Fiscal Year 2001
In building on its research on child health, the Agency for Healthcare Research and Quality (AHRQ) funded grants starting in Fiscal Year 2001 that focus on outcomes; quality; and cost, use, and access, AHRQ's three strategic goals.
This fact sheet summarizes AHRQ-funded studies focusing on child health care outcomes; quality and patient safety; and cost, use and access. It also summarizes AHRQ's support for capacity building in research, education and dissemination.
In Fiscal Year 2001, AHRQ announced support for $16 million in new research and training grants, contracts, and Inter-Agency Agreements on children's health care issues over the life of the projects.
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Quality and Patient Safety
Cost, Utilization, and Access
CARES: Child Abuse Reporting Experience Study
Principal Investigator: Emalee G. Flaherty, Children's Memorial Hospital, Chicago, IL
Grant No.: R0l HS10746 (09/30/01-09/29/05)
Description: The aim of this prospective descriptive study of practitioner management of 16,000 childhood injuries is to provide the first comprehensive analysis of the management of suspected child abuse in primary care practices.
*Minimizing Antibiotic Resistance in Colorado (MARC)
Principal Investigator: Ralph Gonzales, Regents of the University of California, San Francisco, CA
Grant No.: R01 HS13001 (07/01/01-06/30/05)
Description: The aim of this study is to examine the processes and outcomes of care focusing on various intervention strategies to improve ambulatory antibiotic prescribing practices. For example, the program will measure and assess changes in antibiotic prescription rates for pharyngitis in children and bronchitis in adults, using managed care organizations (MCO) and Medicaid data from physician practices.
*Safety and Financial Ramifications of ED Copayments
Principal Investigator: John Hsu, Kaiser Foundation Research Institute, Oakland, CA
Grant No.: R01 HS11434 (07/01/01-06/30/03)
Description: The aim of this study is to evaluate the effects of the size of copayment for emergency department use on patient outcomes and treatment costs within the Kaiser Permanente-Northern California health system using a quasi-experimental pre-post design with concurrent controls.
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Quality and Patient Safety
Medicaid Managed Care for Children with Special Health Care Needs (CSHCN)
Principal Investigator: Jean Mitchell, Georgetown Public Policy Institute, Georgetown University, Washington, DC
Grant No.: R01 HS10912 (06/01/01-05/31/04)
Description: This study will analyze factors determining selection of a managed care plan by the parents of CSHCN, examine difficulties children may have in getting access to care by questioning parents, and examine several quality of care indicators. Indicators include immunizations and dental care, referrals to specialists, appropriateness of medication use, hospitalizations for ambulatory sensitive conditions, and continuity of care.
*Quality Improvement Structures and Practices as Determinants of Hospital Quality Indicators
Principal Investigator: Jeffrey A. Alexander, The Regents of the University of Michigan, Ann Arbor, MI
Grant No.: R01 HS11317 (09/01/01-08/31/03)
Description: The aim of this study is to assess the relationship between hospital quality improvement structures, practices and selected quality indicators in a sample of more than 854 hospitals. The study will combine unique survey data on these hospital structures and practices with data derived from hospital discharge abstract data under the Healthcare Cost and Utilization Project (HCUP) at AHRQ. Children will be incorporated in these data, but researchers will not produce a specific analysis for children.
*Racial/Ethnic Differences in CAHPS Ratings and Reports
Principal Investigator: Robert J. Weech-Maldonado, Pennsylvania State University, University Park, PA
Grant No.: R03 HS11386 (05/01/01-04/30/02)
Description: The purpose of this study is to examine the racial-ethnic differences in consumer health plan assessments for adults and children enrolled in managed care plans.
Projects Funded Under the RFA: Clinical Informatics to Promote Patient Safety (CLIPS)
This Request for Applications (RFA) sought projects to develop and test the use of innovative technologies, such as hand-held electronic medication and specimen management systems, training simulators for medical education, computerized bar-coding, patient bracelets, smart cards, and automated medication-dispensing systems in clinical settings. Projects will assess the extent to which such innovations, contribute to measurable and sustainable improvements in patient safety and quality of care.
Using Hand-held Technology to Reduce Errors in ADHD Care
Principal Investigator: Paula Lozano, University of Washington, Seattle, WA
Grant No.: R18 HS11859 (09/26/01-08/31/04)
Description: This randomized controlled trial in 3 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 attention-deficit/hyperactivity disorder.
Impact of Electronic Prescribing on Medication Errors in Ambulatory Pediatrics
Principal Investigator: Kevin B. Johnson, Johns Hopkins University, Baltimore, MD
Grant No.: R18 HS11868 (09/18/01-08/31/04)
Description: The aims of this study are to assess the baseline medication error rate in an urban pediatric emergency department and clinic; to compare handheld implements for electronic prescription writing; and to determine the effect that electronic prescribing has on medication error rates and prescribing practices.
Projects Funded Under the RFA: Developmental Centers for Evaluation and Research in Patient Safety (DCERPS)
This RFA sought exploratory grants to assist the advancement of DCERPS, including planning for activities to enhance the capacity to conduct quality research and translate research findings into practice.
Center for Evaluation and Research in Pediatric Safety
Principal Investigator: James A. Taylor, University of Washington, Seattle, WA
Grant No.: P20 HS11590 (09/30/01-09/29/04)
Description: The aim of this project is to establish a 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).
Center for Patient Safety in Neonatal Intensive Care
Principal Investigator: Jeffrey D. Horbar, University of Vermont, Burlington, VT
Grant No.: P20 HS11583 (09/30/01-09/29/04)
Description: The aims of this project are to: (1) create a DCERPS in neonatal intensive care to reduce medical errors and enhance patient safety for high-risk newborns, and (2) determine how to learn most effectively from those medical errors and then communicate the information to families.
*The Center for Improving Patient Safety (CIPS)
Principal Investigator: Robert S. Dittus, Vanderbilt University Medical Center, Nashville, TN
Grant No.: P20 HS11563 (09/01/01-08/31/04)
Description: The aim of this project is to create a CIPS to study medical error awareness and experiences within racial and ethnic minority populations focusing 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.
*Oregon Patient Safety Evaluation Center
Principal Investigator: David H. Hickam, Oregon Health & Science University, Portland, OR
Grant No.: P20 HS11550 (10/01/01-09/30/04)
Description: The aim of this project is to establish a DCERPS to build a multi-institutional and interdisciplinary research program focusing on patient safety activities, and provide infrastructure for multiple future research studies. Several medical and clinical infrastructures will support the center that includes four pediatric programs that will review data on adverse outcomes in pediatric patients.
*The American Academy of Family Physicians (AAFP) DCERPS
Principal Investigator: John M. Hickner, American Academy of Family Physicians, Leawood, KS
Grant No.: P20 HS11584 (09/01/01-08/31/01)
Description: The aim of this project is to establish a National DCERPS in primary care to strengthen AAPF's medical education programs to improve the safety of medical care for patients of all ages, including children in the primary care physician's offices, family practices, and residency training clinics.
Project Funded Under the RFA: Centers of Excellence For Patient Safety Research and Practice
This RFA sought research program project grants to support the development of multidisciplinary research teams to build the knowledge base on the scope and impact of medical errors, particularly for diverse care settings and populations.
*Improving Medication Safety Across Clinical Settings
Principal Investigator: David W. Bates, Brigham and Women's Hospital, Boston, MA
Grant No.: P01 HS11534 (09/24/01-08/31/06)
Description: The aim of this project is to extend 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.
Projects Funded Under the RFA: Improving Patient Safety—Health Systems Reporting, Analysis, and Safety Improvement Research Demonstrations
This RFA sought large demonstrations in states, health care systems and/or networks of providers to test reporting strategies and patient safety interventions.
*Surveillance, Analysis, and Interventions to Improve Patient Safety
Principal Investigator: Victoria Fraser, Washington University School of Medicine, St. Louis, MO
Grant No.: U18 HS11898 (09/30/01-9/29/04)
Description: The aims 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 health care workers communicate with patients and families about medical errors. In this study, 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.
*Addressing Preventable Medication Use Variance in Mississippi
Principal Investigator: Andrew C. Brown, University of Mississippi Medical Center, Jackson, MS
Grant No.: U18 HS11923 (09/30/01-09/29/04)
Description: The aims of this project are to: (1) identify the causes of preventable health care errors and patient injury in health care delivery; (2) develop, demonstrate, and evaluate strategies for reducing errors and improving patient safety; and (3) disseminate the results of the project's research and strategies throughout the health care industry. Researchers will focus on ten study sites throughout the state that include priority populations (e.g., inner-city and rural areas, low-income and minority groups, women, children and the elderly).
Project Funded Under the RFA: Patient Safety Research Dissemination and Education
This RFA sought grants to support professional associations, educational leadership organizations and provider organizations to demonstrate and evaluate innovative approaches to provider education; to disseminate patient safety research results and best practices; and to promote positive safety culture.
Transfer of a Novel Pediatric Simulation Program
Principal Investigator: Louis P. Halamek, Stanford University, Stanford, CA
Grant No.: U18 HS12022 (09/30/01-08/31/04)
Description: The aims of this study are to determine whether the skills acquired within a simulated environment can be practiced in the real delivery room, and whether the practice of these skills result in improved patient safety. The long-term objective is to improve the technical and behavioral performance of those caring for mothers and babies in the delivery room and thus reduce the rate of medical errors in that domain.
Evidence-based Practice Program—Synthesizing Scientific Evidence to Improve Quality and Effectiveness in Clinical Care
Under this program, 12 five-year contracts have been awarded by AHRQ to institutions in the United States and Canada to serve as Evidence-based Practice Centers (EPCs). The EPCs will review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities. Public and private sector organizations may use the reports and assessments as the basis for their own clinical guidelines and other quality improvement activities. The following are 2001 topics relevant to children.
Management of Bronchiolitis.
Principal Investigator: Research Triangle Institute and University of North Carolina at Chapel Hill
Principal Investigator: New England Medical Center
Preventing Adolescent Criminal and Other Health-risking Social Behavior.
Principal Investigator: Oregon Health and Science University
Principal Investigator: Emergency Care Research Institute (ECRI)
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Cost, Utilization, and Access
Dynamics of Family Disadvantage and Childhood Asthma
Principal Investigator: Nazil Baydar, University of Washington, Seattle, WA
Grant No.: R01 HS13110 (09/30/01-08/31/04)
Description: The aim of this project is to extend previous research to investigate the impact of having a child with asthma and the burden this condition places on the family's resources (e.g., economic resources, the parents' time and availability for care, access and barriers to health care).
Managing the Health Needs of Vulnerable Children: Families' Experience.
Principal Investigator: Michael Seid, Children's Hospital Research Center, San Diego, CA
Grant No.: R03 HS11751 (09/30/01-09/29/02)
Description: The aim of this project is to provide qualitative information about managing the health care needs of vulnerable children in San Diego. Data will be gathered using semi-structured interviews focusing on health needs, health care services use, problems in using care, and proposals for health care services improvement. Results will be used to design effective interventions to improve health care delivery to vulnerable children.
Assessing Medical Need Among Children in Managed Care
Principal Investigator: Paul Fishman, Group Health Cooperative, Seattle, WA
Grant No.: R01 HS11314 (05/01/01-10/31/03)
Description: The aims of this project are to (1) determine whether risk assessment models are sensitive enough to identify expected health care cost and utilization for children in managed health care plans; (2) evaluate if financial disincentives exist for health plans to enroll children and families with children; and (3) assess how additional health status information improves the predictive performance of risk assessment instruments.
*The Impact of the Oregon Health Plan on TANF Leavers' Ability to Care for Their Families' Health
Principal Investigator: Karen M. Seccombe, Portland State University, Portland, OR
Grant No.: R01 HS11322 (09/05/01-08/31/04)
Description: The aim of this project is to examine the effects of welfare reform on the access to health insurance and use of health services among former welfare recipients and their children in the State of Oregon
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Integrated Delivery System Research Network (IDSRN)
AHRQ's IDSRN was designed to capitalize on the research capacity of integrated delivery systems. The network creates, supports, and disseminates scientific evidence about what works and what does not work in terms of data and measurement systems and organizational "best practices" related to care delivery and research diffusion. It also provides a cadre of delivery-affiliated researchers and sites to test ways to adapt and apply existing knowledge.
*Validating the Healthcare Cost and Utilization Projects (HCUP) Patient Safety Quality Indicators
Principal Investigator: Shula Bernard, Research Triangle Institute, Research Triangle Park, NC
Description: The purpose of this study 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.
Small Business Innovation Research (SBIR)
AHRQ's SBIR program supports innovative research conducted by small business concerns that have potential for commercialization of research.
*Web-Enabled Asthma Application for Personalized Medical Communication
Principal Investigator: Renee J. Goldberg Arnold, Pharmacon International, Inc., New York, NY
Description: The purpose of this study is to develop an integrated medical system that facilitates communication between physicians and asthma patients. The system will enhance compliance with therapeutic regimens and enable self-management through peak flow monitoring. The project proposes to make the integrated technological system appropriate for children under six and their parents.
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AHRQ supports research for infrastructure development in the field of health services research.
Projects Funded Under the RFA: Building Research Infrastructure and Capacity (BRIC) Program
BRIC is a merit-based, peer-reviewed program initiated to broaden geographic distribution of health services research funding by enhancing the competitiveness for research funding among institutions located in states in which the aggregate success rate for applications to the AHRQ has historically been low. This RFA will support a development program to increase the health services research competitiveness of institutions within selected states.
Intermountain Child Health Services Research Consortium
Principal Investigator: Charles J. Hoff, University of Utah, Salt Lake City, UT
Grant No.: P20 HS11826 (09/30/01-09/29/03)
Description: The aim of this project is to develop an infrastructure to generate and support a child health services research program in the Intermountain West to improve the quality and delivery of health care for all children with emphasis on children with special health care needs.
Mississippi Building Research Infrastructure and Capacity Project
Principal Investigator: Linda H. Southward, Mississippi State University, Mississippi, State, MS
Grant No.: P20 HS11849 (09/30/01-09/29/02)
Description: The aim of this project is to develop an innovative multidisciplinary research program to improve the health care and health outcomes of underserved, rural, predominantly minority children in 12 impoverished counties in the Mississippi Delta.
*LSU Health Services Research Program
Principal Investigator: Frederick P. Cerise, LSU Health Sciences Center, New Orleans, LA
Grant No.: P20 HS11834 (09/30/01-09/29/03)
Description: The aim of this study is to launch a Louisiana State University (LSU) Health Services Research Program to increase applied health services research in the State. The program will be a partnership between the LSU medical school and the LSU health care services unit (that delivers health care to approximately 1 million residents, particularly the uninsured and underinsured). Participation of children will be addressed on a project-by-project basis in this program.
Projects Funded Under the RFA: Primary Care Practice-Based Research Networks II
This RFA sought projects to provides continuing support of Practice-Based Research Networks (PBRNs) and assist PBRNs in addressing data-related issues. Grants were awarded to PBRNs which had received planning grants from an earlier RFA.
Pediatric Practice Research Group (PPRG): Retooling for the 21st Century, Phase 2
Principal Investigator: Helen Binns, Children's Memorial Hospital, Chicago, IL
Grant No.: U01 HS11248 (09/30/01-09/29/02)
Description: The aims of this project are to: continue to examine methods of computerized data collection and develop a plan for phased trials of such in the practice setting; strategize with PPRG physicians on ways to implement studies that lead to enhanced patient care; and conduct a National Ambulatory Medical Care Survey among willing PPRG practitioners to examine the challenges and the diversity of clinic flow patterns.
Cincinnati Pediatric Research Group Enhancement Project
Principal Investigator: Michele Kiely, Children's Hospital Medical Center, Cincinnati, OH
Grant No.: P20 HS11201 (09/30/01-09/29/02)
Description: This study will further develop and create a significant, stable infrastructure for an established community-practice based research network to provide pediatric primary care.
Defining Patient visits in a National Pediatric PBRN
Principal Investigator: Richard C. Wasserman, The American Academy of Pediatrics, Elk Grove Village, IL
Grant No.: U01 HS11192 (09/30/01-09/29/02)
Description: The aim of this study is to enroll 40 Pediatric Research in Office Settings (PROS) networks and the National Medical Association Pediatric Sections to compare a traditional paper/pencil data collection for the National Ambulatory Medical Care Survey (NAMCS) with NAMCS data collection accomplished via Web-based technologies. These analyses will compare completeness, accuracy, and practitioner satisfaction with data collected via the two methods.
*Applied Strategies for Interventions of Patient Safety
Principal Investigator: Wilson D. Pace, University of Colorado Health Sciences Center, Denver, CO
Grant No.: U18 HS 11878 (09/30/01-09/27/04)
Description: 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 collect and analyze the causes and effects of errors in primary care, as well as develop and implement interventions aimed at decreasing recognized errors in primary care.
The Effect of Public Insurance on Dental Health Outcomes
Principal Investigator:Tegwyn L. Hughes, University of North Carolina at Chapel Hill, Chapel Hill, NC
Grant No.: R03 HS11514 (09/30/01-06/30/02)
Description: The aim of this dissertation project is to conduct an in-depth comparison of the utilization of dental services, effectiveness of established pediatric oral health performance measures, and dental health status for children (ages 1-5) enrolled in either the NC Medicaid program or the NC SCHIP/Health Choice program.
Effects of WIC on Child Medicaid Dental Use and Costs
Principal Investigator: Jessica Y. Lee, University of North Carolina at Chapel Hill, Chapel Hill, NC
Grant No.: R03 HS11607 (09/30/01-09/29/02)
Description: The aim of this dissertation project is to examine the Women, Infants and Children's (WIC) Supplemental Food Program focusing on oral health utilization patterns and cost to the Medicaid program for children under 5 years. The researcher will also explore a new aspect of Medicaid utilization, the role of WIC, and its partnership to help increase oral health access for these Medicaid children.
The Effect of Medication Errors in the Pediatric ICU
Principal Investigator: Joel D. Portnoy, The Children's Hospital of Philadelphia, Philadelphia, PA
Grant No.: K08 HS11636 (09/04/01-08/31/06)
Description: 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 pediatric ICU; (2) determine the risk of mortality attributable to exposure to medication errors in patients admitted to the pediatric ICU; and (3) determine the risk of requiring inpatient rehabilitation or technology dependence associated with exposure to medication errors.
Measuring Quality of Care for Homeless Adolescents
Principal Investigator: B. Josephine Ensign, University of Washington, Seattle, WA
Grant No.: K08 HS11414 (07/06/01-06/30/05)
Description: The aim of this Mentored Clinical Scientist Development Award is to conduct research using a mixed-method study, including interviews, focus groups and a pilot test, to document the factors necessary for monitoring access and quality of primary health care for homeless youth.
Faculty Development for General Pediatrics Teaching in Community-Based Settings
In collaboration with the Health Resources and Services Administration's Bureau of Health Professions, AHRQ continues to support the Ambulatory Pediatric Association's (APA) Primary Care Pediatrics Research Awards. This special projects program facilitates in building the field of child health services research. The following three projects were awarded in 2001:
Epidemiology and External Causes of Pediatric Injury-Related Visits to Emergency Departments and Hospital Outpatient Departments in the United States
Principal Investigator: Simon J. Hambidge, Denver Health Medical Center, Denver CO
Description: The purpose of this project is to define and examine the epidemiology and external causes of pediatric injuries seen in emergency departments and hospital outpatient departments, and compare the demographic characteristics of children with injury-related visits to those with non-injury related visits.
Trends in the Non-operative Management of Splenic Injury in Children
Principal Investigator: Daniela H. Davis, Children's Hospital of Philadelphia, Philadelphia, PA
Description: The purpose of this project is to characterize the diffusion of non-operative management of splenic injury in children within a regionalized trauma system.
Assessment of School Readiness in Pediatric Office Visits
Principal Investigator: Alice Kuo, UCLA Center for Healthier Children, Families, and Communities, Los Angeles, CA
Description: The purpose of this project is to perform an analysis of the current practices in pediatric office visits focusing on the school readiness assessment from the National Survey of Early Childhood Health.
Small Conference Grants
Improving EMS for Children Through Outcomes Research—March 30-April 1, 2001
Principal Investigator: Ellen Crain, Jacobi Hospital, Bronx, NY
Grant No.: R13 HS10942 (01/01/01-12/31/01)
Description: The Ambulatory Pediatric Association (APA) Conference, "Improving EMS for Children Through Outcomes Research," was held in Reston, VA. The conference introduced young pediatric emergency medicine investigators to important concepts in outcomes research; reviewed measures that exist; determined the applicability of these measures to pediatric emergency medicine research; identified where new measures are needed; and promoted dialogue between health service researchers from other disciplines and pediatric emergency medicine.
Research Agenda for Pediatric Burns Outcomes Measurement—April 9-11, 2001
Principal Investigator: Ronald Tompkins, American Burn Association, Chicago, IL
Grant No.: R13 HS 10950 (03/01/01-02/28/02)
Description: Focusing on the issue of research on outcomes of care for burn injuries in children, this conference convened an invited group of clinicians and other experts on pediatric burn management and outcomes measurement to disseminate and discuss an instrument on functional outcomes in pediatric burn survivors. The conference established the need for a national research agenda for improving the quality of health care for children with burn injuries.
*Asthma Education in the Emergency Department - April 1-3, 2001
Principal Investigator: Carlos Camargo, New York, NY
Grant No.: R13 HS10940 (12/15/00-12/14/01)
Description: The Massachusetts General Hospital, including the Multicenter Airway Research Collaboration (MARC) Coordinating Center, held an expert consensus conference to address the deficiencies in asthma education in the emergency department, and will design a research strategy to implement and assess its effects. Participants will develop a research agenda, including a multicenter, randomized clinical trial to assess the effects of a focused asthma education program on asthma outcomes.
*Meeting the Challenge of Medicaid Managed Care: Best Practices for Clinical Care and Teaching—November 1-3, 2001
Principal Investigator: Rosalie Phillips, Tufts Managed Care Institute, Boston, MA
Grant No.: R13 HS10969. (09/30/01-09/29/02)
Description: Tufts Managed Care Institute in collaboration with Partnerships for Quality Education convened a conference to enhance the competencies of clinicians and faculty in academic health centers and affiliated practices to meet needs of both patients and trainees in Medicaid managed care programs. A workshop focused on "childhood immunization rates." The core audience was primary care physicians and nurse practitioners.
User Liaison Program (ULP) Workshops with Senior State Officials
The User Liaison Program disseminates health services research findings in easily understandable and usable formats through interactive workshops and technical assistance for State and local health policymakers and other health services users. Summaries of workshops are available on AHRQ's Web site at: http://www.ahrq.gov/news/ulpix.htm
Title: Improving the Quality of Care Delivered to Children Served by State Agencies
Date: January 24-26, 2001
Place: New Orleans, LA
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*Project includes children or children's healthcare issues but does not focus exclusively on children.
Select for further information about child and adolescent health activities at AHRQ.
AHRQ Publication No. 02-P008
Current as of January 2002
Research on Child and Adolescent Health: New Starts, Fiscal Year 2001. Fact Sheet. AHRQ Publication No. 02-P008, January 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/childr01.htm