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February 21, 2013
www.aapnews.org
Antibiotics to CT scans
Academy joins Choosing Wisely campaign
to reduce overtreatment
by Alyson Sulaski Wyckoff • Associate Editor
A doctor routinely orders a computed tomography (CT) scan for a
minor head injury. Another prescribes
an antibiotic for a viral respiratory illness or suggests cough medicine for
a toddler.
These physicians probably are not
Choosing Wisely, according to a campaign to reduce unnecessary
care that can drive up health care costs and, in some cases, harm
patients.
On Feb. 21, the Academy became one of 35 medical and 13 consumer organizations participating in Choosing Wisely. AAP President
Thomas K. McInerny, M.D., FAAP, appeared at a Washington, D.C.,
event marking the second phase of the campaign.
An initiative of the ABIM (American Board of Internal Medicine)
Foundation, Choosing Wisely asks physicians and patients to question
whether treatments, tests and procedures are supported by evidence,
free from harm and truly necessary.
Improving care, reducing costs
“I think this is a very good idea because part of the Affordable Care
Act is to do two things: improve the quality of care and reduce the
expense of medical care. And oftentimes, those two things can be
done simultaneously,” Dr. McInerny said. “Unfortunately, the public
doesn’t always see it that way,” he added. “They always think, the
more you do, the better your quality of care. That’s not always true.”
Each medical organization developed “5 things” that may be overused in that specialty (see Resources). Avoiding unnecessary use of
antibiotics and cough and cold medications as well as reducing the
routine use of CT scans in children made the Academy’s Top 5 list
(see sidebar).
The campaign might prompt conversations about overtreatment,
said Ricardo A. Quinonez, M.D., FAAP, chair of the AAP Section
on Hospital Medicine Executive Committee.
“I think the issue of overuse is underappreciated in medicine in
general but in pediatrics in particular,” said Dr. Quinonez, who coordinated the Society of Hospital Medicine’s Choosing Wisely list. He
noted that many efforts — such as safety improvement in hospitals
— are centered around what should be done rather than “things we
could be doing less of.”
Started in 2011, the Choosing Wisely campaign was sparked by
a 2010 article in New England Journal of Medicine in which Howard
Brody, M.D., Ph.D., challenged physicians to do their part to cut
health costs. He suggested medical societies develop Top 5 lists of
commonly ordered, expensive tests or treatments not beneficial to
major categories of patients. A program then was piloted by the
National Physicians Alliance through an ABIM grant. Consumer
Reports also joined the effort.
Last year, the ABIM Foundation released 45 tests and procedures
“to think twice about” from the first group of partners. The items
reflect concerns over safety and cost.
Pediatric priorities
Cutting back on CT scanning to reduce radiation risk in children
is reflected in three of the five AAP items. Dr. McInerny and others
have pointed to these as most concerning. They prefer to see a greater
emphasis on thorough physical exams and the use of ultrasonography
over CT scans, where possible, particularly since many kids get minor
head injuries or have abdominal pain. Half of children who go to
emergency departments (EDs) with a head injury are given a CT
scan, according to the Academy.
Jack Percelay, M.D., FAAP, chair of the AAP Committee on Hospital Care, said parents usually are receptive when he explains the
risks of too many scans. “I’ve certainly told parents,
‘Why don’t we just wait and watch what happens
with your child rather than go immediately to the
CT scan because it’s a significant amount of radiation and it carries risk with it.’”
Another item on the AAP list addresses the need
to stop prescribing antibiotics for viral respiratory
Dr. Percelay
illnesses. AAP District VII Chair Kenneth E.
Matthews, M.D., FAAP, said the “vast overuse of
antibiotics” is partly driven by some physicians’
desire to give families something to take home to
care for their child. It’s worth the extra time it takes
to reassure parents and educate them, he said.
The items on the AAP list “are things we’re trying to do right or trying to bring about for better
care of children,” said Dr. Matthews. “I think if
we work hard in trying to apply these, each time Dr. Matthews
we think about prescribing an antibiotic, each
time somebody recommends a cough-cold medicine, each time we
order imaging studies, then we have to think: ‘What else could I do
instead?’”
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RESOURCES
AAP Top 5
• View the AAP page on the Choosing Wisely website at
www.choosingwisely.org/doctor-patient-lists.
• For Five Things Physicians and Patients Should Question,
from various medical societies, go to http://choosing
wisely.org/?page_id=13.
As part of the Choosing Wisely initiative, the Academy surveyed members to develop
the following Top 5 list:
1. Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis,
pharyngitis, bronchitis).
2. Cough and cold medicines should not be prescribed or recommended for respiratory
illnesses in children under 4 years of age.
3. Computed tomography (CT) scans are not necessary in the immediate evaluation
of minor head injuries; clinical observation/Pediatric Emergency Care Applied
Research Network (PECARN) criteria should be used to determine whether imaging
is indicated.
4. Neuroimaging (CT, MRI) is not necessary in a child with a simple febrile seizure.
5. CT scans are not necessary in the routine evaluation of abdominal pain.
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Antibiotics to CT scans
Academy joins Choosing Wisely campaign to reduce overtreatment
Alyson Sulaski Wyckoff
AAP News originally published online February 21, 2013;
Updated Information &
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Antibiotics to CT scans
Academy joins Choosing Wisely campaign to reduce overtreatment
Alyson Sulaski Wyckoff
AAP News originally published online February 21, 2013;
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://aapnews.aappublications.org/content/early/2013/02/21/aapnews.20130221-1
AAP News is the official journal of the American Academy of Pediatrics. A monthly publication, it has been
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