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Introduction: There are many initiatives aimed at eliminating health care interventions of limited utility in clinical practice. The Committee on Care Quality and Patient Safety of the Spanish Association of Pediatrics has proposed the development of << do not do >> recommenda-tions (DNDRs) to establish a series of practices to be avoided in the care of paediatric patients in primary, emergency, inpatient and home-based care. Material and methods: The project was carried out in 2 phases: a first phase in which possible DNDRs were proposed, and a second in which the final recommendations were established by consensus using the Delphi method. Recommendations were proposed and evaluated by mem-bers of the professional groups and paediatrics societies invited to participate in the project under the coordination of members of the Committee on Care Quality and Patient Safety. Results: A total of 164 DNDRs were proposed by the Spanish Society of Neonatology, the Spanish Association of Primary Care Paediatrics, the Spanish Society of Paediatric Emergency Medicine, the Spanish Society of Internal Hospital Paediatrics and the Medicines Committee of the Spanish Association of Pediatrics and the Spanish Group of Paediatric Pharmacy of the Spanish Society of Hospital Pharmacy. The initial set was limited to 42 DNDRs, and the selection over successive rounds yielded a final set of 25 DNDRs, with 5 DNDRs for each paediatrics group or society. Conclusions: This project allowed the selection and establishment by consensus of a series of recommendations to avoid unsafe, inefficient or low-value practices in different areas of paediatric care, which may contribute to improving the safety and quality of paediatric clinical practice. (c) 2023 Asociacion Espanola de Pediatria. Published by Elsevier Espana, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).

In the United States (US), 25% of healthcare spending is considered wasteful because it is spent reimbursing low-value care. Low-value care is the utilization of healthcare services, medical tests, and procedures that have unclear or no clinical benefit to patients but still exposes them to risk. World-wide, low-value care imposes a significant economic burden on patients, payers, governments, and society. Cancer care among older adults > 65 years is one of the biggest drivers of healthcare expenditure in the US and accounts for nearly 40% of all spending, and low-value care among cancer patients is prevalent and contributes to the financial toxicity of cancer treatment. To date, no study has examined the risk of low-value non-cancer care among patients with cancer. There is a critical need to assess the prevalence of low-value non-cancer care in patients diagnosed with cancer and the risk factors associated with the receipt of low-value care. To fill the knowledge gap, the three related aims of this dissertation were (1) To assess the association of incident cancer (breast, prostate, colorectal, and Non-Hodgkin’s lymphoma) to low-value non-cancer care among older Medicare beneficiaries using machine learning methods. (2) To assess the association of incident cancer (breast, colorectal, prostate, ovarian, uterine, and Non-Hodgkin’s lymphoma) to annual wellness visit utilization among older adults using machine learning methods. (3) To examine the association of low-value care to economic burden (out-of-pocket expenditure) of older cancer survivors (breast, prostate, colorectal, and Non-Hodgkin’s lymphoma) using machine-learning methods. The study used a retrospective cohort study design, leveraging multiple years (2005-2015) of the cancer registry data from the Surveillance, Epidemiology and End Results (SEER) program linked with the Medicare claims data, the American community survey census tract files, and the Area Health Resource Files. In the first aim, among elderly Medicare beneficiaries with incident breast, colorectal, prostate cancers, and non-Hodgkin’s lymphoma (N = 329,267) the rates of low-value care differed significantly by cancer type; the highest rates were observed in Non-Hodgkin’s lymphoma (34%) followed by colorectal cancer (29% ) while the lowest rates were among patients diagnosed with prostate cancer (22%). The most used low-value care services were population-based screening for detection of carotid artery disease (10%), low-value MRI for low back pain (9.8%), traction for low back pain (5%); the association of cancer to low-value care varied by cancer type; both colorectal cancer and NHL were positively associated with low-value care, but breast and prostate cancers were negatively associated with low-value care. In the Second aim, among elderly Medicare beneficiaries diagnosed with incident breast, colorectal, prostate, ovarian, uterine cancer, or Non-Hodgkin’s lymphoma in 2014 (N = 36,447), only one in five eligible adults received an AWV in 2015. Overall, 16.5% of the cohort had an AWV in 2015. The AWV rate in the non-cancer cohort was 16.7%. AWV rates were high among individuals with breast (20%) and prostate (19%) cancer, followed by uterine cancer (16%) and NHL (13%). The lowest rates were among individuals with ovarian cancer (7.5%). In the third aim, among elderly Medicare beneficiaries diagnosed with incident breast, colorectal, prostate and non-Hodgkin’s lymphoma (N = 27,067), Individuals who received one or more low-value procedure had significantly higher mean out-of-pocket expenditure ($8,726±$7,214) vs. ($6,802±$6,102) compared to those who did not have low-value care in the follow-up period. On average, patients who received a low-value procedure experienced between $1,000 and $2,000 higher out-of-pocket expenditure attributable to low-value care. The machine learning models identified low-value care, fragmentation of care, and a higher number of pre-existing chronic conditions to be the most important factors driving excess out-of-pocket expenditure.

Objective: To examine the association between patient- and provider-level characteristics and utilization of five low-value health care services and to estimate the prevalence and costs of those services. Methods: This study uses 2012 administrative claims data from an Upper Midwest health plan on enrollees who were at risk of receiving five commonly overused services, including: (1) Pap tests performed on females younger than 21 years old. (2) HPV tests performed on females younger than 30 years old. (3) PSA tests performed on male patients 75 years and older. (4) Colorectal cancer screening tests performed on patients older than 75 years old. (5) Imaging tests for non-specific low back pain within four weeks of diagnosis. I used a two-level mixed-effects probit model to estimate the association between patient and provider characteristics and occurrence of selected services. Results: The prevalence varied across services from 2.3 percent to 17.4 percent, and generated $1.38 million in allowed charges in one year. Probabilities of cervical cancer screening overuse increased with age for girls, and the probabilities for prostate and colorectal cancer screening declined with age for the elderly. Individuals with moderate and high health risks were more likely to receive low-value services, but the probability decreased for the highest risk category. Medicare enrollment was associated with increased utilization of low-value preventive cancer screenings. Some neighborhood socio-economic determinants were associated with overuse; these included a greater proportion of White residents, less well-educated residents, and neighborhoods with low poverty rate. After controlling for both patient and provider characteristics, overuse was positively associated with older providers, specialists, and physicians, as opposed to other non-physician clinicians. Conclusions: Overall, this study expanded on prior literature by examining additional provider characteristics associated with overuse. The patient- and provider level correlates and their relative contribution varied for the five selected services.