We are in the midst of a transformation in healthcare stemming from the convergence of the quality movement and use of quality indicators, use of EBM in routine practice, and the potential (US) or implementation (UK) of interconnected health information systems. Advances in quality healthcare for children are evidenced by the growing library of quality indicators developed by prestigious institutions in the UK and US.
However, there are gaps in quality measurement and quality indicator development in areas important for child health. First, the majority of indicators are devoted to routine care provided in the outpatient setting, yet nearly 40% of US healthcare spending for children in 2004 was on inpatient care compared to 28% for physician/clinic visits.69
Second, few indicators have been developed for children with special healthcare needs. In 2000, 15.6% of US children younger than 18 years had a special healthcare need yet they accounted for 34% of total healthcare costs.52
Quality indicators are needed for this population of children. Third, there are few quality indicators focused on educating parents about fundamental child-rearing topics such as safety and child development. Education of caregivers in these areas may prevent accidental injury and allow early identification of potential learning or behavioral problems. Finally, the indicators surveyed for this paper do not address the greater social context of childhood, including family functioning and school performance, which may be amenable to intervention and increase the likelihood that a child will be a productive member of society as an adult.
The likelihood that quality indicators will improve care delivery and health outcomes is dependent on many factors. Implementation of quality indicators often leads to increased adherence to those measures (i.e., Hawthorne effect: what gets measured gets improved). If adherence to a quality indicator is also highly correlated with an increase in desired health outcome, then increased adherence to this indicator may result in improved health. However, the degree of improvement may vary across different patient populations due to issues such as general health, co-morbidities, and genetic and environmental factors. Therefore, proving the process-outcome relationship can be difficult.
At this juncture, we propose several recommendations to advance the quality indicator development agenda for children. First, the library of quality indicators for children needs to be expanded, particularly in inpatient care and in chronic care, and made available to the child health community in an integrated, easy-to-use format. Second, continued support of integrated, comprehensive HIT efforts from government and healthcare agencies is necessary to support quality measurement and ultimately provide evidence for the process-outcome relationship and the development of better quality indicators. Finally, the science and tools necessary to measure quality and develop quality indicators should be taught to more healthcare professionals to allow widespread integration of quality efforts into routine clinical practice.
The 20th century saw significant decreases in child mortality following the introduction of immunizations and the use of antibiotics for common childhood illnesses. The science of quality measurement and indicator development combined with a growing scientific evidence base and integrated information systems in healthcare may prove to be the next leap forward in improving child health in the 21st century.