Children's Health Services Research:
Improving Children's Health
Through Health Services Research was a special 1-day meeting held June 26, 1999, in Chicago. The state of the science in children's health services research
was explored, including public and private funding opportunities, networks for
conducting research, and uses of research in policy and practice. The meeting
was co-sponsored by the National Association of Children's Hospitals and Related
Institutions (NACHRI), with the Agency for Health Care Policy and Research (AHCPR),
the American Academy of Pediatrics (AAP), the David and Lucille Packard Foundation, the
Association for Health Services Research (AHSR), the Robert Wood Johnson Foundation, and Data
Dr. Lisa Simpson, Deputy Administrator
of the Agency for Healthcare Research and Quality, welcomed David Helms to the
executive leadership of the Association for Health Services Research, noting
how his in-depth knowledge of States is particularly timely. She noted how preparing
for her talk dramatically increased her appreciation for the work that children's
health services researchers had been doing over the past decades, and how reviewing
their work confirmed her choice to work in this field.
Dr. Simpson's remarks focused on
four substantive areas:
- What is health services research
(HSR) and children's health services research (CHSR)?
- What has been accomplished in
- Who does and funds CHSR?
- What are future needs and strategies?
The field of health services research
was most recently defined by the Institute of Medicine in 1995. Although CHSR
still lacks its own definition as a field, specialized attention to children
by HSR is essential because of the "4 Ds" that generally differentiate
children from adults:
- Developmental change.
- Differential epidemiology (of
health conditions and health services).
In 1998, Christopher Forrest articulated
a goal for CHSR that is worthy of debate and consideration as the field develops.
To use scientific inquiry
to inform decisions on:
- How to improve health systems
for children and adolescents.
- How to improve child and adolescent
health at the level of both individuals and populations.
Although CHSR is still emerging as
a field, it has made substantial contributions, which were illustrated by Dr.
Simpson with the use of the HSR "Pipeline of Investment" as an organizing
Priority I of the pipeline
is the development of new knowledge on priority health issues.
Here CHSR has made significant contributions
- Demonstrated the critical role
of insurance in children's health and health care.
- Articulated the impacts of differences
in the organization and delivery of care for children.
- Showed that children, just like
adults, experience unexplained variations in care.
- Rigorously tested the impacts
(outcomes) of clinical interventions and policy alterations.
- Unearthed problems in quality
of care for children.
Priority II of the pipeline
refers to developing new tools and talent for a new century.
In this area, CHSR has been active
in developing the new research methods that are essential because of the nature
of children and their health care needs.
These tools include:
- Outcomes and quality measures.
- Databases for research and monitoring.
- Research networks.
Multiple government and private mechanisms
for training new CHSR researchers exist, although more are needed.
Priority III addresses the
critical issue of translating research into practice and policy.
This need was articulated by Robert
Haggerty and his colleagues in 1975, and is reinforced whenever HSR funding
agencies appear before Congressional appropriations committees. Past contributions
of CHSR to translating research into (clinical) practice (TRIP) include work
that supported the elimination of unnecessary services such as routine chest
x-rays in childhood and the move of certain screening practices (e.g., lead)
to only high-risk populations of children.
Currently, TRIP efforts include the
many research-based quality improvement efforts under way in delivery of preventive
services and neonatal services and care for specific conditions such as hyperbilirubinemia
and asthma. In the policy arena, research on the critical role of health insurance
for children would not have been worthwhile except for the sustained efforts
to bring this knowledge to the attention of policymakers.
Growth and Funding
Dr. Simpson noted how the fields
of HSR and CHSR have grown. Among the noteworthy developments in CHSR in recent
years have been the increasing number of HSR submissions and presentations at
the APA program at the Pediatric Academic Societies meetings, and the creation
of the Center for Child Health Research at the American Academy of Pediatrics.
The Packard-Foundation-funded directory of CHSR researchers compiled by NACHRI
is still in draft, but contains information on 500 self-identified CHSR.
Funding for CHSR comes from private
and public sources. Principal among the Federal agencies are AHRQ, the Maternal
and Child Health Bureau in the Health Resources and Services Administration,
and, at the National Institutes of Health, the National Institute of Mental
Health, the National Institute on Alcohol Abuse and Alcoholism, the National
Institute on Drug Abuse, and the National Institute of Child Health and Human
Future Challenges and Strategies
Despite a series of remarkable accomplishments
in CHSR, the investment in CHSR to date has been inadequate to meet the current
and future needs of children and adolescents, said Dr.Simpson.
Pressing needs for the attention
of CHSR include:
- The States' implementation of
the State Children's Health Insurance Program, due to be evaluated by 2001.
- Continuing changes in the organization
and delivery of care, much of whose impact on children is unknown.
- The health of ethnic minority
children and of adolescents.
Dr Simpson articulated five strategies
that will contribute to the ability of CHSR to meet these and future needs of
the field and of children, and noted how the rest of the day's program would
help flesh out the needed approaches:
- Increase the overall investment
in CHSR. There is a new policy on inclusion of children in research supported
by the National Institutes of Health and AHRQ and a new emphasis on children
as a priority population in the AHRQ reauthorization bill.
- Make a concerted effort to
increase the size and diversity of the CHSR workforce. This includes investing
in career development for young investigators and expanding the number of
disciplines engaged in CHSR.
- Foster the infrastructure for
CHSR. Develop Centers of Excellence in CHSR, build more and stronger research
networks, and structure innovative collaborations among researchers and funders.
- Be driven by the needs of the
user of research. This will facilitate the timely application of findings
to enhance the health of children.
- Communicate more effectively
the value and contributions of CHSR. This will help CHSR to be appreciated
as the scientific field of inquiry that it is.
Simpson, L.A. Children's
Health Services Research: An Overview. Presentation Summary, Improving Children's
Health Through Health Services Research, Chicago, June 26, 1999. http://www.ahrq.gov/research/chsrover.htm