Dr. Schroeder called for financing reform to disconnect reimbursement from utilization by compensating physicians for how they do their job, not what they do. There was also a pitch for comparative-effectiveness research to confirm that existing therapies are of benefit and if not, should not be reimbursed. As role models, he cited an unfunded, randomized controlled study presented at the meeting on nebulized hypertonic saline, and a voluntary quality improvement collaborative of pediatric hospitalists that cut bronchodilator use by 46% among inpatients with bronchiolitis (J. Hosp. Med. 2013;8:25-30). Not surprising, one of the top five new recommendations for pediatric hospital medicine is: "Do not use bronchodilators in children with bronchiolitis."
Talk about ‘less’
Dr. Schroeder urged the audience of some 1,000 pediatric hospitalists to introduce "safely doing less" into the patient-safety dialogue. Clinicians should always remind their patients and trainees of unanticipated harms. Instead of saying, "It’s a straightforward procedure," try saying, "There isn’t a procedure out there that can’t make someone worse or cause harm."
When there’s an adverse event at your institution, he advised clinicians not to just focus on the details of the incident, but also on the necessity of the interventions that led up to the incident. This strategy was conspicuous in its absence during the recent meningitis outbreak from contaminated steroid injections for back and neuropathic pain, that prompted 749 cases of fungal infection, 63 deaths, and a massive, multistate investigation.
"Everyone wanted to know how this could have happened; where was the regulation behind the compounding pharmacy, which is a worthy question," he said. "But it took weeks before it came out that these epidural steroid injections aren’t evidence based, although they sure make a lot of money."
Finally, he suggested the audience redefine the term "conservative" care from its current definition of test and treat to watch and wait.
During a discussion immediately following the lecture, however, attendee and pediatric hospitalist Lynn Campbell, who is with Dell Children’s Medical Center of Central Texas, in Austin, pointed out that, unlike primary care providers or ED physicians, hospitalists come into the game midstream and thus don’t have the same trust level established with families when trying to take away unnecessary tests or therapies.
Dr. Schroeder said many families don’t want more therapies, like antibiotics, and just want to take their child home, but added, "There are no easy answers."
Dr. Schroeder reported having no financial disclosures.