Pediatric Services With Limited Benefits Cost Millions

Low-value pediatric care was found to be widespread and expensive in a cross-sectional analysis of over 1 million patients encounters at 49 U.S. children’s hospitals.

In 2019, nearly $17 million was spent on 30 measured low-value pediatric services, reported Samantha House, DO, MPH, of Children’s Hospital at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues in JAMA Network Open.

In an emergency department (ED) cohort, they found low-value care was most prevalent in encounters for Group A streptococcal testing in children younger than 3 years with pharyngitis (37.6%), CT scan for minor head injury (17.7%), and bronchodilators for treatment of bronchiolitis (16.0%).

“With low rates of pathogenic streptococcal pharyngitis and very low risk of complications, such as acute rheumatic fever, in this population, this practice places children at risk for unnecessary antibiotics and associated adverse effects,” the study authors noted. The incidence of rheumatic fever in the U.S. is unknown, but dropped dramatically in the last century, according to the CDC.

In a hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics for community-acquired pneumonia (CAP; 60.2%), acid suppression therapy for infants with esophageal reflux (50.8%), and blood cultures for uncomplicated CAP (39.1%).

The 2021 Pediatric Hospital Medicine Choosing Wisely recommendations warned against using broad-spectrum antibiotics for CAP. Yet, the rate of use measured in this study was only slightly lower than that in 2012, House and team pointed out.

“These are among the most common and costly conditions treated in the pediatric hospital setting and are popular targets for quality improvement initiatives, yet low-value care persists,” they wrote.

“Low-value care, or delivery of health services offering limited benefit as compared with harm, is an important domain of health care waste,” they added. Low-value care can result in adverse medication and procedural effects, as well as negative psychosocial and financial impacts, they noted.

In the hospitalized cohort, the costliest service was the receipt of two or more concurrent antipsychotics, totaling $2.4 million.

“Evidence for the effectiveness of this practice has not been established, and the potential for harm related to adverse effects and drug-drug interactions is high,” House and colleagues wrote. “Efforts should be made to explore whether additional hospital-based behavioral health resources may decrease this practice.”

The most expensive services in the ED cohort included CT scan for abdominal pain, at about $1.8 million; CT scan for minor head injury, at approximately $1.5 million; and chest radiography for asthma, at about $1.1 million.

Overall, the prevalence of low-value care was lower in EDs compared with other medical departments, according to the study authors.

This cross-sectional study included 1,011,950 encounters reported in 49 U.S. children’s hospitals in 2019 from the Pediatric Health Information System (PHIS) database, which covers approximately 20% of all annual pediatric hospitalizations and 12% of ED visits.

House and team developed a low-value care calculator using measures from five sources, including the Pediatric Choosing Wisely recommendations and previous studies on low-value pediatric care. In total, 30 measures of low-value care were analyzed among 816,098 unique patients (median age 3 years).

Two measures of low-value care were also analyzed for infants in the neonatal intensive care unit: the use of anti-reflux medication for the treatment of symptomatic gastroesophageal reflux disease and the use of vancomycin or carbapenem with no known risk of resistant pathogens. Both were associated with low numbers of low-value care encounters (32 and 639, respectively).

The authors acknowledged that their analysis relied on diagnostic codes from discharge, which cannot account for over- or underdiagnosis. They also noted that their chosen low-value care measures were not representative of all hospital-based low-value care, and that their data were not representative of all pediatric hospital-based care in the U.S.

“This single-year analysis represents an initial step,” they wrote. “Several future steps may enhance understanding of low-value care patterns in U.S. children’s hospitals. Continued application of this tool will aid in establishing and monitoring temporal low-value care trends and identifying services in need of ongoing deimplementation efforts.”