiotics do nothing to improve patients’ health and risk worsening the population-wide problem of antibiotic resistance. In the outpatient setting, the stumbling block is often that when patients come into the office, they expect to leave with a prescription. For physicians, it’s easier to write an antibiotic prescription than to explain why they don’t need it, Dr. Sweet said.

"American patients aren’t very patient," she said. "They want to be better now."

In the hospital, physicians have more tools at their disposal for managing the use of antibiotics, from good culture techniques, to advice from pharmacists, to an on-site laboratory. But overuse still happens. Hospitalists should try to make a specific diagnosis when they can and do a culture, Dr. Sweet said. If a patient comes into the hospital sick, febrile, hypotensive, and dehydrated, it’s probably appropriate to start them on a broad-spectrum antibiotic. But if after 24-48 hours, there’s nothing growing in the culture, it’s probably a viral infection and the antibiotics should be cut off, she said.

"Restricting both the length and then the spectrum of the antibiotic are the two things that we know will make a difference in trying to combat some of this antibiotic resistance," she said.

The antibiotic overuse work group is looking at ways to align the various definitions of a viral upper respiratory infection and the existing guidelines, Dr. Sweet said.

Transfusion Driven by Lack of Info

When it comes to blood transfusion, another work group will be considering ways to increase the amount of time spent on this topic in medical school.

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