In a recent Policy Statement, the American Academy of Pediatrics (AAP) summarized efforts on quality measurement and reinforced that current efforts often failed to recognize the unique needs of children and their families [39
]. The AAP advocates the use of pediatric measurement data, including public reporting on validated pediatric measures that are appropriately constructed for quality improvement [39
]. The Canadian Pediatric Society (CPS) has also made quality pediatric care a priority [8
], albeit to a lesser extent than the AAP. In a 2009 Position Statement that broadly addressed the role of pediatricians in the health needs of youth, the CPS stated that children and youth who are hospitalized should have access to quality, specialized pediatric expertise that meets their needs [8
]. Following these position statements, we conducted a systematic review to identify and evaluate existing published QIs in pediatric orthopaedic care.
Our review is limited by a number of factors. First, we did not search using Google Scholar. One major advantage of Medline is that it is readily updated not only with printed literature, but also with literature that has been presented online in an early version before print publication by various journals [12
]. Second, our search did not include a review of all published and unpublished literature and did not include databases that are not peer-reviewed [6
]. A scoping review is a consideration for the future. Third, the strength of our recommendations is based on the strength of the results. The articles identified in this search strategy were largely retrospective reviews of administrative databases, other systematic reviews, or surveys. Health record databases are largely administrative and retrospective. This can be problematic because the data depend on medical record coders, whose major focus is billing [34
]. One large national database in Canada is the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), a computerized information system that collects and analyzes data on injuries at participating hospitals since 1990 [7
]. Although more than 80% of the more than 1.5 million records in the CHIRPP data set capture pre-event information on pediatric injuries, the data that are collected are mainly used to establish injury prevention guidelines and do not contain any measures of quality of care or patient-specific outcomes [7
Mortality, postoperative complications, and readmission rates and reoperation rates were the most commonly reported QIs in pediatric orthopaedics despite the fact that they have been adapted from the adult literature and are less than ideal in the pediatric population. For example, despite the use of prophylactic antibiotics a minimum of 60 minutes before incision in adult surgery, this may not be appropriate as a quality measure in pediatric surgery because prophylactic antibiotics are often not given as a result of the lack of supporting evidence [16
]. In the papers that cited mortality, most authors concluded mortality was not a useful indicator. Although experts in this field rank mortality as a potentially very useful indicator and one that is also very likely to prompt action for improving quality of care, this is one QI that is not particularly sensitive to pediatric use because of its relative rarity in children’s hospitals and because death is not often linked to a preventable error or complication. In a 1-year review of all pediatric orthopaedic patients, Cox and Clarke reported a zero mortality rate [10
]. The article by Sedman et al. on 1.92 million discharges across 4 years of data from children’s hospitals in 31 states reported that the majority of mortality cases were very complex cases for which death was a nonpreventable rather than a preventable complication [33
Many unique qualities of pediatric surgical care provide challenges to the development of a quality improvement program. There is marked heterogeneity in outcomes of surgical procedures in children, some resulting from the physiological changes in function, which are a part of normal development and growth [2
]. As well, a positive relationship between volume and outcome has been reported for various orthopaedic procedures [31
]. However, most procedures in pediatrics have much lower volume than adult procedures and mortality rates are so low that statistical analysis and modeling is challenging if not impossible [9
]. In addition, limitations exist in applying this type of information without risk adjustment [36
]. Risk adjustment involves accounting for patients’ characteristics that influence quality measures but are not under the control of the provider [19
]. Risk adjustment is also difficult in pediatrics.
Cost-effectiveness was notably absent as an identified measure of quality in our review. Cost-effectiveness analysis (CEA) provides an important tool by which policymakers may assess and potentially increase the return on healthcare investments [5
]. Although CEA is most useful for the evaluation of new technologies such as in knee and hip arthroplasties, there may be a place for CEA in pediatrics surgery [5
Our review of the literature looking for specific QIs that may be applicable to pediatric orthopaedics highlights that although there appears to be a trend toward performing patient-centered outcomes, there is a long way to go to be able to reliably evaluate the quality of pediatric surgical programs. Patient-centered outcomes capture the impact of a patient’s overall well-being much better than traditional, surgeon-defined outcomes such as mortality or infection rates [28
]. Generic health utilities have limited value in pediatric quality of care evaluation because of they are ill-equipped to account for the developmental changes resulting from normal growth and many are only appropriate for older children.
Although there are benefits and drawbacks to all reported QIs, patient-centered and surgeon-defined outcomes along with cost-effectiveness have important roles in evaluating the quality of pediatric orthopaedic care. When we look specifically at the subspecialty of pediatric orthopaedics, there is a dearth of reliable or applicable measures to address quality of care on the whole. The next step in quality measurement will require targeting specific areas for further literature review to identify any available clinical practice guidelines or evidence to be able to begin to develop some disease-specific measures that can then be assessed for feasibility. Pediatric orthopaedic care cannot be improved until we can better measure quality and identify areas to target for improvement. If there is to be a commitment to providing the highest quality and safest health care for infants, children, adolescents, and young adults, quality measurement must be made a priority.