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TABLE 1

Claims-Based Measures of 20 Low-Value Services in Children

No.ServiceInclusion CriteriaExclusion CriteriaDenominator
Population-based screening for vitamin D deficiency 25-hydroxy vitamin D blood test No diagnosis potentially warranting testing on day of test or previous 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 
   No diagnosis of vitamin D deficiency in previous claimsa  
   No diagnosis indicating pregnancy on day of test  
   Exclude children with complex chronic conditionsb (eg, children with risk factors for severe vitamin D deficiency, such as malabsorption or poor nutrition)  
Skin prick test or IgE blood tests in children with atopic dermatitis Skin prick test or allergen-specific IgE blood test and diagnosis of atopic dermatitis on day of test No other diagnoses potentially warranting testing on day of test (food allergy, anaphylaxis, asthma, allergic or chronic rhinitis, allergic conjunctivitis, allergic colitis or gastroenteritis, history of penicillin allergy) Children with a diagnosis of atopic dermatitis during the year 
Testing for RSV in children with bronchiolitis Test for RSV (eg, rapid RSV test) or respiratory viral panel and diagnosis of bronchiolitis on day of test Exclude infants aged <90 d (may be part of a sepsis workup) Children with a diagnosis of bronchiolitis during the year 
   Exclude testing associated with hospitalizationc (may be required for grouping patients per hospital policy)  
   Exclude children who received Synagis prophylaxis in the previous 30 d (breakthrough RSV infection may prompt discontinuation of prophylaxis)  
   Exclude children with complex chronic conditionsb (could influence decision to initiate influenza therapy in these high-risk patients)  
Blood tests in children with a simple febrile seizure Blood cell count or electrolytes and diagnosis of simple febrile seizure on day of test 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 
   No diagnosis for complex febrile seizure, vomiting and/or diarrhea, or dehydration on day of test (could warrant blood or electrolyte testing)  
   Exclude testing associated with hospitalizationc  
   Exclude children with complex chronic conditionsb (eg, children with epilepsy or congenital neurologic anomalies)  
Cervical cancer screening with human papilloma virus test or Papanicolaou test in children Human papilloma virus test or Papanicolaou test No diagnosis potentially warranting testing on day of test or previous claima (abnormal Papanicolaou test, dysplasia or malignancy of cervix, vagina, and /or vulva) Female children aged ≥14 y 
   Exclude children with complex chronic conditionsb (eg, children with HIV or other immunodeficiency)  
Testing for Group A Streptococcus pharyngitis in children aged <3 y Test for Group A Streptococcus pharyngitis (eg, rapid strep test or throat culture) in children aged <3 y Exclude testing associated with hospitalizationc Children aged <3 y 
   No diagnosis indicating exposure to communicable diseases on day of test (eg, sick contact with strep throat)  
   Exclude children with complex chronic conditionsb (eg, children with immunodeficiency)  
Face or nose radiograph in children with head or face trauma 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 
Ultrasound in children with cryptorchidism Ultrasound of scrotum, pelvis, abdomen, or retroperitoneum and diagnosis of cryptorchidism on day of test 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 
   No diagnosis potentially warranting imaging on day of test or previous claima (indeterminate sex, adrenogenital disorder, hypospadias, obesity)  
Sinus imaging in children with acute sinusitis Paranasal sinus radiograph, maxillofacial CT scan, or face MRI and diagnosis of acute sinusitis on day of test No diagnosis of acute sinusitis between 180 and 30 d before imaging Children with a diagnosis of acute sinusitis during the year 
   No diagnosis of chronic sinusitis on day of imaging or previous 180 d  
   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)  
   Exclude imaging associated with hospitalizationc  
   Exclude children with complex chronic conditionsb (eg, children with cystic fibrosis or immunodeficiency)  
10 Neuroimaging in children with a simple febrile seizure Head CT scan or brain MRI and diagnosis of simple febrile seizure on day of test No other diagnosis potentially warranting imaging on day of test (complex febrile seizure, focal neurologic examination abnormalities, head or face trauma) Children with a diagnosis of simple febrile seizure during the year 
   Exclude imaging associated with hospitalizationc  
   Exclude children with complex chronic conditionsb (eg, children with epilepsy, congenital neurologic anomalies, ventriculoperitoneal shunt)  
11 Neuroimaging in children with headache Head CT scan or brain MRI and diagnosis of headache on day of test in children No diagnosis potentially warranting imaging on day of test (convulsions, syncope, head or 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 
   Exclude imaging associated with hospitalizationc  
   Exclude children with complex chronic conditionsb (eg, children with cancer or hydrocephalus)  
12 Cough and cold medications in children aged <6 y Drug claim for cough or cold medicationd in children aged <6 y No additional exclusions Children aged <6 y 
13 Oral antibiotics for acute upper respiratory infections Drug claim for oral antibiotic 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 
14 Oral antibiotics for acute OME Drug claim for oral antibiotic within 3 d of a diagnosis of acute OME 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 
   No diagnosis of acute OME between 180 and 90 d before the index diagnosis  
   No diagnosis of chronic OME on the day of the index diagnosis or in the previous 180 d  
15 Oral antibiotics for acute otitis externa Drug claim for oral antibiotic within 3 d of a diagnosis of acute otitis externa 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 
   No diagnosis of acute otitis externa during the 30 d before the index diagnosis  
   No diagnosis of chronic or malignant otitis externa on the same day of the index diagnosis or during the previous 180 d  
   Exclude children with complex chronic conditionsb (eg, children with immunodeficiency)  
16 Oral antibiotics after tonsillectomy Drug claim for oral antibiotic within 3 d of tonsillectomy 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 
   Exclude children with complex chronic conditionsb (eg, children requiring endocarditis prophylaxis because of heart disease or implants)  
17 Oral antibiotics for bronchiolitis Drug claim for oral antibiotic within 3 d of a diagnosis of bronchiolitis 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 
18 Oral corticosteroids for bronchiolitis Drug claim for oral corticosteroid within 3 d of a diagnosis of bronchiolitis Exclude children with complex chronic conditionsb (eg, children taking steroids for other conditions) Children with a diagnosis of bronchiolitis during the year 
19 Short-acting β-agonists for bronchiolitis Drug claim for inhaled short-acting β-agonist within 3 d of a diagnosis of bronchiolitis 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 
   Exclude children with complex chronic conditionsb (eg, patients with chronic lung disease)  
20 Acid blockers for infants with uncomplicated gastroesophageal reflux Drug claim for oral H2 blocker or oral proton pump inhibitor in infants aged <1 y No diagnosis potentially warranting acid blockade on the same day of drug claim or in previous claima (failure to thrive, wt loss, underweight, irritability, excessive crying, apnea, apparently life-threatening event, gastritis, peptic ulcer, gastrointestinal bleed) Infants aged <1 y 
   Exclude children with complex chronic conditionsb (eg, children with risk factors for severe gastroesophageal reflux disease, such as neurologic impairment)  
No.ServiceInclusion CriteriaExclusion CriteriaDenominator
Population-based screening for vitamin D deficiency 25-hydroxy vitamin D blood test No diagnosis potentially warranting testing on day of test or previous 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 
   No diagnosis of vitamin D deficiency in previous claimsa  
   No diagnosis indicating pregnancy on day of test  
   Exclude children with complex chronic conditionsb (eg, children with risk factors for severe vitamin D deficiency, such as malabsorption or poor nutrition)  
Skin prick test or IgE blood tests in children with atopic dermatitis Skin prick test or allergen-specific IgE blood test and diagnosis of atopic dermatitis on day of test No other diagnoses potentially warranting testing on day of test (food allergy, anaphylaxis, asthma, allergic or chronic rhinitis, allergic conjunctivitis, allergic colitis or gastroenteritis, history of penicillin allergy) Children with a diagnosis of atopic dermatitis during the year 
Testing for RSV in children with bronchiolitis Test for RSV (eg, rapid RSV test) or respiratory viral panel and diagnosis of bronchiolitis on day of test Exclude infants aged <90 d (may be part of a sepsis workup) Children with a diagnosis of bronchiolitis during the year 
   Exclude testing associated with hospitalizationc (may be required for grouping patients per hospital policy)  
   Exclude children who received Synagis prophylaxis in the previous 30 d (breakthrough RSV infection may prompt discontinuation of prophylaxis)  
   Exclude children with complex chronic conditionsb (could influence decision to initiate influenza therapy in these high-risk patients)  
Blood tests in children with a simple febrile seizure Blood cell count or electrolytes and diagnosis of simple febrile seizure on day of test 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 
   No diagnosis for complex febrile seizure, vomiting and/or diarrhea, or dehydration on day of test (could warrant blood or electrolyte testing)  
   Exclude testing associated with hospitalizationc  
   Exclude children with complex chronic conditionsb (eg, children with epilepsy or congenital neurologic anomalies)  
Cervical cancer screening with human papilloma virus test or Papanicolaou test in children Human papilloma virus test or Papanicolaou test No diagnosis potentially warranting testing on day of test or previous claima (abnormal Papanicolaou test, dysplasia or malignancy of cervix, vagina, and /or vulva) Female children aged ≥14 y 
   Exclude children with complex chronic conditionsb (eg, children with HIV or other immunodeficiency)  
Testing for Group A Streptococcus pharyngitis in children aged <3 y Test for Group A Streptococcus pharyngitis (eg, rapid strep test or throat culture) in children aged <3 y Exclude testing associated with hospitalizationc Children aged <3 y 
   No diagnosis indicating exposure to communicable diseases on day of test (eg, sick contact with strep throat)  
   Exclude children with complex chronic conditionsb (eg, children with immunodeficiency)  
Face or nose radiograph in children with head or face trauma 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 
Ultrasound in children with cryptorchidism Ultrasound of scrotum, pelvis, abdomen, or retroperitoneum and diagnosis of cryptorchidism on day of test 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 
   No diagnosis potentially warranting imaging on day of test or previous claima (indeterminate sex, adrenogenital disorder, hypospadias, obesity)  
Sinus imaging in children with acute sinusitis Paranasal sinus radiograph, maxillofacial CT scan, or face MRI and diagnosis of acute sinusitis on day of test No diagnosis of acute sinusitis between 180 and 30 d before imaging Children with a diagnosis of acute sinusitis during the year 
   No diagnosis of chronic sinusitis on day of imaging or previous 180 d  
   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)  
   Exclude imaging associated with hospitalizationc  
   Exclude children with complex chronic conditionsb (eg, children with cystic fibrosis or immunodeficiency)  
10 Neuroimaging in children with a simple febrile seizure Head CT scan or brain MRI and diagnosis of simple febrile seizure on day of test No other diagnosis potentially warranting imaging on day of test (complex febrile seizure, focal neurologic examination abnormalities, head or face trauma) Children with a diagnosis of simple febrile seizure during the year 
   Exclude imaging associated with hospitalizationc  
   Exclude children with complex chronic conditionsb (eg, children with epilepsy, congenital neurologic anomalies, ventriculoperitoneal shunt)  
11 Neuroimaging in children with headache Head CT scan or brain MRI and diagnosis of headache on day of test in children No diagnosis potentially warranting imaging on day of test (convulsions, syncope, head or 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 
   Exclude imaging associated with hospitalizationc  
   Exclude children with complex chronic conditionsb (eg, children with cancer or hydrocephalus)  
12 Cough and cold medications in children aged <6 y Drug claim for cough or cold medicationd in children aged <6 y No additional exclusions Children aged <6 y 
13 Oral antibiotics for acute upper respiratory infections Drug claim for oral antibiotic 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 
14 Oral antibiotics for acute OME Drug claim for oral antibiotic within 3 d of a diagnosis of acute OME 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 
   No diagnosis of acute OME between 180 and 90 d before the index diagnosis  
   No diagnosis of chronic OME on the day of the index diagnosis or in the previous 180 d  
15 Oral antibiotics for acute otitis externa Drug claim for oral antibiotic within 3 d of a diagnosis of acute otitis externa 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 
   No diagnosis of acute otitis externa during the 30 d before the index diagnosis  
   No diagnosis of chronic or malignant otitis externa on the same day of the index diagnosis or during the previous 180 d  
   Exclude children with complex chronic conditionsb (eg, children with immunodeficiency)  
16 Oral antibiotics after tonsillectomy Drug claim for oral antibiotic within 3 d of tonsillectomy 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 
   Exclude children with complex chronic conditionsb (eg, children requiring endocarditis prophylaxis because of heart disease or implants)  
17 Oral antibiotics for bronchiolitis Drug claim for oral antibiotic within 3 d of a diagnosis of bronchiolitis 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 
18 Oral corticosteroids for bronchiolitis Drug claim for oral corticosteroid within 3 d of a diagnosis of bronchiolitis Exclude children with complex chronic conditionsb (eg, children taking steroids for other conditions) Children with a diagnosis of bronchiolitis during the year 
19 Short-acting β-agonists for bronchiolitis Drug claim for inhaled short-acting β-agonist within 3 d of a diagnosis of bronchiolitis 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 
   Exclude children with complex chronic conditionsb (eg, patients with chronic lung disease)  
20 Acid blockers for infants with uncomplicated gastroesophageal reflux Drug claim for oral H2 blocker or oral proton pump inhibitor in infants aged <1 y No diagnosis potentially warranting acid blockade on the same day of drug claim or in previous claima (failure to thrive, wt loss, underweight, irritability, excessive crying, apnea, apparently life-threatening event, gastritis, peptic ulcer, gastrointestinal bleed) Infants aged <1 y 
   Exclude children with complex chronic conditionsb (eg, children with risk factors for severe gastroesophageal reflux disease, such as neurologic impairment)  

CT, computed tomography; IgE, immunoglobulin E; OME, otitis media with effusion; RSV, respiratory syncytial virus.

a

“Previous claim” refers to all claims from January 1, 2013, to the day before the service.

b

Defined as children with an ICD-9-CM diagnosis or procedure code indicating a complex chronic condition on any claim from January 1, 2013, to the day of the service; codes were based on a widely used algorithm.25 

c

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

d

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

e

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

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