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Health Care Quality

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Researchers examine ways to measure the quality of health services for children and adolescents

Extensive quality problems have been documented across all sectors of health services for children and adolescents. For example, problems persist in asthma care, well-child and adolescent care, childhood immunization rates, and sexually transmitted disease screening for adolescents. Many other problems in children's health care delivery are not being adequately measured and monitored.

A January 2004 supplement to the journal Pediatrics 113(1) is focused on measuring the quality of children's health care as a key step in quality improvement. The supplement was edited by Denise Dougherty, Ph.D., Director of the Agency for Healthcare Research and Quality's Child Health Research Program, and Lisa Simpson M.B., B.Ch., M.P.H., F.A.A.P., formerly Deputy Director of AHRQ, and now the ACH Guild Endowed Chair, Child Health Policy, University of South Florida. The conference was sponsored in part by the Agency for Healthcare Research and Quality. The four papers included in the supplement are briefly summarized here. Reprints of AHRQ staff-authored articles are available from the AHRQ Clearinghouse as noted.

Dougherty, D., and Simpson, L.A., "Measuring the quality of children's health care: A prerequisite to action," pp. 185-198.

The authors summarize the results of the 2-day invitational expert meeting that was informed by the other three commissioned papers in the journal supplement. The authors note that although substantial progress has been made in the development of quality measures and the implementation of quality improvement strategies for children's health care, interest in quality of care for children lags behind that for adult conditions and disorders. Quality measures for children are scarce in many areas, including patient safety, end-of-life care, mental health care, oral health care, neonatal care, care for school-aged children, and coordination of care. Also, many of the available measures are not being applied regularly.

To improve the availability and use of quality measures, the meeting participants recommended that at least four activities be identified as national priorities: building public support for quality measurement and improvement in children's health care; creating an information technology infrastructure that can facilitate collection and use of data; improving the reliability, validity, and feasibility of existing measures; and creating the evidence base for measures development and quality improvement.

Reprints (AHRQ Publication No. 04-R026) are available from the AHRQ Publications Clearinghouse.

Beal, A.C., Co, J.P., Dougherty, D., and others, "Quality measures for children's health care," pp. 199-209.

These investigators identified and collected current health care quality measures for child health. Subsequently, they categorized and classified measures and identified gaps in child health care quality measures requiring additional development. Overall, they identified 19 measure sets and 396 measures to assess children's health care quality. The distribution of measures in health care quality domains was as follows: safety, 14.4 percent; effectiveness, 59.1 percent; patient-centeredness, 32.1 percent; and timeliness, 33.3 percent. The distribution of measures in the patient-perspective domains was: staying healthy, 24 percent; getting better, 40.2 percent; living with illness, 17.4 percent; end of life, 0 percent; and multidimensional 23.5 percent.

Most of the measures were meant for use in the general pediatric population (81.1 percent), with a significant proportion designed for children with special health care needs (18.9 percent). The majority of measures could be applied to children across all age groups, but there were few measures designed specifically for each developmental stage. The application of current measures to assess care disparities has been limited. These areas need additional research and development for a more complete assessment of health care quality for children.

Reprints (AHRQ Publication No. 04-R025) are available from the AHRQ Publications Clearinghouse.

Kuhlthau, K., Ferris, T.G., and Iezzoni, L.I., "Risk adjustment for pediatric quality indicators," pp. 210-216.

One challenge in quality measurement is to ensure that quality comparisons among doctors, groups of doctors, hospitals, or health plans are not adversely affected by the likelihood that different types of patients seek care in different places. However, adjustment for patient risk factors in pediatric quality measures has received little scrutiny. The areas that have generated attention, such as neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) outcomes, represent acute, high-technology care that is needed by only some children.

In this paper, the investigators go beyond the NICU setting to consider risk adjustment for pediatric quality measures more broadly. In particular, they review the conceptual background for risk-adjusting quality measures, present policy issues related to adjusting pediatric quality measures, and catalog existing risk adjustment methodologies for these measures. They conclude with an overall assessment of the status of risk adjustment for pediatric quality measures and recommendations for additional research and application.

Shaller, D., "Implementing and using quality measures for children's health care: Perspectives on the state of the practice," pp. 217-227.

This author examined the issues, obstacles, and priorities related to implementing and using child health care quality measures from the perspective of four groups: funders of quality-measurement development and implementation; developers of quality measures; users of quality measures (for example, Medicaid, employer coalitions, and consumer groups); and health plans and providers. Funders and developers cite several major issues and challenges.

These range from a dearth of trained capacity in the field to conduct needed research and development to lack of clear and compelling evidence that quality measurement and improvement actually result in better outcomes for children. The three most common successes cited across all four groups are: the growing consensus and collaboration among diverse stakeholder groups involved in measurement development and implementation; the increasing collection and use of a few specific measures; and early documentation of tangible results in terms of improved quality of care.

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