Right Care for Children: Top Five Do's and Don'ts


Am Fam Physician. 2019 Mar 15;99(6):376-382.

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Author disclosure: No relevant financial affiliations.

Underuse and overuse of medical interventions, failure to use interventions known to be effective, and provision of tests or interventions in which benefits do not exceed harms are types of low-value care. The Lown Institute's Right Care Alliance Children's Health Council identified five “do” recommendations that highlight underuse and five “don't” recommendations that highlight overuse in children's health care. The five “do” recommendations include: do provide access to long-acting reversible contraception for adolescents, do use nonpharmacologic interventions first for treatment of attention-deficit/hyperactivity disorder, do discuss quality of life for children with complex medical conditions using a shared decision-making model and access resources such as palliative care subspecialists, do promote childhood literacy development by providing free, age-appropriate books in clinical settings, and do screen for socioeconomic status of the patient and family and provide access to community health and wellness resources. The five “don't” recommendations include: don't routinely prescribe antibiotics in children two to 12 years of age with a middle ear infection, don't perform computed tomography of the head for children with minor head trauma, don't use albuterol in children with bronchiolitis, don't routinely screen for hyperlipidemia in children and adolescents, and don't routinely perform preparticipation sports evaluations. These 10 examples of underuse and overuse were identified with the intent of improving health care value and promoting “Right Care.”

Underuse and overuse of medical interventions, failure to use interventions known to be effective, and provision of tests or interventions in which benefits do not exceed harms are all types of low-value care.1,2 American Family Physician has addressed overuse in health care in previous discussions of the Choosing Wisely campaign that highlights overuse in an effort to reduce non-beneficial care.3 In this article, the authors discuss recommendations for underuse and overuse from members of the Lown Institute.

The Lown Institute was founded in response to the epidemic of health care underuse and overuse4 and subsequently created the Right Care Alliance, a network of clinicians, patients, and community leaders focused on care that benefits patients. In 2016, the Lown Institute challenged each of its Right Care Alliance councils to develop a list of 10 evidence-based recommendations highlighting opportunities to improve health care value, including five examples of underuse and five examples of overuse.

A subcommittee of the Right Care Alliance Children's Health Council formed a modified Delphi panel, which is a validated method for generating an expert consensus with minimal peer bias through several rounds of anonymous voting, and developed a list of the top 10 do's and don'ts for children's health care based on criteria listed in Table 1. A flowchart depicting the elements involved in the list creation is presented in eFigure A. The initial lists of 31 items are provided in eTable A and eTable B, and the final 10 recommendations are listed in Table 2.543

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Criteria for Selection and Development of Right Care Recommendations

Each recommendation should:

1. Matter to patients.

2. Be an egregious infraction of good care if not followed.

3. Have high potential to benefit or harm.

4. Be rare (underuse) or common (overuse) enough that avoiding or performing the item routinely would move the needle toward the right care.

5. Examine or illustrate how it ties to system failures.


Criteria for Selection and Development of Right Care Recommendations

Each recommendation should:

1. Matter to patients.

2. Be an egregious infraction of good care if not followed.

3. Have high potential to benefit or harm.

4. Be rare (underuse) or common (overuse) enough that avoiding or performing the item routinely would move the needle toward the right care.

5. Examine or illustrate how it ties to system failures.

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Flowchart of modified Delphi panel process from formation to completion of the final list of recommendations.


Flowchart of modified Delphi panel process from formation to completion of the final list of recommendations.

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Initial List of Do Recommendations for Children and Adolescents

Perform mental health screening using a validated tool.

Provide access to long-acting reversible contraception for adolescents.

Use nonpharmacologic interventions as first-line treatment of neonatal abstinence syndrome.

Use nonpharmacologic interventions as first-line treatment of attention-deficit/hyperactivity disorder.

Discuss quality of life for

The Authors

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MATTHEW SCHEFFT, DO, MSHA, is director of quality in the Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, and an assistant professor in the Department of Pediatrics at Virginia Commonwealth University School of Medicine in Richmond....

ALAN R. SCHROEDER, MD, is associate division chief of the Division of Hospital Medicine at Lucile Packard Children's Hospital Stanford, and a clinical professor in the Department of Pediatrics at Stanford (Calif.) University School of Medicine.

DIANE LIU, MD, is director at Utah Pediatric Partnership to Improve Healthcare Quality, and an assistant professor in the Department of Pediatrics at the University of Utah School of Medicine in Salt Lake City.

DANIEL NICKLAS, MD, is the Director of Primary Care Education of the Pediatric Residency Program at Colorado Children's Hospital, and an assistant professor in the Department of Pediatrics at the University of Colorado, Aurora.

JUSTIN MOHER, MD, is fellow of pediatric emergency medicine and global health and clinical instructor at the Texas Children's Hospital, Baylor College of Medicine, Houston.

RICARDO QUINONEZ, MD, is chief of the section of pediatric hospital medicine at Texas Children's Hospital, and associate professor in the Department of Pediatrics at Baylor College of Medicine.

Address correspondence to Matthew Schefft, DO, MSHA, Virginia Commonwealth University School of Medicine, 1001 E. Marshall St., Richmond, VA 23298 (e-mail: matthew.schefft@vcuhealth.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

Editor's Note: AFP has collaborated with the Lown Institute to create a new feature called “Lown Right Care: Reducing Overuse and Underuse.” The goal is to promote a vision for delivering health care that is true to the evidence, balanced in its approach, and focused on the patient. See related editorial at https://www.aafp.org/afp/2018/1115/p560.html.



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