Children's Healthcare Gets Short Shrift

SEATTLE, Oct. 10 -- Children in the United States get less than half of the medical care recommended for them, investigators here have found.

A review of medical records in 12 metropolitan areas revealed that children received only 46.5% of care indicated as appropriate by quality standards, reported Rita Mangione-Smith, M.D., M.P.H., of the University of Washington, and colleagues in the October 11 issue of the New England Journal of Medicine.

Children got only about two-thirds of acute care services they needed, slightly more than half of appropriate care for chronic conditions, and only slightly more than one third of recommended preventive services, the authors wrote.

The observations by Dr. Mangione-Smith and colleagues are "shocking," according to James M. Perrin, M.D., and Charles J. Homer, M.D., M.P.H. of Harvard Medical School, in an accompanying editorial.

"Services are not delivered when they should be, or they are delivered when they should not be," they wrote. "In general, the same dismal story was apparent in all aspects of pediatric ambulatory care examined."

Previous studies have shown serious deficits in the quality of care for adults in the U.S., but much less is known about the care our children receive, Dr. Mangione-Smith and colleagues wrote.

Research and policy related to children have focused on expanding eligibility for public insurance programs, but expanding access to a system that does not deliver necessary services will not result in optimal outcomes," they wrote. "Deficits in the delivery of care must be identified if appropriate strategies to close the gaps are to be developed and implemented."

So the researchers worked with colleagues in the Community Tracking Study to evaluate the quality of children's care, examining variations in quality according to the type of care; mode of care; clinical area; and diagnosis, treatment, and follow-up.

Staff members from the RAND Corporation reviewed guidelines and the medical literature to develop indicators of quality for the continuum

of care functions. The indicators were reviewed for validity by a panel of four general pediatricians, two family practitioners, two specialists in adolescent medicine, and one specialist in pediatric infectious diseases, selected on the recommendation of professional groups.

The investigators then approached the parents of 1,536 children who were randomly selected from 12 metropolitan areas, and asked for their consent to obtain medical records from all providers who had seen the children during the two-year period before the date of study recruitment.

The medical records were abstracted by trained nurses, and the investigators calculated composite quality scores by dividing the number of times indicated care was actually ordered or delivered by the number of times a care process was indicated.

They found that "on average, according to data in the medical records, children in the study received 46.5% (95% confidence interval 44.5% to 48.4%) of the indicated care.

Children who needed acute medical care received 67.6% (95% CI, 63.9% to 71.3%) of the indicated care, and those with chronic conditions received only 53.4% (95% CI, 50.0% to 56.8%) of the indicated care.

Additionally, only 40.7% of indicated preventive services (95% CI, 38.1% to 43.4%) were actually ordered or delivered to children. For example, only 49.8% of children who reached 2 years of age during the study period

were fully immunized, records showed.

Among children from three to 36 months with fever of unknown origin who were thought to be at high risk for sepsis, only 16.2% had urine cultures, despite a high prevalence of urinary tract infections in this population, the authors noted.

And, only 41.5% of eligible adolescent girls had chart documentation of lab orders or results for Chlamydia trachomatis testing.

"Apparent deficits in the quality of care for children are similar in magnitude to those previously reported for adults," the authors wrote. "Although the data in this study are based on recorded care delivered from [October] 1996 through [August] 2000, it seems unlikely that quality has improved substantially since that period."

"Expansion of access to care through insurance coverage, which is the focus of national health care policy related to children, will not, by itself, eliminate the deficits in the quality of care," they concluded.

In their editorial, Dr. Perrin and Dr. Homer noted that "these new data, together with those from many other studies across both inpatient

and outpatient settings, make it clear that problems with the quality of children's care are as severe as those occurring elsewhere in our

health care system."

"Improvement of the performance of the children's health care system will require system-wide change; entreaties to hard-working and deeply

caring pediatricians, family physicians, nurses, and hospital staff to work harder and care more will not succeed by themselves," they continued.
"Effecting change will require leadership across all levels and systems

involved in children's health care and a wholehearted commitment by those who deliver care, pay for care, and receive care."

Dr. Mangione-Smith and colleagues noted that in addition to the fact that the data in the study are 7 to 11 years old, their study was also limited by a low response rate (42 percent of eligible children) possibly introducing nonresponse bias, potential biases from lack of data on children living in rural areas or households without telephones, and from missing data for some of the children included in the study.

The study was supported by grants from the Robert Wood Johnson Foundation, the Centers for Medicare and Medicaid Services, and the California Health Care Foundation. No potential conflict of interest relevant to this article was reported. Dr. Perrin and Dr. Homer reported no conflicts of interest.