Trends in Low-Value Care Among Children's Hospitals.

BACKGROUND AND OBJECTIVES: Longitudinal pediatric low-value care (LVC) trends are not well established. We used the Pediatric Health Information System LVC Calculator, which measures utilization of 30 nonevidenced-based services, to report 7-year LVC trends. METHODS: This retrospective cohort study applied the LVC Calculator to emergency department (ED) and hospital encounters from January 1, 2016, to December 31, 2022. We used generalized estimating equation models accounting for hospital clustering to assess temporal changes in LVC. RESULTS: There were 5 265 153 eligible ED encounters and 1 301 613 eligible hospitalizations. In 2022, of 21 LVC measures applicable to the ED cohort, the percentage of encounters with LVC had increased for 11 measures, decreased for 1, and remained unchanged for 9 as compared with 2016. Computed tomography for minor head injury had the largest increase (17%-23%; P < .001); bronchodilators for bronchiolitis decreased (22%-17%; P = .001). Of 26 hospitalization measures, LVC increased for 6 measures, decreased for 9, and was unchanged for 11. Inflammatory marker testing for pneumonia had the largest increase (23%-38%; P = .003); broad-spectrum antibiotic use for pneumonia had the largest decrease (60%-48%; P < .001). LVC remained unchanged or decreased for most medication and procedure measures, but remained unchanged or increased for most laboratory and imaging measures. CONCLUSIONS: LVC improved for a minority of services between 2016 and 2022. Trends were more favorable for therapeutic (medications and procedures) than diagnostic measures (imaging and laboratory studies). These data may inform prioritization of deimplementation efforts.

2021 Update on Pediatric Overuse.

This update on pediatric medical overuse identifies and provides concise summaries of 10 impactful articles related to pediatric medical overuse from the years 2019 to 2020.

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

Importance: The scope of low-value care in children's hospitals is poorly understood. Objective: To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services. Design, Setting, and Participants: This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children's hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort. Exposures: Eligible condition-specific hospital encounters. Main Outcomes and Measures: The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes. Results: There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866). Conclusions and Relevance: This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery.

Economics at the frontline: Tools and tips for busy clinicians.

Frontline providers of neonatal care have a moral imperative to enhance value and inform senior administrators of how to most efficiently spend healthcare dollars. This article argues that the frontline is the ideal setting to pursue these efforts, offers recommendations for how to measure value, and describes five simple yet effective concrete tools that can improve value. It concludes with tips on advancing a value-added agenda through the Model for Improvement and advice for teams on ways of approaching senior leaders to help align unit-level aims with system-level goals and mission. Armed with these instruments, multidisciplinary teams can help ensure that neonatal care remains at the forefront of high-value healthcare.

Ten-year trends in infant neuroimaging from US Neonatal Intensive Care Units.

OBJECTIVE: To identify patterns of neuroimaging (NI), including cranial ultrasounds (CUS) and magnetic resonance imaging (MRI), among a large cohort of United States NICU infants. STUDY DESIGN: The retrospective cohort study of the Pediatrix Clinical Data Warehouse for infants discharged between 2008 and 2017. RESULTS: From the 863,863 infants during the study period, 204,197 (24%) had at least one NI study. CUS was the most common study (n = 189,190, 22%) followed by MRI (n = 37,107, 4%). From 2008 to 2017, the percentage of infants who underwent any NI decreased from 28 to 21% (p < 0.001) driven primarily by a reduction in CUS. MRI use for infants ≤33 weeks increased through 2015 and then decreased. CONCLUSIONS: Overall reductions in NI have been driven by decreased use of CUS in infants born at 31-33 weeks' gestational age. MRI use among preterm infants has been more dynamic with an initial rise and recent decrease.

2019 Update on Pediatric Medical Overuse: A Systematic Review.

Importance: Medical overuse is common in pediatrics and may lead to unnecessary care, resource use, and patient harm. Timely scrutiny of established and emerging practices can identify areas of overuse and empower clinicians to reconsider the balance of harms and benefits of the medical care that they provide. A literature review was conducted to identify the most important areas of pediatric medical overuse in 2018. Observations: Consistent with prior methods, a structured MEDLINE search and manual table of contents review of selected pediatric journals for the 2018 literature was conducted identifying articles pertaining to pediatric medical overuse. The structured MEDLINE search consisted of a PubMed search for articles with the Medical Subject Headings term health services misuse or medical overuse or article titles containing the term unnecessary, inappropriate, overutilization, or overuse. Articles containing the term overuse injury or overuse injuries were excluded, along with articles not published in English and those not constituting original research. The same search was performed using Embase with the additional Emtree term unnecessary procedure. Each article was evaluated by 3 independent raters for quality of methods, magnitude of potential harm, and number of patients potentially harmed. Ten articles were identified based on scores and appraisal of overall potential harm. This year's review identified both established and emerging practices that may warrant deimplementation. Examples of such established practices include antibiotic prophylaxis for urinary tract infections, routine opioid prescriptions, prolonged antibiotic courses for latent tuberculosis, and routine intensive care admission and pharmacologic therapy for neonatal abstinence syndrome. Emerging practices that merit greater inspection and discouragement of widespread adoption include postdischarge nurse-led home visits, probiotics for gastroenteritis, and intensive cardiac screening programs for athletes. Conclusions and Relevance: This year's review highlights established and emerging practices that represent medical overuse in the pediatric setting. Deimplementation of disproven practices and careful examination of emerging practices are imperative to prevent unnecessary resource use and patient harm.

A Collaborative Multicenter QI Initiative to Improve Antibiotic Stewardship in Newborns.

OBJECTIVES: To determine if NICU teams participating in a multicenter quality improvement (QI) collaborative achieve increased compliance with the Centers for Disease Control and Prevention (CDC) core elements for antibiotic stewardship and demonstrate reductions in antibiotic use (AU) among newborns. METHODS: From January 2016 to December 2017, multidisciplinary teams from 146 NICUs participated in Choosing Antibiotics Wisely, an Internet-based national QI collaborative conducted by the Vermont Oxford Network consisting of interactive Web sessions, a series of 4 point-prevalence audits, and expert coaching designed to help teams test and implement the CDC core elements of antibiotic stewardship. The audits assessed unit-level adherence to the CDC core elements and collected patient-level data about AU. The AU rate was defined as the percentage of infants in the NICU receiving 1 or more antibiotics on the day of the audit. RESULTS: The percentage of NICUs implementing the CDC core elements increased in each of the 7 domains (leadership: 15.4%-68.8%; accountability: 54.5%-95%; drug expertise: 61.5%-85.1%; actions: 21.7%-72.3%; tracking: 14.7%-78%; reporting: 6.3%-17.7%; education: 32.9%-87.2%; P < .005 for all measures). The median AU rate decreased from 16.7% to 12.1% (P for trend < .0013), a 34% relative risk reduction. CONCLUSIONS: NICU teams participating in this QI collaborative increased adherence to the CDC core elements of antibiotic stewardship and achieved significant reductions in AU.

Characterizing Early State Regulation in Preterm Infants.

OBJECTIVES: To characterize state regulation and behavior of preterm infants after discharge from the neonatal intensive care unit (NICU). METHODS: We recruited singleton infants born at ≤35 weeks of gestational age (GA) before NICU discharge. Parents completed surveys at discharge and 1, 3, and 6 months after discharge. Infant medical history was gleaned from the medical record. Surveys captured sociodemographic information and measures of infant state regulation (Baby Pediatric Symptom Checklist [BPSC]) and feeding behaviors. We calculated the median BPSC subscale scores at each time point and the proportion of infants with scores in the problem range (≥3/5). We explored longitudinal and cross-sectional correlates of BPSC scores. RESULTS: Fifty families completed the discharge questionnaire, and 42 (84%) completed the 6-month questionnaire. The median GA at birth was 34 weeks (IQR 30.1, 34.4 weeks); the median birth weight was 1930 g (IQR 1460, 2255 g). The median scores were above population norms for irritability and difficulty with routines. Twenty-one infants (40%) had irritability subscale scores in the problem range at 1 month, and 20 (38%) had problem scores on difficulties with routines. Only 9 infants (17%) had problem scores on the inflexibility subscale. Scores in all 3 domains showed different patterns from population norms from 1 to 6 months. BPSC scores were correlated with infant feeding behaviors at 1, 3, and 6 months. CONCLUSION: Scores for irritability and difficulty with routines among preterm infants were high compared with population norms and differed from normative values through 6 months after discharge. Preterm infants demonstrate problems with state regulation after NICU discharge that may require directed intervention.

2018 Update on Pediatric Medical Overuse: A Review.

Importance: Efforts to combat medical overuse have gained traction in recent years, but success has been intermittent and shortcomings have been recognized. A commitment to a strong evidence base is needed to more broadly engage clinicians and reduce overuse. Observations: A structured MEDLINE search and a manual review of tables of contents from selected high-impact journals was performed to identify original research published in 2017 relevant to pediatric overuse. Articles were scored from low to high for 3 categories: quality of methods, magnitude of potential harm, and number of patients potentially harmed. The top-scoring articles presented in this review highlight examples of safe reductions in treatment intensity, including in the setting of cancer, appendicitis, acute respiratory tract infection, and elective anesthesia. This year's articles also provide cautionary examples of rational interventions adopted without a full understanding of potential harms, including pharmacologic migraine therapies, docosahexaenoic acid supplementation for preterm neonates, tight glycemic control for individuals with critically illness, and prophylactic antibiotics for children with vesicoureteral reflux. Conclusions and Relevance: The articles represent high-quality, original research from 2017 that may help mitigate overuse. These works should be fundamental to the maturation of the pediatric overuse field.

Adherence of Newborn-Specific Antibiotic Stewardship Programs to CDC Recommendations.

: media-1vid110.1542/5839992664001PEDS-VA_2017-4322Video Abstract BACKGROUND: The Centers for Disease Control and Prevention (CDC) published the Core Elements of Hospital Antibiotic Stewardship Programs (ASPs), while the Choosing Wisely for Newborn Medicine Top 5 list identified antibiotic therapy as an area of overuse. We identify the baseline prevalence and makeup of newborn-specific ASPs and assess the variability of NICU antibiotic use rates (AURs). METHODS: Data were collected using a cross-sectional audit of Vermont Oxford Network members in February 2016. Unit measures were derived from the 7 domains of the CDC's Core Elements of Hospital ASPs, including leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. Patient-level measures included patient demographics, indications, and reasons for therapy. An AUR, defined as the number of infants who are on antibiotic therapy divided by the census that day, was calculated for each unit. RESULTS: Overall, 143 centers completed structured self-assessments. No center addressed all 7 core elements. Of the 7, only accountability (55%) and drug expertise (62%) had compliance >50%. Centers audited 4127 infants for current antibiotic exposure. There were 725 infants who received antibiotics, for a hospital median AUR of 17% (interquartile range 10%-26%). Of the 412 patients on >48 hours of antibiotics, only 26% (107 out of 412) had positive culture results. CONCLUSIONS: Significant gaps exist between CDC recommendations to improve antibiotic use and antibiotic practices during the newborn period. There is wide variation in point prevalence AURs. Three-quarters of infants who received antibiotics for >48 hours did not have infections proven by using cultures.

Improving Value in Neonatal Intensive Care.

Work within the US health care system has sought to improve outcomes, decrease costs, and improve the patient experience. Combining those three elements leads to value-added care. Quality improvement within neonatology has focused primarily on the improvement of clinical outcomes without explicit consideration of cost. Future improvement efforts in neonatology should consider opportunities to decrease or eliminate waste, and improve outcomes. Consideration of how a change affects all stakeholders reveals potential cost-saving opportunities, and developing aims with value in mind facilitates understanding and goal-setting with senior administrative leaders.

Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value.

BACKGROUND: The use of unnecessary tests and treatments contributes to health care waste. The "Choosing Wisely" campaign charges medical societies with identifying such items. This report describes the identification of 5 tests and treatments in newborn medicine. METHODS: A national survey identified candidate tests and treatments. An expert panel of 51 individuals representing 28 perinatal care organizations narrowed the list over 3 rounds of a modified Delphi process. In the final round, the panel was provided with Grading of Recommendation, Assessment, Development and Evaluation (GRADE) literature summaries of the top 12 tests and treatments. RESULTS: A total of 1648 candidate tests and 1222 treatments were suggested by 1047 survey respondents. After 3 Delphi rounds, the expert panel achieved consensus on the following top 5 items: (1) avoid routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants, (2) avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection, (3) avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity, (4) avoid routine daily chest radiographs without an indication for intubated infants, and (5) avoid routine screening term-equivalent or discharge brain MRIs in preterm infants. CONCLUSIONS: The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost. This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.

Structure and mechanism of BRCA1 BRCT domain recognition of phosphorylated BACH1 with implications for cancer.

Germline mutations in the BRCA1 tumor suppressor gene often result in a significant increase in susceptibility to breast and ovarian cancers. Although the molecular basis of their effects remains largely obscure, many mutations are known to target the highly conserved C-terminal BRCT repeats that function as a phosphoserine/phosphothreonine-binding module. We report the X-ray crystal structure at a resolution of 1.85 A of the BRCA1 tandem BRCT domains in complex with a phosphorylated peptide representing the minimal interacting region of the DEAH-box helicase BACH1. The structure reveals the determinants of this novel class of BRCA1 binding events. We show that a subset of disease-linked mutations act through specific disruption of phospho-dependent BRCA1 interactions rather than through gross structural perturbation of the tandem BRCT domains.