New Study Finds Serious Gaps in Health Care Quality for America's Children

Recommended Care Received Less Than Half of the Time; Researchers Call for Improvements in Preventive and Chronic Care

Children in the United States fail to get recommended health care more than half of the time, according to a new study from the RAND Corporation, Seattle Children's Hospital Research Institute, and the University of Washington School of Medicine that is the largest and most comprehensive examination of health care quality for America's children.

The new study shows that, when it comes to getting the right care at the right time, children in this country fare even worse than adults. They are not receiving recommended preventive care and screening services, such as regular weight and measurement checks to ensure that they are growing properly and not at risk for obesity; nor are they receiving standard care for conditions such as asthma and diarrhea. Previous research by RAND Health found that adults, on average, receive only about half of recommended care for the leading causes of death and illness. That study, released in 2003, shattered the widely held perception that health care quality is not a problem in the U.S.

“Our earlier findings provided a wake-up call to improve health care quality for adults,” said senior study author Elizabeth A. McGlynn, Ph.D., associate director of RAND Health. "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."

The study — which assessed 175 measures of quality covering 12 clinical areas, including preventive care – will be published Thursday (Oct. 11) in the New England Journal of Medicine. The researchers reviewed the medical records of more than 1,500 children randomly selected from 12 metropolitan areas whose parents provided written informed consent. Nearly all of the children in the study had some form of health insurance, and 82 percent were privately insured.

Quality varied widely according to type of care: Children received 68 percent of recommended care for acute medical problems, 53 percent of recommended care for chronic medical conditions, and 41 percent of recommended preventive care. In line with those findings, children received 66 percent of recommended care for treatment, but only 38 percent for screening, 47 percent for diagnosis, and 45 percent for follow-up.

"As a pediatrician, the poor performance we found on preventive care is particularly distressing," said lead study author Rita Mangione-Smith, M.D., M.P.H., researcher at Seattle Children's Hospital Research Institute and associate professor of pediatrics at the University of Washington School of Medicine.

She also noted that pediatricians must learn to do a better job of managing chronic conditions, several of which — such as diabetes and hypertension — are on the rise among children, in part because of the obesity epidemic. "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," Mangione-Smith said.

The researchers found significant differences in performance by medical condition, ranging from 92 percent of recommended care received by children for upper respiratory infection to 35 percent of recommended care for adolescent preventive services. Among other key findings:

• Children with asthma received just 46 percent of the care they needed overall. For example, the researchers found that 44 percent of children with persistent asthma had a prescription for an anti-inflammatory medication. Asthmatic children who use anti-inflammatory inhalants have fewer asthma-related symptoms, better lung function, fewer hospitalizations, and lower death rates related to asthma.
• During regular check-ups, only 31 percent of children ages 3 to 6 were weighed and measured. Only 15 percent of adolescents who saw a doctor were weighed and measured. Meanwhile, one-third of American children are obese or at risk for obesity.
• Early diagnosis of urinary tract infection (UTI) in infants is key to preventing recurrent infections, kidney damage, and chronic kidney failure. But the researchers found that urine cultures were obtained from only 16 percent of very young children who had undiagnosed fever and were deemed to be at high risk for sepsis. Prevalence of UTI is relatively high among such children.
• Only 42 percent of adolescent girls in the study were screened for chlamydia, an often silent infection that leads to pelvic inflammatory disease (PID) in 40 percent of untreated women. About 20 percent of women who develop PID have infertility problems, and 9 percent experience life-threatening complications during pregnancy. But screening, early detection, and treatment have decreased chlamydia and PID in adolescent girls by 60 percent.
• According to the U.S. Centers for Disease Control and Prevention, 9 percent of all hospitalizations of children under age 5 are associated with diarrhea. Some 300 to 500 children die each year in the U.S. from this very treatable condition. But the study found that children receive only 38 percent of recommended care for acute diarrhea.

Paul V. Miles, M.D., vice president and director of quality and assessment of practice performance for the American Board of Pediatrics, noted that, if anything, the study results "paint the best possible picture" because nearly all the children in the study had health insurance. "Yet the gaps in quality for children are as great — if not greater — than for adults," he said. "Clearly, children deserve access to a better health care system."

While the State Child Health Insurance Program (SCHIP) faces an uncertain future, McGlynn noted that health care quality for children is an issue in and of itself – apart from health care coverage. "Our study results show that getting children covered simply isn't enough," McGlynn said. "Additional steps are required to ensure that necessary care is delivered."

That, she and Mangione-Smith said, will require greater investment in health information technology systems, as well as increased attention to documenting and measuring quality of care for children. "We can't close the quality gap without first addressing the information gap," Mangione-Smith said.

Collaborating with McGlynn and Mangione-Smith on the study were: Alison H. DeCristofaro, M.P.H., Claude M. Setodji, Ph.D., Joan Keesey, B.A., David J. Klein, M.S., and John Adams, Ph.D., all of RAND; and Mark A. Schuster, M.D., PhD., of RAND and the David Geffen School of Medicine at UCLA.

The study was supported by grants from the Robert Wood Johnson Foundation, the Centers for Medicare & Medicaid Services, and the California HealthCare Foundation.

The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care quality, costs and delivery, among other topics.