Reducing the Use of Unnecessary Tests and Treatments (EBNEO Session)

This was a short, interactive session from EBNEO (Evidence-Based Neonatology) by Dr Kiran Shrivastava and Prof Gautham Suresh on low-value care. It drew lively input from an audience working in very different health systems: India, the US, the UK, Sweden and the Netherlands.

What is low-value care?

There is no single agreed definition. A working one is: any intervention where the evidence suggests little or no benefit to the patient. It can take three forms:

• Ineffective: it works in some subgroups but not in everyone we use it on.

• Inefficient: it works, but costs too much, comes at the wrong intensity, or takes too long.

• Unwanted: it is technically useful but doesn’t meet the family’s needs. The example given was term-equivalent MRI for all preterm babies. It produces images, but at that moment it tells parents little about the future. What they often want is a conversation about what it means and what follow-up looks like.

The speaker was equally clear about what low-value care is not. It is not cost-cutting or rationing. It is not withholding care we know works. And it is not the opposite of caring. Most of it sits in a grey zone, and avoiding it means more thinking about each individual baby, not less.

Examples from the room

• Routine admission bloods and routine blood gases in stable babies “because it’s the protocol”

• Antibiotics started for virtually every NICU admission, plus routine X-rays and blood cultures

• Automatic NICU admission for every baby under 36 weeks, even when transitioning well, which separates mother and baby

• Continuous saturation monitoring in bronchiolitis, which prolongs hospital stay

• Escalation of care, such as intubation, when it isn’t clearly needed

Choosing Wisely: the 2015 neonatal list

The Choosing Wisely campaign started about 15 years ago. Each specialty society names its own low-value practices. The 2015 newborn medicine recommendations were:

1. No routine anti-reflux medication for symptomatic GER, or for apnoea/desaturations in preterm infants

2. No antibiotics beyond 48 h in initially asymptomatic infants without evidence of bacterial infection

3. No routine daily chest X-rays without a clinical indication

4. No routine pneumograms before discharge

5. No routine term-equivalent or discharge MRI in preterm infants

This isn’t a rich-country problem

The Lancet Right Care series (2017) found overuse and underuse side by side in every setting, high- and low-resource, sometimes within the same hospital or even the same patient. Data from India were also cited showing more deaths attributable to poor-quality care than to no access to care at all.

Why do we keep doing it?

It isn’t ignorance. We attend conferences and we know the evidence. The speaker grouped the drivers into four categories:

• Behavioural. It is hard to stand back and do nothing, especially when families want action. We also tend to overestimate pre-test probability. And there is an asymmetry: the harm of overtesting is invisible and statistical, while the one missed diagnosis “has our name on it” in the M&M meeting or in litigation. In other words, defensive medicine.

• Social. Practice spreads person to person, shaped by where we trained, by hierarchy, and by who is on service this week. The speaker described “mindlines” (Gabbay & le May): researchers followed GPs for two years and found they relied on colleagues rather than guidelines. Mindlines are collectively reinforced, internalised, tacit guidelines that nobody questions or traces back to their source.

• Systemic. Order sets with pre-ticked boxes, nursing routines taught at induction, and guidelines that nobody actually uses.

• Economic. Fee-for-service systems reward more tests and longer stays.

The speaker also summarised what sustains a practice as evidence, eminence and economics, with evidence counting for least. The vertebroplasty story illustrated this. After two negative trials, the orthopaedic societies advised against the procedure and orthopaedic surgeons stopped. Interventional radiology issued no such guidance, so their practice didn’t change.

Voices from the floor on money:

• India: families receive a daily itemised bill, and clinicians discuss finances with parents almost every day.

• US: clinicians rarely know what anything costs. One suggestion was that showing the running bill in the electronic record could change ordering behaviour. In one hospital, whole-genome sequencing now needs a genetics consult first, but CBCs, X-rays and MRIs can still be ordered freely.

• UK: almost no pushback on investigations, which may itself entrench routine imaging.

• Netherlands: funding thresholds can create an incentive to keep a baby a few days longer.

What can we actually do?

Ideas from the audience:

• Make costs visible to clinicians, for tests and for materials.

• Know what you are looking for before you order. Don’t do the echo first and then work out the question. Teach trainees the same way.

• Use EHR “hard stops”, such as “Do you really want this? Why?”

• Build a culture where juniors, nurses and all staff can question why we do things. Nurses are often the ones who say “enough”, including when it is time for comfort care.

• Revisit unit practice and guidelines every couple of years.

What the evidence says works:

• ❌ Education alone has little measurable effect, and gains fade over time.

• ✅ Audit and feedback, ideally delivered by respected local leaders (eminence works both ways).

• ✅ Accountability at the point of ordering: state the indication, as in antibiotic stewardship time-outs, and extend that to other tests.

• ✅ Peer comparison and collaborative QI with benchmarking against your region or network.

• ✅ Change the default: no automatic order sets; choose tests baby by baby.

And AI?

The room split. Optimists see AI as a fast evidence assistant for learners, used under senior supervision, and as a help in explaining risk to parents. Sceptics warned of “cognitive surrender”, where we stop thinking and let the tool decide, which would make overuse worse.

Take-home messages

1. Low-value care exists everywhere, in every resource setting.

2. It survives on structure, habit and culture, not ignorance.

3. Before any test, ask: What am I expecting, and what will I do with the result?

4. Education alone won’t fix it. Audit and feedback, accountability, peer comparison and better defaults can.

5. Questioning a practice is not the opposite of caring. It is caring.