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Low-Value Clinical Practices in Pediatric Trauma Care
Theony Deshommes1,2,3, Gabrielle Freire4,5, Natalie Yanchar6
1Department of Social and Preventive Medicine, School of Medicine, Laval University, Québec City, Québec, Canada.
Insights
Low-value care is common in pediatric trauma, with significant variation between hospitals. These practices, including unnecessary imaging and admissions, offer opportunities for improvement through deimplementation strategies.
Area of Science:
- Pediatric Trauma Care
- Health Services Research
- Quality Improvement
Background:
- Reducing low-value care can enhance patient experiences and optimize healthcare resource utilization.
- While frequent in adult trauma, evidence on low-value practices in pediatric trauma care is limited.
Purpose of the Study:
- To determine the incidence of low-value practices in pediatric trauma care.
- To assess the variation in these practices across different hospitals.
Main Methods:
- A retrospective cohort study analyzed data from 10,711 children under 16 in a Canadian provincial trauma system (2016-2022).
- Low-value practices were identified from systematic reviews and clinical guidelines.
- Incidence and interhospital variation (using ICCs) were evaluated for identified practices.
Main Results:
- Nineteen low-value practices were identified; 14 were evaluable via trauma registry data.
- Five practices showed moderate to high frequency and interhospital variation: head CT in low-risk children, pretransfer CT, neurosurgical consultation, and hospital admission for mild TBI or minor abdominal trauma.
- Specific examples include 38.8% hospital admissions for mild traumatic brain injury with high interhospital variation (ICC 12.4%).
Conclusions:
- Low-value practices are prevalent in pediatric trauma care and exhibit significant interhospital variability.
- These findings highlight opportunities for deimplementation interventions, especially for practices measurable with existing data.
- Targeting these practices can improve care quality and resource efficiency in pediatric trauma.
Importance:
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.
Objective:
To estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation.
Design, Setting, And Participants:
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.
Main Outcomes And Measures:
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%).
Results:
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%).
Conclusions And Relevance:
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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