When practices become ingrained in practice it can be very difficult to change them, even when new evidence becomes available, or a review of existing evidence points out that the practice is worthless.
An editorial towards the end of last year in JAMA (Powers BW et al De-adopting Low-Value Care: Evidence, Eminence, and Economics. JAMA. 2020) discusses “Evidence, Eminence, and Economics”, 3 factors that are important in whether or not useless therapies or investigations continue to be common or are de-adopted. Briefly, good quality evidence that a procedure or test is ineffective often has little effect on practice patterns. Statements by learned societies tend to have some effect but it is variable and often a small effect. When a system stops paying for a test or procedure the impacts tend to be major and rapid.
The choosing wisely campaign recommended 5 common neonatal procedures that could be abandoned (Ho T, Dukhovny D, Zupancic JA, Goldmann DA, Horbar JD, Pursley DM. Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value. Pediatrics. 2015;136(2):e482-9).
These are my top 4, there is some overlap with Ho et al.
- Routine day 3 head ultrasound, (followed by day 7-10, day 30, 36 weeks and pre-discharge, near term).
- Routine investigations as a universal screen should be proven to improve outcomes in some way. Clearly, that has never been shown for routine repetitive head ultrasounds, but they have become standard practice and are often performed on multiple occasions.
- Generally speaking, investigations should only be done if they will change the clinical approach. A good rule of thumb is to ask the question, what will I do if the test result is negative, and what will I do if it is positive? If the answers are the same: don’t do the test.
- I think we should do head ultrasounds only if they are going to have an impact on clinical care.
- We should therefore focus on finding treatable conditions, which in this situation means acute post-haemorrhagic ventricular dilatation.
- A single head ultrasound at 5 to 7 days of age in infants who are at risk of that complication, such as babies under 27 weeks and those who have been critically ill, would suffice. Further head ultrasounds are only needed if the initial images show a lesion that could lead to post-haemorrhagic hydrocephalus.
- C-Reactive Protein
- CRPs are frequently performed in many NICUs, but a recent systematic review shows that they are basically useless, with a PPV and NPV no better than tossing a coin. They are neither sensitive nor specific for the diagnosis of true infections, and many babies receive antibiotics to treat an elevated CRP!
- Anti-acid medications
- Many babies with symptoms attributed to reflux receive either H2 blockers or PPIs
- There is no clinical sign that is adequately diagnostic of reflux except for overt regurgitation
- Most reflux in the newborn is non-acid, either neutral or alkaline
- There is no evidence that clinical signs attributed to reflux are due to acid
- Gastric acid is good for you, blocking it changes the intestinal microbiome, increases translocation, and increases infections and necrotising enterocolitis
- Prokinetic/”anti-reflux” medications
- Even if you have proved, by multiluminal impedance, that a baby has reflux which is temporally related to their symptoms, prokinetics don’t work. There is no evidence of beneficial effects of prokinetics on reflux in the newborn, and they are all toxic.
Anyone have other suggestions?