Defining good care: Children’s new role in evaluating pediatric standards

Mark Schuster, MD, PhD

Here’s something everyone can agree on: all children should get the very best health care.

But to make that happen, we need to know what the very best health care for children is. And we don’t.

That sounds strange. But to know if care is good, you need some sort of measure. The measure might be the results of certain lab tests, or being on a certain medication, or how often the person is hospitalized. The measures are different depending on the condition—but whatever they are, they let you say: yes, this child is getting the care they need—or no, this child needs more and better care.

There are lots of measures for adult conditions. There are targets and benchmarks and guidelines for things like diabetes, or cancer screening, or heart disease. Doctors use them, insurers use them and the public uses them to help them choose where they should go for health care. But when it comes to pediatrics, there are hardly any measures at all. Pediatrics is a small portion of the total health care expenditures, so there hasn’t been a strong incentive, and there hasn’t been a system to create the measures.

That is going to change—and Children’s Hospital Boston is going to play a key role. The 2009 Child Health Insurance Program Reauthorization Act calls for the establishment of a national Pediatric Quality Measures Program to ensure that children have the quality measures they need. Through the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Medicare and Medicaid Services, seven centers from around the country will work together to develop these measures. The Children’s Hospital Boston Center for Excellence for Quality Measurement, under the leadership of Mark Schuster MD, PhD, will be one of these centers.

Claire McCarthy, MD

“The quality of health care that is delivered in this country isn’t always as good as people assume it is,“ says Dr. Schuster. “There are huge gaps. Through this project, we can begin to identify and address those gaps. We will be working to improve care for children throughout the United States.”

It’s not easy to develop measures for children. They have different needs than adults—and those needs often vary depending on their age and developmental stage, even within the same illness. Some of the benefits of pediatric care may not even be apparent until kids grow up (for example, the real benefits of treating childhood obesity come in adulthood). And with kids, you have to figure parent understanding and participation into the picture.

“It’s really exciting. We will be part of changing the future of pediatric health care.”

-Dr. Schuster

Dr. Schuster doesn’t know which measures Children’s will be asked to develop over the next four years. AHRQ has been getting input from many stakeholders, including patients and families, as to what measures are needed. They will be assigning these measures to the different centers.

“We will start with reviewing research studies,” says Schuster. “We’ll look for established guidelines. We’ll see if others have already developed quality measures. If we need to, we’ll assemble an expert panel—we want to find the right people, from all over the country, to help us. We will have teams for each measure, and those teams will include patients and parents. We really want input from people who experience these conditions.”

It’s also important to Schuster that the measures they create be usable anywhere: outpatient settings, inpatient settings, primary care practices, urban or rural areas. “We want them to be useful. And we want to be able to identify disparities based on race, ethnicity, income and location.”

These measures are particularly important as insurers move toward paying lump sum payments for all the care a patient needs, instead of paying for each visit or procedure. “If we don’t have quality measures, it’s going to be hard to detect whether some hospitals and practices are skimping on care to save money. It’s important to cut costs in this country, but we need to make sure that we don’t cut back on quality in the process.”

The CHB Center has been awarded $2 million dollars a year for the next 4 years to work on this project. Dr. Schuster will be working with a steering committee that includes Martha Curley, RN PhD, Jonathan Finkelstein MD MPH, Charles Homer, MD MPH, Kathy Jenkins MD MPH, Ashish Jha, MD MPH, Christopher Landrigan MD MPH, Tracy Lieu, MD MPH, Daniel Nigrin, MD MS, Stavroula Osganian, MD ScD, and Alan Zaslavsky, PhD.

“It’s really exciting,” says Schuster. “We will be part of changing the future of pediatric health care.  This will help children everywhere get what they need.”