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 A previous vaccine was withdrawn in 1999 after it was associated with intussusception in infants.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).

Return to Contents 

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).

Return to Contents 

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).

Return to Contents 

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).

Return to Contents 

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).

Return to Contents 

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).

Return to Contents 

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).

Return to Contents

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.

Return to Contents 

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