Highlights
- •Prophylaxis, bed rest or dietary restrictions are recommended daily for most inpatients.
- •In many cases, these supporting clinical practices are not necessary for patient management.
- •Physician should recognise the need to question these practices because they are not harmless.
- •The implementation of interventions to address low-value care is needed for all clinical practices.
- •Those interventions not aimed at the entire process from admission to discharge will fail.
Abstract
Introduction
Besides the main treatment for their disease, hospital patients receive multiple care
measures which include venous lines (VL), urinary catheters (UC), dietary restrictions
(DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer
prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF).
In many cases these practices are of low value.
Methods
We analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients).
We used different methodologies to identify low-value clinical practices.
Results
BR or DR at admission were recommended in 37% (32–44) and 24% (19–30) of the patients
respectively. In 81% (71–87) and 33% (21–45) of the cases this restriction was deemed
unnecessary. Ninety-six percent (92–98) had VL and 25% (19–32) UC. VL were not used
in 10% (6–12), UC had no indications for insertion in 21% (11–35) and for maintenance
in 31% (12–46) patients. Fifty-seven percent (49–64) of the patients were administered
VTP and 69% (62–76) were prescribed SUP. Twenty-two percent (15–31) of patients with
VTP and 52% (43–60) with SUP had no indication. Chronic anticoagulation for AF was
interrupted in 65% (53–75) with BAF was prescribed in 38% (25–52) of them.
An intervention to reduce low-value care supporting clinical practices addressed only
to the Internal Medicine Wards showed very poor results.
Conclusion
These results demonstrate that there is ample room for reduction of low-value care.
Interventions to implement clinical guidelines at admissions should be addressed to
cover the entire admission process, from the emergency room to the ward. Partial approaches
are discouraged.
Keywords
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References
- “Choosing Wisely”: a growing international campaign.BMJ Qual Saf. 2015; 24: 167-174https://doi.org/10.1136/bmjqs-2014-003821
- 2017 update on medical overuse: a systematic review.JAMA Intern Med. 2018; 178: 110-115https://doi.org/10.1001/jamainternmed.2017.4361
- 2018 update on medical overuse.JAMA Intern Med. 2019; 179: 240-246https://doi.org/10.1001/jamainternmed.2018.5748
- Disinvestment from low value clinical interventions: NICEly done?.BMJ. 2011; 343: d4519https://doi.org/10.1136/bmj.d4519
- Too much medicine: from evidence to action.BMJ. 2013; 347: f7141https://doi.org/10.1136/bmj.f7141
- Early trends among seven recommendations from the choosing wisely campaign.JAMA Intern Med. 2015; 175: 1913-1920https://doi.org/10.1001/jamainternmed.2015.5441
- Low-value care: an intractable global problem with no quick fix.BMJ Qual Saf. 2018; 27: 333-336https://doi.org/10.1136/bmjqs-2017-007477
- Frequency of low-value care in Alberta, Canada: a retrospective cohort study.BMJ Qual Saf. 2018; 27: 340-346https://doi.org/10.1136/bmjqs-2017-006778
- Interventions aimed at reducing use of low-value health services: a systematic review.Med Care Res Rev. 2017; 74: 507-550https://doi.org/10.1177/1077558716656970
- Measuring hospital-acquired complications associated with low-value care.JAMA Intern Med. 2019; https://doi.org/10.1001/jamainternmed.2018.7464
- Preoperative testing before low-risk surgical procedures.CMAJ. 2015; 187: E349-E358https://doi.org/10.1503/cmaj.150174
- Identifying and acting on potentially inappropriate care.Med J Aust. 2015; 203: 183e.1-6
- Doing things for no reason in the hospital.BMJ. 2019; 364: l841https://doi.org/10.1136/bmj.l841
- A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both.Int J Cardiol. 2009; 137: 37-41https://doi.org/10.1016/j.ijcard.2008.06.020
- Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica.Cochrane Database Syst Rev. 2010; CD007612https://doi.org/10.1002/14651858.CD007612.pub2
- British Society of Gastroenterology. Guidelines for enteral feeding in adult hospital patients.Gut. 2003; 52: vii1-12
- epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.J Hosp Infect. 2014; 86: S1-70https://doi.org/10.1016/S0195-6701(13)60012-2
- Clinically-indicated replacement versus routine replacement of peripheral venous catheters.Cochrane Database Syst Rev. 2019; CD007798https://doi.org/10.1002/14651858.CD007798.pub5
- TWOC around the clock: a multimodal approach to improving catheter care.J Infect Prev. 2017; 18: 57-64https://doi.org/10.1177/1757177416668584
- A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score.J ThrombHaemost. 2010; 8: 2450-2457https://doi.org/10.1111/j.1538-7836.2010.04044.x
- ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998.Am J Health Syst Pharm. 1999; 56: 347-379https://doi.org/10.1093/ajhp/56.4.347
- Prophylaxis against upper gastrointestinal bleeding in hospitalized patients.N Engl J Med. 2018; 378: 2506-2516https://doi.org/10.1056/NEJMra1605507
- PPI. Choosing Wisely Canada.(n.d.) (accessed March 25, 2019)
- Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis.in: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 9th ed. Chest. 141. 2012: e227S-e277Shttps://doi.org/10.1378/chest.11-2297
- Validation of the international medical prevention registry on venous thromboembolism bleeding risk score.Chest. 2016; 149: 372-379https://doi.org/10.1378/chest.14-2842
- 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American college of cardiology clinical expert consensus document task force.J Am Coll Cardiol. 2017; 69: 871-898https://doi.org/10.1016/j.jacc.2016.11.024
- The appropriate use of proton pump inhibitors (PPIs): need for a reappraisal.Eur J Intern Med. 2017; 37: 19-24https://doi.org/10.1016/j.ejim.2016.10.007
- The overuse of thromboprophylaxis in medical patients: main clinical aspects.G Ital Cardiol (Rome). 2015; 16: 639-643https://doi.org/10.1714/2066.22436
- Bleeding, recurrent venous thromboembolism, and mortality risks during warfarin interruption for invasive procedures.JAMA Intern Med. 2015; 175: 1163-1168https://doi.org/10.1001/jamainternmed.2015.1843
- Are physicians aware of which of their patients have indwelling urinary catheters?.Am J Med. 2000; 109: 476-480
- Overuse of the indwelling urinary tract catheter in hospitalized medical patients.Arch Intern Med. 1995; 155: 1425-1429
- Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital.Am J Infect Control. 2004; 32: 196-199https://doi.org/10.1016/j.ajic.2003.08.007
- Initial inappropriate urinary catheters use in a tertiary-care center: incidence, risk factors, and outcomes.Am J Infect Control. 2007; 35: 594-599https://doi.org/10.1016/j.ajic.2006.11.007
- Do clinicians know which of their patients have central venous catheters?: a multicenter observational study.Ann Intern Med. 2014; 161: 562-567https://doi.org/10.7326/M14-0703
- Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the “idle central venous catheter”.Infect Control Hosp Epidemiol. 2012; 33: 50-57https://doi.org/10.1086/663645
- Bed rest in a Sydney teaching hospital.Arch Gerontol Geriatr. 1994; 19: 39-44
- A program to prevent catheter-associated urinary tract infection in acute care.N Engl J Med. 2016; 374: 2111-2119https://doi.org/10.1056/NEJMoa1504906
Article info
Publication history
Published online: June 20, 2019
Received in revised form:
June 10,
2019
Received:
May 3,
2019
Identification
Copyright
© 2019 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
