Improving Health Care Quality for Children and Adolescents
Preventive Care
Stewardship program improves
antimicrobial use among hospitalized
children.
Use of an antimicrobial stewardship
program (ASP)—in which an infectious
disease consultant controls use of
antimicrobials (antibiotics, antifungals,
and antivirals) by hospital staff—can
improve the appropriate use of these
agents, according to this study. During
the 4-month study period, physicians
placed 652 calls to the ASP at one
children’s hospital. Nearly half of the
calls required an intervention by the
ASP to resolve drug-bug mismatches,
minimize unnecessary use of broad
spectrum antibiotics, prevent duplicate
therapy, and improve dosing. Metjian,
Prasad, Kogon, et al., Pediatr Infect Dis
J 27(2):106-111, 2008 (AHRQ grant
HS10399).
Routine screening is the best way to
detect the majority of Chlamydia
infections in adolescent girls.
Untreated Chlamydia trachomatis (CT)
infections can lead to pelvic
inflammatory disease, ectopic
pregnancy, and infertility. Despite
recommendations for annual screening,
screening rates remain low among all
sexually active adolescents and young
adults under age 26. Since there usually
are no symptoms with these infections,
screening is the only way to detect
them. These researchers describe an
intervention in a California HMO that
improved CT screening during urgent
care. As a result of the intervention, the
change in the proportion of adolescent
girls screened for CT increased by
almost 16 percent in the five
intervention clinics compared with a
decrease of 2 percent in the comparison
clinics. Tebb, Wibbelsman, Neuhaus,
and Shafer, Arch Pediatr Adolesc Med
163(6):559-564, 2009 (AHRQ grant
HS10537).
Hospital rates for intussusception
declined 25 percent from 1993 to
2004.
Rotavirus is the most common cause of
severe gastroenteritis in young children,
and a new rotavirus vaccine was
introduced in 2006. A previous vaccine
was withdrawn in 1999 after it was
associated with intussusception in
infants. Researchers compared annual
intussusception hospitalization rates
before and after introduction of the new
vaccine, and found that the rates have
remained stable since 2000, with about
35 cases per 100,000 infants. They note
that the downward trend might reflect a
true reduction in the incidence of severe
intussusceptions, but it also could reflect
changes in medical management that do
not require hospitalization. Tate,
Simonsen, Viboud, et al., Pediatrics 121,
2008
(AHRQ Publication No. 08-R071)*
(Intramural).
Parental visits to preventive health
Web sites may enhance preventive care
provided to children.
Due to time and other constraints,
pediatricians spend less than 10 minutes
of well-child visits discussing preventive
care. This study found that access to a
prevention-focused Web site can
prompt parents to bring up prevention
topics with their child’s provider during
well-child visits and also can increase
parental and physician adoption of
preventive measures. Christakis,
Zimmerman, Rivara, and Ebel,
Pediatrics 118(3):1157-1166, 2006
(AHRQ grant HS13302).
Distance-based quality improvement
approach shows promise for improving
pediatric immunization rates.
Researchers randomly assigned 29
pediatric research network-based
practices into year-long paper-based
education or distance-based QI groups
to examine differences in immunization
rates at the end of the year. Baseline
immunization rates of 88 percent or less
for children aged 8 to 15 months were
similar for the two groups. Practices in
the paper-based group received only
mailed educational materials. Those in
the distance-based group participated in
monthly conference calls, logged into E-mail
discussion groups, and made use of a Web site that shares best practices and
other information. Pediatricians in the
QI group boosted their immunization
rates by 4.9 percent compared with 0.8
percent for the paper-based education
group. Slora, Steffes, Harris, et al., Clin
Pediatr 47(1):25-36, 2008 (AHRQ
grant HS13512).
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Clinical Guidelines/Recommendations
Adherence to evidence-based guidelines
for catheter management is key to
reducing blood stream infections in
pediatric patients.
According to these authors, many
caregivers in pediatric intensive care
units (ICUs) view central venous
catheter (CVC)-associated blood stream
infections as unavoidable effects of
providing care to critically ill or injured
children. In a study that was conducted
in 26 hospitals, they found a 32 percent
reduction in CVC-associated blood
stream infections when care providers
followed evidence-based guidelines for
inserting and maintaining CVCs in
pediatric ICUs. These guidelines
indicate that providers should prepare
the patient’s skin with antiseptic, wash
their hands thoroughly, and don
protective barriers, such as gloves,
gowns, and masks to prevent infections.
After implementing the guidelines for 9
months, the hospitals saw a median
reduction in CVC-associated blood
stream infections from 6.3 to 4.3 per
1,000 CVC days. Also, the intervention
prevented an estimated 69 CVC-associated
blood stream infections for a
cost savings of nearly $3 million.
Jeffries, Mason, Brewer, et al., Infect
Control Hosp Epidemiol 30(7):645-651,
2009 (AHRQ grant HS13698).
Use of a medical home managed care
model can reduce ED use among
children with special health care needs.
According to this study, a managed care
model that emphasizes care coordination
and does not include strong financial
incentives to limit care use can reduce
the use of emergency department care
among children with special health care
needs. The researchers compared ED
use before and after the children joined
a managed care plan specially designed
for them and found an association
between managed care enrollment and a
nearly one-fourth drop in ED use. The
plan features a medical home approach
to create an environment for the more
effective management of chronic health
problems and facilitate early
intervention when those problems
become acute, thereby reducing ED use.
Pollack, Wheeler, Cowan, and Freed,
Med Care 45(2):139-145, 2007 (AHRQ
grant HS10441).
Use of decision analysis may lead to
better evaluation of pediatric clinical
guidelines.
Decision analysis synthesizes
information and focuses on estimating
the consequences of alternative health
measures. These authors discuss the use
of decision analysis to examine
interventions intended for children.
They note that frequently there is a
paucity of direct evidence for pediatric
interventions, which highlights a key
advantage of decision analysis: its focus
on quantifying outcomes of interest to
the decisionmaker, regardless of the
availability of direct evidence. Cohen
and Neumann, Health Aff 27(5):1467-1475, 2008 (AHRQ grant HS16760).
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Health Insurance/Coverage
Enrollment in SCHIP can improve
quality of care and access for children
with asthma.
This study of more than 2,600 children
with asthma in New York State found
that after enrollment, in the State
Children’s Health Insurance Program
(SCHIP) quality of care improved for
the children, and asthma-related attacks,
medical visits, and hospitalizations
declined. Also, the number of children
lacking a usual source of care declined
from 5 percent to 1 percent. Szilagy,
Dick, Klein, et al., Pediatrics
117(2):486-496, 2006 (AHRQ grant
HS10450).
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Interventions
Interventions show promise for
reducing adverse drug events related to
narcotics in children’s hospitals.
Hospitalized children are harmed more
often by prescribed narcotics than any
other type of medication, and finding a
way to reduce these narcotics-related
adverse drug events (ADEs) could
greatly reduce overall ADEs at children’s
hospitals. Researchers analyzed data
from 13 children’s hospitals for 3
months before and 3 months after a 6-month implantation phase for at least
one of four narcotics-related
interventions: limiting opportunities to
override automated medication
dispensing devices, use of laxatives and
stool softeners, weaning children off
extended narcotic use, and specific steps
to prevent ADEs during transfer of
children from one unit to another or
discharge to home. Overall the program
was associated with a significant 67
percent reduction in narcotic-related
ADEs at the hospitals during the 3
months after the interventions were
fully implemented. Sharek, McClead,
Taketomo, et al., Pediatrics 122(4):e861-e866, 2008 (AHRQ grant HS13698).
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Care Management
Chronic care model does not improve
safety practices among caregivers of
young children in a primary care
practice.
Researchers examined the effectiveness
of a chronic care model (CCM)
approach to injury prevention among
caregivers of children aged 0-5 in
primary care settings compared with
standard anticipatory guidance. Six
months later, there was no difference
between the two groups in the number
of medically attended injuries. Sangvai,
Cipriani, Colborn, and Wald, Clin
Pediatr 46(3):228-235, 2007 (AHRQ
grant HS13523).
Intervention programs that focus on
already violent youth found to be most
effective.
Tertiary intervention programs are more
likely to report effectiveness than
primary and secondary programs for
reducing violent behaviors among
adolescents, according to this study.
Tertiary programs focus on youths who
have already engaged in violent
behavior, while primary programs focus
on reducing risky behaviors (e.g.,
substance abuse) and secondary
programs focus on at-risk youths (e.g.,
those living in poor neighborhoods).
Overall, nearly half of interventions
evaluated were effective; two of six
primary interventions, three of seven
secondary interventions, and both
tertiary interventions were effective.
Limbos, Chan, Warf, et al., Am J Prev
Med 33(1):65-74, 2007 (AHRQ
contracts 290-97-0001 and 290-02-0003).
Medicaid primary care case
management reduces children’s access to
primary and preventive care.
Primary care case management (PCCM)
programs reimburse providers on a fee-for-
service basis. However, they assign
Medicaid patients to gatekeeper
providers who must make specific
referrals for specialty, emergency, and
inpatient care. This arrangement
resulted in disruptions in established
patterns of care use in Alabama and
Georgia and had an unexpected negative
effect on children, especially minority
children, according to this study.
PCCM was associated with lower use of
primary care for all children (except for
white children) in urban Georgia and
reduced preventive care for white
children in urban Alabama and for
black and white children in urban
Georgia. Implementation of PCCM
without fee increases may affect provider
decisions about Medicaid participation
and ultimately may reduce provider
availability, note the researchers. Adams,
Bronstein, and Florence, Med Care Res
Rev 63(1):58-87, 2006 (AHRQ grant
HS10435).
Gait assessment before surgery may
offset the need for repeat surgery in
children with cerebral palsy.
Children with cerebral palsy who have
problems walking often undergo several
rounds of surgery to correct their gait.
According to this study of 313 children
who received gait assessment prior to
their initial surgery and 149 children
who did not, only 11 percent of those
who had gait assessment needed
additional surgery, compared with 32
percent of the children who did not
have gait assessment. Although the cost
of the initial surgical session was higher
in the children who had gait assessment, the additional total cost per person-year
was nonsignificant ($20,448 vs.
$19,535 for those with and without gait
assessment, respectively). Wren,
Kalisvaart, Ghatan, et al., J Pediatr
Orthop 29(6):558-563, 2009 (AHRQ
grant HS14169).
Non-English-speaking parents report
better care and access for their children
when interpreters are present during
doctor visits.
Hispanic and Asian/Pacific Islander
parents who always use an interpreter
when their child has an outpatient
medical visit report enhanced care access
and quality, compared with parents who
don’t always use interpreters. They also
report better service from their health
plan when compared with parents who
do not use interpreters. Morales, Elliott,
Weech-Maldonado, and Hays, Med
Care Res Rev 63(1):110-128, 2006
(AHRQ grant HS09204).
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Practice Organization
Care setting affects the likelihood that
children with persistent asthma will
receive inhaled steroids.
According to this study of 563 children
with persistent asthma, those receiving
care in community health centers or
hospital clinics were significantly less
likely than children seen in
multispecialty practices to have received
inhaled steroids for their asthma. These
differences were not seen for receipt of
influenza vaccinations and asthma care
plans. Key components of quality care
for children with asthma include
prescribing inhaled steroids, vaccinating
children against influenza, and
discussing an asthma action plan with
parents. Galbraith, Smith, Bokhour, et
al., Arch Pediatr Adolesc Med 164(1):38-43, 2010 (AHRQ grant T32
HS00063).
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Health IT
Telemedicine appears effective for
evaluating acute childhood illnesses.
Researchers randomly assigned 253
children to in-person evaluation of acute
illness by study physicians and 239
children to evaluation by study
physicians via telemedicine. Children
were seen in a pediatric primary care
practice or pediatric emergency
department of a university-affiliated
medical center. Results were comparable
for the two groups: study physicians
made a diagnosis in 74.1 percent of
telemedicine visits compared with 76.7
percent of in-person visits.
McConnochie, Conners, Brayer, et al.,
Telemed J E Health 12(3):308-316, 2006
(AHRQ grant HS10753).
Children do not benefit as much as
adults from hospital computer order
entry systems.
Researchers collected data on 627
children hospitalized in a pediatric
surgical or medical unit, pediatric
intensive care unit, or a neonatal
intensive care unit either before or after
implementation of a commercial
computerized physician order entry
system (CPOE). Medication error rates
were not significantly different after
implementation of CPOE, even though
studies have shown reductions of up to
55 percent in serious medication errors
in adults following introduction of
CPOE. The researchers note that the
system they evaluated was not optimally
designed to prevent common pediatric
medication errors, such as mistakes in
the use of weight-based dosing
calculations. Walsh, Landrigan, Adams,
et al., Pediatrics 121(3), 2008 (AHRQ grant
HS13333).
Decision support in an electronic
health record improves asthma care for
children.
This project was conducted in 12
primary care sites in both urban and
suburban locations where children with
asthma were seen on a regular basis.
Before the start of the study, staff at all
of the sites participated in an
educational program on asthma
management, and all sites received an
asthma control tool as part of their
electronic health record (EHR) system.
A clinical decision support (CDS)
component based on Federal guidelines
for asthma care was added to the EHR
at six of the sites. Use of controller
medications, asthma care plans, and
spirometry increased significantly in
practices with the CDS in their EHRs.
Bell, Grundmeier, Localio, et al.,
Pediatrics 125(4):e770-e777, 2010
(AHRQ grant HS14873).
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Tools/Models
Some minority youths benefit more
than others from evidence-based
mental health interventions.
The researchers examined the impact of
a quality improvement intervention
designed to improve access to evidence-based
depression care for minority
youths and found a significant
reduction in depression symptoms
among blacks, significant improvement
in care satisfaction among Hispanics,
and no intervention effects among white
youths. They examined outcomes
among 344 youths who completed a 6-month followup assessment. Ngo,
Asarnow, Lange, et al., Psychiatr Serv
60(10):1357-1364, 2009 (AHRQ grant
HS09908).
Community-wide interventions have
some success in reducing antibiotic use
among children.
The rapid increase in antibiotic-resistant
bacteria is widely believed to result from
the high use of antibiotics, especially by
young children. The research team
tested an antibiotic education
intervention in 16 small and large towns
during three successive cold and flu
seasons (2000-2003) in collaboration
with three private insurers and a State
Medicaid program. The intervention
was aimed primarily at parents of
children age 6 and younger and their
physicians. The program was responsible
for a 4.2 percent decrease in antibiotic
prescribing for children 24 to 48
months of age and a 6 percent decline
among those 48 to 72 months of age.
Finkelstein, Huang, Kleinman, et al.,
Pediatrics 121(1):15-23, 2008 (AHRQ
grant HS10247).
Pocket card facilitates shared
parent/physician decisionmaking about
treatment for acute otitis media.
A simple pocket card has been
developed to help physicians and
parents work together to decide on the
appropriate treatment for a child with
acute otitis media (AOM). The pocket
card combines a parent’s assessment of
the child’s symptoms (using a scale of
facial expressions) with the clinician’s
assessment of tympanic membrane
inflammation and middle ear
appearance (using an otoscopy scale) to
determine AOM severity. After
considering this rating of AOM severity,
the child’s age, and the presence or
absence of other risk factors, the
clinician and parent can decide on the
appropriate treatment plan. Friedman,
McCormick, Pittman, et al., Pediatr
Infect Dis J 25(2):101-107, 2006
(AHRQ grant HS10613).
Results from the Healthy Steps for
Young Children program appear
promising.
Even though the Healthy Steps for
Young Children (HS) program ended at
3 years, its impact was sustained among
5-year-old children, according to this
study. A smaller percentage of HS
parents slapped their child in the face or
spanked their child with an object,
compared with parents in a non-HS
group. Also, HS parents were more
likely to negotiate with their child,
ignore misbehavior, and encourage
children to read and use car seat
restraints than parents in the non-HS
group. Minkovitz, Strobino, Mistry, et
al., Pediatrics 120(3), 2007 (AHRQ grant
HS13086).
* Items in this program brief marked with an asterisk are available free from the AHRQ Clearinghouse. To order, contact the AHRQ Clearinghouse at 800-358-9295, or send an e-mail to ahrqpubs@ahrq.hhs.gov. Please use the AHRQ publication number when ordering.
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For More Information
AHRQ's World Wide Web site (http://www.ahrq.gov) provides information on the Agency's children's health services research agenda and funding opportunities. In addition, AHRQ also offers a child and adolescent health E-mail update service to which users may subscribe (go to https://subscriptions.ahrq.gov and follow the prompts).
Further details on AHRQ's programs and priorities in child health services research are available from:
Denise M. Dougherty, Ph.D.
Senior Advisor, Child Health and Quality Improvement
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
E-mail: Denise.Dougherty@ahrq.hhs.gov
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AHRQ Publication No. 11-P001
(Replaces AHRQ Publication No. 09-PB001)
Current as of February 2011
Internet Citation:
Child Health Research: Identifying Quality Problems and Improving Care, Program Brief. AHRQ Publication No. 11-P001, February 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/childfind/
540 Gaither Road Rockville, MD 20850 