Paeds · professional-practice-and-evidence
High-value care, stewardship and avoiding low-value interventions
Also known as High-value care in paediatrics · Low-value care and overuse · De-implementation and reducing overuse · Resource stewardship and value-based care · Choosing Wisely and antimicrobial stewardship
Fellowship guide to high-value care and stewardship in paediatrics: defining value, recognising low-value care, overuse and overdiagnosis, the clinician, family and system drivers of overuse, how low-value care harms children through care cascades and opportunity cost, common paediatric low-value practices, and the stepwise de-implementation cycle with its evidence-based levers — framed as good medicine and justice rather than rationing, with ANZ, UK, US and Canada guidance.
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Target exams
Red flags
- Ordering a test 'for reassurance' when the pre-test probability is low, seeding a cascade of false positives and further testing
- Treating overdiagnosis as harmless because the finding is real, when the label and its downstream treatment carry their own harms
- Equating restraint with rationing, and so withholding genuinely indicated, high-value care
- Framing stewardship as cost-cutting rather than as patient-centred, evidence-based good medicine
- Assuming a low-value practice will fade on its own without measurement, feedback and system change
- Blaming overuse solely on parent demand when clinician habit and system incentives are the larger drivers
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Quality use of medicines and resource stewardship
- Professional practice and ethics
- Renewed curriculum — Learning goal 11: Quality and safety, and value-based care
- Stewardship and sustainability of health care
- Scholarly activity and quality improvement
- Written assessment of stewardship and quality of care
- Structured discussion of a Choosing Wisely or stewardship scenario
- Long Cases integrating value and resource use with the family
- Short Cases on reducing an overused practice
- 2. Professional skills and knowledge: quality improvement and resource stewardship
- Patient safety themes
- Safeguarding and screening themes
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Communication
- History taking and management
- Health promotion and stewardship
- General Pediatrics Content Outline — quality improvement, patient safety, and high-value care
- General Pediatrics EPA: Stewardship and quality improvement
- Bioethics and professional conduct
- Systems-based Practice: cost-conscious, high-value care and stewardship
- Practice-based Learning and Improvement: reducing overuse through audit and feedback
- Professionalism
- Health Advocate and Scholar
- Manager and Collaborator
- Medical Expert
Two things that get mixed up
High-value care
Low-value care (overuse)
Identify the low-value practice · Measure the baseline rate · Diagnose the drivers · Engage clinicians and families · De-implement with combined levers · Sustain and monitor. Remember it as I-M-D-E-D-S: identify, measure, diagnose, engage, de-implement, sustain. Never announce a de-implementation drive before you have measured the problem and built a coalition to change it. [9] [13]
Overview & Definition
A mother brings her feverish, snuffling two-year-old and asks for "the antibiotics that worked last time." You are confident this is a viral upper respiratory infection, yet the easy path is to prescribe and move on. This ordinary encounter is where stewardship lives. High-value care is care that maximises a child's benefit relative to the harm, cost and opportunity it consumes, and low-value care is any test, treatment or procedure whose likely harm or cost exceeds its likely benefit. [1] [8]
The discipline rests on three ideas that the examiner will expect you to name. Value is a ratio, not a price: an expensive intervention can be high-value and a cheap one low-value. [8] Overuse — doing too much — is the principal target of stewardship in well-resourced settings, sitting alongside underuse and misuse as the ways care can go wrong. [7] And stewardship is an ethical duty, not a budgetary one: every test or treatment consumes a finite resource and carries a finite risk, so the responsible clinician spends them only where they are likely to help. [2] [8]
This page owns the principles, harm, measurement and the de-implementation of low-value care in child health. The statistical machinery for judging whether a therapy works belongs to the evidence-based medicine leaf, and the conversation skills for explaining restraint belong to shared decision-making and risk communication — cross-link them rather than rebuilding their content. [1]
References16ShowHide
- [1]Cassel CK, Guest JA Choosing wisely: helping physicians and patients make smart decisions about their care JAMA, 2012.PMID 22492759
- [2]Berwick DM, Hackbarth AD Eliminating waste in US health care JAMA, 2012.PMID 22419800
- [3]Shrank WH, Rogstad TL, Parekh N Waste in the US Health Care System: Estimated Costs and Potential for Savings JAMA, 2019.PMID 31589283
- [4]Coon ER, Young PC, Quinonez RA, et al. 2017 Update on Pediatric Medical Overuse: A Review JAMA pediatrics, 2018.PMID 29582079
- [5]Coon ER, Quinonez RA, Moyer VA, et al. Overdiagnosis: how our compulsion for diagnosis may be harming children Pediatrics, 2014.PMID 25287462
- [6]Bhatia RS, Levinson W, Shortt S, et al. Measuring the effect of Choosing Wisely: an integrated framework to assess campaign impact on low-value care BMJ quality & safety, 2015.PMID 26092165
- [7]Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of medical services around the world Lancet, 2017.PMID 28077234
- [8]Elshaug AG, Rosenthal MB, Lavis JN, et al. Levers for addressing medical underuse and overuse: achieving high-value health care Lancet, 2017.PMID 28077228
- [9]Morgan DJ, Leppin AL, Smith CD, et al. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction Journal of hospital medicine, 2017.PMID 28459906
- [10]Moynihan R, Doust J, Henry D Preventing overdiagnosis: how to stop harming the healthy BMJ, 2012.PMID 22645185
- [11]Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement JAMA, 1999.PMID 10535437
- [12]Schwartz AL, Landon BE, Elshaug AG, et al. Measuring low-value care in Medicare JAMA internal medicine, 2014.PMID 24819824
- [13]Colla CH Swimming against the current--what might work to reduce low-value care? New England Journal of Medicine, 2014.PMID 25271601
- [14]Ganguli I, Lupo C, Mainor AJ, et al. Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit JAMA network open, 2020.PMID 33306120
- [15]Quinonez RA, Garber MD, Schroeder AR, et al. Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value Journal of hospital medicine, 2013.PMID 23955837
- [16]Gerber JS, Prasad PA, Fiks AG, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial JAMA, 2013.PMID 23757082