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ER doctors join campaign to reduce wasteful care

Dr. Jeremiah Schuur has taken steps to cut down on unneeded medical care in the ER at Brigham and Women’s.

Suzanne Kreiter/Globe Staff

Dr. Jeremiah Schuur has taken steps to cut down on unneeded medical care in the ER at Brigham and Women’s.

Over the past two years, dozens of medical specialty groups have embraced a national campaign to reduce unneeded tests and procedures, with at least one notable exception: Emergency room doctors have been slow to join this push to cut costs and improve care.

But many emergency doctors protested the American College of Emergency Physicians’ decision not to join the campaign as too narrowly self-interested, leading the group’s leaders to change their minds. Instrumental in this reversal was Dr. Jeremiah Schuur, a Brigham and Women’s Hospital emergency physician who has implemented several programs to cut down on unneeded medical care. Schuur is also a member of an American College task force studying the issue.

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On Monday, the American College released its first list of five tests and procedures that patients often do not need — even though doctors routinely perform them — as part of the “Choosing Wisely’’ campaign.

They include head CT scans for patients with minor injuries; urinary catheters to monitor fluid output in stable patients who can urinate on their own, “or for patient or staff convenience;’’ antibiotics for simple skin infections; and intravenous fluids for children with mild to moderate dehydration who can drink.

Dr. David Seaberg, past president of the emergency physicians group, explained in a blog last year that it declined to participate in the campaign when asked in 2011 in part because emergency physicians “often pick up the slack for other members of our esteemed profession.’’

“Many of these patients have been sent in with expressed instructions from the family physician to have this or that test ordered either because their office practice is swamped, the office is closed, or they lack the facilities to perform these tests,’’ he wrote.

Seaberg said doctors were also concerned that patients denied tests might file lawsuits if doctors failed to diagnose life-threatening illnesses and that insurers could use a list of unneeded tests as an excuse to deny payments for legitimate treatment.

“We don’t have a prior relationship with patients,’’ Schuur said. “The fear is without this relationship, if something bad happens after you see a patient, no one faults you for doing more, but frequently you get faulted for doing less.’’

But, he said, there is good evidence that some common interventions done for patients in the emergency room are unneeded. Based on data from a project at the Brigham and other hospitals in the Partners HealthCare network, for example, 15 to 20 percent of head CTs for minor injuries may be avoidable. The hospital is now analyzing how much money the project has saved.

CT scans are used to rule out skull fractures or bleeding in the brain, which are rare. But without one, children and some adults usually are told to wait in the ER for two to four hours for observation. “That’s perceived as inconvenient,’’ Schuur said.

Convenience can also be a factor when ordering urinary catheters, especially in patients who may have to get out of bed often to use the bathroom. The downside is not just cost, but infections.

Dr. Richard Baron, president of the American Board of Internal Medicine Foundation, a nonprofit organization in Pennsylvania that is overseeing the “Choosing Wisely” project, said emergency doctors were not the only group to have reservations about joining the campaign, though they were one of the largest and most important.

“They’re huge to bring in,’’ he said. “More than lots of other physicians, they operate in an environment where it feels comfortable and natural to do stuff. They can have a huge impact on changing practice in an area where a huge number of Americans get health care.’’

Liz Kowalczyk can be reached at kowalczyk@globe.com.
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