SLIDE 1 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
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‘An important conversation about unnecessary tests, treatments and procedures’
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Top 5 low value practices in Paediatrics
Oral antibiotics for fever Chest xrays in asthma Chest xrays and medications in bronchiolitis Acid suppression in gastro-oesophageal reflux Abdominal xray in nonspecific abdo pain
SLIDE 5 Evolve Criteria (RACP, division
Oral antibiotics for fever Chest xrays in asthma Chest xrays and medications in bronchiolitis Acid suppression in gastro-oesophageal reflux Abdominal xray in nonspecific abdo pain
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5 times more likely to receive antibiotics
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SLIDE 10 What are we doing?
All patients aged 1-12 months presenting to ED
with Principle Problem of bronchiolitis between April 2016 – June 2018 excluded those going to ICU
3781 encounters
11.3% had a CXR
Discharged from ED 3.5% Discharged from ward 24.5%
SLIDE 11 Is 11.3% reasonable?
Indications;
- ICU admission/ review (severe) (excluded)
- NGT placement
16%
- underlying cardiac concern
5%
- pneumothorax/ foreign body
4%
73%
SLIDE 12 Bottom Line
BOTTOM LINE
11.3% of all children with ED diagnosis of bronchiolitis receive an CXR
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
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What have we learnt
We know we do have a problem the size of the problem where the problem is occurring what is contributing to the problem
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Top 5 Low Value Practices in Paediatrics
Oral antibiotics for fever Chest xrays in asthma Chest xrays and medications in bronchiolitis Acid suppression in gastro-oesophageal reflux Abdominal xray in nonspecific abdo pain
SLIDE 17 What’s the Issue?
2nd highest PBS cost More risks than initially appreciated Accepted indications……..
1318%
1995-2006
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What are we doing?
All RCH scripts for PPI/ H2R antagonist between August – September 2016 Excluded ICU/ protocols specifying need for acid suppression 303 prescriptions in 232 patients
SLIDE 19 238 of 303 prescriptions were NOT indicated
78.5% of all scripts were not indicated
$15,493 per year of prescriptions Associated with consultant provider OR 2.69 inpatient status OR 2.35 PEJ/ PEG OR 5.5
Who Where Target
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Top 5 Low Value practices in Paediatrics
Oral antibiotics for fever Chest xrays in asthma Chest xrays and medications in bronchiolitis Acid suppression in gastro-oesophageal reflux Abdominal xray in nonspecific abdo pain
SLIDE 21 Asthma
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. 3305 children Key finding:
- 10.5% of patients had a CXR performed.
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Top 5 Low Value Practices in Paediatrics
Oral antibiotics for fever Chest xrays in asthma Chest xrays and medications in bronchiolitis Acid suppression in gastro-oesophageal reflux Abdominal xray in nonspecific abdo pain
SLIDE 23 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%)
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Ferritin ~400/ month $7.40 Iron Studies 630/ month $14.30
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Key Learnings
Loads of data Big data sets to allow us to measure practice, identify problem areas and design targeted interventions It’s only as good as the data we put in
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