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Identifying 'low-value' care in pediatric could save millions of dollars: study

by Thomas Dworetzky, Contributing Reporter | January 06, 2022
Low-value pediatric care — services with limited benefit and potentially harmful consequences — are costly and “an important domain of health care waste,” according to a new JAMA Network Open study.

The review looked at the data from more than a million patient encounters at 49 U.S. children's hospitals in 2019 and found that “30 pediatric, hospital-based, low-value care measures” ran up “nearly $17 million in standardized costs,” according to lead author Samantha House, DO, MPH, of Children's Hospital at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and her colleagues.

The study focused on two groups of young patients, an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort.

For the ED, leading low-value services were Group A streptococcal testing in children under age 3 with pharyngitis, computed tomography scanning for minor head injuries, and bronchodilators for bronchiolitis.

In hospitalized patients, leading low-value services included giving broad-spectrum antibiotics for community-acquired pneumonia, acid suppression therapy for infants with esophageal reflux, and blood cultures for uncomplicated community-acquired pneumonia.

"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," House and colleagues noted.

Low-value services that were the most expensive in the ED were found to be almost $1.8 million for computed tomography scan for abdominal pain and about $1.5 million for minor head injuries. Chest radiography for asthma cost nearly $1.1 million.

For hospitalized patients, getting 2 or more concurrent antipsychotics was costliest at about $2.4 million, with chest radiography for bronchiolitis at $800,000 and asthma at $625,000.

"This single-year analysis represents an initial step," advised the researchers.

This is far from the first effort to get a handle on medical waste.

A 2021 RAND Corporation study recorded only a marginal drop between 2014 and 2018 in low-value health care for Medicare patients.

“Because the majority of American medicine operates using a fee-for-service payment model, there is little incentive for physicians and hospitals to deliver less low-value care. Second, there are cultural and patient expectations that 'more care is often better care' that influences physician decision-making, and in a rushed visit it takes less time to order the low-value test than to counsel the patient on why it may not be necessary. Third, there is also an asymmetry of risk/reward,” lead author John Mafi, an adjunct physician policy researcher at RAND and an assistant professor of medicine at the David Geffen School of Medicine at UCLA, told HCB News at the time.

And in February 2020, a study by the Research Consortium for Healthcare Value Assessment, formed by Altarum, reported that commercial payers invested more than $5.5 billion in 20 select low-value healthcare services in 2015.

“Our analysis shows how hard it is to change behavior in a health system or practice,” Beth Beaudin-Seiler, senior analyst at Altarum and lead author of the study, told HCB News. “It requires a focused effort to align attitudes, standard operating procedures, education, and incentives in order to move in the right direction. It also shows that clinical and financial incentives remain misaligned, but to get past this, providers should continue working with payers to negotiate low-risk contracts built upon transparency and better infrastructure and data.”

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