Health Services Research Unit

Low value care

  • 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…

    1. Prescribe oral antibiotics in fever without an identified specific bacterial infection
    2. Undertake a chest x-ray for the diagnosis of bronchiolitis or routinely prescribe salbutamol or systemic corticosteroids to treat bronchiolitis
    3. Treat gastroesophageal reflux disease (GORD) in infants with acid suppression therapy
    4. Order a chest x-ray for the diagnosis of asthma
    5. 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

    • Do not routinely treat GORD in infants with acid suppression therapy
      Two projects measure the extent of unnecessary prescribing of anti-reflux medications and associated factors. One project is measuring this across RCH inpatient, outpatient, and ED settings. The second is measuring this across community (GPs, paediatricians) care in Australia, using Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data. This project will also provide costs to the Australian healthcare system associated with unnecessary use of these medications in infants.

    • Do not routinely order a chest x-ray for the diagnosis of asthma
      Using MBS and PBS data, this project will estimate the number of children with asthma who receive a likely unnecessary chest x-ray across Australia. The project will include 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 will measure 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 will estimate the potential costs saved from reducing this test at the RCH which has potential to cause harm through radiation to children.

    Completed projects

    • 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. 

    Collaboration

    National: RCH; MCRI; University of Melbourne; Menzies Kids, University of Sydney (A/Prof Natasha Nassar); RACP (Mr Jason Soon); Australian Institute of Health Innovation, Macquarie University (Prof Andrew Georgiou).
    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

    RCH Foundation.