Improving Quality in Child and Adolescent Health

Research and Tools

Fact Sheet

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This fact sheet describes research projects and findings focusing on the quality of health care for children and adolescents as well as tools designed to improve that quality.

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Contents

Introduction
Research in Progress
   Quality Improvement
   Quality Measurement
   Quality Determinants
   Making the Case for Investments In Quality
   Addressing Racial and Ethnic Disparities
Recent Findings
   Quality Improvement
   Quality Measurement
   Quality Problem Identification
   Quality Determinants
   Addressing Racial and Ethnic Disparities
Tools for Quality Improvement
   Evidence-based Practice Centers
   Child Health Toolbox
   Consumer Assessment of Health Plans Study (CAHPS®)
   Kids' Inpatient Database (KID)
   AHRQ Quality Indicators
   Put Prevention Into Practice
   20 Tips to Help Prevent Medical Errors
   User Liaison Program (ULP) Workshops with Senior State Officials
For More Information

Introduction

The Agency for Healthcare Research and Quality sponsors research that focuses on improving health care quality, reducing the costs of health care, ensuring patient safety, and broadening access to health care services for all Americans, including children and adolescents. This fact sheet provides examples of ongoing projects and recent findings from AHRQ's portfolio of research focusing on improving the quality of health care for children and adolescents.

AHRQ's quality of care research aims to:

• Determine what works in quality improvement (QI) efforts.
• Develop measures for accountability and improvement.
• Identify important quality problems in children's health care.
• Identify factors in the health care system that determine quality.

This fact sheet also highlights QI tools that stem from AHRQ-supported research. The goal is for these tools to be useful to health care providers, health systems, and children and their families.

* Asterisk indicates that the project includes children or children's health care issues, but does not focus exclusively on children.

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Research in Progress

Quality Improvement

Improvements are being sought in safety practices for pediatric patients.
The goals of this project are to develop and expand a medication error reduction program, identify and collaborate on best practices in pediatric pain management, and implement a pediatric patient-safety best-practices program.
Principal Investigator: Paul Sharek (AHRQ grant HS13698).

Researchers will test a parent-initiated prevention program.
This randomized controlled trial is testing a computer-driven, patient-centered expert system to improve the receipt of evidence-based preventive services by pediatric patients. The study will assess the effectiveness of a real-time parent-initiated prevention program in changing physicians' delivery of preventive care and parental preventive behaviors.
Principal Investigator: Dimitri A. Christakis (AHRQ grant HS13302).

Quality of care for newborns with jaundice will be assessed.
The impact of a quality-improvement intervention on adherence to the American Academy of Pediatrics' guidelines for jaundice management is being assessed.
Principal Investigator: R. Heather Palmer (AHRQ grant HS09782).

Study aims to eliminate barriers to implementing adolescent preventive health guidelines.
This study addresses provider and system-level barriers to delivery of preventive services to adolescents during primary care visits. The goal is to determine whether a systems intervention in a managed health care organization—including provider training and customized screening and charting tools—increases the rates of provider delivery of clinical preventive services to adolescents.
Principal Investigator: Charles E. Irwin (AHRQ grant HS11095).

Internet learning modules for physicians may improve chlamydia screening for adolescents.
Study physicians will complete a year-long series of Internet learning modules that integrate case-based education with audit, feedback, and benchmaking of practice profiles. The goal is to improve chlamydia screening and treatment rates among 16-26 year old patients, which should result in lowered rates of pelvic inflammatory disease.
Principal Investigator: Jeroan Allison (AHRQ grant HS11124).

Study compares two pediatric asthma management programs.
Researchers are comparing a modified "easy breathing" program with a disease management program being used by 66 providers in 18 communities. Outcome measures will include adherence to guidelines, antiinflammatory prescription and use rates, hospitalization and emergency room (ER) visits, patient/family satisfaction, and quality of life.
Principal Investigator: Michele M. Cloutier (AHRQ grant HS11147).

A multisite intervention project for children with asthma should lead to improved outcomes and reduced costs.
Using a family-focused QI intervention for children with asthma, this study is targeting providers of care to poor, inner-city, minority youths ages 5-18 who are enrolled in a community health center-based Medicaid managed care organization. The goals are to deliver patient-linked guideline prompts at the point of care using affordable information technology and evaluate the system's effects on the process and outcomes of pediatric asthma care.
Principal Investigator: Judith Fifield (AHRQ grant HS11068).

Study findings will build an asthma case-management model for Head Start.
The researchers are developing a pediatric asthma management model for Head Start personnel using evidence-based asthma management criteria. The goal is to improve the asthma management practices of children, parents, and staff, as well as reduce school absences and use of acute care services.
Principal Investigator: Perla A. Vargas (AHRQ grant HS11062).

Study focuses on using evidence to enhance care for childhood illnesses.
Investigators are examining whether providing evidence at the point of ambulatory pediatric care will improve antibiotic use in pediatric disorders, reduce duration of therapy for acute sinusitis, reduce use of bronchodilators, and increase the use of intranasal steroids for allergic rhinitis.
Principal Investigator: Robert L. Davis (AHRQ grant HS10516).

Standardizing surfactant therapy for preterm infants will improve outcomes.
One of the goals of this QI study is to reduce morbidity and mortality among preterm infants by standardizing use of surfactant therapy for preventing and treating neonatal respiratory distress syndrome.
Principal Investigator: Jeffrey D. Horbar (AHRQ grant HS10528).

*Study aims to improve ambulatory antibiotic prescribing practices.
Data from the Minimizing Antibiotic Resistance in Colorado (MARC) study are being used to examine the processes and outcomes of care of two intervention strategies. The program will measure and assess changes in antibiotic prescription rates for pharyngitis in children and bronchitis in adults, using managed care organization (MCO) and Medicaid data from physician practices.
Principal Investigator: Ralph Gonzales (AHRQ grant HS13001).

Impact of electronic prescribing on medication errors in ambulatory pediatrics being examined.
The goals of this research are to assess the baseline medication error rate in an urban pediatric emergency department (ED) and clinic; compare handheld implements for electronic prescription writing; and determine the effect that electronic prescribing has on medication error rates and prescribing practices.
Principal Investigator: Kevin Johnson (AHRQ grant HS11868).

*Project will build on previous studies to improve medication safety across clinical settings.
This project is extending previous studies to new populations and settings to improve drug safety across the continuum of care in diverse patient groups. One study will determine the rates, types and predictors of medication errors and adverse drug events in a pediatric ambulatory setting, and perform a randomized controlled trial to assess the effectiveness of an intervention on reducing serious medication errors in children.
Principal Investigator: David W. Bates (AHRQ grant HS11534).

Researchers evaluate the effects of using hand-held technology to reduce errors in attention-deficit/hyperactivity disorder (ADHD) care.
This randomized controlled trial in three primary care practices will develop and evaluate a computerized system for laptop use in the examining room as an extension of an existing in-house prescribing system to improve the care of children with ADHD.
Principal Investigator: Paula Lozano (AHRQ grant HS11859).

Four Developmental Centers for Evaluation and Research in Patient Safety will address quality and patient safety for neonates and children.

• Researchers are establishing a Developmental Center for Evaluation and Research in Patient Safety (DCERPS) to develop programs to reduce and prevent medical errors in children in diverse settings (e.g., inpatient and intensive care units, emergency departments, private pediatric practices in rural and urban areas, and primary care centers serving minority populations).
  Principal Investigator: James A. Taylor (AHRQ grant HS11590).
• A second DCERPS is being established to reduce medical errors and enhance patient safety for high-risk newborns.
  Principal Investigator: Jeffrey D. Horbar (AHRQ grant HS11583).
• *A third DCERPS will build a multi-institutional and interdisciplinary research program focusing on patient safety activities, including four pediatric programs that will review data on adverse outcomes in pediatric patients.
  Principal Investigator: David H. Hickam (AHRQ grant HS11550).
• *For the fourth DCERPS, the American Academy of Family Physicians will create a national center in primary care to strengthen medical education programs. These programs are designed to improve the safety of medical care for patients of all ages, including children seen in office-based primary care and residency training clinics.
  Principal Investigator: John M. Hickner (AHRQ grant HS11584).

* Researchers examine the use of surveillance, analysis, and interventions to improve patient safety.
The goals of this project are to study: the best methods to identify and improve reporting of medical errors and adverse events; the epidemiology of medical errors including the organizational, process, and human factors that contribute to the occurrence of medical errors; the effectiveness of educational and process interventions to reduce medical errors and improve patient safety; and how healthcare workers communicate with patients and families about medical errors. Researchers will use risk management and incident report data on children from the St. Louis Children's Hospital to document and catalogue medical errors and patient safety issues in children.
Principal Investigator: Victoria Fraser (AHRQ grant HS11898).

*Investigators address preventable medical errors in Mississippi.
The goals of this project are to identify the causes of preventable health care errors and patient injury in health care delivery and develop, demonstrate, evaluate, and widely disseminate strategies for reducing errors and improving patient safety. Researchers will focus on 10 study sites throughout the State and priority populations, including urban and rural residents, low-income and minority groups, women, children, and the elderly.
Principal Investigator: Andrew C. Brown (AHRQ grant HS11923).

Study focuses on the transfer of a novel pediatric simulation program for the delivery room.
The goal is to determine whether the skills acquired in a simulated environment can be applied in a real delivery room, and whether using these skills results in improved patient safety for mothers and babies.
Principal Investigator: Louis P. Halamek (AHRQ grant HS12022).

*Researchers explore applied strategies for more patient safety interventions.
The setting of this study involves two Practice-Based Research Networks: the Colorado Research Network (includes a pediatric practice) and the High Plains Research Network. Both provide services to the rural, urban, minority, frontier and underserved populations. Researchers will analyze the causes and effects of errors in primary care, as well as develop and implement interventions aimed at decreasing errors.
Principal Investigator: Wilson D. Pace (AHRQ grant HS11878).

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Quality Measurement

Researchers are measuring the quality of neonatal care.
Researchers are examining the validity of volume as an indirect quality indicator for neonatal intensive care by evaluating the association between volume and multiple outcomes for very low birthweight infants, including measures of respiratory, infectious, neurological, gastrointestinal and ophthalmological diseases.
Principal Investigator: Jeannette Rogowski (AHRQ grant HS13371).

A new measure for assessing quality of asthma care is being tested.
This study will test the feasibility and validity of a new measure of quality of asthma care for poor inner-city children with asthma. The project will also test the Asthma Visit Questionnaire to assess the quality of asthma care in primary care settings.
Principal Investigator: Yvonne Senturia (AHRQ grant HS13081).

Findings from three projects will strengthen pediatric health plan assessments.
This initiative involves development of the pediatric version of the CAHPS® instrument for assessing care at the group practice level and production of refined and tested instruments that will be suitable for a large-scale field test.
Principal Investigators: Paul Cleary (AHRQ grant HS09205); Ron Hays (AHRQ grant HS09204); and Steven Garfinkel (AHRQ grant HS13193).

Quality-of-care measurements for high-risk infants are being developed.
This project has three objectives: (1) develop new methods for measuring quality of care for very low birthweight infants, (2) apply the methods to estimating past and future quality of care, and (3) apply measures that summarize quality differences and economic performance across time and place.
Principal Investigator: Jeanette A. Rogowski (AHRQ grant HS10328).

Investigators are developing and validating quality measures for insertion of tympanostomy tubes.
Researchers are developing quality measures and evidence-based criteria to identify appropriate candidates for tympanostomy tube placement in children with recurring otitis media with effusion. They also will examine the relationship between various patient, parent, and physician attributes and the appropriateness of tube placement.
Principal Investigator: Mark R. Chassin (AHRQ grant HS10302).

Mortality data will be used to develop quality indicators.
This 5-year project will examine the epidemiological transition in pediatric mortality from mostly accidental and sudden death to deaths due to complex chronic conditions. The goals are to develop techniques to monitor health care use for indicators of quality of care for dying children and develop and test a longitudinal needs assessment program for children with complex chronic conditions.
Principal Investigator: John Feudtner (AHRQ grant HS00002).

*Researchers are validating the Healthcare Cost and Utilization Project (HCUP) Patient Safety Quality Indicators.
The objective is to validate HCUP quality indicators to include patient safety indicators using data from three integrated delivery systems (Intermountain Health Care, Providence Health System, and UPMC Health System) to accurately measure adverse events. Some of the HCUP quality indicators being validated will focus on the care of children.
Principal Investigator: Shula Bernard (AHRQ contract 290-00-0018).

Quality of care for homeless adolescents is being measured.
This project will use interviews, focus groups, and a pilot test to document the factors necessary for monitoring access and quality of primary health care for homeless youths.
Principal Investigator: B. Josephine Ensign (AHRQ grant HS11414).

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Quality Determinants

Study will assess how physician networks affect the care of children with chronic conditions.
This study will examine whether out-of-network benefits and cost-sharing of managed health plans are associated with the likelihood of seeing an in-network versus out-of-network physician, and whether health care quality and expenditures are similar or different for children seeing in- versus out-of-network physicians.
Principal Investigator: David Grembowski (AHRQ grant HS13147).

Study will assess quality of care for low-income adolescents.
Researchers are assessing the effects of the organizational features of KidCare, Florida's State Children's Health Insurance Program (SCHIP), on access to and quality of primary and preventive care for enrolled adolescents, ages 12 to 19. In addition, investigators will examine the impact of differences in provider practice settings and the impact of clinician characteristics. This study is part of the Child Health Insurance Research Initiative (CHIRI™).
Principal Investigator: Elizabeth A. Shenkman (AHRQ grant HS10465).

Researchers are assessing health care delivery for children with special needs.
This CHIRI™ project investigates the effects of providing services in a managed care versus fee-for-service setting to children with dual enrollment in Medicaid and the Children with Special Health Care Needs (CSHCN) program. Cost, use of services, coordination of care, provider perspectives, and parent's perceived access and satisfaction with the two delivery systems will be examined.
Principal Investigator: G. Elaine Beane (AHRQ grant HS10441).

A second study is analyzing factors that influence selection of a Medicaid managed care plan by the parents of CSHCN, examining barriers to care for CSHCN, and assessing several quality of care indicators such as receipt of preventive services, referrals to specialists, appropriateness of medication use, hospitalizations for ambulatory sensitive conditions, and continuity of care.
Principal Investigator: Jean Mitchell (AHRQ grant HS10912).

Study examines how to improve quality of care for publicly insured children.
Researchers are assessing the impact of health care features on access, use, and quality of care for enrollees in Child Health Plus, New York's SCHIP. Sub-studies of children with asthma and minority children also are being conducted. This is a CHIRI™ project.
Principal Investigator: Peter G. Szilagyi (AHRQ grant HS10450).

What determines the quality of children's health care?
This project will focus on the mechanisms by which managed care organizations influence children's access to medical care, their use of specialty care, and their expenditures for health care. The impact of alternative models of primary-specialty care collaboration on quality, costs, and outcomes for children with chronic and mental health disorders also will be examined.
Principal Investigator: Christopher Forrest (AHRQ grant HS00003).

Study is assessing how managed care policies affect the quality of pediatric asthma care.
Investigators are determining the impact of the transition from fee-for-service to managed care on quality of treatment, quality of life, and health outcomes for indigent children with asthma, and they are assessing the impact of organizational policies on quality and outcomes.
Principal Investigator: Bruce Stuart (AHRQ grant HS09950).

Managed care practices that affect children with chronic illnesses are being examined.
Researchers are examining the structural characteristics, incentives, and quality-assurance efforts of managed care organizations in Washington State. They will determine how those factors affect the quality of care for children with chronic conditions such as asthma, diabetes, and cerebral palsy.
Principal Investigator: Frederick Connell (AHRQ grant HS09948).

Study of neonatal intensive care addresses regionalization, market forces, and mortality.
Researchers are assessing differences in neonatal mortality over time, focusing on assessing the volume of newborns in high-risk groups, comparing insurance coverage with mortality, and assessing how competition affects the diffusion of neonatal intensive care units (NICUs) into community hospitals.
Principal Investigator: Ciaran S. Phibbs (NIH/AHRQ grant HD36914).

Effects of teamwork on errors in NICUs are being examined.
Researchers are testing the hypothesis that specific behaviors in teamwork correlate with errors in delivering care to preterm infants during initial resuscitation and in the first 90 minutes of care.
Principal Investigator: Eric J. Thomas (AHRQ grant HS11164).

New center will focus on diversity and therapeutics for the pediatric population.
Improvement in child health is the focus of this Center for Education and Research on Therapeutics (CERTs). Activities may include innovative education and research on new drugs and devices used in pediatric care and new uses of existing drugs and devices. Potential study topics include therapeutic drug monitoring in HIV-infected children, drug metabolism, vitamin D-deficient rickets, asthma care, attention deficit/hyperactivity disorder, and adverse drug reactions.
Principal Investigator: William Campbell (AHRQ grant HS10397).

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Making the Case for Investments In Quality

Collaborators will use multilevel approach to improve children's health care quality.
This project will bring together pediatric organizations to support large-scale activities that have been shown to be effective in improving care for children. These partners will engage State American Academy of Pediatrics chapters in evidence-based collaborative learning sessions as well as an interactive Web-based QI tool with the goal of supporting practice changes leading to improved care for children with attention-deficit/hyperactivity disorder.
Principal Investigator: Carole Lannon (AHRQ grant HS13721).

Researchers are assessing the economic impact of breast-feeding promotions.
Using a randomized controlled trial, researchers are comparing the effects of pre- and postnatal breastfeeding promotions on child health care costs, breast-feeding practices, and outcomes.
Principal Investigator: Karen A. Bonuck (AHRQ grant HS10900).

Study focuses on the effect of medication errors in the pediatric intensive care unit (PICU).
The aims of this Mentored Clinical Scientist Development Award are to: (1) calculate the increase in resource utilization attributable to exposure to medication errors in patients admitted to the PICU; (2) determine the risk of mortality attributable to exposure to medication errors in patients admitted to the PICU; and (3) determine the risk of requiring inpatient rehabilitation or technology dependence associated with exposure to medication errors.
Principal Investigator: Joel D. Portnoy (AHRQ grant HS11636).

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Addressing Racial and Ethnic Disparities

*Investigators are assessing the impact of health maintenance organizations (HMOs) on disparities.
These researchers are assessing the scope and magnitude of racial/ethnic and socioeconomic disparities in HMOs and developing age, sex, and case-mix adjusted use and quality measures. The measures will be used to examine racial/ethnic disparities in preventive care, satisfaction, change in health status, use of expensive hospital-based procedures, and avoidable hospital complications and mortality.
Principal Investigator: Kevin Fiscella (AHRQ grant HS10910).

*Investigators are studying medical errors in racial/ethnic communities.
The goals of this project are to create a Center for Improving Patient Safety; study medical error awareness and experiences within racial and ethnic minority populations; and focus on various settings, levels of care, and medical specialties. One pilot study will use aggregated risk management incident reports to detect, prevent, and treat common causes of medical errors and near misses in selected medical care settings (including general pediatrics, cardiology, emergency medicine, and radiology).
Principal Investigator: Robert S. Dittus (AHRQ grant HS11563).

Two studies focus on racial/ethnic variations in managing prematurity and infant mortality.

• In the first study, the researchers are using vital statistics to determine the relationship between newborn ethnicity, obstetric volume, and neonatal intensive care unit volume in the hospital of birth.
  Principal Investigator: Mark Chassin (AHRQ grant HS10859).
• Researchers in the second study are using linked birth records, death records, and hospital discharge abstract data to examine racial/ethnic differences in infant mortality.
  Principal Investigator: Martin Shapiro (AHRQ grant HS10858).

Project focuses on improving quality of care for Latino children.
This researcher is analyzing access and quality of care barriers for poor children with asthma; improving survey methods for evaluating morbidity and risk factors for asthma, with particular attention to the effects of bilingualism (English/Spanish); and examining differences in morbidity among Latino children with asthma. The long-term goal is to improve health outcomes and quality of life for Latino children with asthma.
Principal Investigator: Marielana Lara (AHRQ grant K08 HS00008).

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