When it comes to health care, more isn’t always better – especially for kids. Although advancements in pediatric care, including vaccines, antibiotics and sophisticated imaging studies (x-ray, ultrasound, CT and MRI), have led to substantial improvements in child health, more recently there have been calls to reduce medical interventions that are ineffective, overused or not cost-effective.
When pediatrician Elizabeth Wolf, MD, isn’t caring for kids and families in our primary care clinic, she is researching new and better ways to care for children. She recently authored an article in JAMA Pediatrics that addresses concerns about negative health impacts from common, and often unnecessary, medical interventions. She and her co-authors propose curbing the amount of low-value care provided to children – a practice called deimplementation.
What is low-value care?
Low-value care is care that is of no net benefit to the patient and may even result in harm. Consider a test that is conducted on a child that results in a false positive (the results indicate that the child has the condition that was tested for, when they actually do not). This can not only be needlessly worrisome to the family, but may also lead to further invasive testing and unnecessary treatment.
“Children may be particularly vulnerable to some of the harms of low-value care, including radiation from unnecessary radiologic studies and alterations in the microbiome – the good bacteria that lives in and on the human body and provides important functions – from overuse of antibiotics,” said Dr. Wolf. “It’s important to stop providing low-value care so fewer patients are harmed and health care costs are reduced.”
The financial costs of overuse are estimated to be in the hundreds of billions of dollars, contributing to rising out-of-pocket costs for families.
Do the benefits outweigh the risks?
This question is at the heart of the matter. Choosing Wisely works with specialty societies such as the American Academy of Pediatrics to determine which interventions are beneficial, and which are potentially harmful. The bottom line is: if the benefits do not outweigh the risks, the practice should be stopped.
There are also opportunity costs to consider, which are particularly noticeable in primary care visits that tend to be fairly short in duration. If an unnecessary test is done, it can take time and resources away from something else that may be more valuable for that patient’s health. Providers must weigh the pros and cons of all diagnostic and treatment approaches.
There are many factors that may lead to low-value care, including clinicians wanting a definitive diagnosis, parents requesting additional testing/medications (often as a result of advertising) and clinical habits that have been established over time.
At CHoR we focus on only providing tests, medications and other treatments that are necessary and beneficial for children. For example, if a child presents with a cold, we don’t want to give them antibiotics since we know antibiotics don’t work against viral infections and antibiotics can have negative side effects. Medications are not always required for a child to get healthy and feel better.
What does the future hold?
There has been significant progress in the identification of low-value services, but overuse continues. Dr. Wolf is working closely with Matthew Schefft, DO, hospital medicine physician at CHoR, and Alan Schroeder, MD, associate chief for research in the division of pediatric hospital medicine at Lucile Packard Children’s Hospital Stanford to develop new ways to safely reduce low-value care provided to kids.
“We will need to continually reevaluate which practices need to be deimplemented as disease prevalence changes, new evidence emerges, new technology is developed and cultural values shift,” added Wolf.
){kind=link}
){kind=link}
){kind=link}