A new study on the quality of health care received by American children suggests that half the time, they are not receiving recommended standard care for conditions such as asthma and diarrhea and neither are they getting recommended preventive care and screening to check for things like weight, obesity and developmental problems.
The study is published in the New England Journal of Medicine and is the work of researchers from the RAND Corporation, the Seattle Children’s Hospital Research Institute, and the University of Washington School of Medicine.
Writing in what has been described as the largest and most comprehensive review of the quality of healthcare delivered to American children, the authors said that US children failed to get recommended health care more than half of the time, and they fared worse than adults. They called for improvements in both preventive and chronic care.
RAND investigators had earlier reported, in 2003, that US adults were getting only half the recommended health care for the leading causes of death and illness.
Senior author of this latest study on child health care and associate director of RAND Health, Elizabeth A McGlynn said:
“Our earlier findings provided a wake-up call to improve health care quality for adults.”
“Up until now, most people probably assumed that quality was not a problem for children. This new study tells us that’s not true. We need to get health care right for children; and we need to do it now.”
McGlynn and colleagues reviewed medical records, with written consent from parents, on more than 1,500 children selected at random from 12 metropolitan areas. They assessed 175 quality measures spanning 12 clinical areas, including preventive care. Nearly all the children were insured, 82 per cent of them privately.
The results showed that the quality of care received by the children varied widely depending on the type care:
- For acute medical problems the children received 68 per cent of recommended care.
- For chronic medical conditions they received 53 per cent.
- For preventive care they received 41 per cent.
- For treatment they received 66 per cent.
- For screening they received 38 per cent.
- For diagnosis they received 47 per cent.
- For follow-up the children received 45 per cent of recommended care.
Lead author Dr Rita Mangione-Smith, researcher at Seattle Children’s Hospital Research Institute and associate professor of pediatrics at the University of Washington School of Medicine, gave her reaction to the results:
“As a pediatrician, the poor performance we found on preventive care is particularly distressing.”
She also said pediatricians have to improve the way they manage chronic childhood conditions such as diabetes and high blood pressure, on the rise mostly because of rising numbers of obese children.
“We need to get on top of these problems now, both to keep children healthy and to avoid the higher costs of treating out-of-control chronic diseases in adulthood,” said Mangione-Smith.
The researchers also found significant variation in quality of care by medical condition. This ranged from children getting 92 per cent of recommended care for upper respiratory infection to 35 per cent of recommended care for preventive services for adolescents.
These results showed, among others, that:
- For asthma, children received 46 per cent of the overall care they needed.
- This included 44 per cent of children with persistent asthma receiving a prescription for an anti-inflammatory medication.
- During regular check ups, 31 per cent of children aged 3 to 6 were weighed and measured.
- 15 per cent of adolescents who saw a doctor were weighed and measured.
- Urine cultures were obtained in 16 per cent of children with undiagnosed fever deemed to be at high risk for sepsis.
- 42 per cent of adolescent girls were screened for chlamydia.
- Children received 38 per cent of recommended care for acute diarrhea.
The researchers drew attention to the finding that only 44 per cent of children with persistent asthma are receiving medication because there is evidence that asthmatic children who take anti-inflammatory inhalants have fewer asthma-related symptoms, improved lung function, fewer hospitalizations, and lower ashtma-related death rates.
They also pointed out that early diagnosis of urinary tract infection (UTI) in babies is crucial in order to prevent recurrent infections and problems with kidneys. Also, UTI is high among children at risk for sepsis, they said, and yet only 16 per cent of them are checked for it.
Chlamydia is described as a “silent infection” that can develop into pelvic inflammatory disease (PID) in 40 percent of untreated women and lead to infertility and life threatening pregnancy complications. Screening, detection and treatment have reduced chlamydia and PID in adolescent girls by 60 per cent, which is why the researchers drew attention to the low rate of screening they discovered.
The researchers said that 38 per cent of recommended care for acute diarrhea is low, especially in the light of information from the US Centers for Disease Control and Prevention (CDC) that shows 9 per cent of hospital admissions of children under 5 are linked to the condition and between 300 and 500 American children die every year from it, and yet it is highly treatable.
Vice president and director of quality and assessment of practice performance for the American Board of Pediatrics, Paul V Miles pointed out that even though most of the children in the study had health insurance, the gaps in quality of health care were as great “if not greater” than for adults:
“Clearly, children deserve access to a better health care system,” he added.
McGlynn noted that:
“Our study results show that getting children covered simply isn’t enough. Additional steps are required to ensure that necessary care is delivered.”
The researchers said it was essential to invest in health information technology and increase attention in measuring and recording quality of care for children:
“We can’t close the quality gap without first addressing the information gap,” said Mangione-Smith.
A pediatrician in private practice in Burlington, Vermont, and co-author of practice guidelines to be published by the American Academy of Pediatrics, Dr Joseph Hagan told WebMD that he disagreed with some of the methods of the study but he also called the conclusion that children received less than half of recommended care “abysmal”. He said he saw the report as “little bit of a face slap”.
The researchers suggested that doctors don’t spend long enough with patients, their schedules are too tight, and there isn’t enough time for dispensing the care they need. Also, residency training for pediatricians tends to prioritize the more serious acute conditions in the hospital, neglecting the essential routines of preventive care.
Dr James M Perrin and Dr Charles J Homer wrote in an editorial accompanying the paper that the “observations are shocking: the right services appear to be carried out less than half the time”.
They wrote that a potential limitation of the study was that it relied on medical records, and the findings could be a reflection of poor charting rather than poor practice. For instance, in the medication parts of the records, an area when clinicians are likely to chart more accurately, the adherence rate is much higher.
But the researchers took great pains to correct for non response, and the editorial also points out that the records in question are from the period after the new guidelines on quality of care emerged. So while one might argue with the precise figure of 46.5 per cent for the percentage of overall care delivered, wrote Perrin and Homer:
“One cannot avoid the main observation that there exists a yawning chasm in the quality of health care provided to children.”
“The Quality of Ambulatory Care Delivered to Children in the United States.”
Mangione-Smith, Rita, DeCristofaro, Alison H., Setodji, Claude M., Keesey, Joan, Klein, David J., Adams, John L., Schuster, Mark A., McGlynn, Elizabeth A.
N Engl J Med 2007 357: 1515-1523
Volume 357:1515-1523, October 11, 2007, Number 15
Written by: Catharine Paddock