Child care deficits could lead to preventable adverse outcomes

There are deficits in delivery of indicated care to children that are similar in magnitude to those that have been reported for adults, according to new research conducted by RAND, the University of Washington, Seattle Children's Hospital and Regional Medical Center, and the University of California at Los Angeles.

Lead researcher Rita Mangione-Smith tells State Health Watch there has been an assumption for many years that the quality of care for children is quite good. "But that's not a fair assumption unless quality is being measured," she says. "And we haven't been measuring. Because we have not been measuring quality regularly and reporting on performance, people think it's just fine."

But the researchers say the deficits may result in avoidable adverse health outcomes. For example, they say, only 44% of children with asthma who were noted to be using beta-agonists at least three times per day had a prescription for an anti-inflammatory medication recorded in the chart. Similarly, studies of children with persistent asthma have shown that only 39% to 51% were treated with anti-inflammatory medications. Children with persistent asthma who are treated with inhaled anti-inflammatory drugs, as compared with those who are not, have fewer asthma-related symptoms and improved pulmonary function, are hospitalized less frequently, and have lower asthma-related mortality.

Likewise, immunizations are effective in protecting children against a variety of serious childhood diseases. But only 49.8% of children in the study who reached 2 years of age during the study period were fully immunized, according to their records.

According to chart data, urine cultures were obtained for 16.2% of children aged 3 months to 36 months who presented with fever of unknown origin and who were thought to be at high risk for sepsis. The reported prevalence of urinary tract infection is high (4% to 5%) among children 2 months to 2 years of age who have fever without an identified source of infection on the basis of the history and physical examination, the researchers said. Early diagnosis of urinary tract infection might lead to earlier identification of high-grade vesicoureteral reflux, allowing for prevention of recurrent infections, worsening renal damage, and chronic renal failure.

Chlamydia screening down

Only 41.5% of eligible adolescent girls in the study had charts showing evidence of laboratory orders for teats for Chlamydia trachomatis or the results of such testing, as compared with 37% of adolescent girls enrolled in Medicaid and 24% of those with commercial health insurance, according to HEDIS data from 2000. The researchers said chlamydia screening is important because 75% of such infections are asymptomatic and it is reported that 40% of untreated women and adolescents will have pelvic inflammatory disease. Of that 40% of women, 20% will have infertility due to tubal factors and 9% will have life-threatening complications during pregnancy. The researchers said broad-based screening, early detection, and treatment have decreased incidence of pelvic inflammatory disease associated with chlamydia in adolescent girls by 60%, lowering rates of hospitalization and complications.

The researchers said this study has been needed because quality problems so far have been documented mainly from studies of care delivered to adults and the elderly. Previous studies of children have examined few quality measures; have involved self-reported data from parents, patients, or providers; or have been limited to Medicaid enrollees or to a particular geographic region.

"Research and policy related to children have focused on expanding eligibility for public insurance programs, but expanding access to a system that does not deliver necessary services will not result in optimal outcomes," the researchers say. "Deficits in the delivery of care must be identified if appropriate strategies to close the gaps are to be developed and implemented," they point out.

Using a RAND comprehensive method for evaluating quality on the basis of information in medical records, the researchers sought to answer five questions: 1) How good is the quality of care for children overall? 2) Does quality vary according to the type of care (care for acute or chronic medical problems or preventive care)? 3) Does care vary across the continuum of care functions (screening, diagnosis, treatment, and follow-up)? 4) Does quality vary according to the mode of care (history taking, physical examination, laboratory testing or radiography, medication, immunization, encounter, education, or counseling? and 5) Does quality vary according to the type of clinical area?

The researchers say a potential limitation of their work is that the data on which the results are based are 7 to 11 years old, which raises the question of whether today's practice patterns are different. "Although the data in this study are based on recorded care delivered from 1996 to 2000, it seems unlikely that quality has improved substantially since that period," they conclude. "Expansion of access to care through insurance coverage, which is the focus of national health care policy related to children, will not, by itself, eliminate the deficits in the quality of care."

Ms. Mangione-Smith says leadership for improving health care quality for children must come from a number of areas through a multi-faceted approach. First, she says, doctors should assess what they are doing to deliver care in their offices and ask if there is anything they should change or standardize.

One technique that works, she says, is to use structured encounter forms that provide triggers to prompt doctors to ask certain questions during a well-child visit, such as safety issues, immunizations, developmental issues, and screening tests.

Another answer, she says, is to build a better information technology infrastructure in physician practices so reminder notices can be automatically generated and sent to patients when checkups or other medical services are due.

Ms. Mangione-Smith says office visits are currently too short for doctors to have enough time to cover everything that should be covered and allow parents an opportunity to talk about concerns and ask questions. Insurers need to realize their payments are the same no matter how much time the doctor spends, she says, and thus doctors are being incentivized to see more patients rather than to provide high-quality care. "We need to incentivize high-quality care and spending enough time," she declares. She also believes insurers should make sure there is continuity of care when people change jobs and are told they can no longer visit the provider who has been treating them.

A third area to be addressed, according to Ms. Mangione-Smith, is training of physicians. She says their training focuses on acute illness care rather than prevention and wellness. "Most doctors' training time in hospitals involves taking care of very sick kids," she says, "and they learn to do that very well. But they need to learn how to take care of basically well children in an outpatient setting. Our training today is kind of backwards."

Most people who have responded to the study have seen it as a "serious call to action," Ms. Mangione-Smith says, noting there could have been a defensive response from medical professionals but that has not happened. Pediatrics groups, she says, have indicated they see the results as a significant problem that must be addressed.

"I have a great hope about what we're capable of doing," Ms. Mangione-Smith concludes. "But we have a lot of work ahead of us."

Download the study at http://www.nejm.org. Contact lead researcher Rita Mangione-Smith at (206) 221-6631 or e-mail ritams@u.washington.edu.