Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children’s Hospitals

House, Samantha A.; Hall, Matthew; Ralston, Shawn L.; Marín, Jennifer R.; Coon, Eric R.; Schroeder, Alan R.; Souza, Heidi Gruhler De; Davidson, Amber; Duda, Patti J.; Ho, Timmy; Genies, Marquita; Mestre, Marcos; Reyes, Mario A

doi:10.1001/jamanetworkopen.2021.35184

Cited by 22 publications

(12 citation statements)

References 38 publications

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“…on the prevalence and costs of low-value care in 49 American pediatric hospitals, the authors found these services were costly, but prevalence varied widely (from 1% to 60%) across measured services. Measures on bronchiolitis, community-acquired pneumonia, and asthma that have been targeted for quality improvement initiatives such as CW recommendations, have resulted in the most common and expensive overtreated conditions ( 42 ).…”

Section: Discussionmentioning

confidence: 99%

Choosing Wisely in pediatric healthcare: A narrative review

2023

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BackgroundIt has been estimated that 20% of the tests and therapies currently prescribed in North America are likely unnecessary, add no value, and may even cause harm. The Choosing Wisely (CW) campaign was launched in 2012 in the US and Canada to limit the overuse of medical procedures in adult and pediatric healthcare, to avoid overdiagnosis and overtreatment.MethodsIn this narrative review, we describe the birth and spread of the CW campaign all over the world, with emphasis on CW in pediatric healthcare.ResultsTo date, CW has spread to more than 25 countries and 80 organizations, with 700 recommendations published. The awareness of medication overuse also made its way into pediatrics. One year after the launch of the CW campaign, the American Academy of Pediatrics and the pediatric section of the Society of Hospital Medicine provided the first recommendations specifically aimed at pediatricians. Thereafter, many European pediatric societies also became active in the CW campaign and published specific top-5 recommendations, although there is not yet a common set of CW recommendations in Europe.DiscussionWe reviewed the main pediatric CW recommendations in medical and surgical fields and discussed how the recommendations have been produced, published, and disseminated. We also analyzed whether and how the CW recommendations impacted pediatric medical practice. Furthermore, we highlighted the common obstacles in applying CW recommendations, such as pressure from patients and families, diagnostic uncertainty, and worries about legal problems. Finally, we highlighted the necessity to foster the CW culture, develop an implementation plan, and measure the results in terms of overuse decline.

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Section: Discussionmentioning

confidence: 99%

Choosing Wisely in pediatric healthcare: A narrative review

2023

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“…Numerous studies, including several recent Pediatric Health Information System database studies, reveal high blood culture collection rates among these three diagnoses, with significant variability noted across hospitals. 8,20–22 Data at our institution suggested similarly high collection rates and highlighted the need for local quality improvement (QI) efforts.…”

Section: Introductionmentioning

confidence: 81%

“…In a nontoxic child with uncomplicated CAP, multiple studies have shown that routine blood cultures are unnecessary given the very low likelihood that a blood culture will be positive or result in a change in management. [4][5][6][7][8] The low utility is partly driven by increased immunization against Haemophilus influenzae type b and Streptococcus pneumoniae, dramatically decreasing bacteremia rates. 9,10 Among SSTI, despite the increasing prevalence of methicillin-resistant Staphylococcus aureus, evidence discourages routine collection of blood cultures in immunocompetent children.…”

Section: Introductionmentioning

confidence: 99%

Decreasing Blood Culture Collection in Hospitalized Patients with CAP, SSTI, and UTI

Combs,

Liberman,

Lee

2023

Pediatric Quality &Amp; Safety

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Background: Blood culture collection in pediatric patients with community-acquired pneumonia (CAP), skin and soft tissue infections (SSTI), and urinary tract infections (UTI) remains high despite evidence of its limited utility. We aimed to decrease the number of cultures collected in children hospitalized for CAP, SSTI, and UTI by 25% over 11 months. Methods: Quality improvement initiative at a children’s hospital among well-appearing patients aged 2 months or more to 18 years diagnosed with CAP, SSTI, or UTI. Our primary and secondary outcomes were blood culture collection rate and positivity rate, respectively. Interventions focused on three key drivers: academic detailing, physician awareness of personal performance, and data transparency. Results: Over the 2-year study period, there were 105 blood cultures collected in 223 hospitalized patients. Blood culture collection rates demonstrated special cause variation, decreasing from 63.5% to 24.5%. For patients with UTI, 86% (18/21) of blood cultures were negative, whereas 100% were negative for CAP and SSTI. All three patients with bacteremic UTI had a concurrent urine culture growing the same pathogen. Balancing measures remained unchanged, including escalation to a higher level of care and return to the emergency department or hospital within 14 days for the same infection. Conclusions: A multifaceted quality improvement approach can reduce blood culture collection for hospitalized patients with CAP, SSTI, and UTI without significant changes to balancing measures. Despite the reduction achieved, the near-universal negative culture results suggest continued overutilization and highlight the need for more targeted approaches to blood culture collection.

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“…28 They identified low-value care for several conditions totaling approximately $17 million in standardized cost. 28 Obtaining blood cultures in uncomplicated CAP and bronchiolitis were identified as low-value care in both patients evaluated in the ED and hospitalized children, costing a combined total of $232,006 and $556,050, respectively. 28 Prospective application of the study criteria to guide blood culture decisions would reduce low-value care and waste and thus improve the care provided to children.…”

Section: Discussionmentioning

confidence: 99%

Evaluating the Proportion of Low-Value Blood Cultures Obtained in a Pediatric Emergency Department

Graham,

Ahmad,

Bram

et al. 2023

Pediatr Emer Care

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Background Existing literature suggests that for some pediatric conditions, blood cultures may be of low value in specific clinical circumstances. The goals of our study were to: 1) identify common pediatric illnesses and define criteria for low-value blood cultures in children aged from 91 days to 19 years, 2) apply these criteria retrospectively to identify the patients in our emergency department (ED) who had low-value blood cultures obtained, and 3) describe this cohort and assess the proportion of true bacteremia in low-value blood cultures. Method The study team reviewed the literature and developed consensus criteria to identify conditions in which blood cultures were of low value for our study population. The criteria were applied retrospectively to well-appearing patients aged from 91 days to 19 years, without a central venous catheter, and evaluated in our ED with a peripheral blood culture from June 2018 to April 2020. Children admitted to the intensive care/hematology-oncology/cardiology/pulmonary units, those transferred from our ED to an outside facility, who transferred to our ED due to a positive blood culture from an outside facility, and repeat visits of a patient within 30 days from a previous visit were excluded from the study. After chart review, children with fever for 7 days or more, who were unvaccinated, immunosuppressed, had implanted devices, had a complex medical history, or had provider concerns for bacteremia/sepsis were excluded. Results The study population consisted of 1436 children. Children at risk for bacteremia (n = 718) were excluded. Four hundred twenty-four children had discharge diagnoses not included in our study. There were 294 (20.5%) patients who had low-value cultures per our study criteria. Nine children (9/294, 3.1%) had false-positive blood cultures, and three (3/294, 1.0%) had true-positive blood cultures. Conclusions We identified a cohort of patients in our ED with blood cultures obtained when available literature indicates they were of low value.

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Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children’s Hospitals

Cited by 22 publications

References 38 publications

Choosing Wisely in pediatric healthcare: A narrative review

Choosing Wisely in pediatric healthcare: A narrative review

Decreasing Blood Culture Collection in Hospitalized Patients with CAP, SSTI, and UTI

Evaluating the Proportion of Low-Value Blood Cultures Obtained in a Pediatric Emergency Department

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