SGP wählt weise

Prof. Dr. med. G.P. Ramelli

Servizio di Neuropediatria

Istituto Pediatrico delle Svizzera Italiana

6500 Bellinzona

Bellinzona, 7 June 2019

Objectives

• Choosing wisely in Paediatrics

• Review paediatric involvement

• How is SGP/SSP getting involved

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Why

- 20-30% of test/therapies unnecessary

- 2011: 160-225 Billion US Dollars

- Add no value

- May cause harm

- False positives: more tests, more stress

- Incidentalomas

Berwick et al, Eliminating waste in US health care: JAMA 2012; 307(14) 1513-1516

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Why

• Overtesting

• Overdiagnosis

• Overtreatment

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•

Dangers of Unnecessary Care in Pediatrics

• Discomfort: needles, catheters

• Risks: sedation, anesthesia

• Side effects of drugs: Stevens Johnson, Clostridium diff., antibiotic resistance

• Radiation exposure long-term effects

• Anxiety, stress

• False positive test results

• Overdiagnosis

• Incidentalomas

• Inconvenience to family/child –missed work/school

• Costs to family –parking, lost wages

• Costs to the systems/longer wait times

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• Concern about the overuse of unnecessary diagnostic tests and treatments, particularly…

• Those that may cause unintended harm

• Those that lack evidence

• Concern about (unsustainable) rising healthcare costs

Motivation for Change

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What can we do?

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Critical Thinking

1. Will this test help me to make a diagnosis?

2. Will this test potentially result in a change in management?

3. Is this test redundant with existing information?

4. Is there a reasonable pre-test probability for this test to be useful?

5. Does the benefit of the test outweigh the risk to the patient?

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• To focus attention on overuse of certain tests and therapies that are not supported by good evidence, add no value, result in harm or may promote unnecessary resource utilization

• To create a list specific to our patient population.

• To develop strategies to decrease inappropriate use and measure results.

Choosing Wisely and SSP

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What has been done

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There is a large and unexplained variation in the use of treatments and tests for children between and within countries.

This suggests that non-scientific factors such as clinical traditions and availability determine their use.

• Collection of all existing data in paediatrics

• 120 issues of 9 countries in around 12 disciplines

• Survey done through EAP

• In Europe only Spain, Italy, Norway and Israelhas a Choosing Wisely list specific for Paediatrics published

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What has been done

What has been done

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Do not routinely order chest X-rays for the diagnosis of asthma in children

Australia Rev. 2017

Avoid overviews of abdomen in children with abdominal pain Norway 2019

Do not routinely order abdominal X-rays for the diagnosis of non-specific abdominal pain in children

Australia Rev. 2017

Don’t routinely obtain CT scanning of children with mild head injuries.

U.S.A. 2014

Overtesting: unnecessary medical imaging

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17-25% of children receiving abdominal CT scans after trauma are at very low risk for intra-abdominal injury (IAI)

• Expected yields (positive CT imaging) of 0-0.1% intraabdominal injury (IAI) requiring intervention

• Unnecessary radiation exposure, procedural sedation and increased system costs

PECARN 2012, PSRC 2017

Overtesting: unnecessary medical imaging

Don’t routinely order a CT abdomen/pelvis for pediatric trauma patients deemed low risk by established decision rules for clinically significant intra-abdominal injury.

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Pearce MS et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study Lancet 2012; 380: 499-505.

Overtesting: Abdominal CT imaging medical

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Significant reduction in unnecessary testing and ionizing radiation in a vulnerable population without any missed injuries.

Example Antibiotic overuse

• 3 fold variation of rate of prescription of AB use throughout Europe and other countries

• Not equal difference of incidence of bacterial infection

Youngster I et al. Antibiotic Use in Children - A Cross-National Analysis of 6 Countries. J Pediatr 2017;182:239-244 .

Clavenna A, Bonati M. Differences in antibiotic prescribing in paediatric outpatients. Arch Dis Child 2011;96:590-5.

Brauer R et al. Prevalence of antibiotic use: a comparison across various European health care data sources. PharmacoepidemiolDrug Saf 2016;25 Suppl 1:11-20.

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Example including Antibiotic use

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Do not give antibiotics routinely to children with gastroenteritis Spain

Avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection.

Do not routinely use Antibiotics in newborns >36-48 hours when infection is unlikely

U.S.A.

Norway

Do not prescribe antibiotics to treat respiratory infections probably due to viral agents in children (pharyngitis, sinusitis, bronchitis).

Italy

Avoid routine antibiotic treatment for acute ear infection in children over 1 year of age.

Norway

Implementation

Adapted from CW Candada

Low leverage

interventionshigh leverage

interventions

Swiss Med Wkly. 2015 Mar 26;145:w14125. doi: 10.4414/smw.2015.14125. eCollection 2015.Smarter medicine: do physicians need political pressure to eliminate useless interventions?

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EASY

HARD

• Creating the list

• Find Enablers

• Medical champions

• Leadership

• Measurement

• Implementation

• Sustainability

Implementation

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Timeline Choosing Wisely SGP/SSP

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Bern, 11.6.2015, Autismus 21

Thank for your attention

• Corinne Wyder

• Sara Schnyder

• Kerstin Walter

• Dominique Gut

• Gerald Berthet

• Benedikt Huber

• Ermindo Di Paolo

• Andreas Geiser

• Gian Paolo Ramelli