TABLE 1.

Claims-Based Measures of 20 Low-Value Pediatric Services

Service No.	Service	Source	Justification	Broad Measure Definition	Narrow Measure Definition (Additional Exclusions)	Denominator
1	Population-based screening for vitamin D deficiency	CW	Because vitamin D deficiency is common, healthy patients at risk should take supplements instead of being tested. Screening is useful for very high-risk patients when laboratory values will be used to determine the aggressiveness of supplementation24,25	25-hydroxy vitamin D blood test	(1) No diagnosis potentially warranting testing on day of test or prior claimsa (osteomalacia, rickets, hyperparathyroidism, osteoporosis, pathologic fracture, obesity, sarcoidosis, hepatic failure, chronic kidney disease, inflammatory bowel disease, cystic fibrosis, celiac disease, failure to thrive, malnutrition, eating disorder, developmental motor delay, long-term glucocorticoid use)	All children
					(2) No diagnosis of vitamin D deficiency in prior claimsa
					(3) No diagnosis indicating pregnancy on day of test
					(4) Exclude children with complex chronic conditionsb (eg, children with risk factors for severe vitamin D deficiency such as malabsorption or poor nutrition)
2	Skin prick test or IgE blood tests in children with atopic dermatitis	CW	Patch testing is more useful for evaluating atopic dermatitis than skin prick tests or IgE blood tests26,27	Skin prick test or allergen-specific IgE blood test and diagnosis of atopic dermatitis on day of test	(1) No other diagnoses potentially warranting testing on day of test (food allergy, anaphylaxis, asthma, allergic or chronic rhinitis, allergic conjunctivitis, allergic colitis/gastroenteritis, history of penicillin allergy)	Children with a diagnosis of atopic dermatitis during the year
3	Testing for RSV in children with bronchiolitis	AAP	Testing is only indicated in the rare situation in which knowledge of the etiologic agent would change clinical management28	Test for RSV (eg, rapid RSV test) or respiratory viral panel and diagnosis of bronchiolitis on day of test	(1) Exclude infants aged <90 d (may be part of a sepsis evaluation)	Children with a diagnosis of bronchiolitis during the year
					(2) Exclude testing associated with hospitalizationc (may be required for cohorting patients per hospital policy)
					(3) Exclude children who received Synagis prophylaxis in the prior 30 d (breakthrough RSV infection may prompt discontinuation of prophylaxis)
					(4) Exclude children with complex chronic conditionsb (could influence decision to initiate influenza therapy in these high-risk patients)
4	Blood tests in children with a simple febrile seizure	AAP	Electrolyte levels are often abnormal in children with simple febrile seizures; incidence of bacteremia is not increased in children with simple febrile seizures29	Blood cell count or electrolytes and diagnosis of simple febrile seizure on day of test	(1) Exclude infants aged <1 y (blood cell count may be part of an evaluation for central nervous system infections in this age group)	Children with a diagnosis of simple febrile seizure during the year
					(2) No diagnosis for complex febrile seizure, vomiting/diarrhea, or dehydration on day of test (could warrant blood or electrolyte testing)
					(3) Exclude testing associated with hospitalizationc
					(4) Exclude children with complex chronic conditionsb (eg, children with epilepsy or congenital neurologic anomalies)
5	Cervical cancer screening with human papillomavirus test or Papanicolaou test in children	CW	Evidence does not support cervical cancer screening before age 21 y in most cases30,31	Human papillomavirus test or Papanicolaou test	(1) No diagnosis potentially warranting testing on day of test or prior claima (abnormal Papanicolaou test result, dysplasia, or malignancy of cervix/vagina/vulva)	Female children aged ≥14 y
		USPTF			(2) Exclude children with complex chronic conditionsb (eg, children with HIV or other immunodeficiency)
6	Testing for group A streptococcal pharyngitis in children aged <3 y	IDSA	Streptococcal pharyngitis (and therefore acute rheumatic fever) are rare before age 3 y32	Test for group A streptococcal pharyngitis (eg, rapid streptococcal test or throat culture) in children aged <3 y	(1) Exclude testing associated with hospitalizationc	Children aged <3 y
					(2) No diagnosis indicating exposure to communicable diseases on day of test (eg, sick contact with strep throat)
					(3) Exclude children with complex chronic conditionsb (eg, children with immunodeficiency)
7	Face or nose radiograph in children with head or face trauma	CW	Radiographs are not sensitive for the detection of facial or nasal fractures in children; CT scans are preferred33–35	Radiographs of face or nose and diagnosis of head or face trauma on same day of test	No additional restrictions	Children with a diagnosis of head or face trauma during the year
8	Ultrasound in children with cryptorchidism	CW	Ultrasound is neither sensitive nor specific for localizing nonpalpable testes36–38	Ultrasound of scrotum, pelvis, abdomen, or retroperitoneum and diagnosis of cryptorchidism on day of test	(1) Exclude imaging in neonates aged ≤28 d (ultrasound may be part of an evaluation for a disorder of sex development in neonatal period)	Children with a diagnosis of cryptorchidism during the year
					(2) No diagnosis potentially warranting imaging on day of test or prior claima (eg, indeterminate sex, adrenogenital disorder, hypospadias, obesity)
9	Sinus imaging in children with acute sinusitis	CW	Sinus imaging is not routinely necessary to diagnose acute sinusitis39	Paranasal sinus radiograph, maxillofacial CT scan, or face MRI and diagnosis of acute sinusitis on day of test	(1) No diagnosis of acute sinusitis between 180 and 30 d before imaging	Children with a diagnosis of acute sinusitis during the year
					(2) No diagnosis of chronic sinusitis on day of imaging or prior 180 d
					(3) No other diagnosis potentially warranting imaging on day of test (orbital cellulitis, cranial nerve palsy, meningismus, seizures, visual disturbances, exophthalmos, altered mental status, nasal polyps)
					(4) Exclude imaging associated with hospitalizationc
					(5) Exclude children with complex chronic conditionsb (eg, children with cystic fibrosis or immunodeficiency)
10	Neuroimaging in children with a simple febrile seizure	AAP	Evidence does not support need to routinely obtain neuroimaging in children with simple febrile seizures; neuroimaging may involve risks of radiation exposure or procedural sedation29	Head CT or brain MRI and diagnosis of simple febrile seizure on day of test	(1) No other diagnosis potentially warranting imaging on day of test (complex febrile seizure, focal neurologic examination abnormalities, head/face trauma)	Children with a diagnosis of simple febrile seizure during the year
					(2) Exclude imaging associated with hospitalizationc
					(3) Exclude children with complex chronic conditionsb (eg, children with epilepsy, congenital neurologic anomalies, ventriculoperitoneal shunt)
11	Neuroimaging in children with headache	CW	Results of neuroimaging are typically negative in the absence of risk factors for structural disease42–44	Head CT or brain MRI scan and diagnosis of headache on day of test	(1) No diagnosis potentially warranting imaging on day of test (convulsions, syncope, head/face trauma, posttraumatic headache, complicated headache syndromes, bleeding disorders, history of stroke, focal neurologic examination abnormalities)	Children aged ≥12 y with a diagnosis of headache during the year
					(2) Exclude imaging associated with hospitalizationc
					(3) Exclude children with complex chronic conditionsb (eg, children with cancer or hydrocephalus)
12	Cough and cold medications in children aged <6 y	CW	Evidence does not support efficacy; concerns about side effects45,46	Drug claim for cough or cold medicationd in children aged <6 y	No additional exclusions	Children aged <6 y
		CC
13	Oral antibiotics for acute upper respiratory infections	CW	Evidence does not support efficacy; concerns about side effects and antibiotic resistance47	Drug claim for oral antibiotics within 3 d of a diagnosis of acute upper respiratory infection	No other diagnosis potentially warranting oral antibiotics on the same day of the index diagnosis of acute upper respiratory infection or in the following 3 de	Children with a diagnosis of acute upper respiratory infection during the year
		CC
		NICE
14	Oral antibiotics for acute OME	CW	Evidence does not support efficacy; concerns about side effects and antibiotic resistance48,49	Drug claim for oral antibiotic within 3 d of a diagnosis of acute OME	(1) No other diagnosis potentially warranting oral antibiotics on the same day of the index diagnosis of acute OME or in the following 3 de	Children with a diagnosis of acute OME during the year
		CC			(2) No diagnosis of acute OME between 180 and 90 d before the index diagnosis
		NICE			(3) No diagnosis of chronic OME on the day of the index diagnosis or in the prior 180 d
15	Oral antibiotics for acute otitis externa	CW	Otic antibiotics are the first-line therapy for acute otitis externa50	Drug claim for oral antibiotic within 3 d of a diagnosis of acute otitis externa	(1) No other diagnosis potentially warranting oral antibiotics on the same day of the index diagnosis of acute otitis externa or in the following 3 de	Children with a diagnosis of acute otitis externa during the year
					(2) No diagnosis of acute otitis externa during the 30 d before the index diagnosis
					(3) No diagnosis of chronic or malignant otitis externa on the same day of the index diagnosis or during the prior 180 d
					(4) Exclude children with complex chronic conditionsb (eg, children with immunodeficiency)
16	Oral antibiotics after tonsillectomy	CW	Evidence does not support efficacy; concerns about side effects and antibiotic resistance51,52	Drug claim for oral antibiotic within 3 d of tonsillectomy	(1) No other diagnosis potentially warranting oral antibiotics on the same day of the tonsillectomy or in the following 3 de	Children undergoing tonsillectomy during the year
		CC			(2) Exclude children with complex chronic conditionsb (eg, children requiring endocarditis prophylaxis due to heart disease or implants)
17	Oral antibiotics for bronchiolitis	AAP	Evidence does not support efficacy; concerns about side effects and antibiotic resistance53	Drug claim for oral antibiotic within 3 d of a diagnosis of bronchiolitis	(1) No other diagnosis potentially warranting oral antibiotics on the same day of the index diagnosis of bronchiolitis or in the following 3 de	Children with a diagnosis of bronchiolitis during the year
		NICE
18	Oral corticosteroids for bronchiolitis	CW	Evidence does not support efficacy; concerns about side effects28	Drug claim for oral corticosteroid within 3 d of a diagnosis of bronchiolitis	(1) Exclude children with complex chronic conditionsb (eg, children taking steroids for other conditions)	Children with a diagnosis of bronchiolitis during the year
		AAP
		CC
		NICE
19	Short-acting β-agonists for bronchiolitis	CW	Evidence does not support efficacy; concerns about side effects28,53	Drug claim for inhaled short-acting β-agonist within 3 d of a diagnosis of bronchiolitis	(1) Limit to first-time wheezing (defined as no diagnosis of wheezing, bronchiolitis, or asthma before the index diagnosis of bronchiolitis)	Children with a diagnosis of bronchiolitis during the year
		CC			(2) Exclude children with complex chronic conditionsb (eg, patients with chronic lung disease)
		NICE
20	Acid blockers for infants with uncomplicated gastroesophageal reflux	CW	Reflux in infancy is most often physiologic and does not require treatment; little is known about safety of proton pump inhibitors, particularly in infants54–56	Drug claim for oral histamine2-blocker or oral proton pump inhibitor in infants aged <1 y	(1) No diagnosis potentially warranting acid blockade on the same day of drug claim or in prior claima (failure to thrive, weight loss, underweight, irritability, excessive crying, apnea, apparently life-threatening event, gastritis, peptic ulcer, gastrointestinal bleed)	Infants aged <1 y
		NICE			(2) Exclude children with complex chronic conditionsb (eg, children with risk factors for severe gastroesophageal reflux disease such as neurologic impairment)

AAP, American Academy of Pediatrics; CC, Cochrane Collaboration; CT, computed tomography; CW, Choosing Wisely; IDSA, Infectious Diseases Society of America; IgE, immunoglobulin E; NICE, National Institute for Health and Care Excellence; OME, otitis media with effusion; RSV, respiratory syncytial virus; USPTF, US Preventive Task Force.

^aRefers to all claims from January 1, 2013, until the day before the service.

^bDefined as children with an ICD-9 diagnosis or procedure code indicating a complex chronic condition on any claim from January 1, 2013, until the day of the service; codes were based on a widely used algorithm (see Feudtner et al⁵⁷).

^cDefined as a test occurring on or between the admission and discharge dates for a hospitalization.

^dDefined as medications containing pseudoephedrine, phenylephrine, guaifenesin, dextromethorphan, brompheniramine, chlorpheniramine, homatropine/hydrocodone, codeine/promethazine, and codeine/pyrilamine. Diphenhydramine was excluded because it is commonly used for indications other than cough and cold.

^eBacterial infections such as acute suppurative otitis media, urinary tract infection, pneumonia, and cellulitis.