Use of low-value pediatric services in the Military Health System

Abstract

Background: Low-value care (LVC) is understudied in pediatric populations and in the Military Health System (MHS). This cross-sectional study applies previously developed measures of pediatric LVC diagnostic tests, procedures, and treatments to children receiving care within the direct and purchased care environments of the MHS. Methods: We queried the MHS Data Repository (MDR) to identify children (n = 1,111,534) who received one or more of 20 previously described types of LVC in fiscal year 2015. We calculated the proportion of eligible children and all children who received the service at least once during fiscal year 2015. Among children eligible for each measure, we used logistic regressions to calculate the adjusted odds ratios (AOR) for receiving LVC at least once during fiscal year 2015 in direct versus purchased care. Results: All 20 measures of pediatric LVC were found in the MDR. Of the 1,111,534 eligible children identified, 15.41% received at least one LVC service, and the two most common procedures were cough and cold medications in children under 6 years and acid blockers for infants with uncomplicated gastroesophageal reflux. Eighteen of the 20 measures of pediatric LVC were eligible for comparison across care environments: 6 were significantly more likely to be delivered in direct care and 10 were significantly more likely to be delivered in purchased care. The greatest differences between direct and purchased care were seen in respiratory syncytial virus testing in children with bronchiolitis (AOR = 21.01, 95% CI = 12.23-36.10) and blood tests in children with simple febrile seizure (AOR = 24.44, 95% CI = 5.49-108.82). A notably greater difference of inappropriate antibiotic prescribing was seen in purchased versus direct care. Conclusions: Significant differences existed between provision of LVC services in direct and purchased care, unlike previous studies showing little difference between publicly and privately insured children. In fiscal year 2015, 1 in 7 children received one of 20 types of LVC. These proportions are higher than prior estimates from privately and publicly insured children, suggesting the particular need to focus on decreasing wasteful care in the MHS. Collectively, these studies demonstrate the high prevalence of LVC in children and the necessity of reducing potentially harmful care in this vulnerable population.

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

“…11 Modestly higher rates of low-value service delivery were identified among publicly insured and military-insured children. 12,33 Reyes et al, 14,15 Bronchiolitis, CAP, and asthma measures had a relatively high prevalence of low-value care among both cohorts. These are among the most common and costly conditions treated in the pediatric hospital setting 34 and are popular targets for quality improvement initiatives, yet low-value care persists.…”

“… 11 Modestly higher rates of low-value service delivery were identified among publicly insured and military-insured children. 12 , 33 Reyes et al, 14 , 15 using the PHIS database, created a report card to measure performance on the original measures included in the pediatric Choosing Wisely Campaign by the Society of Hospital Medicine among hospitalized patients and found that low-value care delivery ranged from 12% to 49% across these measures. Our work incorporates a broad set of hospital-based, pediatric, low-value care measures into a tool capable of sustaining these measurement efforts.…”

“…An analysis of care delivered in 2014 found that at least 10% of commercially insured children received 1 or more of these services, accounting for $27 million in spending; 34% of this total was paid out of pocket . Modestly higher rates of low-value service delivery were identified among publicly insured and military-insured children . Reyes et al, using the PHIS database, created a report card to measure performance on the original measures included in the pediatric Choosing Wisely Campaign by the Society of Hospital Medicine among hospitalized patients and found that low-value care delivery ranged from 12% to 49% across these measures.…”

Low-value care: an evolutionary concept analysis

“…Fee-for-service payment system: many authors have observed that payment structures emphasizing volume over value, such as the fee-for-service (FFS) payment system, are linked to the provision of low-value care 6,14,16,17,36,39,40,46,47,57,59,[61][62][63][64][65] . The FFS payment system offers a perverse incentive that drives health care providers to provide low-value care 66 .…”