Improving Children's Health Through Health Services Research
Children's Health Services Research: An Overview
Children's Health Services Research: An Overview
Improving Children's Health Through Health Services Research was a special 1-day meeting held June 26, 1999, in Chicago. The state of the science in children's health services research was explored, including public and private funding opportunities, networks for conducting research, and uses of research in policy and practice. The meeting was co-sponsored by the National Association of Children's Hospitals and Related Institutions (NACHRI), with the Agency for Health Care Policy and Research (AHCPR), the American Academy of Pediatrics (AAP), the David and Lucille Packard Foundation, the Association for Health Services Research (AHSR), the Robert Wood Johnson Foundation, and Data Harbor, Inc.
Dr. Lisa Simpson, Deputy Administrator of the Agency for Healthcare Research and Quality, welcomed David Helms to the executive leadership of the Association for Health Services Research, noting how his in-depth knowledge of States is particularly timely. She noted how preparing for her talk dramatically increased her appreciation for the work that children's health services researchers had been doing over the past decades, and how reviewing their work confirmed her choice to work in this field.
Dr. Simpson's remarks focused on four substantive areas:
- What is health services research (HSR) and children's health services research (CHSR)?
- What has been accomplished in CHSR?
- Who does and funds CHSR?
- What are future needs and strategies?
The field of health services research was most recently defined by the Institute of Medicine in 1995. Although CHSR still lacks its own definition as a field, specialized attention to children by HSR is essential because of the "4 Ds" that generally differentiate children from adults:
- Developmental change.
- Differential epidemiology (of health conditions and health services).
In 1998, Christopher Forrest articulated a goal for CHSR that is worthy of debate and consideration as the field develops.
To use scientific inquiry to inform decisions on:
- How to improve health systems for children and adolescents.
- How to improve child and adolescent health at the level of both individuals and populations.
Although CHSR is still emerging as a field, it has made substantial contributions, which were illustrated by Dr. Simpson with the use of the HSR "Pipeline of Investment" as an organizing framework.
Priority I of the pipeline is the development of new knowledge on priority health issues.
Here CHSR has made significant contributions as it:
- Demonstrated the critical role of insurance in children's health and health care.
- Articulated the impacts of differences in the organization and delivery of care for children.
- Showed that children, just like adults, experience unexplained variations in care.
- Rigorously tested the impacts (outcomes) of clinical interventions and policy alterations.
- Unearthed problems in quality of care for children.
Priority II of the pipeline refers to developing new tools and talent for a new century.
In this area, CHSR has been active in developing the new research methods that are essential because of the nature of children and their health care needs.
These tools include:
- Outcomes and quality measures.
- Databases for research and monitoring.
- Research networks.
Multiple government and private mechanisms for training new CHSR researchers exist, although more are needed.
Priority III addresses the critical issue of translating research into practice and policy.
This need was articulated by Robert Haggerty and his colleagues in 1975, and is reinforced whenever HSR funding agencies appear before Congressional appropriations committees. Past contributions of CHSR to translating research into (clinical) practice (TRIP) include work that supported the elimination of unnecessary services such as routine chest x-rays in childhood and the move of certain screening practices (e.g., lead) to only high-risk populations of children.
Currently, TRIP efforts include the many research-based quality improvement efforts under way in delivery of preventive services and neonatal services and care for specific conditions such as hyperbilirubinemia and asthma. In the policy arena, research on the critical role of health insurance for children would not have been worthwhile except for the sustained efforts to bring this knowledge to the attention of policymakers.
Growth and Funding
Dr. Simpson noted how the fields of HSR and CHSR have grown. Among the noteworthy developments in CHSR in recent years have been the increasing number of HSR submissions and presentations at the APA program at the Pediatric Academic Societies meetings, and the creation of the Center for Child Health Research at the American Academy of Pediatrics. The Packard-Foundation-funded directory of CHSR researchers compiled by NACHRI is still in draft, but contains information on 500 self-identified CHSR.
Funding for CHSR comes from private and public sources. Principal among the Federal agencies are AHRQ, the Maternal and Child Health Bureau in the Health Resources and Services Administration, and, at the National Institutes of Health, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and the National Institute of Child Health and Human Development.
Future Challenges and Strategies
Despite a series of remarkable accomplishments in CHSR, the investment in CHSR to date has been inadequate to meet the current and future needs of children and adolescents, said Dr.Simpson.
Pressing needs for the attention of CHSR include:
- The States' implementation of the State Children's Health Insurance Program, due to be evaluated by 2001.
- Continuing changes in the organization and delivery of care, much of whose impact on children is unknown.
- The health of ethnic minority children and of adolescents.
Dr Simpson articulated five strategies that will contribute to the ability of CHSR to meet these and future needs of the field and of children, and noted how the rest of the day's program would help flesh out the needed approaches:
- Increase the overall investment in CHSR. There is a new policy on inclusion of children in research supported by the National Institutes of Health and AHRQ and a new emphasis on children as a priority population in the AHRQ reauthorization bill.
- Make a concerted effort to increase the size and diversity of the CHSR workforce. This includes investing in career development for young investigators and expanding the number of disciplines engaged in CHSR.
- Foster the infrastructure for CHSR. Develop Centers of Excellence in CHSR, build more and stronger research networks, and structure innovative collaborations among researchers and funders.
- Be driven by the needs of the user of research. This will facilitate the timely application of findings to enhance the health of children.
- Communicate more effectively the value and contributions of CHSR. This will help CHSR to be appreciated as the scientific field of inquiry that it is.
Simpson, L.A. Children's Health Services Research: An Overview. Presentation Summary, Improving Children's Health Through Health Services Research, Chicago, June 26, 1999. http://www.ahrq.gov/research/chsrover.htm