Choosing the future of paediatrics wisely

The COVID-19 pandemic has provided an unexpected opportunity to ‘reboot’ our health-care system but the one area we haven’t been talking about enough is the overuse of tests and procedures, resulting in avoidable needles, catheters, spinal taps, exposure to medication with side effects, and even admission to hospital. As a paediatrician, I know there is tremendous anxiety for both parents and frontline clinicians around diagnostic uncertainty of any kind when it comes to our children. Physicians, myself included, generally agonize over any delay in diagnosis, not wanting to leave any stone unturned when it comes to reassuring our patients and their families, and ourselves, that we aren’t missing something serious. We all want to know – and need to know – the answer to the problem in front of us, so we can provide the best possible care and get our patients back to doing the things they love.

Doctors have historically tended to choose doing something over nothing, even when it may not be helpful, and it’s time to address and change these habits to benefit our patients. A false-positive test result or discovery of incidental findings often leads to a cascade of further unnecessary interventions. This scenario is often not black and white, and we know the quest for certainty is sometimes unrealistic and may cause harm through unnecessary care.

In my opinion, in paediatrics we are late to the Choosing Wisely movement– an international initiative aimed at reducing unnecessary tests, treatments and procedures. We have not yet fully appreciated the critical importance of this program and its relevance to providing high-quality, safe and high-value care. Why is that? Maybe because in children’s health care the focus has traditionally been on underuse, or the lack of data that challenges us to gather sufficient evidence to have full confidence in support of our recommendations. These habits and expectations will likely be difficult to break, but the stakes are high in paediatric practice as the harms of unnecessary interventions on our young patients are magnified with their entire lifespan still ahead.

This is what motivated me to build a team to develop a Choosing Wisely initiative at The Hospital for Sick Children (SickKids), to support our most vulnerable young patients seeking care in our hospital. Our patients are not just little adults and need their own unique recommendations. Beginning in 2016, we asked our staff to identify areas of potential unnecessary care and created a list of five recommendations for tests or treatments that we felt were being overused at the hospital, and on occasion inappropriately utilized in patients who wouldn’t benefit from them. This work required clinical champions to lead improvement for each Choosing Wisely recommendation enabled by support and engagement with various representatives from SickKids' Family Advisory Network; divisions and departments at the hospital including Diagnostic Imaging, Paediatric Laboratory Medicine, Pharmacy, Paediatrics, as well as the Utilization Management and Antimicrobial Stewardship Committees.

The results were excellent – certain types of unnecessary x-rays and viral testing in the emergency department (ED) were drastically reduced (by 50 and 80 per cent respectively) and inappropriate intravenous immunoglobulin use for certain conditions went down by 50 per cent, with no detectable negative outcomes. The success of our first Choosing Wisely list motivated us to develop a second list in 2018 with the involvement of our surgical and antibiotic stewardship colleagues. These subsequent recommendations have all resulted in additional measurable improvements including decreased inappropriate CT scans in trauma patients, improved adherence to perioperative antibiotic recommendations and a significant drop in misdiagnosed urinary tract infection in the ED, saving hundreds of unnecessary antibiotic days. Despite the pandemic, we recently launched our third SickKids Choosing Wisely list – for a total of 15 recommendations at SickKids that are uniquely tailored to children. Some new areas of overuse being addressed include inappropriate outpatient opioid prescribing practices and reducing unnecessary bladder catheterization in infants and toddlers.

Our next challenge is to scale up these successes to impact and change practice both inside and outside the walls of SickKids. Choosing Wisely is quickly becoming part of the culture at SickKids, with a particular appetite and passion for stewardship from the new generation of medical school trainees and paediatric residents. The COVID-19 pandemic has unexpectedly provided an opportunity to address some of these issues. Across health-care organizations, we saw drops in in-person visits to the ED and outpatient clinics, opening the door to alternate options such as virtual care when appropriate. Lockdowns and infection control requirements resulting from the COVID-19 pandemic have also significantly impacted wait lists for procedures – a serious challenge that will benefit from the application of a Choosing Wisely lens to help determine how best to deal with these backlogs.

In Canada, we are privileged to live in a wealthy country with tremendous resources, but we should not always do things ‘just because we can’. Successful programs like Choosing Wisely allow us to address overuse and overdiagnosis that can contribute to inequities within our health-care system, drawing resources away from critically important areas that need attention such as societal determinants of health. With constant critical thinking and collaborative partnerships with our patients and their families, we can continue in our quest to improve the provision of safe, quality, high-value care to the right patient at the right time.