Denise Dougherty

The “3T’s” Road Map to Transform US Health Care: The “How” of High-Quality Care

THE ONGOING SIGNIFICANT INVESTMENT IN BASIC SCIence and clinical discovery in the United States continues to produce impressive results. However, the United States struggles to deliver high-quality care and improved health outcomes due to the systematic failure of discoveries to reach patients in a timely fashion. Despite expenditures that reached

Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by income.

2 trillion or more than

Committee report: Method for evaluating conditions nominated for population-based screening of newborns and children.

6000 per capita in 2005, the United States will continue to fail to fully leverage new clinical discoveries into improved health outcomes unless there is an accelerated transformation of the health care system. The research enterprise cannot achieve this alone. We propose a model to transform the US health care system (FIGURE), intended to accelerate the pace at which innovations are implemented in clinical settings by addressing the “how” of health care delivery.

Identifying Children’s Health Care Quality Measures for Medicaid and CHIP: An Evidence-Informed, Publicly Transparent Expert Process

OBJECTIVES To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States. METHODS Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patients zip code of residence is used to assign community-level income to individual hospitalizations. RESULTS Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children. CONCLUSIONS While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

Annual Report on Health Care for Children and Youth in the United States: Focus on Injury-Related Emergency Department Utilization and Expenditures

Abstract: The Secretarys Advisory Committee on Heritable Disorders in Newborns and Children is charged with evaluating conditions nominated for addition to the uniform screening panel and consequently making recommendations to the secretary of the US Department of Health and Human Services. This report describes the framework by which the committee approaches its task. Key decision nodes include initial review of every nomination to determine whether conditions are amenable for systematic evidence review, review of systematic evidence reviews conducted by the committees external review group, and deliberation and formal recommendation for addition or exclusion to the uniform panel. Data analyzed include the accuracy and specificity of screening and diagnostic tests for nominated disorders, the extent of predicted health benefits, harms impact on disease course, and cost from early diagnosis and treatment. The committee process is guided by approaches used by similar entities, but more flexible criteria are sometimes needed to accommodate data limitations stemming from the rarity of many of these conditions. Possible outcomes of committee review range from recommendation to add a nominated condition to the uniform panel; provide feedback on specific gaps in evidence that must be addressed before making a decision; or rejection of a nomination (e.g., because of identified harms). The committees structured evidence-based assessment of nominated conditions supports a consistently rigorous, iterative and transparent approach to its making recommendations regarding broad population-based screening programs for rare conditions in infants and children.

The Children’s Health Insurance Program Reauthorization Act Quality Measures Initiatives: Moving Forward to Improve Measurement, Care, and Child and Adolescent Outcomes

OBJECTIVE To describe the process used to identify the recommended core set of quality measures as mandated by the Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and provide an overview of the measures selected. METHODS In May 2009, the multidisciplinary Agency for Healthcare Research and Quality (AHRQ) National Advisory Council for Healthcare Research and Quality Subcommittee on Childrens Healthcare Quality Measures for Medicaid and CHIP Programs (SNAC) was formed. The SNAC established criteria to evaluate quality measures on the basis of their validity, feasibility, and importance. Subsequently, AHRQ implemented a measure nomination process. Nominators supplied key information related to measure validity, feasibility, and importance. Oxford Centre for Evidence-Based Medicine (CEBM) criteria were used to assess evidence supporting the validity/scientific soundness of nominated measures. SNAC members applied an adaptation of the RAND-UCLA modified Delphi process to all nominated measures. Measures passing the Delphi process were further assessed on the basis of criteria pertaining to legislative priorities. RESULTS Seventy of 119 nominated measures met criteria for validity, feasibility, and importance according to Delphi scoring. After further prioritization, 25 measures were recommended for the initial core set. Twelve of the recommended measures focus on preventive care and health promotion including prenatal/perinatal care (4), well-child care (1), immunizations (2), screening for: developmental delays (1), obesity (1), and sexually transmitted infections (1), and receipt of preventive dental services (2). Five acute care measures were recommended which focus on management of upper respiratory illnesses (2), receipt of acute care dental services (1), emergency department utilization (1), and inpatient rates of central line associated bloodstream infections (1). Five of the recommended measures focus on chronic care, specifically asthma (1), attention-deficit/hyperactivity disorder (1), diabetes (1), and care for children with mental health conditions (2). Two of the measures focus on family experiences with care, and one of the measures assesses utilization of outpatient primary care services. Thirteen (52%) of the measures were derived from the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS). Eighteen of the measures were supported by relatively high levels of evidence (Oxford CEBM grade A or B). CONCLUSIONS An open national public process combined with an evidence-informed evaluation methodology resulted in identification of a balanced, grounded, and parsimonious core set of measures that should become feasible to implement on a widespread scale over time.

Health Care for Children and Youth in the United States: 2002 Report on Trends in Access, Utilization, Quality, and Expenditures

OBJECTIVE To examine state differences in childrens utilization of injury-related emergency department (ED) care across 14 states, benchmarking aggregate state estimates against national expenditure estimates for outpatient injury-related ED care. METHODS A retrospective analysis was performed using the 2003 State Emergency Department Databases and State Inpatient Databases from the Healthcare Cost and Utilization Project and data from the Medical Expenditure Panel Survey. Pediatric ED visits with any injury International Classification of Diseases Ninth Version Clinical Modification (ICD-9-CM) diagnosis code were selected. The Barell Injury Diagnosis Matrix, ICDMAP-90 software, and the Trauma Information Exchange Program data were used to classify injuries, produce injury severity scores, and examine utilization in trauma centers. Aggregate and state-specific descriptive analyses compared differences in patient and injury characteristics and admission status by age, severity of injury, and expected payer. RESULTS Over 1.5 million or nearly one-third of ED visits were for pediatric injuries in the 14 states studied. Nationally, 5.4% of children had an injury-related ED visit, and approximately

Annual Report on Health Care for Children and Youth in the United States: Racial/Ethnic and Socioeconomic Disparities in Children's Health Care Quality

2.3 billion was spent on outpatient injury-related ED visits in 2003. The pattern of injury-related ED visit care varied considerably by state. For example, injury-related ED visit rates ranged from 63.3 to 164.4 per 1000 children. Infants, adolescents, children from very low income communities, and children from nonmetropolitan and nonmicropolitan areas were more likely to have an injury-related ED visit than their peers. Although patient characteristics were fairly consistent across states, admission rates and expected source of payment for injury-related ED visits varied considerably by state. Hospital admission rates ranged from 1.5% to 4.4% of injury-related ED visits and expected payer estimates ranged from 37.1% to 71.0% of visits billed to private insurance, 17.9% to 47.0% billed to Medicaid, and 2.1% to 10.4% billed as uninsured. CONCLUSIONS This study suggests that injuries account for a significant portion of pediatric ED visits. There is substantial variation in ED use and hospital admissions for injured children across states and payers. This variation suggests that there are several opportunities for improvement in emergency care for children. To better understand the underlying reason for the variation, multivariate and hypothesis-driven research should focus on the nature and outcomes of injury-related ED care in the context of small area practice patterns and state programs, policies, and care system characteristics.

Introduction to the Academy for Healthcare Improvement conference on advancing the methods for healthcare quality improvement research

In 2009, a publicly transparent evidence-informed process responded to the requirement of the Childrens Health Insurance Program Reauthorization Act (CHIPRA) legislation to identify an initial core set of recommended childrens health care quality measures for voluntary use by Medicaid and the Childrens Health Insurance Program, which together cover almost 40 million of Americas children and adolescents. Future efforts under CHIPRA will be used to improve and strengthen the initial core set, develop new measures as needed, and post improved core measure sets annually beginning in January 2013. This supplement aims to make available useful information about issues surrounding the initial core set and key concepts for moving forward toward improvement of childrens health care quality measures, childrens health care quality, and childrens health outcomes. The set of articles in this supplement includes a detailed description of how the identification of a balanced, grounded, and parsimonious core set of childrens health care quality measures was accomplished by means of an open, public process combined with an evidence-informed evaluation methodology. Additional articles note that Medicaid and Childrens Health Insurance Program (CHIP) officials put a high priority on childrens health care quality and desire better measures; that publicly insured children are more likely than privately insured children to experience severe, complex chronic conditions and experience poorer quality in some respects; and that some key CHIPRA topics did not yet have valid, feasible measures (eg, availability of services, duration of enrollment and coverage, most integrated health care settings, and some aspects of family experiences of care). Key stakeholders and observers provide commentary noting the unprecedented scope and nature of the CHIPRA legislation as well as noting areas in which the nation still needs to move to improve health care quality, including its measurement. These areas include greater engagement of families and health care providers in the quality measurement and improvement enterprises, collaboration across federal agencies, more emphasis on clinical effectiveness research to enhance the validity of childrens health care services and quality measures, and a need to maintain an emphasis on children as the nation expands health care coverage and attention to quality for all populations. This overview also notes areas of future priorities for measure enhancement and development, including inpatient specialty, health outcomes, and a focus on inequity. We and others contributing to this supplement consider the identification of the initial core set to be a significant initial accomplishment under CHIPRA. With sufficient attention to making the measures feasible for use across Medicaid and CHIP programs, and with technical assistance, voluntary use should be facilitated. However, the initial core set is but one step on the road toward improved quality for children. The identification of future challenges and opportunities for measure enhancement will be helpful in setting and implementing a future pediatric quality research agenda.

Accelerating evidence into practice for the benefit of children with early hearing loss.

OBJECTIVE To examine changes in insurance coverage, health care utilization, perceived quality of care, and expenditures for children and youth in the United States using data from 1987-2001. METHODS Three national health care databases serve as the sources of data for this report. The Medical Expenditure Panel Survey (1996-2001) provides data on insurance coverage, utilization, expenditures, and perceived quality of care. The National Medical Expenditure Survey (1987) provides additional data on utilization and expenditures. The Nationwide Inpatient Sample (1995-2000) from the Healthcare Cost and Utilization Project provides information on hospitalizations. RESULTS The percent of children uninsured for an entire year declined from 10.4% in 1996 to 7.7% in 1999. Most changes in childrens health care occurred between 1987 and the late 1990s. Overall utilization of hospital-based services has declined significantly since 1987, especially for inpatient hospitalization. Several of the observed changes from 1987 varied significantly by type of health insurance coverage, poverty status, and geographic region. Quality of care data indicate some improvement between 2000 and 2001, which varies by insurance coverage. Overall, mean length of stay of hospitalizations did not change significantly from 1995 to 2000, but changes in the prevalence of hospitalizations and the length of stay associated with age-specific diagnoses were evident during this time period. CONCLUSIONS Health care for children and youth has changed significantly since 1987, with most of the changes occurring between 1987 and 1996. Insurance coverage has improved, the site of care has shifted toward ambulatory sites, hospital utilization has declined, and expenditures on children as a proportion of total expenditures have decreased. Variation in these changes is evident by insurance status, poverty, and region.