Reducing unnecessary phototherapy for jaundice in newborns

Up to 4 in 5 newborns will develop jaundice from the accumulation of unconjugated bilirubin during the first week of life. Most of the time, neonatal hyperbilirubinemia is benign and does not require intervention. To prevent the rare outcomes of acute bilirubin encephalopathy (1 in 10,000 infants) and kernicterus (1 in 100,000 infants), the American Academy of Pediatrics (AAP) recommends universal screening of newborns 35 weeks' gestational age or greater using total serum bilirubin and transcutaneous bilirubin at 24 to 48 hours of life or before hospital discharge if occurring sooner.

Online tools such as the BiliTool allow clinicians to quickly compare measured bilirubin levels with the AAP’s hour- and gestational age-specific thresholds for phototherapy (these are slightly lower in infants with neurotoxicity risk factors). Phototherapy converts unconjugated bilirubin to lumirubin, a structural isomer that is directly excreted via urine or stool. In its 2022 guideline, the AAP increased previous phototherapy thresholds based on updated evidence regarding the risk of neurotoxicity. An FPIN (Family Physicians Inquiries Network) Clinical Inquiry found that rebound elevation of bilirubin levels after phototherapy discontinuation is uncommon (less than 2% of infants with levels less than 14 mg per dL at initial discontinuation). In infants without known hemolytic disease or other significant risk factors, repeating a bilirubin level after phototherapy discontinuation is not recommended.

Reducing unnecessary treatment of jaundiced neonates with safe bilirubin levels, or subthreshold phototherapy, was previously identified by pediatric hospitalists as a Choosing Wisely campaign goal. Subthreshold phototherapy is common and may have increased after the 2022 AAP guideline.

A recent report in Pediatrics described the Learning and Implementing Guidelines for Hyperbilirubinemia Treatment (LIGHT) Collaborative, a national quality improvement collaborative involving 146 hospitals that aimed to reduce subthreshold phototherapy use to 10% of all phototherapy encounters over a 12-month period. Baseline data was collected from February 2022 to January 2023. Hospitals implemented a combination of quality improvement coaching, educational webinars, electronic health record order sets and documentation templates, clinical algorithms, and communication aids from February 2023 to January 2024. Individual sites were encouraged to use Plan-Do-Study-Act (PDSA) cycles to identify and address barriers to reducing subthreshold phototherapy.

The final analysis included more than 33,000 patient encounters. Subthreshold phototherapy decreased from a median of 48.2% of encounters prior to August 2022 (when the updated AAP guideline was published) to 41.1% during the last 6 months of the intervention, well short of the goal of 10%. A secondary outcome, the median deviation from the phototherapy threshold in subthreshold phototherapy encounters, decreased from 1.57 mg/dL (26.85 μmol/L) to 1.13 mg/dL (19.33 μmol/L). (Of note, the guideline offers the option to consider phototherapy for selected patients when the total serum bilirubin level is within 1.9 mg/dL [32.50 μmol/L] below the phototherapy threshold.) There were no significant changes in hospital length of stay, phototherapy duration, or readmissions for rebound elevation of bilirubin levels.

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This post first appeared on the AFP Community Blog.

Advocacy groups killed the Canadian Task Force. Is the USPSTF next?

If the "third rail" of the U.S. health care system is Medicare, the third rail of preventive medicine is screening mammography. History has shown that North American evidence-based medicine panels are imperiled when they suggest that breast cancer screening can be optional for women younger than 50, even if that happens to be the norm for the rest of the world.

In November 2009, advocacy groups came close to fatally wounding the U.S. Preventive Services Task Force (USPSTF) after it downgraded screening mammography in average-risk women aged 40 to 49 from a "B" (do routinely) to a "C" (do selectively with shared decision-making) grade. Armed with advocacy talking points, politicians from both parties subjected the USPSTF to withering attacks, and Republicans darkly predicted that the health reform legislation then under consideration in Congress (which eventually became the Affordable Care Act of 2010) would lead to widespread rationing of all kinds of health care. Then-Secretary of Health and Human Services Kathleen Sebelius publicly disavowed the recommendations and tried to blame the previous administration for having appointed the members who voted for the changes. Public affairs personnel at the Agency for Healthcare Research and Quality (AHRQ), where I worked, were prevented from assisting USPSTF members with media appearances explaining the recommendations.

The USPSTF eventually recovered and even thrived from 2010 to 2025, becoming more influential and for the most part, managing to keep politics at bay. However, it is facing a different sort of existential crisis under the second Trump administration, not being allowed to meet for the past 16 months and having its support team at AHRQ eviscerated to the point where it's not clear how the panel would function even if HHS Secretary RFK Jr. eventually appoints new members to replace the ones he fired.

Meanwhile, the Canadian Task Force on Preventive Health Care, the original model for the USPSTF, was disbanded earlier this year, a victim of a similar breast cancer screening recommendation that the federal health minister never allowed to be finalized. As Dr. Guylene Theriault, the former chair of the Canadian Task Force, recently wrote in BMJ Evidence-Based Medicine:

The evidence-based guidance conflicted with certain lobbyists' arguments and elected officials' beliefs in the unambiguous positive outcomes of screening. Ultimately, these arguments and perceptions prevailed over rigorous scientific evidence, making it more difficult for a woman to access clear, unbiased information on which to base her decisions. Perhaps naively, the Task Force members and I thought that placing the patient at the center of the decision-making process would be something everyone could agree on. We were wrong.

A recent study in the American Journal of Preventive Medicine documented worrisome trends in primary care associated with the sidelining of the USPSTF and the remaking of the Advisory Committee on Immunization Practices:

Clinicians report that patients are increasingly hesitant about vaccines and preventive services. For example: 64% report patients are confused as to what vaccination guidelines they should follow; 46% report parents are expressing new hesitancy about childhood vaccinations; 36% report patients are declining preventive services they previously accepted. Most responding clinicians (58%) report spending more visit time explaining the evidence behind clinical recommendations, and 61% report patients more frequently are seeking information from non-medical sources.

As the Canadian Task Force is being reconstituted as the National Advisory Committee on Preventive Health Services, the USPSTF may also rise again - but will the next iteration have the necessary resources (in dollars and staff) and editorial independence to write trustworthy recommendations that place patients, rather than politics, at the center? The stakes for patients and public health could not be higher.

Deprescribing statins

If you found out that a medication you had been taking for years was much less effective than previously advertised, would you keep taking it?

An estimated 20 to 30 percent of Americans over the age of 45 takes a statin for high cholesterol, a history of heart attack or stroke, or to prevent a cardiovascular event. Once a patient starts a statin, provided that they don't experience side effects, they usually continue taking it for life. The medication lists of nursing home residents almost invariably include statins. Statin prescribing has been overwhelmingly positive for population health; a recent study credited them with closing the gap in cardiovascular risk factors between middle-aged adults with obesity and those with normal weight. Ultimately, though, an individual reaches a point where a statin is likely to cause more harm than benefit, even if the harm is having to take one extra medication that costs as little as 30 cents per day.

An expert panel at Deprescribing.org, which previously published evidence-based guidelines on discontinuing proton pump inhibitors, antihyperglycemics, and antipsychotics, among others, recently added statins to its deprescribing guidelines. A synopsis of the guideline is available as an algorithm on their website. In adults over age 65, several factors may prompt a conversation about discontinuing statins: frailty, pill burden, functional limitations, cognitive impairment, complex care needs, and advanced illness (e.g., cancer). A person with a terminal illness who isn't expected to live for more than a year is an ideal candidate for stopping a statin, but some patients with longer life expectancies may reasonably decide to discontinue them based on their personal goals and the value they assign to preventing future cardiovascular events.

None of this should be particularly controversial, but I would have gone farther if I had been on the guideline committee. The replacement of the Pooled Cohort Equations with the PREVENT calculator has resulted in many adults now having a significantly lower estimated risk of cardiovascular events. That should have prompted a reconsideration of statin use for patients whose new risk estimate fell under the threshold for statin initiation. Instead, as I discussed in a Medscape commentary, the American College of Cardiology / American Heart Association simply moved the goalposts, recommending statin initiation (and continuation) at lower thresholds:

Although these changes make it unnecessary to have potentially awkward conversations with patients about why they may no longer need medications that they’ve been taking for years, moving the goalposts is not warranted by primary prevention RCTs, which generally enrolled persons with 10% or greater 10-year risk. Even if one assumes that the relative benefits are the same, patients deserve to be informed about their lower risk estimates so that they can weigh the higher numbers needed to treat before deciding if starting or continuing statin therapy is worthwhile.

I went on to make a deprescribing recommendation that I expect many cardiologists and primary care physicians will disagree with:

Patients at lower risk [based on the PREVENT calculator], particularly less than 5%, should be offered the option of discontinuing statins, keeping in mind the “risk enhancers” listed in the ACC/AHA guideline, which may suggest that the calculated value underestimates their true risk.

Statins haven't become less effective in relative terms, but changes in risk estimates mean that the absolute risk reductions in cardiovascular events and deaths that patients can expect from these drugs are smaller than they were before. And that means that in some cases, deprescribing statins may be a clinically appropriate action.