Don’t routinely use bronchodilators in children with bronchiolitis.

Don’t use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.

This set of recommendations encompasses a huge subset of pediatric visits to the emergency department, and these tests and interventions may be frequently performed in many settings. Despite the seemingly innocuous nature of these items, they are associated with rare benefits, exceeding the costs and harms.

Likewise, the evolution and additions to these lists are likely to continue in the months and years to come. A study group led by Jeremiah D. Schuur, MD, MHS, FACEP, at Harvard Medical School in Boston used a modified Delphi consensus to create a list of care with “little value” for the institution.⁸ The process proposed more than 64 items initially, and the team surveyed physicians about 17 of these and ultimately created its own top five:

1. Do not order CT of the cervical spine after trauma for patients who do not meet the National Emergency X-ray Utilization Study (NEXUS) low-risk criteria or the Canadian C-Spine Rule.
2. Do not order CT to diagnose pulmonary embolism without first risk-stratifying for pulmonary embolism (pretest probability and D-dimer tests if low probability).
3. Do not order magnetic resonance imaging of the lumbar spine for patients with lower back pain without high-risk features.
4. Do not order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule.
5. Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy (eg, with anticoagulation therapy, clinical coagulopathy).

Whether this list, or any of the Choosing Wisely recommendations, meets your expectations as representing the “low-hanging fruit” of low-yield care in your clinical setting, these efforts illuminate important cultural changes. Beyond the specific proposals by each specialty, it is clear physicians are acutely aware of the tests and therapies that are overused despite minimal benefit. These tools provide the first steps toward more robust resource stewardship efforts that will improve the cost-effectiveness of health care delivery.

Dr. Radecki is assistant professor of emergency medicine at The University of Texas Medical School at Houston. He blogs at Emergency Medicine Literature of Note (emlitofnote.com) and can be found on Twitter @emlitofnote.

References

1. ACEP joins Choosing Wisely campaign. ACEP website. Available at: https://www.acepnow.com/article/acep-joins-choosing-wisely-campaign. Accessed June 16, 2014.
2. Choosing Wisely website. Available at: http://www.choosingwisely.org. Accessed June 16, 2014.
3. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatr. 2013;131:e964-e999.
4. Venekamp RP, Sanders S, Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2013;1:CD000219.
5. Imaging efficiency measures. Quality Net website. Available at: https://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228695266120. Accessed June 16, 2014.
6. Schuur JD, Brown MD, Cheung DS, et al. Assessment of Medicare’s imaging efficiency measure for emergency department patients with atraumatic headache. Ann Emerg Med. 2012;60:280-290.
7. Napoli AM. The association between pretest probability of coronary artery disease and stress test utilization and outcomes in a chest pain observation unit. Acad Emerg Med. 2014;21:401-407.
8. Schuur JD, Carney DP, Lyn ET, et al. A top five list for emergency medicine. JAMA Intern Med. 2014;174:509-515.