Measuring pediatric hospital-based low-value care: Urban-rural disparities and associated downstream healthcare utilization

Low-value care (LVC), defined as care for which the likely degree of benefit is outweighed by harms or costs, is a critical domain of healthcare waste. Efforts to reduce LVC have intensified as literature has elucidated the magnitude of associated patient- and system-level harms. In the pediatric hospital setting (inclusive of inpatient and emergency departments (ED)), describing the impact of LVC has been identified as a research priority. LVC persists for many conditions commonly cared for in this environment despite increasing evidence of their ineffectiveness. While a growing body of literature describes the prevalence of pediatric hospital-based LVC, research on this topic in the United States (US) to date has focused largely on freestanding children’s hospitals, all of which are located in urban regions. Little is known about the prevalence and impact of pediatric LVC in rural hospitals, which provide the majority of hospital care for the one-in-five US children who reside in rural regions. This is particularly relevant because rural-residing children are under-represented in research and have poorer health outcomes and child mortality than their urban-residing peers. Additionally, the downstream implications of hospital-based LVC, including health outcomes and additional healthcare utilization, have not been well-characterized in children. Our research group previously utilized a framework endorsed by the National Quality Forum to develop the Pediatric Health Information System (PHIS) LVC Calculator, a tool measuring 30 low-value pediatric inpatient and ED services. The current proposal seeks to apply the content and methodology employed by the PHIS LVC Calculator to develop and implement a similar tool applicable to Medicaid data from eight states. Through application of this tool, we specifically aim to: 1) measure urban-rural disparities in pediatric hospital-based LVC delivery and determine if these disparities are moderated by hospital type and setting; 2) characterize downstream healthcare utilization (hospital revisits, imaging studies and prescription fills) and Medicaid spending associated with LVC delivery; and 3) using qualitative methods, identify deimplementation considerations in rural regions from the perspectives of rural hospital stakeholders.