What are examples of unnecessary practices in outpatient clinics, as highlighted in the 'Things We Do for No Reason' paper in the Journal of Hospital Medicine (JHM)?

From the Guidelines

Unnecessary practices in outpatient clinics include routine diagnostic tests, unnecessary transfusions, and inappropriate use of parenteral nutrition, as highlighted in the 'Choosing Wisely' campaign 1. These practices not only increase healthcare costs but also may harm patients due to unnecessary phlebotomy, aggressive work-up of incidental results, and limited benefits in certain patient populations. Some examples of such practices include:

• Ordering diagnostic tests at regular intervals rather than in response to specific clinical questions 1
• Transfusing red blood cells in hemodynamically stable, nonbleeding patients with an Hb concentration greater than 7 mg/dl 1
• Using parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay 1
• Deeply sedating mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation 1
• Continuing life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort 1 A recent study also highlighted the negative consequences of overuse of medical tests and treatments, including physical, psychological, and financial effects on patients 1. Key points to consider when evaluating these practices include:
• The potential harms and benefits of each practice
• The clinical context and patient population
• The availability of alternative treatments or management strategies
• The importance of shared decision-making and patient-centered care By recognizing and addressing these unnecessary practices, physicians can improve patient outcomes, reduce healthcare costs, and promote high-value care.

From the Research

Unnecessary Practices in Outpatient Clinics

• Overprescription of antibiotics for acute bronchitis, which has been associated with only a half-day reduction in duration of cough and no significant differences in overall clinical improvement compared to placebo 2
• Unnecessary medical procedures and healthcare costs due to lack of evidence-based practice, which can be reduced through educational interventions and printed evidence-based practice recommendations 3
• Unnecessary utilization of diagnostics and other services by physicians practicing in outpatient clinics, which can be reduced through quarterly verification of results and feedback 3
• Overuse of parenteral antimicrobials in outpatient settings, which can lead to complications and antimicrobial resistance 4

Examples of Unnecessary Practices

• Administering antibiotics to approximately two thirds of patients with acute bronchitis, despite the marginal effectiveness of antibiotic therapy 2
• Performing unnecessary diagnostic tests and procedures, such as orthopedic tests, which can be reduced by over 30% through evidence-based practice interventions 3
• Using parenteral antimicrobials for infections that can be effectively treated with oral antibiotics, which can lead to increased costs and complications 4

Reducing Unnecessary Practices

• Implementing evidence-based practice interventions, such as printed recommendations and quarterly verification of results, can reduce unnecessary medical procedures and healthcare costs 3
• Using rapid tests and delayed prescribing of antibiotics can reduce the unnecessary utilization of antibiotics for acute bronchitis 2
• Improving patient education and awareness about the risks and benefits of different treatments can help reduce unnecessary practices and improve patient outcomes 3