Eric R. Coon

Overdiagnosis: How Our Compulsion for Diagnosis May Be Harming Children

Overdiagnosis occurs when a true abnormality is discovered, but detection of that abnormality does not benefit the patient. It should be distinguished from misdiagnosis, in which the diagnosis is inaccurate, and it is not synonymous with overtreatment or overuse, in which excess medication or procedures are provided to patients for both correct and incorrect diagnoses. Overdiagnosis for adult conditions has gained a great deal of recognition over the last few years, led by realizations that certain screening initiatives, such as those for breast and prostate cancer, may be harming the very people they were designed to protect. In the fall of 2014, the second international Preventing Overdiagnosis Conference will be held, and the British Medical Journal will produce an overdiagnosis-themed journal issue. However, overdiagnosis in children has been less well described. This special article seeks to raise awareness of the possibility of overdiagnosis in pediatrics, suggesting that overdiagnosis may affect commonly diagnosed conditions such as attention-deficit/hyperactivity disorder, bacteremia, food allergy, hyperbilirubinemia, obstructive sleep apnea, and urinary tract infection. Through these and other examples, we discuss why overdiagnosis occurs and how it may be harming children. Additionally, we consider research and education strategies, with the goal to better elucidate pediatric overdiagnosis and mitigate its influence.

When technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis

Pulse oximetry drives overtreatment in children with bronchiolitis without improving clinical outcomes, argue Ricardo Quinonez and colleagues

Update on Pediatric Overuse

As concerns over health care–related harms and costs continue to mount, efforts to identify and combat medical overuse are needed. Although much of the recent attention has focused on health care for adults, children are also harmed by overuse. Using a structured PubMed search and manual tables of contents review, we identified important articles on pediatric overuse published in 2015. These articles were evaluated according to the quality of the methods, the magnitude of clinical effect, and the number of patients potentially affected and were categorized into overdiagnosis, overtreatment, and overutilization. Overdiagnosis: Findings included evidence for overdiagnosis of hypoxemia in children with bronchiolitis and skull fractures in children suffering minor head injuries. Overtreatment: Findings included evidence that up to 85% of hospitalized children with radiographic pneumonia may not have a bacterial etiology; many children are receiving prolonged intravenous antibiotic therapy for osteomyelitis although oral therapy is equally effective; antidepressant medication for adolescents and nebulized hypertonic saline for bronchiolitis appear to be ineffective; and thresholds for treatment of hyperbilirubinemia may be too low. Overutilization: Findings suggested that the frequency of head circumference screening could be relaxed; large reductions in abdominal computed tomography testing for appendicitis appear to have been safe and effective; and overreliance on C-reactive protein levels in neonatal early onset sepsis appears to extend hospital length-of-stay.

Categorization of National Pediatric Quality Measures

This study describes nationally promoted quality measures applicable to pediatric populations, classifying them based on measure type and content. BACKGROUND AND OBJECTIVE: The number of quality measures has grown dramatically in recent years. This growth has outpaced research characterizing content and impact of these metrics. Our study aimed to identify and classify nationally promoted quality metrics applicable to children, both by type and by content, and to analyze the representation of common pediatric issues among available measures. METHODS: We identified nationally applicable quality measure collections from organizational databases or clearinghouses, federal Web sites, and key informant interviews and then screened each measure for pediatric applicability. We classified measures as structure, process, or outcome using a Donabedian framework. Additionally, we classified process measures as targeting underuse, overuse, or misuse of health services. We then classified measures by content area and compared disease-specific metrics to frequency of diagnoses observed among children. RESULTS: A total of 386 identified measures were relevant to pediatric patients; exclusion of duplicates left 257 unique measures. The majority of pediatric measures were process measures (59%), most of which target underuse of health services (77%). Among disease-specific measures, those related to depression and asthma were the most common, reflecting the prevalence and importance of these conditions in pediatrics. Conditions such as respiratory infection and otitis media had fewer associated measures despite their prevalence. Other notable pediatric issues lacking associated measures included care of medically complex children and injuries. CONCLUSIONS: Pediatric quality measures are predominated by process measures targeting underuse of health care services. The content represented among these measures is broad, although there remain important gaps.

Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness.

BACKGROUND AND OBJECTIVE Imperfect diagnostic tools make it difficult to know the extent to which a bacterial process is contributing to respiratory illness, complicating the decision to prescribe antibiotics. We sought to quantify diagnostic and antibiotic prescribing disagreements between emergency department (ED) and pediatric hospitalist physicians for children admitted with respiratory illness. METHODS Manual chart review was used to identify testing, diagnostic, and antibiotic prescribing decisions for consecutive children admitted for respiratory illness in a winter (starting February 20, 2012) and a summer (starting August 20, 2012) season to a tertiary, freestanding childrens hospital. Respiratory illness diagnoses were grouped into 3 categories: bacterial, viral, and asthma. RESULTS A total of 181 children admitted for respiratory illness were studied. Diagnostic discordance was significant for all 3 types of respiratory illness but greatest for bacterial (P<.001). Antibiotic prescribing discordance was significant (P<.001), with pediatric hospitalists changing therapy for 93% of patients prescribed antibiotics in the ED, including stopping antibiotics altogether for 62% of patients. CONCLUSIONS Significant diagnostic and antibiotic discordance between ED and pediatric hospitalist physicians exists for children admitted to the hospital for respiratory illness.

2017 Update on Pediatric Medical Overuse: A Review

Importance Medical overuse has historically focused on adult health care, but interest in how children are affected by medical overuse is increasing. This review examines important research articles published in 2016 that address pediatric overuse. Observations A structured search of PubMed and a manual review of the tables of contents of 10 journals identified 169 articles related to pediatric overuse published in 2016, from which 8 were selected based on the quality of methods and potential harm to patients in terms of prevalence and magnitude. Articles were categorized by overtreatment, overmedicalization, and overdiagnosis. Findings included evidence of overtreatment with commercial rehydration solution, antidepressants, and parenteral nutrition; overmedicalization with planned early deliveries, immobilization of ankle injuries, and use of hydrolyzed infant formula; and evidence of overdiagnosis of hypoxemia among children recovering from bronchiolitis. Conclusions and Relevance The articles were of high quality, with most based on randomized clinical trials. The potential harms associated with pediatric overuse were significant, including increased risk of infection, developmental disability, and suicidality.

Paediatric overdiagnosis modelled by coronary abnormality trends in Kawasaki disease

Objective Compare trends in coronary artery (CA) abnormality diagnoses to trends in adverse cardiac outcomes among American children with Kawasaki disease (KD) to assess the fit of detection of CA abnormalities to an established model of overdiagnosis. Design Multicenter retrospective cohort. Setting 48 US children’s hospitals in the Paediatric Health Information System database. Participants Children <18 years receiving care for KD between 2000 and 2014. Main outcome measures The main outcomes were rates of CA abnormality diagnoses and adverse cardiac outcomes, measured during a child’s incident KD visit and longitudinally at all subsequent visits to the same hospital, through December 2016. CA abnormalities were considered severe if long-term anticoagulation other than aspirin was prescribed. Trends were tested using mixed effects logistic regression, adjusting for patient demographics. Results Among 17 809 children treated for KD, a CA abnormality was diagnosed in 1435 children (8%), including 1117 considered non-severe and 318 severe. The rate of non-severe CA abnormality diagnoses increased from 45 per 1000 patients with KD in 2000 to 81 per 1000 patients with KD in 2014, representing an adjusted 2.3-fold increased odds (95% CI 1.8 to 3.0) of diagnosis. There was no significant change in diagnoses of severe CA abnormalities. Adverse cardiac outcomes were stable over the study period at 19 per 1000 patients with KD (P=0.24 for trend). Conclusions The rising rate of detection of non-severe CA abnormalities accompanied by an unchanging rate of adverse cardiac outcomes among American children with KD fits an overdiagnosis pattern.

Shortened IV Antibiotic Course for Uncomplicated, Late-Onset Group B Streptococcal Bacteremia

Contrary to existing recommendations, early transition to oral antibiotic therapy may be appropriate for carefully selected infants with GBS bacteremia. BrightcoveDefaultPlayer10.1542/6138657125001PEDS-VA_2018-0345 Video Abstract BACKGROUND: Guidelines recommend a prolonged course (10 days) of intravenous (IV) antibiotic therapy for infants with uncomplicated, late-onset group B Streptococcus (GBS) bacteremia. Our objective was to determine the frequency with which shorter IV antibiotic courses are used and to compare rates of GBS disease recurrence between prolonged and shortened IV antibiotic courses. METHODS: We performed a multicenter retrospective cohort study of infants aged 7 days to 4 months who were admitted to children’s hospitals in the Pediatric Health Information System database from 2000 to 2015 with GBS bacteremia. The exposure was shortened IV antibiotic therapy, defined as discharge from the index GBS visit after a length of stay of ≤8 days without a peripherally inserted central catheter charge. The primary outcome was readmission for GBS bacteremia, meningitis, or osteomyelitis in the first year of life. Outcomes were analyzed by using propensity-adjusted, inverse probability–weighted regression models. RESULTS: Of 775 infants who were diagnosed with uncomplicated, late-onset GBS bacteremia, 612 (79%) received a prolonged IV course of antibiotic therapy, and 163 (21%) received a shortened course. Rates of treatment with shortened IV courses varied by hospital (range: 0%–67%; SD: 20%). Three patients (1.8%) in the shortened IV duration group experienced GBS recurrence, compared with 14 patients (2.3%) in the prolonged IV duration group (adjusted absolute risk difference: −0.2%; 95% confidence interval: −3.0% to 2.5%). CONCLUSIONS: Shortened IV antibiotic courses are prescribed among infants with uncomplicated, late-onset GBS bacteremia, with low rates of disease recurrence and treatment failure.

Trends in Pediatric Head CT Use: Looking Beyond the Ivory Tower

* Abbreviations: ciTBI — : clinically important traumatic brain injury CT — : computed tomography ED — : emergency department LOC — : loss of consciousness PECARN — : Pediatric Emergency Care Applied Research Network TBI — : traumatic brain injury In this month’s Pediatrics , Burstein et al1 report disappointing statistics in their work entitled “Use of CT for Head Trauma: 2007–2015.” Using the National Hospital Ambulatory Medical Care Survey, a representative data set for emergency department (ED) visits,2 they found that 32% of pediatric patients presenting for head trauma had computed tomography (CT) imaging as part of their evaluation. This proportion was unchanged over the study period despite publication of algorithms3–5 and an international effort intended to safely decrease unnecessary radiation exposure from head CTs among infants and children with head injuries. Additionally, they reported that ∼90% of US children received their trauma care at general (nonteaching and nonchildren’s) hospitals, where CT use was higher.1 Some history regarding CT use for pediatric head injury is helpful. In 1999, the American Academy of Pediatrics reviewed treatment of minor head injury and divided recommended evaluation and treatment by whether there was brief loss of consciousness (LOC).6 Head CT imaging was recommended for patients with LOC. If the LOC was … Address correspondence to Susan L. Bratton, MD, MPH, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108. E-mail: susan.bratton{at}hsc.utah.edu

Continuous Physiologic Monitoring: False Alarms and Overdiagnosis

What is the most common intervention to which hospitalized children are exposed? Acetaminophen? IV access? Phlebotomy? Or is it being connected to a monitor? In a study conducted in five children’s hospitals, Schondelmeyer et al found that exposure to continuous electronic physiologic monitoring was extremely common. During a selected 24-hour window of observation, nearly 100% of PICU and NICU patients and 26%-48% of medical–surgical patients were exposed to continuous monitoring.1 The latter is undoubtedly an underestimate given that monitoring periods less than 24 hours were not captured, patients may have been exposed before or after the 24-hour study window, and monitoring in the emergency department was not included. The omnipresence of electronic physiologic monitoring in children’s hospitals is striking, particularly because we know very little about its benefits. Outside of the perioperative period, there is a dearth of evidence demonstrating improved outcomes for hospitalized children as a result of continuous physiologic monitoring. Guidelines for the most common inpatient pediatric conditions do not advocate for continuous physiologic monitoring. Presumably, this practice has become so pervasive in the absence of a strong evidence base and guideline recommendations because it is a passive, seemingly innocuous intervention that continuously collects important components of the physical examination (after all, they are known as “vital” signs). It is tempting to assume that providing clinicians with this information will make patients safer. The danger of routinely exposing children to an intervention for which the benefits are unproven is that the net effect of the intervention may be harm. What could be harmful? The simple act of monitoring is distressing to children; sticky electrode pads stuck to their skin and a tangle of wires that restrict their movement–all impeding physical activity and contact with loved ones. Then, there are the alarms. Schondelmeyer et al report a staggering number of them: between 42 and 152 alarms per monitored day on the floor; between 54 and 351 alarms in the intensive care units. The vast majority are false alarms, triggered by inappropriate preselected thresholds or displaced leads. This cacophony of noise only amplifies an already stressful environment for our patients–and their parents. Nurses and physicians are similarly stressed by alarms, not only by the noise but also by the frequent need to respond to them. The combination of frequent and largely unnecessary interruptions leads to alarm fatigue, whereby providers are desensitized to the alarms and may be slower to recognize a truly decompensating patient. Continuous monitoring also risks overdiagnosis, the accurate detection of abnormalities that are not destined to cause problems, but nonetheless trigger interventions that can cause harm.2 Studies in adult populations have demonstrated that continuous monitoring can produce overdiagnosis. Repeated Cochrane reviews conclude that continuous electronic fetal monitoring during labor is associated with overdiagnosis of fetal distress—with attendant increase in cesarean sections without decreasing the risk for important neonatal outcomes such as cerebral palsy and mortality.3 A recent randomized trial of continuous pulmonary impedance monitoring intended to reduce readmission rates in patients with CHF instead found that continuous monitoring resulted in overdiagnosis of CHF exacerbations—paradoxically increasing hospital admission with no significant change in mortality (in fact, mortality was nominally higher in the monitoring group).4 Pediatric providers are probably no less susceptible to the impulse to act in the face of abnormalities detected by continuous monitoring. EKGs and electrolyte panels may be ordered in response to transient arrhythmias. Similarly, it is challenging for providers to watch a monitor flashing elevated respiratory rates in an otherwise healthy infant with bronchiolitis and not seek an escalation in care, including increased oxygen flow or transfer to a higher acuity unit. Although arrhythmia and respiratory rate alarms were common in Schondelmeyer et al’s study, low oxygen level was far and away the most common alarm. Indeed, the poster child of pediatric overdiagnosis in the setting of electronic physiologic monitoring is hypoxemia. The present body of literature suggests that overreliance on pulse oximetry among patients with bronchiolitis increases admission rates to the hospital and prolongs length of stay, without a measurable improvement in morbidity or mortality.5 Few patients cared for at American children’s hospitals will be discharged without exposure to prolonged periods of continuous physiologic monitoring. Undoubtedly, there are inpa*Address for correspondence: Eric R. Coon MD, MS, Department of Pediatrics, Division of Inpatient Medicine, University of Utah School of Medicine, Primary Children’s Hospital, 100 North Mario Capecchi Dr, Salt Lake City, UT 84113; Telephone: (801) 662-3645; Fax: (801) 662-664; E-mail: eric.coon@hsc. utah.edu