Low-Value Clinical Practices in Pediatric Trauma Care
Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to...
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| Published in | JAMA network open Vol. 7; no. 10; p. e2440983 |
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| Main Authors | , , , , , , , , , , , , , , , , , , , , , , , , |
| Format | Journal Article |
| Language | English |
| Published |
United States
American Medical Association
01.10.2024
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| Subjects | |
| Online Access | Get full text |
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| Abstract | Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking.
To estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation.
A retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included.
Low-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%).
A total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%).
In this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data. |
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| AbstractList | Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking.ImportanceReducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking.To estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation.ObjectiveTo estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation.A retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included.Design, Setting, and ParticipantsA retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included.Low-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%).Main Outcomes and MeasuresLow-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%).A total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%).ResultsA total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%).In this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data.Conclusions and RelevanceIn this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data. This cohort study examines low-value clinical practices, ie, those with the potential for harm exceeding the potential for benefit, in pediatric trauma centers. Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking. To estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation. A retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included. Low-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%). A total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%). In this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data. ImportanceReducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking.ObjectiveTo estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation.Design, Setting, and ParticipantsA retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included.Main Outcomes and MeasuresLow-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%).ResultsA total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%).Conclusions and RelevanceIn this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data. |
| Author | Bérubé, Melanie Yanchar, Natalie Berthelot, Simon Stelfox, Henry Thomas Zemek, Roger Beno, Suzanne Moore, Lynne Deshommes, Theony Beaudin, Marianne Stang, Antonia Freire, Gabrielle Klassen, Terry Ben Abdeljelil, Anis Labrosse, Melanie Lauzier, François Giroux, Marianne Weiss, Matthew John Gagnon, Isabelle J. Turgeon, Alexis F. Belcaid, Amina Neveu, Xavier Gabbe, Belinda J. Tardif, Pier-Alexandre Beaulieu, Emilie Carsen, Sasha |
| AuthorAffiliation | 8 Department of Pediatric Surgery, CHU Sainte-Justine, University of Montreal, Québec, Canada 11 Division of Pediatric Critical Care Medicine, Mère-Enfant Soleil hospital, Québec City, Québec, Canada 15 School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia 5 Child Health Evaluative Sciences Program, Peter Gilgan Institute for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada 3 Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island 16 Faculty of Nursing, Université Laval, Québec City, Québec, Canada 18 Division of Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada 19 Department of Pediatrics, Division of Emergency Medicine, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada 4 Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada 12 Division of Or |
| AuthorAffiliation_xml | – name: 7 Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada – name: 22 Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada – name: 9 Department of Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada – name: 3 Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island – name: 2 Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec – Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada – name: 12 Division of Orthopaedic Surgery, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada – name: 19 Department of Pediatrics, Division of Emergency Medicine, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada – name: 23 Institut National d’Excellence en Santé et Services Sociaux, Québec City, Québec, Canada – name: 14 School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Québec, Canada – name: 21 George & Fay Yee Centre for Health Care Innovation, Children’s Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada – name: 1 Department of Social and Preventive Medicine, School of Medicine, Laval University, Québec City, Québec, Canada – name: 17 Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Alberta, Canada – name: 4 Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada – name: 5 Child Health Evaluative Sciences Program, Peter Gilgan Institute for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada – name: 8 Department of Pediatric Surgery, CHU Sainte-Justine, University of Montreal, Québec, Canada – name: 13 Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal Children’s Hospital, Montreal, Québec, Canada – name: 20 Department of Pediatrics, Université Laval, Québec City, Québec, Canada – name: 11 Division of Pediatric Critical Care Medicine, Mère-Enfant Soleil hospital, Québec City, Québec, Canada – name: 15 School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia – name: 18 Division of Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada – name: 16 Faculty of Nursing, Université Laval, Québec City, Québec, Canada – name: 10 Department of Pediatrics, School of Medicine, Laval University, Québec City, Québec, Canada – name: 6 Department of Surgery, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada |
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fullname: Giroux, Marianne organization: Department of Social and Preventive Medicine, School of Medicine, Laval University, Québec City, Québec, Canada, Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec – Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada – sequence: 25 givenname: Lynne surname: Moore fullname: Moore, Lynne organization: Department of Social and Preventive Medicine, School of Medicine, Laval University, Québec City, Québec, Canada, Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec – Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada |
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| Snippet | Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research... ImportanceReducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources.... This cohort study examines low-value clinical practices, ie, those with the potential for harm exceeding the potential for benefit, in pediatric trauma centers. |
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| SubjectTerms | Adolescent Canada - epidemiology Child Child, Preschool Cohort analysis Female Humans Infant Male Online Only Original Investigation Pediatrics Pediatrics - standards Pediatrics - statistics & numerical data Practice Patterns, Physicians' - statistics & numerical data Retrospective Studies Tomography Trauma Trauma care Trauma Centers - statistics & numerical data Wounds and Injuries - epidemiology Wounds and Injuries - therapy |
| Title | Low-Value Clinical Practices in Pediatric Trauma Care |
| URI | https://www.ncbi.nlm.nih.gov/pubmed/39470640 https://www.proquest.com/docview/3143268545 https://www.proquest.com/docview/3121591014 https://pubmed.ncbi.nlm.nih.gov/PMC11522939 |
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