Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value

Abstract

OBJECTIVES The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children. METHODS A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations. RESULTS Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis. CONCLUSIONS We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.

Choosing Wisely in pediatric healthcare: A narrative review

“…Finally, in 2021, Tchou et al provided a timely and extensive update to the 2013 CW list for pediatric hospital medicine: they produced and published the last 5 highest-scoring American pediatric recommendations, using a structured approach, with a focus on specific aspects of hospital care such as the length of intravenous antibiotic therapy, the length of stay for febrile infants evaluated for severe bacterial infection, the threshold of phototherapy for neonatal hyperbilirubinemia, the use of narrow-spectrum antibiotic therapy for community-acquired pneumonia, and the appropriateness of intravenous antibiotics in infants with maternal risk factors for sepsis ( Supplementary Table S2 ) ( 13 ).…”

Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review

“…Barriers to the identification of low-value care were discussed in four records,15 19 42 57 enablers in three records10 42 45 and other contextual factors in two records 15 41. Some contextual factors aligned with the four factors driving overuse that were used for the framework synthesis 19.…”

“…A diverse range of clinical settings were targeted, spanning specific wards or services through to whole of hospital, health system and global approaches. Three of 27 studies targeted paediatric hospitals or health services specifically 40–42. The entire continuum of care (primary care to specialist care or healthcare system) was covered by six records 19 43–47.…”

Do Unpaid Children’s Hospital Account Balances Correlate with Family Income or Insurance Type?

“…41 Prior studies also examined interhospital variation in disease prevalence and costs, emphasizing the need for standardization of high-value, quality care across children's hospitals through evidence-based quality improvement initiatives. [42][43][44][45] Measures taken to mitigate high costs at children's hospitals include more conscientious utilization of low-value services, with decrease in duration of intravenous antibiotic therapy, reduction in laboratory tests, and use of X-rays. 27,44,46 Additionally, with increased use of telemedicine in the setting of the COVID-19 pandemic, a single institution study demonstrated that surgical specialty telehealth visits are associated with lower hospital charges compared with in-person encounters, though reimbursements were not significantly different.…”

“…[42][43][44][45] Measures taken to mitigate high costs at children's hospitals include more conscientious utilization of low-value services, with decrease in duration of intravenous antibiotic therapy, reduction in laboratory tests, and use of X-rays. 27,44,46 Additionally, with increased use of telemedicine in the setting of the COVID-19 pandemic, a single institution study demonstrated that surgical specialty telehealth visits are associated with lower hospital charges compared with in-person encounters, though reimbursements were not significantly different. 47 The introduction of evidence-based clinical care and/or enhanced recovery after surgery protocols for common surgical procedures such as cleft palate repair, appendicitis, and blunt abdominal trauma have also effectively decreased length of stay and costs.…”