Quality Of Child Health Services Research Articles

MHealth platform improved health worker's compliance to WHO’s IMNCI guideline in Nairobi, Kenya

Abstract Poor access to quality health services, especially in urban slums, is a global challenge. Given similar challenges in Nairobi's Kibra informal settlement area, we collaborated with the Langata/Kibra sub-county health management team to conduct a pilot program for improving the quality of child health services delivered by health care providers (HCPs). The pilot introduced a digital mHealth platform to HCPs working in Kibra informal settlement area in Nairobi. This mHealth platform was compliant to WHO's recommended guideline for integrated management of newborn and child illnesses (IMNCI) and was designed to help sick child assessment, diagnosis and management by HCPs. We aimed to determine if using this digital platform, coupled with supportive supervision and community outreach, would lead to improve compliance to the IMNCI guideline for assessment, diagnosis and treatment of sick children. We conducted baseline (February 2019) assessment, trained selected HCPs on the mHealth platform on handheld android tablets, conducted end line (March 2020) and measured any change in HCP's compliance to IMNCI guidelines. Total 89 HCPs were the mHealth platform users during end line assessment. When asked about the choice of antibiotic for treating childhood pneumonia, we found proportion of HCPs who preferred Amoxycillin dispersible tablet, the recommended treatment for childhood pneumonia, increased from 3% at baseline to 38% at end line. Proportion of HCPs who were aware that antibiotics should NOT be used for the management of simple diarrhea increased from 14% (at baseline) to 50% (at end line). At end line, more than 90% HCPs were found compliant in their practice to IMNCI guidelines for sick child assessment, diagnosis and management. These results demonstrate the use of the IMNCI compliant mHealth platforms as a potential important effective way to improve capacity and compliance among HCPs who are serving communities like Kibra informal settlement in Nairobi, Kenya. Key messages • WHO recommended IMNCI compliant mHealth platform enables health care providers to offer quality child health care. • Using mHealth platform to ensure WHO’s IMNCI guideline implementation by health care providers might have potential impact on saving sick children’s lives from preventable deaths.

The feasibility and ongoing use of electronic decision support to strengthen the implementation of IMCI in KwaZulu-Natal, South Africa

BackgroundContinued efforts are required to reduce preventable child deaths. User-friendly Integrated Management of Childhood Illness (IMCI) implementation tools and supervision systems are needed to strengthen the quality of child health services in South Africa. A 2018 pilot implementation of electronic IMCI case management algorithms in KwaZulu-Natal demonstrated good uptake and acceptance at primary care clinics. We aimed to investigate whether ongoing electronic IMCI implementation is feasible within the existing Department of Health infrastructure and resources.MethodsIn a mixed methods descriptive study, the electronic IMCI (eIMCI) implementation was extended to 22 health facilities in uMgungundlovu district from November 2019 to February 2021. Training, mentoring, supervision and IT support were provided by a dedicated project team. Programme use was tracked, quarterly assessments of the service delivery platform were undertaken and in-depth interviews were conducted with facility managers.ResultsFrom December 2019 – January 2021, 9 684 eIMCI records were completed across 20 facilities, with a median uptake of 29 records per clinic per month and a mean (range) proportion of child consultations using eIMCI of 15% (1–46%). The local COVID-19-related movement restrictions and epidemic peaks coincided with declines in the monthly eIMCI uptake. Substantial inter- and intra-facility variations in use were observed, with the use being positively associated with the allocation of an eIMCI trained nurse (p < 0.001) and the clinician workload (p = 0.032).ConclusionThe ongoing eIMCI uptake was sporadic and the implementation undermined by barriers such as low post-training deployment of nurses; poor capacity in the DoH for IT support; and COVID-19-related disruptions in service delivery. Scaling eIMCI in South Africa would rely on resolving these challenges.

Healthcare Providers and Caregivers' Perspectives on the Quality of Child Health Services in Urban Indonesia: A Mixed-Methods Study.

Although Indonesia’s child mortality rate has decreased in tandem with the global trend, healthcare services can be further improved for children. This study aims to explore the perceptions of healthcare providers and caregivers of children aged below five years to improve child health in urban Indonesia. A mixed-methods study design was adopted. Quantitative data were collected via questionnaires from the caregivers. Qualitative data were collected via semi-structured interviews from the healthcare providers. Analysis of 540 caregiver questionnaires regarding the care provided to their child revealed that the majority of them were very satisfied (46.1%) and satisfied (52.2%) with the care received. Analysis of 12 interviews with healthcare providers derived three major themes: (1) importance of one’s role as a healthcare provider; (2) factors affecting the delivery of healthcare; and (3) the way forward in caring for young children. Although caregivers were very satisfied with the care received for their children, the perception of healthcare providers regarding their responsibility in delivering care to children under five years old provides insights into improving the quality of services for children in Indonesia. Our findings suggest that mortality and morbidity of children aged below five years can be best reduced by optimizing primary and secondary preventive measures.

The Quality of Inpatient Child Health Services at RSUD Dr. Doris Sylvanus Palangka Raya

This study aims to identify the quality of child health services in the inpatient room, identifying and analyzing inhibiting and supporting factors for the quality of child health services at dr. Doris Sylvanus Hospital Palangka Raya. It is a qualitative descriptive study conducted by applying observation, interviews, and documentation to collect data. It involved 3 nurses at dr. Doris Sylvanus Hospital Palangka Raya and 11 families of child patients as research subjects. The research showed that the quality of inpatient child health services dr. Doris Sylvanus Palangka Raya Hospital, especially those in the flamboyant room can be said to be good and able to meet the satisfaction of patients reviewed from 3 elements of service quality refers to Haywood-farmer, namely: Physical Facilities and Processes, People's Behaviour, Professional Judgment. However, there are some patient complaints caused by several factors inhibiting the quality of service at dr. Doris Sylvanus Hospital reviewed the quality of service elements referring to Haywood-farmer, namely: Physical Facilities and Processes, and Professional Judgment.

Tailored communication methods as key to implementation of evidence-based solutions in primary child health care.

BackgroundEvidence-based policies should underpin successful implementation of innovations within child health care. The EU-funded Models of Child Health Appraised project enabled research into effective methods to communicate research evidence. The objective of this study was to identify and categorize methods to communicate evidence-based research recommendations and means to tailor this to stakeholder audiences.MethodsWe conducted an online survey among national stakeholders in child health. Analysis of the most effective strategies to communicate research evidence and reach the target audience was carried out in order to ensure implementation of optimal child health care models at a national level.ResultsRepresentatives of stakeholders from 21 of the then 30 EU MS and EEA countries responded to the questionnaire. Three main approaches in defining the strategies for effective communication of research recommendations were observed, namely: dissemination of information, involvement of stakeholders and active attitude towards change expressed in actions. The target audience for communicating recommendations was divided into two layers: proximal, which includes those who are remaining in close contact with the child, and distal, which contains those who are institutionally responsible for high quality of child health services. They should be recipients of evidence-based results communicated by different formats, such as scientific, administrative, popular and personal.ConclusionsInfluential stakeholders impact the process of effective research dissemination and guide necessary actions to strengthen the process of effective communication of recommendations. Communication of evidence-based results should be targeted to each audience’s profile, both professional and non-professionals, by adjusting appropriate communication formats.

THE IMPACT OF HOSPITAL BASED INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS TRAINING ON PEDIATRIC NURSE COMPETENCY

Background: Although the WHO strategy integrated management of childhood illness (IMCI) for primary care has been implemented in over 100 countries, there is less global experience with hospital-based IMCI training. Until recently, no training had been done in Indonesia, and globally there has been limited experience of the role of IMCI in rebuilding health systems after complex emergencies.&#x0D; Objective: We aimed to examine the effect of hospital-based IMCI training on pediatric nurse competency and explore the perception of Indonesian doctors, nurse managers and pediatricians about IMCI training and its development in West Aceh, a region that was severely affected by the South-Asian tsunami in December 2004.&#x0D; Methods: This study used stepped wedge design. Training was conducted for 39 nurses’ staff, 13 midwives, 6 head nurses, 5 nurse managers, 5 doctors, 1 pediatrician, and 3 support facilities (nutritionist, pharmacist, laboratory) in Cut Nyak Dien (CND) Hospital in Meulaboh, West Aceh, Indonesia. The IMCI training was developed based on the WHO Pocketbook of Hospital Care for Children. A nurse’s competency questionnaire was used based on the guideline of assessment of the quality of child health services at the first level reference hospitals in districts / municipalities issued by the Ministry of Health in 2007. A linear mixed model was used for data analysis.&#x0D; Results: The hospital based IMCI training improved the competences of nurses pediatric in assessing emergency signs of the sick children, management of cough and difficulty breathing, diarrhea, fever, nutritional problems, supportive care, monitoring, discharge planning and follow-up. The assessment highlighted several problems in adaptation process of material training, training process and implementation in an environment soon after a major disaster.&#x0D; Conclusion: Hospital based IMCI training can be implemented in a setting after major disasters or internal conflict as part of a rebuilding process. The program requires strong management support and the emergency phase to be subsided. Other pre-requisites include the existence of standard operating procedures, adequate physical facilities and support for staff morale and well-being. Improving the quality of pediatric care requires more than just training and clinical guidelines; internal motivation and health worker support are essential.

Identifying Critical Issues in the Perception of Caregivers about Quality of Child Health Care Services Using a Modified Delphi Technique

Background: Identification of the elements of the perception users of health services is a critical step in the development of measurement scales to assess such perception. This study is the second of a three phase approach to create a validated tool for the assessment of caregiver’s perceived quality of child health care in Primary health care (PHC) facilities. The first phase was exploratory using qualitative methods to assess the perceptions of caregivers about quality of child health care services; it yielded 39 quality-of-care items. Method: In this current study, we subjected the 39 quality of care items to expert review using the modified Delphi method. This method is useful for providing evidence for content validity in quantitative scale design. A total of 33 experts, including public health specialists, pediatricians and medical sociologists, participated in three iterative rounds. In each round the experts awarded score to the items and consensus amongst experts was determined by calculating inter quartile range of the assigned scores. Results: At the end of the three rounds of expert review, the total number of question items that had shown consensus considerably amongst the expert reviewers was 23. Conclusion: For these 23 items, a three point Likert scale response format was framed appropriately as a quantitative scale for assessing perceived quality of child health services in PHC facilities.

Quality of care and effective coverage of child health services in rural Burkina Faso

Objective To evaluate the technical quality of child health services at the first level facilities in Burkina Faso and determine the effective coverage of child health services. Methods A cross sectional study was conducted in six regions of Burkina Faso and the data was collected from facility and household surveys. To assess the quality of care we used signal functions of three dimensions of care (routine care, management of severe childhood diseases and non-medical aspects of care) the availability of relevant drugs, equipment and the staffing. Each of this dimension was categorized in high, intermediate and low quality level. Linking the household survey to health facility assessment we determined the proportion of children who sought care in facilities with high quality level. We calculate the effective coverage of preventive childcare defined as the proportion of children who have completed the specific vaccination schedule appropriate to their age. Results In total, 494 primary healthcare facilities and 8205 households were included in the study. More than half of health facilities (51%) had high quality level regarding non-medical care aspects while more than 70% of primary care health facilities had a low quality level in management of severe childhood diseases. We found globally that 50% of health facilities had a low quality in all dimensions. While 69.7% of sick children sought care in a health facility, only 18.8% of them went in facilities high quality. There was a large difference between effective coverage and crude coverage of vaccination in the study regions. Conclusion Our assessment found that the quality level in the health facilities was low, and the quality gap was large. In addition, there was a low effective coverage of vaccination in the study regions. Effective coverage could be a relevant metric to improve the performance of child health services.

Evaluation of input and process components of quality of child health services provided at 24 × 7 primary health centers of a district in Central Gujarat.

Context:With the critical Indian challenge on child survival and health, time is ripe to initiate focus on quality of services apart from measuring coverage, to bring about improvements.Aims:To assess the quality of child health services provided at 24 × 7 Primary Health Centers of Vadodara District in Gujarat in terms of Input and Process Indicators.Settings and Design:The study was carried out in 12 randomly chosen 24 × 7 Primary Health Centers (PHCs) of Vadodara district using a modified quality assessment checklist of the Program on District Quality Assurance for Reproductive and Child Health (RCH) services with use of scores from May 2010 to June 2011.Subjects and Methods:Inputs assessment was done by facility survey. Process assessment for the four child health service components used actual observation of service, review of records and interview of service providers and clients.Results:The mean obtained score for facilities in Input section was 65%. Highest score was obtained for Drugs and Consumables (86%) followed by Equipments and Supplies (74%). The score obtained for Infrastructure facility was 65%, Personnel and training was 56% and Essential protocols and guidelines scored 43%. The mean obtained score in the process section was 55%. Highest scores were obtained for immunization at 76%. This was followed by newborn care (52%), growth monitoring (52%). management of sick child (41%).Conclusion:Quality improvement efforts should focus not only on resource-intensive structural improvements, but also on cost-effective measures at improving service delivery process, especially adherence to service guidelines by providers.

Does implementation of the IMCI strategy have an impact on child mortality? A retrospective analysis of routine data from Egypt

BackgroundBetween 1999 and 2007, the Ministry of Health and Population in Egypt scaled up the Integrated Management of Childhood Illness (IMCI) strategy in 84% of public health facilities.ObjectivesThis retrospective analysis,...

Child health nurses in the Solomon Islands: lessons for the Pacific and other developing countries

ObjectivesTo understand the roles of nurses with advanced training in paediatrics in the Solomon Islands, and the importance of these roles to child health. To understand how adequately equipped child health nurses feel for these roles, to identify the training needs, difficulties and future opportunities.DesignSemi-structured interviews.SettingsTertiary hospital, district hospitals and health clinics in the Solomon Islands.ParticipantsTwenty-one paediatric nurses were interviewed out of a total of 27 in the country.ResultsAll nurses were currently employed in teaching, clinical or management areas. At least one or two nurses were working in each of 7 of the 9 provinces; in the two smaller provinces there were none. Many nurses were sole practitioners in remote locations without back-up from doctors or other experienced nurses; all had additional administrative or public health duties. Different types of courses were identified: a residential diploma through the University of Papua New Guinea or New Zealand and a diploma by correspondence through the University of Sydney.ConclusionsChild health nurses in the Solomon Islands fulfill vital clinical, public health, teaching and administrative roles. Currently they are too few in number, and this is a limiting factor for improving the quality of child health services in that country. Current methods of training require overseas travel, or are expensive, or lack relevance, or remove nurses from their work-places and families for prolonged periods of time. A local post-basic child health nursing course is urgently needed, and models exist to achieve this.

Caregivers’ satisfaction and supervision of primary health care services in Nnewi, Nigeria

Although major gains were made in the reduction of childhood health indicators in the previous decade, stagnations or reversals were seen in many countries since the 1990s. Despite presence of primary health centers (PHC) in Nigeria, there are still high levels of morbidity and mortality among children because the quality of child health services falls short of what it could be in the country. Supportive supervision of PHCs should also improve the quality of child health services. This study assessed the level of clients’ satisfaction with care received and the quality of supervision of child health services in selected PHC facilities of Nnewi, Nigeria. The study design was cross sectional. Four health facilities were selected by simple random sampling technique from a list of 12 public PHC facilities that provide at least three of the range of essential child health services. Using interviewer administered questionnaire, data were collected from 305 caregivers and analyzed accordingly. Also key informant interviews were used to elicit information facility supervision frequency and adequacy. The mean age of the mainly female caregivers was 31.9 ± 9.4 years. Majority of the caregivers attended health facilities closest to them but 18.5% of the 65 who do not, said they did not like the health workers. Although more than 80% of clients were satisfied with quality of child health services received, yet 41.3% of them felt that the number of service days were inadequate. None of the health facilities had a work plan, supervision schedule or supervision checklist. Increasing the number of service days and providing supervision schedules and checklists at the health facilities can improve caregiver satisfaction and hopefully enhance quality of child health services at the PHCs. Key words: Caregivers, satisfaction, supervision, PHC, Nnewi

Age at orchidopexy as an indicator of the quality of regional child health services

Early treatment for primary undescended testis (UDT) is necessary to prevent testicular degeneration and improve fertility. The general recommended age for orchidopexy is before 2 years of age. Comparing the age distribution of orchidopexy between different services may give an indirect indication of the quality of the child health services, since timely diagnosis and referral will lead to boys undergoing orchidopexy at the optimal age. This paper reviews the age distribution of boys having orchidopexies for UDT between 1997 and 2006 in the South Island of New Zealand and the state of Victoria, Australia: 64.2% of boys on the South Island and 48.0% of boys in Victoria had orchidopexies before the age of 5. There was a considerable difference in the proportions of children from 0 to 4 years and from 10 to 14 years between the two regions. No distinct trend in age was seen in either population during the period reviewed. These results show that many boys do not receive treatment for UDT at the optimal age. Age at orchidopexy may be an indicator of the quality (in terms of diagnosis, access and timeliness) of a region's paediatric surgical service and may identify where attention should be paid if earlier diagnosis and referral is to be achieved.

Quality of care offered to children attending primary health care clinics in Johannesburg

Objective. To assess the quality of child health services provided at primary health care (PHC) facilities in Johannesburg, South Africa. Design. Observational study conducted at 16 PHC clinics. A researcher-developed structured checklist, based on national guidelines and protocols, was utilised. Results. The majority of facilities were adequately equipped and well stocked with drugs. A total of 141 sick child and 149 well child visits were observed. Caregivers experienced long waiting times (mean 135 (standard deviation 72) minutes). Many routine examination procedures were poorly performed, with an adequate diagnosis established in 108 of 141 consultations (77%), even though health professionals were experienced and well trained. Triage and attention to danger signs were poor. An antibiotic was prescribed in almost half (65/141) of the consultations, but antibiotic use was unwarranted in one-third of these cases. Health promotion activities (such as growth monitoring) were consistently ignored during sick child visits. HIV status was seldom asked about or investigated, for the mother or for the child. Growth monitoring and nutritional counselling at well child visits was generally inadequate, with not one of 11 children who qualified for food supplementation receiving it. Conclusion. The poor quality of PHC offered to children in the richest city in Africa is a sad indictment of the inability of health service providers to address children’s health needs meaningfully. A deliberate and radical restructuring of PHC for children, with clearly defined and monitored standard clinical practice routines and norms, is required to change the status quo.

Policy challenges to the quality of child health services in Bulgaria

Our study aimed to explore policy challenges to the quality of child health services in Bulgaria. The study was based on qualitative in-depth interviews, analysis of regulatory documents, and review of the literature. Respondents included policy-makers, providers and users of health services, from both rural and urban areas. Problems identified included insufficient training of general practitioners, medical errors, delays in response to emergencies, inadequate information provided to patients, and underdeveloped child public health. A common view was that paediatricians provide better quality care than general practitioners. Respondents described a lack of clinical guidelines for rational use of pharmaceuticals, overprescribing of antibiotics, reliance on pharmaceutical companies for information, and unrestricted sales of drugs over-the-counter. 'Clinical pathways', introduced as a payment mechanism in hospitals, were perceived as lacking transparency, complicating clinical practice, and forcing doctors to record wrong diagnoses and conduct unnecessary investigations. Our findings indicate the need to develop evidence-based clinical guidelines for primary and secondary care, establish payment mechanisms that facilitate quality improvements, promote rational use of pharmaceuticals, improve continuing training of physicians and strengthen child public health.

Improving the quality of child health services: participatory action by providers

To test a quality improvement approach called COPE (Client-Oriented, Provider-Efficient services), for use in strengthening health systems and supporting Integrated Management of Child Health (IMCI) efforts. Pre- and post-intervention observations of client/provider interactions, facility audits, staff and client surveys, and focus groups to evaluate differences between eight COPE intervention and eight matched non-intervention facilities after a 15-month intervention in 2001. Primary care clinics in Guinea and Kenya. Health care providers and child caregivers. Over 15 months, the intervention supported four COPE exercises at each intervention site, supported supervisor training in quality management, and organized minimal training in topics selected by site staff as areas where training was needed. Differences in staff's and child caregiver's knowledge, attitudes, and practices; differences in the quality of services provided. On almost every quality indicator (over 65 indicators), whether reported by staff, observed by evaluators, or reported by clients, the intervention sites performed statistically significantly better than control sites. sites were cleaner and more pleasant, with more respect and information for clients, and more privacy. Staff had better personal communication skills, better diagnostic skills, and prescribing practices and gave better home care instructions to carers. Clients in intervention sites were more informed and more satisfied, and their children had better immunization coverage than those in control sites. COPE is a simple process, yet our study confirms that it can have a very dramatic effect on the quality of services. This study demonstrated how all areas of quality can be addressed by empowering health care providers to take action by using COPE. We suggest that COPE can complement Integrated Management of Childhood Illness (IMCI) training and can help to achieve better health for children.

Quality of child health services in primary health care facilities in south‐east Nigeria

To assess the quality of child health services in primary health care (PHC) facilities in Calabar, south-east Nigeria. Cross-sectional, descriptive design. Key informant interviews, structured observation, self-administered questionnaire and focus group discussion. Calabar, south-east Nigeria. Participants All 10 PHC facilities in Calabar, 252 PHC workers serving in the facilities, and 76 mothers whose children received care in the facilities. Adequacy of structure (equipment and personnel); process (diagnosis, training and knowledge, use of national case-management algorithm, and supervision), and output (clients' satisfaction). PHC facilities were adequately equipped to the extent of providing immunization services and management of diarrhoea but not for other aspects of care expected of a PHC centre, including management of acute respiratory infections (ARI), a common problem in children in the region. Supply of essential drugs was inadequate in all centres and facilities for emergency care were lacking. Many of the health care workers (68.3%) had adequate training in immunization, and their knowledge scores on immunization issues (62%) was higher than in other aspect of PHC. Use of the national case management algorithm was low among PHC workers. Results of the focus group discussions with mothers showed that a few perceived quality of care to be poor. The main concerns were long waiting time, lack of essential drugs, and attitude of the health workers. Inadequacy in the quality of child health services in PHC facilities is a product of failures in a range of quality measures -- structural (lack of equipment and essential drugs), process failings (non-use of the national case management algorithm and lack of a protocol of systematic supervision of health workers). Efforts to improve the quality of child health services provided by PHC workers in the study setting and similar locales in less developed countries should focus not only on resource-intensive structural improvements, but also on cheap, cost-effective measures that address actual delivery of services (process), especially the proper use of national guidelines for case management, and meaningful supervision.

Effect of compliance with health supervision guidelines among US infants on emergency department visits.

There are few studies that demonstrate the health benefit of compliance with early periodic health supervision. To examine the association between emergency department (ED) use and compliance with prevailing guidelines for periodic health supervision for conditions that potentially could be avoided among a national cohort of US children. This was a historic cohort study that combined maternal and primary care physician reports of the use of preventive care services for infants during the first 7 months of life from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-up study. A preventive care scale used in Cox proportional hazards survival regression predicted the time to the first ED visit for selected diagnoses and all-cause visits controlling for illness severity. Among children with incomplete well-child care in the first 6 months of life, there was an increased risk of having an ED visit for an upper respiratory tract infection (hazard ratio, 2.3; 95% confidence interval, 1.6-3.2), gastroenteritis (hazard ratio, 1.8; 95% confidence interval, 1.0-3.0), asthma (hazard ratio, 2.1; 95% confidence interval, 1.0-4.3), and all-cause ED visits (hazard ratio, 1.6; 95% confidence interval, 1.4-1.98). Because of the positive effect compliance with national guidelines for early well-child care has on lowering the risk of experiencing ED use, national efforts to improve the quality of child health services for young children should focus on increasing compliance with periodic preventive care for young children.

Effectiveness of compliance with pediatric preventive care guidelines among Medicaid beneficiaries.

Because research has not confirmed a relationship between compliance with health supervision in infancy and improved health outcomes, we examined the association between adherence to prevailing guidelines for periodic health supervision and adverse health outcome indicated by incidence of avoidable hospitalizations. This was a historic cohort study of 308 131 children enrolled in Medicaid at birth in California, Georgia, and Michigan in 1990 using Medicaid records linked across 3 years. We used avoidable hospitalizations as indicators of health in a survival analysis. The analysis used variables that represented completeness and timeliness of well-child visits and immunizations using AAP guidelines for health supervision as the gold standard. When the children in this cohort were up-to-date for age on their schedule of well-child visits, they were less likely to have an avoidable hospitalization (race, illness, and level of poverty adjusted hazard ratios 0.52 [95% confidence interval (CI): 0.50-0.55] in California, 0.54 [95% CI: 0.50-0.55] in Georgia, and 0.7 [95% CI: 0.69-0.79] in Michigan). Among children who were not up-to-date with well-child visits, a sporadic preventive care visit conferred a mild benefit. Immunizations and race/ethnicity had no consistent relationship with incidence of avoidable hospitalizations. A series of well-child visits maintained during the first 2 years of life has a positive effect on health outcomes as indicated by a decrease in avoidable hospitalizations among poor and near-poor children, regardless of race, level of poverty, or health status. National efforts to improve the quality of child health services for young children should focus on increasing compliance with periodic preventive care for young children in addition to improving immunization levels.

A report card on quality improvement for children's health care.

Improving the quality of health care is a national priority. Nonetheless, no systematic effort has assessed the status of quality improvement (QI) initiatives for children or reviewed past research in child health care QI. This assessment is necessary to establish priorities for QI programs and research. To assess the status of QI initiatives and research, we reviewed the literature and interviewed experts experienced in QI for child health services. We defined QI as activities intended to close the gap between desired processes and outcomes of care and what is actually delivered. We classified reports published between 1985 and 1997 by publication characteristics, study design, clinical problem addressed, site of intervention, the QI method(s) used, and explicit association with a continuous quality improvement program. We reviewed 68 reports meeting our definition of QI. More than half (48) were published after 1994. The reviewed reports included controlled evaluations in 36% of all identified interventions, and 3% of the reports were associated with continuous quality improvement. QI methods demonstrating some effectiveness included reminder systems for office-based preventive services and inpatient pathways for complex care. Reportedly successful QI initiatives more commonly described improvement in administrative measures such as rate of hospitalization or length of stay rather than functional status or quality of life. Interviews found that barriers to QI for children were similar to those for adults, but were compounded by difficulties in measuring child health outcomes, limited resources among public organizations and small provider groups, and relative lack of competition for pediatric tertiary care providers. Research and dissemination of QI for children were seen as less well developed than for adults. Attempts to improve the quality of child health services have been increasing, and the evidence we reviewed suggests that it is possible to improve the quality of care for children. Nonetheless, numerous gaps remain in the understanding of QI for children, and widespread improvement in the quality of health services for children faces significant barriers.