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Smarter indicators

In health care, overtesting and overtreatment do more harm than good for patients. Scientifically-based guidelines have been developed and established by societies of various medical specialties on the main medical procedures that are usually unnecessary.

Introduction

In June 2020, Hôpital de La Tour became the first private health care facility in the Swiss region of Romandy to partner with smarter medicine – Choosing Wisely Switzerland.  

Hôpital de La Tour is therefore committed to the principle that a treatment should only be given if it provides a clear benefit to the patient.

As a result, several medical procedures that are potentially harmful for patients when prescribed unnecessarily were identified: prescribing certain drug classes (antibiotics, proton-pump inhibitors, and benzodiazepines), blood tests, blood transfusions, urinary catheters, and medical imaging examinations that use radiation. 

Key indicators

1.    Benzodiazepine prescriptions

Benzodiazepines are too often prescribed in hospital to treat insomnia. In Switzerland, it is estimated that one in every five patients will be given benzodiazepines during their hospital stay. However, large-scale studies show that the risk of falls and hip fractures can more than double in elderly people who are taking benzodiazepines and other sedative-hypnotic drugs. 

This potential harm should be considered when deciding the treatment plan for insomnia, agitation, or delirium. Benzodiazepines should only be used for alcohol withdrawal symptoms, delirium tremens, and severe generalized anxiety disorders that have not responded to other treatments. 


2.    PPI prescriptions

Proton-pump inhibitors (PPIs) are among the most prescribed medications in Switzerland. However, it is estimated that approximately 30% to 50% of PPI prescriptions are not needed. PPIs are overprescribed due to off-label use outside of the established indications, the failure to reassess treatment during transitions between care settings, and rebound effects that are poorly tolerated by patients during withdrawal. The indication for using PPIs should be reviewed during each transition in care while following good clinical practice guidelines to avoid unnecessarily exposing patients to known side effects, such as Clostridium difficile infections. 


3.    Urinary catheters

Infections related to urinary catheters are the most common type of healthcare-associated infections. They have a major impact on morbidity and mortality rates as well as health care costs. Nearly half of urinary catheters are placed without a specific medical indication. Urinary catheters are also left in place longer than necessary, often due to inattentive care. Yet, the risk of developing an infection is closely related to the duration of the urinary catheter placement. Simple measures to improve patient safety involve following indications, considering different alternative options and reassessing the need for urinary catheters on a daily basis. These measures reduce the number of catheter-associated urinary tract infections by more than 50% with a positive impact on quality of care and costs.


4.    Blood transfusions

In line with international guidelines, a liberal transfusion strategy is not only unnecessary but may be harmful in certain situations. Blood transfusions are associated with a risk of infection and allergic reaction as well as hemodynamic risks. The use of this limited and expensive resource should therefore be optimized. International guidelines recommend a restrictive transfusion strategy, with a transfusion threshold of 70–80 g/L, except in special cases. The clinician should always use single-unit red blood cell transfusions and clinically reassess and check hemoglobin levels before administering a second transfusion. This does not apply to hemorrhaging patients.


5.    Repeated blood tests

Multiple laboratory tests are prescribed regularly, sometimes even on a daily basis. Yet, laboratory tests should only be requested to meet a specific clinical need. Regularly prescribing tests increases health care costs and is not beneficial to patients, with the potential to even harm them due to the detrimental side effects, such as pain when drawing blood, anemia, and a series of unnecessary further tests caused by a false-positive result. 


6.    Medical imaging examinations

Medical imaging examinations expose patients to potentially toxic doses of radiation. These examinations are only necessary if they meet a clinical need and when an alternative examination that uses less or no radiation is not available. For example, a study in Geneva found that over half of abdominal X-rays performed in emergency departments are prescribed unnecessarily. This examination has a radiation dose that is nearly equivalent to that of a low-dose CT scan and often does not provide enough information to help the clinician make an appropriate care plan.


7.    Antibiotics

Several studies have shown that nearly half of antibiotic treatments prescribed in a health care setting are not indicated, have a spectrum of activity that is too broad, or are prescribed for too long. Using a treatment for too long unnecessarily exposes patients to an increased risk of complications, such as Clostridium difficile infections, while misusing and overusing antibiotics accelerate antibiotic resistance in the general population and form poor preventive practices. Guidelines must be strictly followed to reduce these negative consequences. 

 

Why are these indicators important?

The indicators selected concern medical procedures that are not supported by evidence and provide no real benefit to patients. A key priority is deciding the procedures that doctors use too often and where the prescribing behavior is likely to change following appropriate training. 

 

Smarter indicators

22%

Prescription rate of benzodiazepines

21%

Prescription rate of PPIs

8

Average duration of PPI dose in days

11.4%

Percentage of patients fitted with a urinary catheter

4.6

Average duration of urinary catheter placement in days

5.9%

Percentage of patients who received a blood transfusion 

5.5

Average number of blood draws per patient during one hospital stay 

36%

Percentage of patients who had at least one medical imaging examination that used radiation

Improvement measures taken

In addition to an internal awareness campaign, the doctors prescribing these procedures take part in continuing medical education (CME) programs and have access to dashboards to help them compare their prescription rates with those of their colleagues. This combination of increased awareness and education is therefore encouraging doctors to question their practice and consider the benefit to the patient before each prescription.