Identifying Health Care Quality Problems

Pediatricians appear less likely than other physicians to exhibit race bias or harbor stereotypes.

Researchers surveyed academic pediatricians about their implicit and explicit racial attitudes and stereotypes using a specially designed test. To measure quality of care, subjects were asked how they would treat patients using four pediatric vignettes (pain control, urinary tract infection, ADHD, and asthma). Each participant was given two black and two white patients; most of the pediatricians were white, and 93 percent were American-born. The majority of pediatricians reported no difference in feelings toward racial groups; there was a much smaller implicit preference for whites relative to blacks than found with other physicians. Sabin, Rivara, and Greenwald, Med Care 46(7):678-685, 2008 (AHRQ grant HS15760).

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Infectious Disease

Prior to 2006, rotavirus was implicated in one-fourth of diarrhea-related ER visits for young children.

Researchers examined the number of diarrhea-related emergency department (ED) and clinic visits for diarrhea-related illness in children younger than age 5 and found that the rate of outpatient visits and ED visits remained essentially stable over 1995-1996 and 2003-2004. Black children with diarrhea-related illnesses were more likely than white children to be seen in the ER, even when both groups had insurance. These data will help determine the impact of the new rotavirus vaccine introduced in 2006 on reducing diarrhea-related clinic and ED visits, note the researchers. Pont, Grijalva, Griffin, et al., J Pediatr 155(1):56-61, 2009 (AHRQ grant HS13833).

Frequency and severity of invasive fungal infections in immunocompromised children have increased.

Factors such as cancer chemotherapy and medications used to suppress rejection following organ or stem cell transplant weaken a child's immune system, making him or her vulnerable to invasive fungal infections that can be fatal. According to this study of data from 25 U.S. children's hospitals, there has been a rise in the use of antifungal therapy for hospitalized children and a shift to new antifungal agents. Overall, 62,842 children received antifungal therapy—including 5,839 neonates—with prescriptions increasing significantly during the 7-year study period (2000-2006). The researchers call for more studies to determine the optimal dosing, efficacy, and safety of these newer agents in children. Prasad, Coffin, Leckerman, et al., Pediatr Infect Dis J 27(12):1083-1088, 2008 (AHRQ grant HS10399).

Blood cultures taken from children show drug resistance to a class of antibiotics usually used for adults.

Children usually are not given the broad-spectrum antibiotics called fluoroquinolones because they cause joint toxicity. Nevertheless, two common bacteria—Escherichia coli and Klebsiella—showed fluoroquinolone resistance in 217 blood cultures taken from children at the Children's Hospital of Philadelphia. Eight of the cultures (2.9 percent) were resistant to two common fluoroquinolones, ciproflaxin and levofloxacin. These drugs are commonly used in adults, and ciproflaxin was recently approved for children to treat inhalation anthrax and problematic urinary tract infections. Kim, Lautenbach, Chu, et al., Am J Infect Control 36(1):70-73, 2008 (AHRQ grant HS10399).

Strategies are needed to improve immunization rates among adolescents.

According to two recent studies, opportunities to vaccinate adolescents are often missed during health care visits. In their early years, children routinely receive immunizations during regular health checkups. However, when they become adolescents, vaccination rates tend to wane as checkups become less frequent. The first study found that vaccination rates among 13-year-olds for hepatitis and measles-mumps-rubella were lower than the national estimate. The second study found that influenza vaccination rates for adolescents with chronic conditions improved over a 10-year period, but rates are still too low. Lee, Lorick, Pfoh, et al., Pediatrics 122(4):711-717, 2008 and Nakamura and Lee, Pediatrics 122(5):920-928, 2008 (AHRQ grants HS13908 and T32 HS00063).

Many underinsured children are not getting needed vaccines due to current U.S. vaccine financing system.

The number of newly recommended vaccines for children and adolescents has nearly doubled in the past 5 years, boosting the cost to fully vaccinate a child in the public sector from $155 in 1995 to $1,170 in 2007. Childhood vaccines in the United States are financed by a patchwork of public and private sources, resulting in many underinsured children being unable to receive publicly purchased vaccines in either private practices or public health clinics, according to this study. The researchers conducted a national survey of State immunization program managers in 2006 and found that only 34 percent of States had a health insurance mandate requiring insurers to cover currently recommended vaccines for children and adolescents. Lee, Santoli, Hannan, et al., JAMA 298(6):638-643, 2007 (AHRQ grant HS13908).

Mental and Behavioral Health

Only one-third of adolescents are screened for emotional health during routine physicals.

Even though most mental health problems begin in adolescence, only about one-third of youths aged 13 to 17 represented in this study reported discussing their emotional health during well-care visits with their primary care providers. The researchers assessed providers' rates of screening for emotional distress among a clinic-based sample (1,089) and a population-based sample (899) of adolescents. In both groups, significantly higher screening rates were reported by females. Ozer, Zahnd, Adams, et al., J Adolesc Health 44:520-527, 2009 (AHRQ grant HS11095).

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Emergency Care

Black children are more likely than white children to be hospitalized for a ruptured appendix.

An analysis of data presented in the 2009 National Healthcare Disparities Report revealed that black children were about 33 percent more likely than white children to be hospitalized for a ruptured appendix in 2006. Hispanic children had the second highest rate at 344.5 per 1,000 admissions (compared with 276 per 1,000 admissions for white children), followed by Asian/Pacific Island children at 329 per 1,000 admissions. Poverty played a role for all children, regardless of race or ethnicity. Children from poor families were 26 percent more likely to be hospitalized for a ruptured appendix than those from higher income families (337 vs. 268.5 per 1,000 admissions, respectively). National Healthcare Disparities Report, 2009; available at http://www.ahrq.gov/qual/qrdr09.htm (AHRQ Publication No. 10-0004)* (Intramural).

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Chronic Illness

Primary care doctors often don't know that a child has received ER care for asthma.

Researchers reviewed medical records of 350 children who regularly received care at community health centers but ended up in an emergency department (ED) after experiencing an asthma flareup. Nearly 63 percent of patient records at the community health center contained faxed discharge summaries or a note from the ED provider, but the remaining 37 percent had no mention of the child's ED visit. Also, almost two-thirds of patients did not follow up with their usual provider after an asthma-related ED visit. The researchers stress the importance of notifying primary care providers when a child visits the ED so they aware of the treatment provided and changes to medications and can avoid medical errors. Hsiao and Shiffman, Jt Comm J Qual Patient Saf 35(9):467-474, 2009 (AHRQ grant HS15420).

Poor asthma control is linked to family and insurance factors.

Researchers surveyed parents of 362 children about asthma-related impairment (symptoms, activity limitations, and use of albuterol for acute asthma episodes) and the number of asthma exacerbations in a 1-year period. Based on parental reports, 76 percent of children took daily controller medications, yet asthma was well controlled for only 24 percent of children, partially controlled for 20 percent, and poorly controlled for 56 percent. Medicaid insurance, presence of another family member with asthma, and maternal employment outside the home were significant factors associated with poor asthma control. Bloomberg, Banister, Sterkel, et al., Pediatrics 123(3):829-835, 2009 (AHRQ HS15378).

Study finds link between differences in health care coverage and higher readmission rates for pediatric asthma.

The researcher analyzed Rhode Island hospital discharge data from 2001 to 2005 to identify 2,919 children at the time of their first asthma hospitalization. During the study period, 15 percent of those children were readmitted to the hospital for asthma. Although factors such as crowded housing conditions, proportion of minority residents in a neighborhood, and poverty did not affect rehospitalization rates, Medicaid coverage did. Children insured by Medicaid at the time of their initial admission had readmission rates that were 33 percent higher than those of children with private insurance. Liu, Public Health Rep 124:65-78, 2009 (AHRQ cooperative agreement with CDC).

Hospitals vary widely in use of corticosteroids to treat acute chest syndrome in children with sickle cell disease.

Researchers reviewed records on more than 5,200 hospital admissions for acute chest syndrome (ACS) at 32 pediatric hospitals in the United States. ACS is a frequent cause of sickness and death in patients with sickle cell disease, and corticosteroids are used to fight inflammation in children with ACS and sickle cell disease. The researchers found that use of these drugs varied dramatically between hospitals, ranging from 10 to 86 percent for all patients with ACS and 18 to 92 percent for those who had both ACS and asthma. Sobota, Graham, Heeney, et al., Am J Hematol 85(1):24-28, 2010 (AHRQ grant T32 HS00063).

Treatment of children with Crohn's disease varies widely.

Clinicians vary in their care for children with Crohn's disease (CD)—a chronic inflammatory bowel disease—mostly because there are few clinical guidelines and many treatments. These variations in care can result in differences in health care costs, quality, and outcomes, according to these researchers. They reviewed data on drugs given to 311 children newly diagnosed with CD at 10 U.S. and Canadian gastroenterology centers from January 2002 to August 2005 and found that physicians used several types of drugs to reduce children's symptoms. The drugs that offer the most benefit (immunomodulators) also carry the greatest risk, which may explain the variation in treatment. Other drugs used included steroids, antibiotics, anti-inflammatory medications, and an antibody that reduces inflammation. Kappelman, Bousvaros, Hyams, et al., Inflamm Bowel Dis 13(7):890-895, 2007 (AHRQ grant T32 HS00063).

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Inpatient Care

Parents of hospitalized children vary in their rating of inpatient care.

Researchers surveyed 12,562 parents of children receiving care at 39 hospitals from 1997 through 1999, to gather information about coordination of care, physical comfort, confidence and trust, care continuity, and other aspects of care. They found that even though 51 percent of parents reported that their child had a chronic health problem, most of the parents rated their child's inpatient care as excellent (47 percent) or very good (32 percent). Parents of children in fair or poor health with nonchronic conditions reported the lowest quality of care. Mack, Co, Goldmann, et al., Arch Pediatr Adolesc Med 161(9):828-834, 2007 (AHRQ grant T32 HS00063).

High hospital occupancy rates can affect the care children receive.

Researchers studied claims data (1996-1998) on over 69,000 respiratory and 49,000 non-respiratory pediatric admissions in Pennsylvania and New York to investigate the association between hospital occupancy and admission workload on length of stay for common pediatric diagnoses. They found the effect of admission day occupancy on length of stay was apparent only for children with respiratory conditions and was greatest when the occupancy rate was higher than 60 percent. Lorch, Millman, Zhang, et al., Pediatrics 121, 2008 (AHRQ grant HS09983).

Management of postoperative pain in newborns found suboptimal in some NICUs.

Researchers found that while management of postoperative pain in neonates is well accepted, the practice is highly variable. They found deficiencies in the assessment and management of postoperative pain in neonates treated at NICUs in 10 hospitals. Physician pain assessment (not postnatal age or surgery type) was the only significant predictor of postsurgical analgesic use. Taylor, Robbins, Gold, et al., Pediatrics 118(4):992-1000, 2006 (AHRQ grant HS13698).

Drugs to reduce complications of prematurity are not given as often as they should be.

When given to women during preterm labor, antenatal corticosteroids have been shown to reduce the incidence of respiratory distress syndrome and other complications associated with prematurity. This study included 515 women eligible for antenatal corticosteroids; 70 percent of the women were black or Hispanic, and most had Medicaid coverage. One-fifth of the women studied did not receive the drugs. The researchers cite problems with language in the NIH consensus statement for much of the disparity in use of these drugs, particularly some ambiguity over who should and should not receive the drugs and when during labor they should be administered. Howell, Stone, Kleinman, et al., Matern Child Health J 14:430-436, 2010 (AHRQ HS10859).

Study identifies problems with pediatric quality indicators.

Low event rates and inadequate numbers of relevant pediatric inpatients at many hospitals limit the usefulness of AHRQ's inpatient pediatric quality indicators (PDIs), according to this study. Researchers used 2005-2007 data on pediatric hospital discharges in California to calculate statewide rates for nine PDIs and found that none of the 401 hospitals had sufficient patient volume to detect a doubling of the statewide average event rate for one of the measures, and only one-quarter of the hospitals doing pediatric heart surgery had sufficient volume to detect doubling of the statewide measure for mortality related to heart surgery. Bardach, Chien, and Dudley, Acad Pediatr 10(4):266-273, 2010 (AHRQ grant HS17146).

Most pediatric hospitals do not respond appropriately to overcrowding.

Researchers used midnight census data during 2006 from 39 children's hospitals to examine occupancy levels and overcrowding. They found that overall, the hospitals reported 70 percent of midnights with at least 85 percent occupancy, including 42 percent with at least 95 percent occupancy. Only a few of the hospitals took active steps to reduce crowding through admissions cutoff or transfers out. The researchers note that crowding has been shown to be associated with increases in patient safety events, including medical errors. Fieldston, Hall, Sills, et al., Pediatrics 125(5):974-981, 2010 (AHRQ grant HS16418).

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Specialty Care

Minority children are much less likely than white children to receive specialized therapies.

Researchers used Medical Expenditure Panel Survey data to examine therapy use for children and found that 3.8 percent of children who are age 18 or younger obtain specialized therapies from the health care system, including physical, occupational, and speech therapy or home health services. Children most likely to use specialized therapies tended to be males (60 percent), white children (81 percent), and children with a chronic condition (39 percent). Kuhlthau, Hill, Fluet, et al., Dev Neurorehabil 11(2):115-123, 2008 (AHRQ grant HS13757).

Children with private insurance have better access to specialty care than other children.

Researchers reviewed 30 studies on the relationship between access to specialty care and insurance coverage and found that children with private insurance have better access to such care than those who have public coverage or no insurance. Although children insured by Medicaid or SCHIP have better access to specialty care than uninsured children, their access to specialists is worse and their specialists are less likely to be board-certified compared with privately insured children. Skinner and Mayer, BMC Health Serv Res 7, 2007 (AHRQ grant T32 HS00032).

Children with special health care needs benefit from Medicaid managed care programs.

According to this study, children with special health care needs who have disabilities and are enrolled in Medicaid programs that have a managed care option, including case management services, have better access to care and receipt of occupational and physical therapy at school, compared with those in Medicaid fee-for-service (FFS) plans. The researchers evaluated use of speech, occupational, and physical therapy by children with special health care needs who were enrolled in the managed care or FFS plans of the District of Columbia Medicaid program that serviced only children with disabilities. Schuster, Mitchell, and Gaskin, Health Care Financ Rev 28(4):109-123, 2007 (AHRQ grant HS10912).

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Dental Care

Rural children with special health care needs often do not receive needed dental care.

Children with special health care needs (CSHCN) who reside in rural areas are less likely than their urban counterparts to receive needed dental care. An analysis of data on more than 37,000 CSHCN aged 2 and older revealed that children living in rural areas were 17 percent more likely than those living in urban areas to have an unmet need for dental care. The researchers cite two main reasons for this disparity: one, rural parents do not fully appreciate the need for dental care, and two, dental care may be difficult to access for rural families. Skinner, Slifkin, and Mayer, J Rural Health 22(1):36-42, 2006 (AHRQ grant HS13309).

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Patient Safety

Medical injuries among children result in longer hospital stays and higher charges.

This study found that 3.4 percent of children hospitalized between 2000 and 2002 in Wisconsin suffered a medical injury while in the hospital. These injuries were due to problems with medications, procedures, and medical devices. Injured children had a longer hospital stay (0.5 day) and higher charges ($1,614) than children who were not injured. The study involved more than 318,000 children admitted to 1 of 134 Wisconsin hospitals between 2000 and 2002. Meurer, Yang, Guse, et al., Quality Safety Health Care 15:202-207, 2006 (AHRQ grant HS11893).

Outpatient advice on pediatric medication safety is often inadequate.

According to this study, little advice is being given to parents on medication safety in the outpatient setting, and when advice is given, it often is inadequate. Researchers examined data from charts and prescription reviews on 1,685 children from six medical practices in Boston. They also interviewed parents at 10 days after their child's first visit and again 2 months later to find out what kind of information, if any, they received on medication safety and whether there had been any medication errors or "near misses." Although 91 percent of providers had given information on why a medication was being prescribed, they only mentioned side effects 28 percent of the time, and they provided written information on medication safety just 14 percent of the time. Lemer, Bates, Yoon, et al., J Patient Saf 5(3):168-175, 2009 (AHRQ grant HS11534).

Most vaccination errors involve vaccines with similar names.

After studying 607 vaccine error reports, these researchers found that the wrong vaccines, incorrect times, and wrong doses were at the heart of most vaccine-related errors, but wrong route of administration and wrong patient errors were rare. Vaccine names were implicated in many of the wrong vaccine errors. For example, tetanus group vaccines, which accounted for more than one-third of wrong vaccine errors, not only look alike, they also have brand names that sound alike. Wrong time errors most often occurred with scheduled vaccines being given earlier or later than recommended for a child's age. Bundy, Shore, Morlock, and Miller, Vaccine 27(29):3890-3896, 2009 (AHRQ grant HS16774).

Children are often harmed by adverse events in pediatric ICUs.

Researchers analyzed data on safety incidents that took place in pediatric intensive care units (ICUs) around the country over a 2-year period. During that time, 23 of the ICUs reported 464 incidents. Physical injuries harmed children in 35 percent of the incidents, and three incident-related patient deaths were reported. To improve safety in pediatric ICUs, the researchers recommend developing protocols for high-risk procedures, improved monitoring, and staffing, training, and communication initiatives. Skapik, Pronovost, Miller, et al., J Patient Saf 5(2):95-101, 2009 (AHRQ grant HS11902).

Incidence of pediatric medication errors is significant for treatment of ADHD.

According to this study of reports involving medications used in the treatment of attention-deficit/hyperactivity disorder (ADHD) in children, the incidence of medication errors between 2003 and 2005 was significant. Of 361 error reports, 329 involved medications used only in the treatment of ADHD, and 32 involved medications used for ADHD and other conditions. Improper dose, wrong dosage form, and prescribing errors were the three most common errors. Bundy, Rinke, Shore, et al., Jt Comm J Qual Patient Saf 34(9):552-560, 2008. See also Winterstein, Gerhard, Shuster, and Saidi, Pediatrics 124(1):e75-e80, 2009 (AHRQ grant HS16774).

Medication error rates are high in children receiving outpatient chemotherapy for cancer.

Researchers reviewed the medical records of patients receiving treatment from one pediatric and three adult oncology clinics involving 117 pediatric visits (913 medications) and 1,262 adult visits (10,995 medications). They identified 112 medication errors for an overall rate of 8.1 errors per 100 clinic visits. More than half of the errors had the potential to cause patient injury, and only 4 percent of the errors were stopped before they reached the patient. Most involved medication administration and prescribing. The medication error rate was much higher in children than in adults: 18.8 errors per 100 visits compared with 7.1 errors per 100 visits. More than half of the pediatric errors that had the potential for patient harm occurred when medications were given in the home. Walsh, Dodd, Seetharaman, et al., J Clin Oncol 27(6):891-896, 2009 (AHRQ grant HS10391).

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Efficiency

Children receive ear tubes more frequently than experts recommend.

The researchers reviewed the cases of 682 children who had ear tubes surgically inserted in five New York City hospitals in 2002 and compared the children's clinical characteristics with the recommendations of an expert panel. They found that just 7 percent of the surgeries (48 cases) were deemed appropriate by the panel's criteria, while nearly 70 percent (475 cases) were deemed inappropriate. The authors conclude that this widespread deviation from recommended practice suggests ear tube insertion is overused and performed too quickly, exposing children to risk and using resources that could be otherwise spent improving children's health. Keyhani, Kleinman, Rothschild, et al., Br Med J 337:a1607, 2008; available at htpp://www.bmj.com/content/337/bmj.a1607 (AHRQ grant HS10302).

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Access to Care

Children with insurance may not receive needed services if their parents are uninsured.

According to this study, insured children living with at least one parent in families where the children were insured but the parents were not were more than twice as likely as children with insured parents not to have a usual source of care. They also were 11 percent more likely to have unmet health needs and 20 percent more likely to have never received any preventive counseling services. The researchers examined 2002-2006 data from AHRQ's Medical Expenditure Panel Survey (MEPS) on 43,509 individuals. These findings suggest that the long-term improvement of health care for children cannot be met by covering children alone, note the researchers. DeVoe, Tillotson, and Wallace, Ann Fam Med 7(5):406-413, 2009 (AHRQ grant HS16181).

Even modest increases in cost-sharing in Medicaid and CHIP are burdensome for poor families.

These researchers examined the effects of increased cost-sharing arrangements in Medicaid and CHIP that were instituted by many States in 2007. They found that parents would struggle with high out-of-pocket costs and financial burdens if premiums or copayments were increased for their children covered by CHIP, forcing many families to choose between getting medical care for their children and financial hardship. The researchers suggest that implementing caps on out-of-pocket spending could help address the burden for low-income families without reducing potential budgetary savings. Selden, Kenney, Pantell, and Ruhter, Health Aff 28(4):w607-w619, 2009 (AHRQ Publication No. 09-R072)* (Intramural).

Children in rural areas must travel far distances to receive specialty care.

Children who need care from pediatricians specializing in areas such as cardiology, rheumatology, or endocrinology may not have ready access to these doctors if they are from low-income families and live in isolated regions of the United States, according to this study. It showed that children from low-income families in the Mountain States or West North Central regions of the United States had to travel the farthest for pediatric specialty care. These geographic barriers may limit the children's access to needed care and lead to poor outcomes, notes the author. She suggests the use of novel approaches, such as telemedicine, be considered in these areas so that children have access to quality care without traveling long distances. Mayer, Matern Child Health J 12(5):624-632, 2008 (AHRQ grant HS13309).

Access to primary care is linked to fewer ER visits by Medicaid-insured children.

Quality pediatric primary care can reduce both urgent and nonurgent emergency department (ED) visits, according to this study involving visits by 5,468 children insured by the Wisconsin Medicaid program. Researchers linked the visits to parents' scores in three domains of their child's primary care: family centeredness, timeliness, and access to care. Overall, 28 percent of the children visited the ED during the followup year, and 59 percent of those ED visits were nonurgent. A high quality score on family centeredness was associated with 27 percent fewer nonurgent ED visits, but no change in urgent visits. High-quality timeliness was associated with 18 percent fewer nonurgent and urgent visits, and high-quality access was associated with 27 percent fewer nonurgent visits and 33 percent fewer urgent visits. Brousseau, Gorelick, Hoffman, et al., Acad Pediatr 9:33-39, 2009 (AHRQ grant HS15482).

Uncertainty about insurance coverage may put children at risk for unmet medical needs.

When parents are uncertain whether or not their child is insured, the child's risk of having unmet health care needs is increased, according to this study. Researchers identified children whose parents were uncertain about their coverage from data on nearly 2,700 low income families in Oregon. In 13.2 percent of the families, parents were uncertain about their child's public health insurance coverage. Their children were at increased risk for having unmet medical needs compared with children whose parents were sure of their child's coverage. DeVoe, Ray, Krois, and Carlson, Fam Med 42(2):121-132, 2010 (AHRQ grant HS16181).

Gaps in coverage are linked to unmet health care needs.

Researchers analyzed survey results from 2,681 families with children enrolled in Oregon's food stamp program at the end of January 2005 and found that one-fourth of the children had coverage gaps during the 12 months preceding the survey. The gaps were less than 6 months (17.5 percent), 6 to 12 months (1.5 percent), and more than 12 months (3.1 percent); nearly 4 percent of the children never had health insurance. Study results showed that the longer the insurance gap, the higher the chance of a child having an unmet need for care, including medical or dental care, prescriptions, not having a regular provider, and delays in urgent care. DeVoe, Graham, Krois, et al., Ambul Pediatr 8(2):129-134, 2008 (AHRQ grants HS14645, HS16181).

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