P4.003: Low-Value Pediatric Care in the United States: Excess Specialty Referrals from Primary Care, A Scoping Review

Purpose/Objectives: Low-value care (LVC)—defined as services that provide little or no clinical benefit—is a major contributor to U.S. healthcare waste, accounting for up to $100 billion annually. In pediatric care, one under-recognized form of LVC is excess or inappropriate specialty referrals from primary care. These referrals may lead to unnecessary travel, care delay, inefficient use of resources, and increased financial burden without improving patient outcomes. Despite these implications, referral practices and their impact remain poorly understood in pediatric settings. In preparation for an improvement/implementation science enterprise initiative to understand and mitigate excess specialty referrals from primary care this scoping review aimed to (1) identify the extent and types of excess specialty referrals in pediatric care, (2) examine associated quality and cost outcomes, and (3) map multilevel drivers of LVC using the Social Ecological Model (SEM).

Design/Methods: This scoping review followed the Joanna Briggs Institute (JBI) methodology and used the Population–Concept–Context (PCC) framework. A comprehensive search was conducted across PubMed, Cochrane Library, and Web of Science for peer-reviewed U.S.-based studies published from 2010–2024. Inclusion criteria focused on pediatric populations ( < 18 years) and studies addressing specialty referrals originating in primary care. Data extraction and thematic analysis were structured according to the SEM framework, which includes personal, interpersonal, organizational, environmental, and policy-level domains.

Results: Thirteen studies met inclusion criteria. High rates of excess referrals were reported in pediatric orthopedics (~50–65%), surgery (~19–40%), and scoliosis care (~40%). Key drivers of over-referral included limited provider training, diagnostic uncertainty, inconsistent referral guidelines, and lack of access to continuing medical education. Disparities were consistently noted, with lower referral completion rates among publicly insured, non-English-speaking, and racially minoritized patients. Health system factors such as specialist shortages, complex scheduling processes, and practice variation contributed to inefficient referrals. Organizational interventions—including referral templates, telemedicine, and clinical decision support—were associated with improved referral clarity and potential cost savings. At the policy level, gatekeeping models influenced referral frequency but had mixed effects on care coordination.

Conclusion/Discussion: Excess specialty referrals represent a significant form of low-value care in pediatrics. Addressing this issue requires a multilevel strategy that includes clinical decision support, guideline development, continuing provider education, and structural policy reform. The SEM framework provides a useful lens for identifying actionable targets across the healthcare ecosystem. Future research should evaluate the effectiveness of targeted interventions and explore long-term impacts on cost, access, and pediatric health outcomes.