High-Value Care/Things We Do For No Reason

In this impactful session, Dr. Lee defined value as the sum of quality of care, equity, patient outcome, and experience divided by costs of care and nonfinancial risks and harms. High-value care provides the best care most efficiently and achieves optimal results for each patient. In the U.S., the cost of care continues to rise, but many outcomes are inferior to those in other countries. Between 25 and 34% of U.S. health care expenditures are considered waste, including in pediatrics. Waste can be due to clinician, clinical, and patient factors, culture, economics, and technology.

Dr. Lee identified four practices within pediatric hospital medicine as things we (still) do for no reason (TWDFNR), contributing to low-value care. First, withholding feeds in patients with bronchiolitis on high-flow nasal cannula (HFNC) for a predetermined amount of time after HFNC initiation is a TWDFNR. You may think this lessens the likelihood of aspiration, but there is no evidence to suggest an increase in aspiration risk with early feeding.¹ Holding feeds could cause distress and increase length of stay (LOS) and costs. Instead, allow feeding unless there’s a significant clinical concern.

The next TWDFNR is administering stress ulcer prophylaxis in patients with critical asthma. While both critical illness and steroid treatment are risks for gastritis and gastrointestinal bleeding, their incidence in patients with critical asthma is negligible.² Furthermore, risks associated with these medications include the potential for C. difficile infection, prolonged administration upon transfer out of the ICU or at discharge, and increased costs. Instead, assess for other risk factors that would indicate the need for stress ulcer prophylaxis or continuation of these medications.

Dr. Lee described the routine use of procalcitonin and the use of blood cultures for patients hospitalized with certain uncomplicated infections (community-acquired pneumonia, urinary tract infection, skin, and soft tissue infection) as another TWDFNR. Procalcitonin use is rapidly increasing over time.³ We might think it helps identify bacterial infections, but it can cause more uncertainty as it hasn’t been shown to outperform sepsis clinical algorithms or antibiotic stewardship programs, and it may increase the cost and number of blood draws. Instead, obtain procalcitonin only in selected patients, such as febrile infants, where evidence-based clinical guidance is available. Similarly, routine use of blood cultures in uncomplicated infections has a low true-positive rate and when there is a contaminant, repeat blood cultures, longer duration of broad-spectrum antibiotics, and increased LOS or readmission can occur.^4,5

Finally, using intravenous antibiotics to complete a treatment course for infections such as bacteremic urinary tract infection, osteomyelitis, and complicated pneumonia in pediatric patients is still a TWDFNR. Early transition to oral antibiotics has equivalent or better outcomes in these conditions and fewer harms associated with prolonged intravenous or PICC line placement, such as thrombosis, infection, increased LOS, and higher costs.^6,7 Instead, consider the early transition to oral antibiotics based on the patient’s condition and response to treatment.

The good news is that hospitalists can lead the change towards high-value care by choosing services that optimize quality and minimize harm, reflecting on the evidence available, seeking to understand costs, advocating for health care reform and health equity, and identifying low-value practices. We should participate in and lead local de-implementation efforts by working with key institutional stakeholders such as hospital quality, safety, and nursing leadership to establish local practice guidelines, understand barriers, and monitor adherence. Using well-regarded initiatives like Choosing Wisely and TWDFNR, which address low-value care, is an excellent starting point. We can participate in national quality improvement and research collaboratives that target the de-implementation of low-value care. Finally, it is critical to examine low-value care with a health-equity lens, as the impact likely varies between demographic groups. 

Key Takeaways

• Low-value care contributes to health care waste and harm. Identifying TWDFNR as targets for de-implementation can improve value.
• Feeding on HFNC can be safe and well-tolerated; waiting a pre-determined amount of time from initiation of HFNC to starting feeds is a TWDFNR.
• The incidence of major gastrointestinal bleeds is negligible in patients with critical asthma; empiric stress ulcer prophylaxis is a TWDFNR.
• Routine use of procalcitonin, as well as routine blood cultures for patients hospitalized with uncomplicated infections, are TWDFNR.
• Prescribing intravenous antibiotics for a predetermined duration for patients hospitalized with infections such as bacteremic urinary tract infection, osteomyelitis, or complicated pneumonia is a TWDFNR; we should consider early transition to oral antibiotics.
• Hospitalists can lead the change! Work with key stakeholders on the de-implementation of low-value care in your institution.

References

1. Gray S, et al. Oral feeding on high-flow nasal cannula in children hospitalized with bronchiolitis. Hosp Pediatr. 2023;13(2):159-67.
2. Roberts AR, et al. Stress ulcer prophylaxis for critical asthma. Pediatrics. 2022;149(4):e2021054527. doi: 10.1542/peds.2021-054527.
3. Dorney K, et al. Trends in the use of procalcitonin at US children’s hospital emergency departments. Hosp Pediatr. 2023;13(1):24-30.
4. Zwemer E, Stephens JR. Things we do for no reason: Blood cultures for uncomplicated skin and soft tissue infections in children. J Hosp Med. 2018;13(7):496-99.
5. Johnson DP, et al. Things we do for no reason: Routine blood culture acquisition for children hospitalized with community-acquired pneumonia. J Hosp Med. 2020;15(2):107-10.
6. Olson J, et al. Impact of early oral antibiotic therapy in infants with bacteremic urinary tract infections. Hosp Pediatr. 2022;12(7):632-8.
7. Tchou MJ, et al. Choosing wisely in pediatric hospital medicine: 5 new recommendations to improve value. Hosp Pediatr. 2021;11(11):1179-90.

Dr. Hadley

Dr. Hadley is a med-peds hospitalist and chief of pediatric hospital medicine at Corewell Health/Helen DeVos Children’s Hospital, and an assistant professor of internal medicine and pediatrics at Michigan State University College of Human Medicine, both in Grand Rapids, Mich.