By Debra Wood, RN, contributor
October 4, 2012 - Leaders from two health care organizations committed to safe, quality care recently convened the National Summit on Overuse and called for reducing the overuse of five treatments that offer limited benefit and the possibility of harm. The five targeted treatments include prescribing antibiotics for viral upper respiratory infections, early inductions of births, placement of heart vessel stents, blood transfusions and tympanostomy tubes for brief episodes of fluid behind the ear drum.
Mark R. Chassin, MD, FACP, MPP, MPH, called overuse of some treatments a serious quality problem.
“Overuse is a serious quality problem that’s been neglected despite evidence going back 25 years that it exists and in fact is pervasive,” said Joint Commission President Mark R. Chassin, MD, FACP, MPP, MPH, at the event, held on September 24, 2012. “This is not about rationing. This is not about an effort to prevent patients from getting necessary care. This is about protecting patients from getting unnecessary tests, treatments and procedures.”
The Joint Commission and the American Medical Association’s (AMA) Physician Consortium for Performance Improvement (PCPI) co-sponsored the event, so key stakeholders could discuss strategies for appropriate use of these five treatments and procedures.
“This is an issue of quality, an issue of patient safety, an issue of avoiding patient harm and an issue of improving the health and outcomes of our country,” said Bernard M. Rosof, MD, chair of the PCPI.
Participants at the National Summit on Overuse considered the existing evidence surrounding these treatments and discussed ways to raise awareness among health care professionals and patients that would lead to reduced overuse.
Recommendations included the creation of educational tools for health care professionals and patients, dissemination of leading practices to health care professionals, standardized reporting of data and the alignment of existing guidelines.
Rosof called for a patient-centered approach with shared decision making. Next steps will include sending specific messages to various stakeholders and, perhaps, the drafting of a consensus document.
Internist Donna E. Sweet, MD, AAHIVS, MACP, with the American College of Physicians (ACP), worked with a panel--which included nurses--that assessed antibiotic use for the common cold and viral infections. The panel came up with four ideas: a standard definition for a viral upper respiratory infection, a set of guidelines for treatment, behavior change concepts to promote “watchful waiting” as the best policy, and an educational campaign for patients and prescribers that emphasizes the benefit–harm ratio to prescribing antibiotics for a viral infection.
Irena L. Kenneley, PhD, APRN-BC, CIC, called antibiotic stewardship a global concern, but an area in which nurses can help educate patients.
Nurses can help inform consumers, said Irena L. Kenneley, PhD, APRN-BC, CIC, assistant professor at Case Western Reserve University, Frances Payne Bolton School of Nursing in Cleveland, Ohio, and chair of the research committee for the Association for Professionals in Infection Control and Epidemiology (APIC).
“Nurses don’t play a large enough role in educating patients about antibiotic use and misuse,” Kenneley said. “There are more of us seeing patients than other health care providers. What an opportunity to spread the word.”
Kenneley cited research that has shown that when patients are informed, the misuse of antibiotics for viral infections decreased significantly. She suggested a need to educate nurses, not just in America but also around the world, about how to best have that discussion with consumers. Information from the Get Smart Campaign, of which the American Association of Nurse Practitioners (AANP) is a partner, is available from the Centers for Disease Control and Prevention (CDC).
“We need to look at the appropriate use of antibiotics and antibiotic stewardship now, before it’s too late,” Kenneley said.
Early, elective delivery of babies is another pervasive problem. Perinatologist Bryan T. Oshiro, MD, Loma Linda University Medical Center and Children’s Hospital in California, co-facilitator of the early, elected, nonmedically indicated deliveries subgroup, discussed the long-term and short-term consequences to the baby when delivering prior to 39-weeks gestation.
“Babies born prior to 39 weeks could have increased NICU admissions; they could have adverse respiratory outcomes,” said Susan Fair, RN, BSN, BA, labor and delivery nurse manager at Women and Infants Hospital in Providence, R.I., which has a policy not allowing elective deliveries before 39 weeks. When an induction request is received, nursing and medical staff review the information to ensure the patient meets established criteria.
“We have tried to involve our patients, our providers and our nurses with the March of Dimes to get this message out,” Fair said. “We are taking a proactive approach.”
Barriers to preventing an optimal rate of early deliveries include nonalignment of payment incentives, which could lead to decreases in revenues with fewer neonatal intensive care admissions; better lifestyles for obstetricians with planned deliveries; and patients’ lack of awareness of the consequences, Oshiro said. The National Summit subgroup suggested more public, physician, payor and hospital nursing staff education about the risks of early, elected deliveries. It also will prepare a white paper.
Pediatric otolaryngologist David W. Roberson, MD, FACS, with the American Academy of Otolaryngology, Head and Neck Surgery, participated in a multidisciplinary group to evaluate tympanostomy tube overuse. The group agreed tubes should not be placed in children with isolated otis media with effusion of less than 90 days, except in certain circumstances. It suggested hospitals monitor appropriateness and develop guidelines to ensure patients receive the right treatment.
Aryeh Shander, MD, president of the Society for the Advancement of Blood Management, addressed the increased number of blood transfusions and suggested implementing evidence-based bundles to outline appropriate use.
The overuse group for percutaneous coronary interventions discussed whether patients with stable angina could have been treated medically vs. an elective invasive procedure or surgery for reduction of symptoms, said Carl L. Tommaso, MD, NorthShore University HealthSystem in Skokie, Ill., chair of the subgroup. The group did not focus on acute cardiac patients.
Tommaso’s group called for better compliance with existing guidelines and an upstream evaluation with better stress test reporting to quantify ischemia, and education of physicians and patients about the benefits and risks of percutaneous coronary interventions and the alternatives.
Many of the speakers emphasized the importance of a multidisciplinary approach to solving the problem of overuse. Nurses can be part of the solution, becoming aware of the latest research and communicating with patients about the risks and benefits of various treatment options.
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