# High-Value Care and Choosing Wisely in Pediatrics and Internal Medicine

## Introduction

**High-value care** delivers the best possible health outcomes relative to cost, avoiding unnecessary tests, treatments, and procedures that provide no benefit or may cause harm. The **Choosing Wisely** campaign, launched by the ABIM Foundation in 2012, has engaged over 80 specialty societies in identifying commonly overused practices. Med-peds physicians practice across settings where low-value care is prevalent and must champion evidence-based resource stewardship in both pediatric and adult medicine.

## Defining Value in Healthcare

**Value = Outcomes / Cost**: High-value care improves outcomes while minimizing waste. **Low-value care**: Tests or treatments where evidence shows no benefit, or harms outweigh benefits. Categories of waste: **overuse** (unnecessary imaging), **underuse** (missed vaccinations), **misuse** (wrong antibiotic choice) U.S. healthcare spending exceeds $4 trillion annually; an estimated 25-30% represents waste. High-value care is not about rationing; it is about providing the right care for the right patient at the right time.

## Choosing Wisely: Key Recommendations

| Specialty | Recommendation | Rationale |
|-----------|---------------|-----------|
| Pediatrics | No CXR for uncomplicated asthma/bronchiolitis | Rarely changes management; unnecessary radiation |
| Pediatrics | No systemic steroids for bronchiolitis in <2 years | No proven benefit; potential harm |
| Pediatrics | No antibiotics for pharyngitis without positive strep test | Viral pharyngitis predominates; reduces resistance |
| Pediatrics | No head CT for minor head injury if PECARN low-risk | Validated rule safely reduces radiation exposure |
| Internal Medicine | No imaging for low back pain <6 weeks without red flags | Incidental findings lead to unnecessary procedures |
| Internal Medicine | No continuous telemetry without clear indication | Alert fatigue; cost without benefit |
| Internal Medicine | No treatment of asymptomatic bacteriuria (except pregnancy) | Drives antibiotic resistance without benefit |
| Internal Medicine | No RBC transfusion for Hgb >7 in stable patients | Restrictive strategy equivalent or superior outcomes |

### Pediatric Recommendations (AAP and Subspecialties)

**Do not order chest radiographs** in children with uncomplicated asthma or bronchiolitis. **Do not use systemic corticosteroids** in children under 2 with bronchiolitis. **Do not prescribe antibiotics** for pharyngitis without a positive strep test (rapid or culture) **Do not obtain CT scans** of the head for minor head injury when PECARN criteria indicate low risk. **Do not routinely prescribe antireflux medications** (PPIs, H2 blockers) for physiologic infant reflux. **Avoid routine preoperative testing** (CBC, coagulation studies) in otherwise healthy children undergoing low-risk procedures.

### Internal Medicine Recommendations (ACP, SGIM, SHM)

**Do not obtain imaging** for low back pain within the first 6 weeks without red flags. **Do not order continuous telemetry** outside of the ICU without a clear clinical indication. **Do not perform routine preoperative testing** for low-risk surgical procedures in healthy patients. **Do not treat asymptomatic bacteriuria** (except in pregnancy or prior to urologic procedures) **Do not transfuse red blood cells** for hemoglobin >7 g/dL in hemodynamically stable hospitalized patients without active bleeding. **Do not continue antibiotics** beyond the recommended course without reassessment.

![Top Choosing Wisely recommendations in pediatrics and internal medicine](illustration-choosing-wisely-recommendations.jpg)

## Common Areas of Overuse

### Diagnostic Imaging

**CT usage in children**: Radiation exposure carries a higher lifetime cancer risk in children; the ALARA principle (As Low As Reasonably Achievable) should guide decisions. **PECARN head CT rule**: Validated clinical decision rule identifies children at very low risk for clinically important traumatic brain injury, safely reducing CT use. **Low back pain imaging in adults**: MRI and CT for non-specific low back pain without red flags leads to incidental findings, unnecessary procedures, and higher costs.

### Laboratory Testing

**Daily routine labs** in hospitalized patients: Contribute to hospital-acquired anemia, increased costs, and rarely change management. **Thyroid screening in asymptomatic adults**: Universal screening is not recommended; test only when clinical suspicion exists. **Vitamin D screening**: Widespread testing of low-risk individuals has led to unnecessary supplementation without proven benefit.

### Antimicrobial Stewardship

**Antibiotic overuse** drives resistance, Clostridioides difficile infection, and adverse drug events. **URI and bronchitis**: Antibiotics are not indicated for viral upper respiratory infections. **UTI in children**: Avoid prophylactic antibiotics for vesicoureteral reflux in most cases (RIVUR trial nuance) **Duration of therapy**: Shorter antibiotic courses are effective for many infections (pneumonia, cellulitis, UTI)

### Screening

**PSA screening**: Shared decision-making for men aged 55-69; not recommended for men >70 or <55. **Cervical cancer screening**: Not recommended before age 21 regardless of sexual history. **ECG screening in asymptomatic adults**: Routine screening not recommended (USPSTF Grade D)

## Barriers to High-Value Care

**Defensive medicine**: Fear of malpractice drives unnecessary testing. **Patient expectations**: Patients may equate more testing with better care; communication is essential. **Financial incentives**: Fee-for-service reimbursement rewards volume over value. **Diagnostic uncertainty**: Discomfort with uncertainty leads to test cascades. **Training culture**: Modeling low-value practices during residency perpetuates overuse. **System factors**: Pre-populated order sets, EMR defaults, and lack of decision support.

## Strategies for Promoting High-Value Care

### Education and Culture

Incorporate high-value care curricula into residency training with case-based learning. **Morning report and case conferences**: Discuss cost and value alongside clinical reasoning. Role model high-value decision-making as attendings and senior residents. Teach residents to discuss costs transparently with patients.

### Systems-Level Interventions

**Clinical decision support**: Embed evidence-based guidelines into order entry systems. **Audit and feedback**: Provide physicians with data on their ordering patterns relative to peers. **Order set review**: Remove low-value default orders; add indication requirements for high-cost tests. **Choosing Wisely Champions**: Designate departmental leads to drive awareness and culture change.

### Communication with Patients

Use shared decision-making to explain why a test or treatment is not indicated. Frame the conversation around **avoiding harm** rather than cost savings. Provide patient-facing Choosing Wisely materials in accessible language. The phrase "Let's not do harm" resonates more than "Let's save money".

![Strategies for reducing low-value care across clinical settings](illustration-high-value-care-strategies.jpg)

![Cost awareness education model for resident training](illustration-cost-awareness-education.jpg)

## Clinical Pearls

High-value care means providing evidence-based care that benefits the patient, not simply doing less. The PECARN head CT decision rule safely reduces unnecessary radiation exposure in children with minor head trauma. Treating asymptomatic bacteriuria in non-pregnant adults is a common low-value practice that drives antibiotic resistance. Framing conversations with patients around safety rather than cost is more effective in reducing low-value care requests. Residents learn high-value care by example; attending physician behavior is the strongest driver of trainee practice patterns.

## References

1. Choosing Wisely. An initiative of the ABIM Foundation. www.choosingwisely.org. Accessed 2024.
2. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma (PECARN). *Lancet*. 2009;374(9696):1160-1170.
3. Morgan DJ, Dhruva SS, Coon ER, et al. 2019 update on medical overuse. *JAMA Intern Med*. 2020;180(1):131-136.
4. Coon ER, Quinonez RA, Moyer VA, et al. Overdiagnosis: How our compulsion to diagnose may be harming children. *Pediatrics*. 2014;134(5):1013-1023.