One in ten children receive low-value care, new study shows

By Judith Garber | January 17, 2020

From unnecessary tonsillectomies to overprescription of antibiotics, overuse in pediatrics is prevalent. As Dr. Shawn Ralston and Dr. Alan Schroeder wrote back in 2017, “The problem of unnecessary health care in this country starts with children.”

Low-value pediatric care

A recent study in Pediatrics dives into the issue of overuse in pediatrics by estimating the rate at which American children covered by private insurance or public insurance (Medicaid) received a low-value service. The authors measured the prevalence of 20 different low-value services in pediatrics, including vitamin D screening, sinus imaging, cervical cancer screening, overuse of antibiotics and cold medication, and more.

They found that overall, 10.6% of the children received at least one low-value service in a single year. There was a small difference between the two groups, with 11% of publicly-insured children and 9% of privately-insured children receiving at least one low-value service.

For parents trying to avoid low-value care, Lown Insitute president Vikas Saini suggests asking the doctor questions before a procedure to make sure it’s really necessary. For example, when considering doing a test, ask the doctor what she or he would do differently given the results the test. Sometimes doctors order tests to rule out a diagnosis, but the diagnosis would not change the course of action.

“Asking questions is helpful — and it does, I think, moderate what’s otherwise an automatic tendency,” said Saini in an interview with MarketWatch about the study.

Unnecessary cervical cancer screening in adolescents

Another recent study in JAMA Internal Medicine examined the prevalence of cervical cancer screening in women age 15-20. In their analysis of survey data from the National Survey of Family Growth, they found that 12.5% of young women received a potentially unnecessary bimanual pelvic examination in the past year, and 13.8% received a potentially unnecessary Pap test in the past year. Of all the women who received pelvic exams, a little more than half were unnecessary. Of the Pap tests received, more than 70% were unnecessary.

Women under 21 who don’t have symptoms and aren’t pregnant do not need pelvic exams or pap tests; leading professional organizations do not recommend cervical cancer screening in this population. Yet because of standards of care that are difficult to change, these tests are still prevalent. Historically, gynecologists have performed pelvic exams before prescribing birth control or screening for STIs, although there is no medical reason why this is necessary.

It is incredibly concerning that one in eight young women receive unnecessary cervical cancer screening, because overscreening often leads to overdiagnosis, anxiety, and unnecessary costs. The bimanual pelvic examination in particular is very intrusive. “Many young women associate the examination with fear, anxiety, embarrassment, discomfort, and pain,” the authors write. While some argue that requiring annual pelvic examinations prompts women to visit their clinician regularly, there is no evidence to support this claim. In fact the opposite is likely true; women may delay a visit to the gynecologist for STI testing or birth control if they are nervous about getting a pelvic exam.

Pediatric professional groups have known for years that certain tests and procedures are unnecessary and potentially harmful. Yet one in ten children overall and an even greater proportion of women age 15-20 are receiving low-value care. These studies indicate that “we have a lot of educating to do” to get pediatricians and ob-gyns on the same page, says Dr. George Sawaya, professor of obstetrics at the University of California, San Francisco, and author of the cervical cancer screening study. In an NPR interview, Sawaya said that he hopes that the study will “cause physicians to be a little shocked — and then be reflective about their own practice.”

To eliminate medication overload, serious cultural, educational, and policy changes are needed. This action plan offers recommendations for policymakers, health care institutions, clinicians, and patients across five key categories to reduce harm from multiple medication use. Suggested Citation: Eliminating medication overload: A national action plan. Working Group on Medication Overload. Brookline, MA: The Lown Institute, 2020. DOI: https://doi.org/10.46241/LI.YLBW4885

Pharmaceutical marketing is a significant factor in the growing public health crisis of medication overload, which puts millions of older adults at risk of preventable harm and premature death. This issue brief provides recommendations to reduce pharmaceutical industry influence by limiting pharma sales rep visits to clinicians and direct-to-consumer advertising.

This issue brief provides recommendations for clinical practice guidelines and electronic health records that would give clinicians the information they need to appropriately prescribe and deprescribe.