What is low value care?
Low value care is care that provides little or no benefit, may cause patient harm, or yields marginal benefits at a disproportionately high cost.
This problem of low value, or unnecessary, care is gaining wide recognition through professionally led initiatives such as the international Choosing Wisely movement and the UK NICE “do not do” guidelines. These initiatives strive to achieve clinician consensus on what constitutes low value care with the hope
that identifying low value care practices will catalyse efforts to reduce such care.
In Australia, the Royal Australasian College of Physicians’
EVOLVE initiative
has identified a top five list of ‘do not do’ treatments in child health. These are, do not routinely…
- Prescribe oral antibiotics in fever without an identified specific bacterial infection
- Undertake a chest x-ray for the diagnosis of bronchiolitis or routinely prescribe salbutamol or systemic corticosteroids to treat bronchiolitis
- Treat gastroesophageal reflux disease (GORD) in infants with acid suppression therapy
- Order a chest x-ray for the diagnosis of asthma
- Order an abdominal x-ray for the diagnosis of non-specific abdominal pain.
However, we do not know what proportion of care provided to children in Australia is low value. Determining to what extent such care exists, where it is occurring (i.e. in primary or secondary care, in the public or private system, in emergency department
(ED) or inpatient care etc.), and how to reduce it is crucial to a sustainable healthcare system.
Current projects
The RCH HSRU is
supporting the work of the Choosing Wisely team at RCH to reduce low value care in the hospital setting.
Completed projects
REducing MEDications in Infants (REMEDI)
The REMEDI project co-designed, implemented and evaluated a targeted behaviour change intervention to reduce unnecessary prescribing of infant reflux medications across four hospitals in Victoria. Overall we found a decrease in the number of infants
prescribed reflux medication and an increase in clinician knowledge of potential harms caused by reflux medications.
You can find out more about the
REMEDI project, infant reflux and access our resources for parents and clinicians.
What works to reduce unnecessary imaging
and pathology testing in children?
This systematic review examined how best to reduce clinician ordering of unnecessary imaging and pathology tests in children. We will use this information to identify effective interventions to reduce unnecessary care at the RCH and hence reduce waste in
hospital funds. Based on preliminary findings, an effective intervention will likely include a combination of staff education, audit & feedback on low value care at the doctor level, and changes to systems or processes.
Do not routinely treat GORD in infants
with acid suppression therapy
Two projects measured the extent of unnecessary prescribing of anti-reflux medications and associated factors. The first project is measured unnecessary prescribing across RCH inpatient, outpatient, and ED settings. The second project measured this across community (GPs, paediatricians)
care in Australia, using Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data. This project also examined costs to the Australian healthcare system associated with unnecessary use of these medications in infants.
Reference
- Reiss S, Lei S, Huang L, O'Loughlin R, Hiscock H. Non-indicated acid-suppression prescribing in a tertiary paediatric hospital: an audit and costing study. Journal of Paediatrics and Child Health doi:10.1111/jpc.14287.
Dr Suzi Reiss won a prize for this work at the 2017 The Royal Children's Hospital Advanced Trainee Research Symposium.
Do not routinely order a chest x-ray for
the diagnosis of asthma
Using MBS and PBS data, this project looked at the number of children with asthma who received a likely unnecessary chest x-ray across Australia. The project examined potential costs to the Australian healthcare system that could be saved if this unnecessary care stopped.
Do not order an abdominal x-ray for the
diagnosis of non-specific abdominal pain
This project measured the extent of unnecessary abdominal x-rays in children with non-specific abdominal pain across inpatient, outpatient and ED settings at the RCH. The project estimated the potential costs saved from reducing the number of X-rays, which have potential to cause harm through radiation to children.
Related projects
Prof Hiscock is conducting related projects through the Health Services research group at MCRI. You can read more about these projects
here.
Collaborations, datasets and funding
Collaborations
National: RCH; MCRI; University of Melbourne; Menzies Kids, University of Sydney (Prof Natasha Nassar); RACP (Mr Jason Soon); Australian Institute of Health Innovation, Macquarie University (Prof Andrew Georgiou); Safer Care Victoria.
International: USA - University of Michigan, Child Health Evaluation and Research Center (Prof Gary Freed).
Datasets
Medicare Benefits Schedule (MBS); Pharmaceutical Benefits Scheme (PBS); The Royal Children’s Hospital (RCH; Epic).
Funding source
The Royal Children's Hospital Foundation.