Pediatric Health Care Quality Research Articles

The imperative of the child life profession in KSA in transforming the quality of pediatric healthcare

Saudi Arabia has made substantial advancements in its pediatric healthcare infrastructure. However, substantial gaps persist in addressing hospitalized children's emotional safety, and psychosocial and developmental needs. Internationally, the child life profession has evolved over decades to specifically address these needs, through interventions such as therapeutic play, age-appropriate patient education, and family support.This article evaluates the imperative for integrating the child life profession into healthcare services in Saudi Arabia to transform the quality of pediatric healthcare. An analysis of the current landscape revealed gaps in pediatric psychosocial care. These gaps are listed as national priorities in the health transformation program aimed at improving healthcare quality and enhancing well-being. Integrating the child life profession can help achieve these objectives for children and families in Saudi Arabia.This article highlights the multifaceted benefits of the child life profession in improving patient experiences, healthcare delivery efficiency, pediatric healthcare quality, and the overall well-being of children and families. Strategies for phased implementation, involving healthcare institutions, academic partners, relevant non-profit partners, and policymakers, are proposed.

Aligning to Improve Pediatric Health Care Quality.

Measures that focus attention on populations who experience disparities in health outcomes– including high-risk pediatric groups - are critically important to ensure quality and equity in evidence-based care. As part of the AHRQ-CMS Pediatric Quality Measures Program, 2 grantees developed validated quality measures for state Medicaid/Children's Health Insurance Program agencies, health plans and providers to support better care for 2 highly vulnerable but small populations. Our efforts highlight the need for aligned incentives at multiple levels to drive quality improvement.

Editors’ Note and Prologue

Editors’ Note and Prologue

Telehealth: Improving Access to and Quality of Pediatric Health Care

All children and adolescents deserve access to quality health care regardless of their race/ethnicity, health conditions, financial resources, or geographic location. Despite improvements over the past decades, severe disparities in the availability and access to high-quality health care for children and adolescents continue to exist throughout the United States. Economic and racial factors, geographic maldistribution of primary care pediatricians, and limited availability of pediatric medical subspecialists and pediatric surgical specialists all contribute to inequitable access to pediatric care. Robust, comprehensive telehealth coverage is critical to improving pediatric access and quality of care and services, particularly for under-resourced populations.

Collaborative Improvement and Innovation Networks Improving the Quality of Pediatric Physical and Mental Health Care

Youth throughout the United States face physical and mental health concerns that threaten their wellbeing and academic success. This is especially true among low-income communities and communities of color. School-Based Health Centers (SBHCs) and Comprehensive School Mental Health Systems (CSMHSs) are evidence-based delivery models that provide essential health services to students and their communities, recognized for targeting barriers like transportation, cost, and time. This paper describes a national initiative to increase the number of SBHCs and CSMHSs, improve the quality of care delivered, and strengthen the sustainability of school-based health and mental health through Collaborative Improvement and Innovation Networks (CoIINs). In spring 2020, when schools nationwide closed abruptly due to the COVID-19 pandemic, this initiative provided participants an essential professional network and space to share challenges, innovations, and best practices to sustain high quality care delivered to students. Participants shared that their involvement encouraged staff and state agencies to work more closely together and provided protected time to focus solely on student health. The CoIIN was especially helpful as sites transitioned from in-person to telehealth care due to school closures. Participation helped sites engage in peer-to-peer sharing, comparison, benchmarking, and a continuous piloting of new strategies. This case report describes the CoIIN with a particular focus on implementation during COVID-19. This will benefit school-based health and mental health practitioners and stakeholders interested in employing a similar model of quality improvement and support.

Organizational characteristics associated with high performance on quality measures in pediatric primary care: A positive deviance study.

Pediatric health care quality in the United States varies, but the reasons for variation are not fully understood. Differences in pediatric practices' organizational characteristics, such as organizational structures, strategies employed to improve quality, and other contextual factors, may contribute to the variation observed. To assess the relationship between organizational characteristics and performance on clinical quality (CQ) and patient experience (PE) measures in primary care pediatric practices in Massachusetts. A 60-item questionnaire that assessed the presence of selected organizational characteristics was sent to 172 pediatric practice managers in Massachusetts between December 2017 and February 2018. The associations between select organizational characteristics and publicly available CQ and PE scores were analyzed using analysis of variance; open-ended survey questions were analyzed using qualitative content analysis. Eighty-six practices (50.0%) responded; 80 (46.5%) were included in the primary analysis. Having a quality champion ( p = .03), offering co-located specialty services (e.g., behavioral health; p = .04), being a privately owned practice ( p = .04), believing that patients and families feel respected ( p = .03), and having a lower percentage of patients (10%-25%) covered by public health insurance ( p = .04) were associated with higher CQ scores. Higher PE scores were associated with private practice ownership ( p = .0006). Qualitative analysis suggested organizational culture and external factors, such as health care finance, may affect quality. Both modifiable organizational practices and factors external to a practice may affect quality of care. Addressing differences in practice performance may not be reducible to implementation of changes in single organizational characteristics. Pediatric practices seeking to improve quality of care may wish to adopt the strategies that were associated with higher performance on quality measures, but additional studies are needed to better understand the mechanisms behind these associations and how they relate to each other.

Hospital-Based Quality Measures for Pediatric Mental Health Care.

Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record-based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings. We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children's hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital. Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%-38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3). These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.

The Quality of Pediatric Healthcare: What Are We Measuring?

The Quality of Pediatric Healthcare: What Are We Measuring?

Improving the Quality of Pediatric Healthcare through Quality Improvement Collaboratives

Purpose of review This review summarizes the current need for Quality Improvement Collaboratives (QICs) and includes considerations specific to pediatric healthcare, such as low-frequency of outcomes and unique funding barriers. This review will consider nuances within measure formation and data collection within QICs, available models for structured formation of a QIC, components that are integral to a QICs success, as well as lessons learned and future directions.Recent findings The literature has demonstrated an increase in the number of pediatric QI collaboratives in recent years. These collaboratives have varied in size, duration, and composition of team members. While some QICs have included members at the organizational level, others have included more novel groups such as insurance companies. Novel methodologies have also been utilized such as N of 1 trials focused on continued interventions for one patient and provider dyad. Successful QICs include use of a steering committee or pre-planning group to guide measures development, use of robust QI methodology to implement small tests of change and continuous feedback of individual and aggregate data and transparency among benchmarking sites. Ideal QI methods for use within QICs have been vetted in prior collaboratives and include formal barriers assessments using driver diagrams, PDSA cycles and analyzing data and measures using run and statistical process control (SPC) charts to inform real-time change and interventions.Summary QICs are pivotal to closing the gap in delivery of evidence based practice while minimizing widespread unnecessary practice variation across multiple organizations using available QI methodologies and tools. Novel approaches to funding such as partnership with insurance companies and educational organizations can allow for more robust participation. Future research should broaden the scope of their measures to include patient centered outcomes.

Using Information Technology to Improve the Quality of Pediatric Healthcare

Purpose of the review The goal of this article is to provide the reader an up-to-date overview of the role that health information technology (HIT) plays in modern-day healthcare quality improvement (QI) work and processes. The reader should be able to understand the unique benefits and challenges that HIT can impart on QI efforts, as well as calibrate their expectations appropriately. Examples will be grounded in recent informatics evidence and standard practices. Recent findings Technology has been shown to an effective enabler and potentiator for quality improvement in initiatives and programs such as population health management, research, and QI networks, and minimizing use of unproven therapies (e.g., unindicated antibiotics), for example. HIT challenges remain that can limit this positive effect, including data management and quality issues, technical interoperability barriers, and the general nature of quality reporting as it exists today. Summary Information technology in the form of electronic health records and other systems are ubiquitous and powerful enablers of quality improvement efforts in healthcare. When these digital tools are applied according to best practices and in an evidence-based manner, they can have profound impacts on both quality improvement processes and outcomes. Technology and the general healthcare environment are rapidly changing, though, and further study of the intersection of HIT and QI will continue to inform us of the real promise and pitfalls of this intersection.

Family-Centered Care Measurement and Associations With Unmet Health Care Need Among US Children

ObjectiveFamily-centered care (FCC), including shared decision making (SDM), has become increasingly emphasized in pediatric health care delivery. Past studies using national surveys have used different FCC measurement approaches without determining their validity. We, therefore, sought to develop an FCC measurement model with Medical Expenditure Panel Survey (MEPS) items previously used to assess FCC or SDM; and to determine temporal associations of FCC with unmet health care need. MethodsFour longitudinal MEPS data files (2007–2011) were combined. The study sample included 15,764 US children aged 0 to 17 years. Eight items assessed FCC, and 5 items assessed unmet health care need. We performed exploratory factor analyses to develop an FCC measurement model and fit a cross-lagged structural equation model to determine temporal associations between FCC and unmet health care need. ResultsResults supported a 2-factor FCC model including family–provider communication and SDM. The family–provider communication factor was indicated by items reflecting general communication between the child's doctor and family. The SDM factor was indicated by items reflecting decision-making about the child's health care. Adjusted cross-lagged structural equation model results showed family–provider communication and SDM were associated with a reduced likelihood of unmet health care need the following year. Unmet health care need was not significantly associated with family–provider communication or SDM the subsequent year. ConclusionsStudy results support differentiating between family–provider communication and SDM as interrelated aspects of FCC in future pediatric health care quality measurement and improvement. Family–provider communication and SDM may reduce the likelihood of unmet health care need the following year among US children.

Medicaid Politics and Policy

Medicaid Politics and Policy

Pediatric Health Quality Assessment in Different Regions of Russian Federation

The quality of pediatric healthcare is a cornerstone for good maternal and infant health. To evaluate the quality of healthcare in secondary and tertiary regional pediatric hospitals in the Russian Federation. Healthcare quality assessment was performed in 21 pediatric hospitals (tertiary, n=5; secondary, n=16) of four regions. The WHO recommendations were used. In all regions, similar traits of inpatient pediatric healthcare determining a poor quality were observed. These included low preparedness for emergent care at admission departments; a high rate of unjustified hospitalization due to lack of clear indications for inpatient care; a widespread polypharmacy and unnecessary painful procedures and treatment; inadequate unjustified antimicrobial and parenteral therapy. The revealed identity of problems in different regions of the country allows to consider a common strategy to overcome them, which, obviously, should primarily involve education of medical personnel, restructuring of hospital beds to increase day care beds, increasing the clinical expert work in hospitals.

Technologies for Complex Intelligent Clinical Data Analysis

The paper presents the system for intelligent analysis of clinical information. Authors describe methods implemented in the system for clinical information retrieval, intelligent diagnostics of chronic diseases, patient's features importance and for detection of hidden dependencies between features. Results of the experimental evaluation of these methods are also presented. Healthcare facilities generate a large flow of both structured and unstructured data which contain important information about patients. Test results are usually retained as structured data but some data is retained in the form of natural language texts (medical history, the results of physical examination, and the results of other examinations, such as ultrasound, ECG or X-ray studies). Many tasks arising in clinical practice can be automated applying methods for intelligent analysis of accumulated structured array and unstructured data that leads to improvement of the healthcare quality. the creation of the complex system for intelligent data analysis in the multi-disciplinary pediatric center. Authors propose methods for information extraction from clinical texts in Russian. The methods are carried out on the basis of deep linguistic analysis. They retrieve terms of diseases, symptoms, areas of the body and drugs. The methods can recognize additional attributes such as "negation" (indicates that the disease is absent), "no patient" (indicates that the disease refers to the patient's family member, but not to the patient), "severity of illness", disease course", "body region to which the disease refers". Authors use a set of hand-drawn templates and various techniques based on machine learning to retrieve information using a medical thesaurus. The extracted information is used to solve the problem of automatic diagnosis of chronic diseases. A machine learning method for classification of patients with similar nosology and the methodfor determining the most informative patients'features are also proposed. Authors have processed anonymized health records from the pediatric center to estimate the proposed methods. The results show the applicability of the information extracted from the texts for solving practical problems. The records ofpatients with allergic, glomerular and rheumatic diseases were used for experimental assessment of the method of automatic diagnostic. Authors have also determined the most appropriate machine learning methods for classification of patients for each group of diseases, as well as the most informative disease signs. It has been found that using additional information extracted from clinical texts, together with structured data helps to improve the quality of diagnosis of chronic diseases. Authors have also obtained pattern combinations of signs of diseases. The proposed methods have been implemented in the intelligent data processing system for a multidisciplinary pediatric center. The experimental results show the availability of the system to improve the quality of pediatric healthcare.

Clarifying the Predictive Value of Family-Centered Care and Shared Decision Making for Pediatric Healthcare Outcomes Using the Medical Expenditure PanelSurvey.

To estimate (1) family-centered care (FCC) and shared decision-making (SDM) prevalence, and (2) associations of FCC and SDM (FCC/SDM) with health care outcomes among U.S. children. The Medical Expenditure PanelSurvey Household Component (MEPS-HC), a nationally representative survey of the noninstitutionalized, civilian population. Secondary analyses of prospectively collected data on 15,764 U.S. children were conducted to examine FCC/SDM prevalence in year 1 and associations of FCC/SDM in year 1 with health services utilization, medical expenditures, and unmet health care needs in year 2. We combined four MEPS-HC longitudinal files from 2007 to 2011. FCC/SDM prevalence in year 1 varied from 38.6 to 93.7 percent, and it was lower for composites with more stringent scoring approaches. FCC/SDM composites with stringent scoring approaches in year 1 were associated with reduced unmet needs in year 2. FCC/SDM, across all year 1 composites, was not associated with health services utilization or medical expenditures in year 2. FCC/SDM year 1 subcomponents describing consensus building and mutual agreement were consistently associated with unmet health care needs in year 2. FCC/SDM composites with stringent scoring approaches measuring consensus building and mutual agreement may have the greatest utility for pediatric health care quality improvement efforts.

The Doublespeak Dilemma: Effectively Communicating With Children and Adolescents and Their Caregivers.

Communication is the most common and, one might argue, the most essential “procedure” in medical practice (2). It is the foundation of the therapeutic doctor-patient relationship. Effective communication within the health care setting is essential for accurate diagnosis, successful treatment, and enhanced patient satisfaction (3). In the pediatric setting, the task of communicating effectively—building a rapport, listening empathically, and providing clear, culturally sensitive and developmentally appropriate observations and explanations—includes both the parents and the child or adolescent. This requires having specialized expertise for engagement, a high level of sensitivity to the parentchild dynamic, and attention to the needs and preferences of the parents while appropriately advocating for and protecting the confidences of the youth. This can be a fine line to tread, especially for the older child and adolescent. Three basic elements of physician-parent-child communication were identified by Richard Street (4): partnership building, interpersonal sensitivity, and informativeness. The first task, partnership building, involves forming a therapeutic rapport, such that the child patient and his or her parents feel comfortable stating their concerns, perspectives, and suggestions during the consultation. A physician that is attentive and displays, by language and behavior, that he or she is interested in the patient as a unique person with a complex inner life is demonstrating interpersonal sensitivity. Finally, informativeness includes the quality and quantity of the health information provided by the physician. Skill in these three domains with child and adolescent patients and their parents is needed for successful engagement and adherence to an agreed-upon treatment plan. One of the dilemmas for psychiatristsworkingwith children and adolescents is the degree to which there is confidentiality in the doctor-patient communication. Confidentiality, one of the tenants of psychiatric practice, is a mutable dimension when treating a pediatric patient. For example, with infant mental health, the parent is the primary focus of treatment and the doctor-patient confidentiality is with the parent. As the child matures socially, emotionally, and intellectually, more confidentiality is appropriate. The issue of what is and what is not confidential is very important to address early in the therapeutic relationship—with parents as well as the child or adolescent patient. In general, the younger and more developmentally immature a child, the more a parent needs, and is entitled, to know about the treatment. Regular meetings with the child and parents may assist in providing information for the parents, while engaging them in the work of effective parent-child communication. For adolescents, the issues of safety take precedence, but confidentiality is maintained for more personal communications, as requested. Clear communication with the adolescent and parents about the nature of the confidential relationship helps to maintain parental support of the treatment. In addition, specifying how parents will be informed about the progress of treatment is required. Parent-adolescent meetings in which the adolescent shares the information they feel the parents should know is an excellent opportunity for enhancing communication within the family. Transparency about the process of treatment, the goals, and how issues of confidentiality will be addressed enhances engagement and improves outcomes (5). For child and adolescent psychiatrists, the dilemma of communicating with anxious parents of an adolescent who does not want confidential information discussed may lead to a temptation for doublespeak—to provide the parents with vague information that is designed to conceal the true nature of the adolescent’s issues that have been identified in therapy. However, clear, honest communication with parents is essential to maintaining a trusting, family-centered relationship. What can and cannot be shared should be jointly discussed and understood.

Partnering health disparities research with quality improvement science in pediatrics.

Disparities in pediatric health care quality are well described in the literature, yet practical approaches to decreasing them remain elusive. Quality improvement (QI) approaches are appealing for addressing disparities because they offer a set of strategies by which to target modifiable aspects of care delivery and a method for tailoring or changing an intervention over time based on data monitoring. However, few examples in the literature exist of QI interventions successfully decreasing disparities, particularly in pediatrics, due to well-described challenges in developing, implementing, and studying QI with vulnerable populations or in underresourced settings. In addition, QI interventions aimed at improving quality overall may not improve disparities, and in some cases, may worsen them if there is greater uptake or effectiveness of the intervention among the population with better outcomes at baseline. In this article, the authors review some of the challenges faced by researchers and frontline clinicians seeking to use QI to address health disparities and propose an agenda for moving the field forward. Specifically, they propose that those designing and implementing disparities-focused QI interventions reconsider comparator groups, use more rigorous evaluation methods, carefully consider the evidence for particular interventions and the context in which they were developed, directly engage the social determinants of health, and leverage community resources to build collaborative networks and engage community members. Ultimately, new partnerships between communities, providers serving vulnerable populations, and QI researchers will be required for QI interventions to achieve their potential related to health care disparity reduction.

The search for a national child health coverage policy.

Thirty-eight percent of US children depend on publicly financed health insurance, reflecting both its expansion and the steady erosion of employment-based coverage. Continued funding for the Children's Health Insurance Program (CHIP) is an immediate priority. But broader reforms aimed at improving the quality of coverage for all insured children, with a special emphasis on children living in low-income families, are also essential. This means addressing the "family glitch," which bars premium subsidies for children whose parents have access to affordable self-only employer-sponsored benefits. It also means addressing the quality of health plans sold in the individual and small-group markets-whether or not purchased through the state and federal exchanges-that are governed by the "essential health benefit" standard of the Affordable Care Act (ACA). In this article we examine trends in coverage and the role of Medicaid and CHIP. We also consider how the ACA has shaped child health financing, and we discuss critical issues in the broader insurance market and the need to ensure plan quality, including the scope of coverage, use of a pediatric medical necessity standard that emphasizes growth and development, the structure of pediatric provider networks, and attention to the quality of pediatric health care.

Patient Reported Outcomes as Indicators of Pediatric Health Care Quality

Health care reform has increased demand for pediatric health care quality evaluations, particularly those that assess the impact of care on patient and population health outcomes. Many of today's most common childhood conditions are characterized by symptoms, behaviors, and functional limitations that are best assessed as patient reported outcomes (PROs). Although they remain greatly underutilized, PROs have the potential to improve pediatric health care quality assessment at the point of care and through system-level performance evaluations. The functions, benefits, and challenges of these PRO applications are described and illustrated in case examples. Although challenges remain, numerous methodological and technical innovations facilitate the use of PROs as health care quality metrics. These include advances in PRO measure development methodologies, the integration of PRO measures into electronic health records, and developing consensus among providers that PROs provide valuable information that can be used to enhance patient care. Although additional work is needed to address remaining methodological challenges, pediatric PROs are increasingly recognized as valuable indicators of health care quality in the clinical environment and as measures of organization- and provider-level performance.

Quality Measures and the Practicing Pediatrician: Perspectives From the American Academy of Pediatrics

Quality measurement is an important step for improving the quality of health care for children. The recent implementation of the Affordable Care Act, with its emphasis on improving quality of health care, further underscores the urgency and need for developing robust quality measures that have a strong evidence base and that can successfully measure and improve the quality of pediatric health care in multiple settings, including hospital inpatient and outpatient settings, communities, and community practice.