PROJECT SUMMARY
Low-value care, or the provision of care without net benefit, is associated with patient harm and billions of dollars
in unnecessary medical costs.18,19 One example is the prescription of antibiotics for viral upper respiratory
infections (URIs). It is estimated that over 50% of antibiotic prescriptions for respiratory infections are
unnecessary and cost over $700 million per year.20 Antibiotics can increase antimicrobial resistance, and cause
adverse events in 10% of patients.21 The Choosing Wisely initiative has been joined by over 80 specialty
societies, including the American Academy of Pediatrics, to develop recommendations against low-value care.
Despite these recommendations, low-value care continues to affect one in ten children every year.22 To plan for
future de-implementation research involving claims-based audit and feedback, we selected three types of
pediatric low-value care based on high prevalence22 and the ability to distinguish low-value care using claims
data: 1) antibiotics for viral URIs, 2) vitamin D screening in healthy children and 3) antacid medications for infant
reflux. It is not well understood to what extent providers are familiar with these recommendations against low-
value care. Even if a provider is aware of recommendations against low-value care, there can be other barriers
to de-implementation such cognitive biases that favor historical practices, discomfort with diagnostic uncertainty
or unease in discussing low-value care with families.23 In Aim 1, we will first evaluate the patient (age, race, sex,
insurance type), provider (medical specialty) and system-level factors (clinical setting, healthcare system,
rurality) associated with the three different types of low-value care. In Aim 2, we will query providers about 1)
knowledge of, 2) agreement with, and 3) actions regarding the three Choosing Wisely recommendations. We
will use the Consolidated Framework for Implementation Research (CFIR) framework24-26 to interview a subset
of providers about barriers to de-implementation. We will use this information to design a targeted and effective
de-implementation strategy that can be used across the Commonwealth of Virginia.
This proposal builds on Dr. Wolf's KL2 study related to the delivery of evidence-based, high-value care and her
clinical training in general pediatrics. The Center for Clinical and Translational Research (CTSA) will support use
of the All-Payers Claims Database (APCD) and mentorship by Drs. Krist and Sabo who have expertise in patient-
oriented health services research and implementation science. During the study period, Dr. Wolf will address
critical gaps of knowledge about what drives the delivery of low-value care in children and what prevents
providers from de-implementing low-value practices. By engaging providers in her research, she will design an
intervention that is consistent with their values, preferences, and goals. Ultimately, this proposal will allow Dr.
Wolf to build a larger research program to investigate system-oriented, patient-centered solutions to reduce low-
value care for children.
