High-value care, stewardship and avoiding low-value interventions — formative SAQs

SAQ 1 (10 marks)

You are the registrar in a busy paediatric emergency department. A two-year-old with a clear viral upper respiratory infection is prescribed antibiotics by a colleague "to reassure the family", and a parent on a nearby trolley is asking why their child, who meets a low-risk head-injury rule, is not being scanned. ^[1]

1. Define high-value and low-value care, and explain how the antibiotic prescription and the omitted scan both illustrate principles of stewardship. (3) ^[8]
2. Describe the mechanism by which an unnecessary test or treatment harms a child, using the concept of the care cascade and overdiagnosis. (4) ^{[14] [5]}
3. Outline how you would counsel the parent requesting the scan so that restraint is understood as good care rather than denial. (3) ^{[13] [9]}

Model answer

High-value care maximises a child's benefit relative to harm and cost; low-value care is a test or treatment whose likely harm or cost exceeds its likely benefit. ^[8] The antibiotic is low-value because a viral illness will not respond to it and the prescription carries resistance, adverse-drug and demand harms, while the omitted scan is high-value restraint because, at low pre-test probability, computed tomography yields more false positives and cascades than true findings. ^{[1] [16]}

An unnecessary test seeds a care cascade: applied to a low-risk child it throws up a false positive or incidentaloma, prompting confirmatory imaging, biopsy and further intervention, with attendant radiation, anxiety and cost. ^[14] Overdiagnosis compounds this by labelling a true but clinically irrelevant finding, so the child is treated for a condition that would never have caused harm. ^[5]

To counsel the parent, I would first acknowledge and validate their worry rather than dismiss it, then explain in plain terms that, at their child's low risk, a scan is more likely to cause harm than to help. I would share the decision, set out the safety-net and clear return precautions, and frame restraint as the higher-value choice that protects their child. ^{[13] [9]}