High-value care, stewardship and avoiding low-value interventions — formative SAQs

SAQ 1 (10 marks)

You are the registrar in a busy paediatric emergency department. A two-year-old with a clear viral upper respiratory infection is prescribed antibiotics by a colleague "to reassure the family", and a parent on a nearby trolley is asking why their child, who meets a low-risk head-injury rule, is not being scanned. [1]

1. Define high-value and low-value care, and explain how the antibiotic prescription and the omitted scan both illustrate principles of stewardship. (3) [8]
2. Describe the mechanism by which an unnecessary test or treatment harms a child, using the concept of the care cascade and overdiagnosis. (4) [14] [5]
3. Outline how you would counsel the parent requesting the scan so that restraint is understood as good care rather than denial. (3) [13] [9]

Model answer

High-value care maximises a child's benefit relative to harm and cost; low-value care is a test or treatment whose likely harm or cost exceeds its likely benefit. [8] The antibiotic is low-value because a viral illness will not respond to it and the prescription carries resistance, adverse-drug and demand harms, while the omitted scan is high-value restraint because, at low pre-test probability, computed tomography yields more false positives and cascades than true findings. [1] [16]

An unnecessary test seeds a care cascade: applied to a low-risk child it throws up a false positive or incidentaloma, prompting confirmatory imaging, biopsy and further intervention, with attendant radiation, anxiety and cost. [14] Overdiagnosis compounds this by labelling a true but clinically irrelevant finding, so the child is treated for a condition that would never have caused harm. [5]

To counsel the parent, I would first acknowledge and validate their worry rather than dismiss it, then explain in plain terms that, at their child's low risk, a scan is more likely to cause harm than to help. I would share the decision, set out the safety-net and clear return precautions, and frame restraint as the higher-value choice that protects their child. [13] [9]

SAQ 2 (10 marks)

Your department has the highest rate of routine pre-operative blood tests in otherwise healthy children in the network, and the medical lead asks you to lead a de-implementation effort. [13]

1. Outline the stepwise de-implementation cycle you would follow, in the correct order. (4) [9]
2. Describe the clinician, family and system drivers of overuse, and why naming them matters for choosing a lever. (3) [9]
3. Explain how you would demonstrate that the campaign was successful, and what you would monitor to guard against harm. (3) [8]

Model answer

I would follow the de-implementation cycle: identify the low-value practice using Choosing Wisely recommendations and local report, measure the baseline rate and its variation and cost to set a tractable target, diagnose the drivers, engage clinicians and families to build consensus to stop, de-implement with combined levers such as order sets, decision support and audit with feedback, and then sustain and monitor by re-measuring and guarding against re-adoption. [9] [13]

The drivers sit in three domains. Clinician drivers include habit, fear of intra-operative surprise and unfamiliarity with the evidence; family drivers include the expectation that "preparation" means testing; and system drivers include the ease of ordering, default order sets and the absence of feedback. [9] Naming the driver matters because the lever must match it: a habit needs audit and feedback, a default needs a changed order set, and a family expectation needs a decision aid and explanation. [13]

Success is not a fall in the target practice alone. I would demonstrate a sustained fall in routine pre-operative testing, with no compensatory rise in underuse of genuinely indicated testing, no rise in peri-operative adverse events, and sustained family satisfaction. [8] Monitoring both directions — overuse and underuse — is the test of a safe and durable campaign. [8] [14]