Addressing Low-Value Care: Training the Spotlight on Children!

The study “Differences in Receipt of Low-Value Services Between Publicly and Privately Insured Children” in this issue of Pediatrics provides valuable new information on the topic of low-value care in pediatrics with actionable information for policy makers and improvement efforts.¹ Low-value care is costly to the health care system and to individuals and their families, with estimated annual costs of $75 to $101 billion.² Beyond the unnecessary financial costs to the system, low-value care can cause harm and as such is an important dimension of patient safety. In the past 5 years, several initiatives have actively addressed low-value care, the most notable of which is the Choosing Wisely campaign, launched by the American Board of Internal Medicine Foundation in 2012.³ This campaign has national and international influence in encouraging medical specialties to identify and combat low-value services. Since 2012, >70 medical specialty societies have published >550 recommendations about overused tests and treatments that clinicians and patients should avoid. The American Academy of Pediatrics published their list of 10 low-value services in 2013.⁴

The key lesson of the study by Chua et al,¹ that the delivery of low-value care is common and present in approximately equal measure among both publicly and privately insured children, clearly reveals the need for improvement strategies across the health care system. Another noteworthy finding is that delivery of low-value care was more prevalent in certain states. This points to the need to target improvement efforts within certain states or geographic areas. The finding that the rate of low-value care among publicly insured children ranged from 7.4% to 26.6% among the 12 states begs the question about what health system, cultural, or other factors are driving high rates of low-value care. Importantly, the article not only reveals where improvement efforts are most needed but also for what: low-value medication prescribing was the most commonly overused service in both public and private sectors and in all states studied. Leading the list of inappropriate prescriptions was antibiotics. Across all outpatient settings, there were >60 million unnecessary antibiotic prescriptions in 2014 despite years of attention devoted to reducing this problem.⁵

Given the lack of difference in low-value care among publicly and privately insured children, improvement efforts would benefit by involving many stakeholders and are an ideal target for regional health improvement collaboratives (RHICs). The key differences between RHICs and other health care organizations is that the RHICs are governed by individuals and organizations from the 4 key health care stakeholder groups (payers, purchasers, providers, and consumer and/or patient organizations) and address quality and cost issues across a broad range of patients and providers. More than 30 RHICs in different states have successfully implemented a range of improvement efforts, but few of them have focused on child health care delivery.⁶ Another strategy to reduce low-value care given the wide variation across states is for Medicaid programs to address this through their managed care contracts. When Congress provided Medicaid new flexibilities to expand managed care, it also added provisions to ensure that states are held accountable for the services they have agreed to provide to enrollees, including the development and implementation of a managed care quality assessment and improvement strategy.⁷ There is an active network of Medicaid medical directors, with participation from >40 states, that previously addressed topics such as early elective deliveries and rehospitalizations and continues to collaborate and share lessons learned in implementing improvement strategies.^8,9

As Chua et al1 note, multicomponent strategies, such as combining decision support with provider or patient education, appear to be the most effective at reducing low-value care. Unfortunately, few of the studies of this type of approach specifically target child health care delivery.¹⁰ Authors of a recent report found that research on low-value care, including studies to identify, understand, and/or reduce low-value care, has increased in volume over the last 5 years according to HSRProj (https://hsrproject.nlm.nih.gov/), a database of >36 000 archived, recently completed and ongoing health services research projects funded by >370 agencies. Of the 191 extramurally funded studies cataloged in HSRProj from 2014 to 2019, only 11 were focused on children and adolescents.¹¹ It is time for the child health services research community and its funders to focus on low-value care, not only identifying instances and drivers, but also developing and testing effective interventions that can be scaled across populations.

This timely article by Chua et al¹ reminds us that children are not immune from receiving low-value, wasteful, and even potentially harmful care. Now is the time for action. Much is known about reducing low-value care for adults; the spotlight now must be trained on children.

• Copyright © 2020 by the American Academy of Pediatrics