专家视点：过度干预问题

检查、治疗和手术的过度使用正被日益视为影响患者安全的问题。联合委员会和美国医学协会召集的医师绩效改善联合会近期举行峰会，探讨了一些不必要且可能导致伤害的医学干预过度使用的问题及如何减少这类问题的措施。峰会集中讨论的5种常见治疗和手术操作包括经皮冠脉介入治疗(PCI)、输血、鼓膜切开置管治疗鼓膜后积液、抗生素治疗病毒性上呼吸道感染，以及在无医学需求情况下进行早期引产。

抗生素过度使用

常用抗生素并不能改善病毒性上呼吸道感染患者的健康，且可能加剧抗生素耐药问题。在门诊治疗中，来就诊的患者通常希望带药回去服用。对医生而言，开张抗生素的单子比花时间跟患者解释为什么他们不需要使用抗生素来得更容易些。

在住院治疗中，医生可根据先进的培养技术、听取药师建议和进行现场实验室检查来帮助决定抗生素的使用。但过度使用问题仍然存在。医生的诊断应尽可能具体明确且应进行培养。如果某位患者入院症见不适、发热、低血压和脱水，则使用广谱抗生素进行初始治疗可能合适。但如果24~48 h后，培养未见细菌生长，则可能为病毒性感染，此时应停用抗生素。

限制抗生素的使用时间和谱系将有助于在一定程度上克服耐药问题。

抗生素过度使用工作组目前正着手设法对不同的病毒性上呼吸道感染定义和现行指南进行统一规范化。

输血问题源于知识不足

输血工作组表示，输血是对住院患者进行的10种常见侵入性操作之一。输血问题源于知识的匮乏。医学院校的输血课程时间一般仅为2~6小时，时间主要花在讲解血型兼容性和适合输血的临床情况上。

众所周知，输血可能导致并发症，此外，越来越多的证据显示，输血并不能改善经常输血的患者的预后，如非出血性患者和缺乏功能性骨髓的患者。

如果发现患者有问题，医生通常会采取输血措施，而不是采取其他同样有效但风险较低的措施。例如，对于血红蛋白水平极低且完全稳定的患者，许多医院可能会采取输血，但此类患者更可能需要的是补铁。

PCI过度使用率触底

目前，全美PCI的过度使用率已经较低，约为6%~8%，这是因为该领域已有指南、适当使用标准和报告预后的全国数据库。目前要做的是继续倡导医生使用这些标准来指导PCI决策。

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By: MARY ELLEN SCHNEIDER, Cardiology News Digital Network

The overuse of tests, treatments, and procedures is getting increased attention as a patient safety issue.

The Joint Commission, along with the American Medical Association–convened Physician Consortium for Performance Improvement, recently held a summit to look at how to cut back on the overuse of certain medical interventions being performed even though they are not medically necessary and could cause harm.

The summit was centered on five common treatments and procedures:

• Percutaneous coronary intervention (PCI).

• Blood transfusions.

• Tympanostomy tubes for brief periods of fluid behind the eardrum.

• Antibiotics to treat viral upper respiratory infections.

• Early induction of labor without medical need.

"We have come to believe in American medicine that everything we do is beneficial," said Dr. Donna E. Sweet, an internist and professor of medicine at the University of Kansas, Wichita, who headed up the work group looking at antibiotic overuse for upper respiratory tract viral infections. "There’s always a downside."

Antibiotic Overuse

In the case of viral upper respiratory infections, commonly prescribed antibiotics do nothing to improve patients’ health and risk worsening the population-wide problem of antibiotic resistance. In the outpatient setting, the stumbling block is often that when patients come into the office, they expect to leave with a prescription. For physicians, it’s easier to write an antibiotic prescription than to explain why they don’t need it, Dr. Sweet said.

"American patients aren’t very patient," she said. "They want to be better now."

In the hospital, physicians have more tools at their disposal for managing the use of antibiotics, from good culture techniques, to advice from pharmacists, to an on-site laboratory. But overuse still happens. Hospitalists should try to make a specific diagnosis when they can and do a culture, Dr. Sweet said. If a patient comes into the hospital sick, febrile, hypotensive, and dehydrated, it’s probably appropriate to start them on a broad-spectrum antibiotic. But if after 24-48 hours, there’s nothing growing in the culture, it’s probably a viral infection and the antibiotics should be cut off, she said.

"Restricting both the length and then the spectrum of the antibiotic are the two things that we know will make a difference in trying to combat some of this antibiotic resistance," she said.

The antibiotic overuse work group is looking at ways to align the various definitions of a viral upper respiratory infection and the existing guidelines, Dr. Sweet said.

Transfusion Driven by Lack of Info

When it comes to blood transfusion, another work group will be considering ways to increase the amount of time spent on this topic in medical school.

"We know that there is a lack of knowledge," said Dr. Aryeh Shander, chief of the department of anesthesiology and critical care medicine at Englewood Hospital and Medical Center in New Jersey, who headed up the transfusion work group.

Medical schools devote only about 2-6 hours to the subject of blood transfusion, and most of that time is spent on blood type compatibility, not only the clinical situations in which blood transfusion is appropriate, said Dr. Shander, who is also the president of the Society for the Advancement of Blood Management, a group that advocates for reducing the number of blood transfusions.

"This is one of the 10 most common invasive procedures done in hospitalized patients," Dr. Shander said. "I don’t think you would want a cardiac surgeon doing heart surgery on you with 6 hours of education."

While it is well known that blood transfusions run the risk of complications, there is also a growing body of literature showing that transfusions don’t improve outcomes in patients who are regularly transfused, such as nonhemorrhaging patients and those who don’t have a functioning bone marrow, Dr. Shander said.