I attended an excellent presentation by Hopkins' Leonard Feldman, MD, FAAP, FACP, SFHM, that challenged some of our practices, most notably unnecessary diagnostic tests that cost the hundreds of billions of dollars per year. Dr. Feldman focused on the evaluation of syncope, seizure prophylaxis for brain tumors, adjusting serum potassium levels in STEMI, and GI prophylaxis outside of the ICU.
Here are the key takeways for hospitalists:
- Using carotid Doppler for the evaluation of syncope adds no value in unveiling the etiology. Even if used in a high-risk group with cardiovascular disease, Doppler is helpful in determining the etiology only in the presence of focal neurological symptoms or carotid bruits. On the other hand, checking orthostatics is very helpful and inexpensive, providing an etiology about 25% to 30% of the time.
- There is no benefit of a 7-day peri-operative seizure prophylaxis in patients undergoing resection for a brain tumor (Wu et al, Journal of Neurosurgery, April 2013). The number of seizures within 30 days was actually slightly higher in the group of patients, who had received prophylaxis.
- In the past, medical societies have published guidelines for target serum potassium levels. These had been developed in the setting of STEMI and date back quite a while, before beta-blockers or reperfusion therapies were utilized in the acute management of STEMI. Target potassium levels of >4.0 or even between 4.5 and 5.5 had been recommended. Review of the literature did not find evidence to support this, but rather suggests that a target range of 3.5 to 4.5 is advisable.
- Hospitalized patients are frequently placed on proton-pump inhibitors (PPI) or H2-blockers for GI prophylaxis. Is there any benefit of this practice outside of the ICU? According to a study by Herzig et al (Archives of Internal Medicine, June 2011) clinically significant GI bleeding occurred in 0.18% of patients without prophylaxis compared to 0.26% with prophylaxis. To look at it from a different angle: The number needed to treat to prevent 1 episode of clinically significant GI bleeding was 834, whereas the number needed to harm was 553 for C. diff and 111 for hospital-acquired pneumonia. According to these data, there is no benefit and, if anything, harm done by providing GI prophylaxis to hospitalized patients outside of the ICU.
This is just a small sample of all the things we do. The results should motivate us to look for many other things we may do for no reason in our daily practice. TH
Dr. Suehler is a hospitalist at Mercy Hospital, Allina Health, in Minneapolis, and Team Hospitalist member.