SOME SUCCESSES, MANY SHORTFALLS IN QUALITY OF HEALTH CARE PROVIDED AMERICAN CHILDREN
New chartbook: up to three-quarters of children and adolescents don't get appropriate care
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April 15, 2004
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Washington, D.C., April 15, 2004—Despite a number of noted successes, American children largely don't get the quality of health care they should, with up to three-quarters of children and adolescents not receiving care scientifically proven or recommended, according to a new overview of children's health care released today by The Commonwealth Fund.
The review, Quality of Health Care for Children and Adolescents: A Chartbook, <http://www.cmwf.org/programs/child/leatherman_pedchartbook_700.pdf> shows a number of clear advances in children's health care and improved outcomes on a series of measures. But it also notes that one-third of children with asthma don't get appropriate controller medications and three-fourths of children with severe mental health problems don't get evaluation or treatment. In addition, it illustrates ongoing racial disparities in care and inadequate attention to widely effective preventive measures.
Distilled from a review of 500 studies, the report illustrates through 40 charts and commentary the quality of care children receive in numerous categories, such as preventive care and treatment of chronic conditions. The chartbook was produced by Sheila Leatherman, research professor at the University of North Carolina School of Public Health, and Douglas McCarthy, president of Issues Research, Inc., based in Durango, CO, in consultation with national experts in child and adolescent care quality.
"Given the fact that we spend far more on health care than other countries, we should be doing better for our children," Leatherman said. "The report shows dangerous lapses in patient safety, substantial shortcomings in providing effective and recommended care, persistent racial and ethnic disparities in care, and widespread failure to provide needed preventive services to teens."
The chartbook does illustrate dramatic progress in some areas, such as reduced hospital-acquired infections in some pediatric intensive care units. It describes efforts that have improved quality of care in such preventive services as lead screening, as well as better health promotion for adolescents. Treatment of acute illness has improved; inappropriate use of antibiotics in children with the common cold has been cut in half as physicians have heeded warnings about the spread of antibiotic-resistant pathogens. And there is clear evidence that significant improvements in quality are possible with careful study to identify deficiencies and implement well-designed interventions to improve delivery of services.
But the chartbook points to serious challenges in many other areas, such as gaps in preventive care and developmental services. In fact, according to the authors, care is deficient in some way in each of the major dimensions of quality studied.
"This chartbook paints a sobering picture of the state of quality for American children," said Commonwealth Fund President Karen Davis. "Unfortunately, that picture is one of a system that not only fails our nation's children, but fails to invest in a future healthy and productive workforce."
According to Leatherman and McCarthy, the U.S. health care system has devoted less attention to measuring and reporting on quality of care for children and adolescents than it has for adults. "We need a better understanding of what quality health care means for children," said McCarthy. "As a society, we too often think of children as little adults. But they aren't. Their unique developmental needs, different disease patterns, and dependency on adults means that quality of health care for children deserves special attention. This report is a start," he added.
Other reasons for the poor state of quality of children's health care include the fragmented "non-system" of care for children that is often difficult for families to negotiate, and less attention to children's health care needs, which consist mostly of preventive and child developmental services.
"These data provide more than enough information for child health care professionals to act to improve quality, but better data would paint a clearer picture of the scope of the problems, and help target these problems with appropriate solutions," said Charles Homer, MD, president and CEO of the National Initiative for Children's Healthcare Quality and chair of the American Academy of Pediatrics Steering Committee on Quality Improvement and Management. "Preventive care is especially important because of the long term impact it has on both developmental and physical well-being. In addition, children with special health care needs or chronic illnesses are particularly dependent on the health care system, and the system is failing them as well. Although the current system appears designed for acute care issues, even in this area we find substantial gaps in the quality of care."
The report's charts are broken into areas similar to those outlined in the Institute of Medicine report, Crossing the Quality Chasm, which outlined goals for improvement in the health care system generally. Highlights include:
Effectiveness - Staying Healthy
* One-quarter of young children don't get all recommended doses of five key vaccines on time. Rates vary widely, from 14% of children in Massachusetts not getting these vaccines on time to 37% of children in Colorado. (Chart 1:2)
* Up to three-quarters of sexually active adolescents were not tested for chlamydia infections in the past year. (Chart 1:6)
* One-third of children with asthma don't get appropriate controller medication. (Chart 1:8)
* Low-income children with sickle cell disease on average received less than half of the recommended supply of prophylactic antibiotics; 10% received none at all. (Chart 1:9)
* Potentially preventable adverse events among hospitalized children ranged from 0.003 per 1,000 patients at risk for transfusion reactions to 7.67 per 1,000 at risk for bed sores. Further, children who experience medical mistakes have 2 to 18 times the hospital death rates, and hospital stays that are 2 to 6 times longer and 2 to 12 times more costly, than those who don't. (Chart 2:1)
Access To Care and Patient-Centeredness of Care
* Of children with mental health problems severe enough to indicate a clinical need for evaluation, 79% did not get the evaluation or treatment; an estimated 7.5 million children don't get the mental health care they need. (Chart 3:3)
* Seventeen percent of new mothers did not start prenatal care in the first trimester of pregnancy. This gap ranged from one in 10 in Rhode Island to nearly one in three in New Mexico. (Chart 3:5)
* One-third of parents report that the health care professional caring for their child did not always communicate well during office visits. (Chart 4:1) One study showed 25% of parents reporting problems in the quality of their child's hospital stay. (Chart 4:2)
* The proportion of children with special health care needs who did not receive coordinated, ongoing, comprehensive, family-centered care in a "medical home"-a primary care professional or multidisciplinary team that helps ensure that health care and other needed services are coordinated-ranged from 39% in Massachusetts to 59% in Washington, DC. The American Academy of Pediatrics recommends that all children and adolescents have a medical home; this is especially important for children with special health care needs and their families, who often need help to get services from a complex web of providers and programs. (Chart 3:8)
* Poor, minority, and urban young children are less likely than non-poor, white, and suburban young children to receive timely immunizations. (Chart 5:2)
* Black and Latino children with asthma had similar access to care as did whites in one study. Yet black and Latino children were less likely to be regularly using an inhaled anti-inflammatory medication for persistent asthma, although they had worse asthma than white children. (Chart 5:3)
* Uninsured children are much more likely than those with public or private insurance to lack a usual health care provider and to have unmet needs for health and dental care, according to parents. (Chart 3:2)
Examples of Improvement
* A statewide program promoting lead-screening in Rhode Island led to 80% of very young Medicaid-insured children receiving a blood lead test, four times the rate for young children enrolled in Medicaid in 15 other states. (Chart 6:3)
* Hospital-acquired infections in pediatric intensive care units were reduced by up to 36% in hospitals participating in an ongoing national monitoring program. (Chart 2:3)
* Five community and migrant health centers substantially increased adolescent health promotion services through an intensive program focused on national guidelines and enhanced care delivery. (Chart 6:4)
* Children in an asthma education/outreach program in an inner-city hospital specialty clinic were more likely to get flu shots, increased their use of anti-inflammatory medications, and required fewer hospital stays and emergency room visits than a control group, saving an average of $543 in health care costs per child. (Chart 6:7)
This report is the latest in a series of groundbreaking chartbooks on the quality of health care in the United States. The Fund began this series in April 2002 with the release of Quality of Health Care in the United States, a review of the quality of care for the population as a whole. A third chartbook in the series will look at the quality of care in the Medicare population.
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The Commonwealth Fund is a private foundation supporting independent research on health and social issues. To order publications, visit our website at www.cmwf.org.