Low Value Care No Hiding In The EMR Dr Joanna Lawrence , Paediatrician, EMR trainer On behalf of; Lauren Andrew (EMR Optimisation Manager) Harriet Hiscock (HSRU), Alice Voskoboynik (EMR reporting) , Ahuva Segal (EMR research), Emma Weiss, Suzi Riess (Paediatricians) and others
‘An important conversation about unnecessary tests, treatments and procedures’
Oral antibiotics for fever Chest xrays in asthma Top 5 Chest xrays and medications in bronchiolitis low value Acid suppression in gastro-oesophageal reflux practices in Abdominal xray in nonspecific abdo pain Paediatrics
Oral antibiotics for fever Chest xrays in asthma Chest xrays and medications in bronchiolitis Evolve Criteria Acid suppression in gastro-oesophageal reflux (RACP, division Abdominal xray in nonspecific abdo pain of Paediatrics)
5 times more likely to receive antibiotics
All patients aged 1-12 months presenting to ED with Principle Problem of bronchiolitis between April 2016 – June 2018 excluded those going to ICU What are we 3781 encounters Discharged 3.5% doing? from ED Discharged 24.5% 11.3% had a CXR from ward
Indications; - ICU admission/ review (severe) (excluded) - NGT placement 16% - underlying cardiac concern 5% - pneumothorax/ foreign body 4% - ?consolidation/ collapse 73% Is 11.3% reasonable?
BOTTOM LINE 11.3% of all children with ED diagnosis of bronchiolitis receive an CXR Bottom Line 70% of these made no difference to patient management and may have increased antibiotic use ~1200 CXRs per year that could be avoided $58,000 per year
We know we do have a problem the size of the problem where the problem is occurring What have we what is contributing to the problem learnt
Oral antibiotics for fever Chest xrays in asthma Chest xrays and medications in bronchiolitis Top 5 Low Acid suppression in gastro-oesophageal reflux Value Practices Abdominal xray in nonspecific abdo pain in Paediatrics
1318% What’s the 1995-2006 Issue? 2 nd highest PBS cost More risks than initially appreciated Accepted indications……..
All RCH scripts for PPI/ H2R antagonist between August – September 2016 What are we Excluded ICU/ protocols specifying need for acid suppression doing? 303 prescriptions in 232 patients
238 of 303 prescriptions were NOT indicated 78.5% of all scripts were not indicated Who $15,493 per year of prescriptions Where Associated with consultant provider OR 2.69 inpatient status OR 2.35 PEJ/ PEG OR 5.5 Target
Oral antibiotics for fever Chest xrays in asthma Chest xrays and medications in bronchiolitis Top 5 Low Acid suppression in gastro-oesophageal reflux Value practices Abdominal xray in nonspecific abdo pain in Paediatrics
Benchmark; CXR is indicated in ~10% of children with asthma All children aged 1- 18yo given a principal problem of ‘asthma’ in the emergency department between April 2016 to June 2018. Asthma 3305 children - 10.5% of patients had a CXR performed. Key finding:
Oral antibiotics for fever Chest xrays in asthma Chest xrays and medications in bronchiolitis Top 5 Low Acid suppression in gastro-oesophageal reflux Value Practices Abdominal xray in nonspecific abdo pain in Paediatrics
All patients aged 1 month to 18 years with ‘reason for attendance’ in ED or ‘hospital problem’ for inpatient admissions from July -Nov 2017 2117 encounters 98 had AXR (4.7%)
x Iron Studies 630/ month Ferritin ~400/ month $14.30 $7.40
Loads of data Big data sets to allow us to measure practice, Key Learnings identify problem areas and design targeted interventions It’s only as good as the data we put in
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