Has outcomes movement neglected children? New measures fill the gap
NCQA, FACCT team up to define prevention, treatment indicators
Half a decade of health plan performance assessment brought us indicators on staying well and getting better, living with illness, and gaining access to doctors. Now the next wave of outcomes measurement will seek to close a glaring gap: the paucity of measures of children’s health, satisfaction, and well-being.
The Children’s Health Measurement Initiative, led by the National Committee for Quality Assurance (NCQA) in Washington, DC, and the Foundation for Accountability (FACCT) in Portland, OR, began last summer with an ambitious two-year goal of identifying measures geared toward children. At least some of them will be incorporated into NCQA’s Health Plan Employer Data and Information Set (HEDIS) to assess health plan performance.
The first step begins with Accreditation ’99, which requires health plans to report survey results of parents whose children received care. (See box, p. 127.) "Previously we had no information within HEDIS about the experiences parents had with their children’s health care," says Joe Thompson, MD, an Arkansas pediatrician and former NCQA assistant vice president of research and measures development. "This is a major expansion to make sure parents have help selecting health plans."
Other new children’s health measures are likely to look very different from those developed for adults, with far more attention on psychosocial issues, performance assessment experts say.
"Most kids who are receiving care are, in general, healthy," he says. "They have acute illnesses that are self-limiting. With appropriate treatment they get better and are normal.
"The outcome would be a healthy, normal development pattern," says Thompson, who is now a professor at the University of Arkansas School of Medicine in Little Rock. "By a certain grade, they’re reading, they’re socially developed, and they’re emotionally mature. That’s a tough measure to develop and implement."
Clearly, it’s more challenging to tap into a realm of behavior, development, and emotion. Nonetheless, leaders in outcomes measurement are already drafting lists of dozens of possible indicators and data collection tools. The measures will be influenced by a plethora of guidelines, such as Healthy Children 2000, that detail what issues physicians should address at each well-child visit, says Christina Bethell, PhD, MPH, FACCT director of accountability measurement and project director of the Children’s Health Measurement Initiative. For example, the guidelines outline risk assessment, counseling, and follow-up.
"We know from the bit of research [that’s been done] that they often aren’t followed," she says. "We have a lot of opportunity for improvement."
Why outcomes bypassed children
There are many reasons why children haven’t gotten much attention from the accountability movement, but they can be summed up as money, influence, and practicality. "While children’s health care is enormously important, it’s not the highest cost item for private purchasers who were influential in the inception of performance measurement," she notes.
Government funding also focused on adult outcomes measures, as the Health Care Financing Administration sought ways to ensure that Medicare managed care plans lived up to their promises. Next year, the Health of Seniors Survey becomes the first health status measure that must be reported as a part of HEDIS.
In contrast, functional health surveys geared toward children have just been developed and haven’t evolved as a performance assessment tool. (For more information on survey instruments in use, see examples, pp. 133-135.)
Children lack lobby group, political voice
With adult indicators, quality care often involves the proper management or treatment of a disease: The patient came in with symptoms, received care, and reported improvement.
"In kids you’re really concerned about where they’re going with their health, not just where they are," says Barbara Starfield, MD, MPH, university distinguished professor at Johns Hopkins Medical Institution in Baltimore and a leading outcomes researcher. Her child health status questionnaire, the Child Health and Illness Profile, includes such domains as risk and resilience.
Power — or the lack of it — also may have hampered the evolution of quality measures for children’s health. After all, kids can’t vote and they don’t have their own lobbying organizations. And with fewer chronic illnesses, they have less impact on the overall health system. "While children’s health care is enormously important, it’s not the highest cost item for private purchasers who were influential in the beginning of performance measurement," says Bethell.
New insurance program raises stakes
A new, $25 billion government program to cover uninsured children — the State Children’s Health Insurance Program — has raised the stakes and put children’s health on the forefront of quality assessment. "We anticipate virtually all of that [coverage] being in prepaid managed systems of care, with a critical need to document the quality of care for kids," says Thompson.
The Children’s Health Measurement Advisory Committee met for the first time in June to begin to identify possible measures. The initiative will follow the framework set for adult health, with measures to address the basics such as access, staying healthy, getting better, living with illness, and changing needs. The measures will address both healthy kids and those with chronic illnesses such as diabetes, asthma, and juvenile rheumatoid arthritis. (For a list of current and future measures, see box, p. 128.)
Sample size is an issue in measuring outcomes for children with chronic illnesses, she notes. "Even though a lot of children have asthma, it’s often not enough to define performance in any single plan population."
NCQA recently concluded that a measure for children with diabetes based on clinical data would be too costly and difficult for health plans to administer. Instead, the organization will seek information from surveys and use measures that address care for children with chronic diseases. (See related story, p. 138.)
For example, a supplement to the pediatric version of the Consumer Assessment of Health Plans may ask parents about the care their children received. The American Academy of Pediatricians in Oak Grove Village, IL, also is developing condition-specific health status questionnaires for asthma, otitis media, and juvenile rheumatoid arthritis, as well as clinical performance measures.
The committee wants the new measures to be applicable for measurement at the medical group level and for quality improvement, Bethell says.
Otitis media: A cautionary tale
The Children’s Health Measurement Initiative is working on a two-year time line to devise the new measures. But despite that fast track, its leaders have reason for caution.
In 1996, NCQA included a measure on inappropriate antibiotic use for otitis media in HEDIS. Confusion reigned as health plans misinterpreted the measure’s specifications. "We had plans that reported very high percentages of time — almost unreasonable periods of time — in which they administered the wrong antibiotic," recalls Thompson. "They reported the percent of time they used the right antibiotic rather than wrong antibiotic."
NCQA pulled the measure back to the testing set and has yet to re-release it. (For information on a different project to measure care for otitis media with effusion, see related story, p. 129.) That experience will undoubtedly add to the scrutiny given to new HEDIS requirements.
"We have a responsibility to make sure that the measures that are put out are providing high quality information," says Thompson. "Pushing too fast can cause problems, as we experienced with the children’s otitis media measure. Philosophically, it was a good measure. [But] all the technical aspects hadn’t been worked out."
Still, NCQA expects to eventually reinstitute a measure on that and other common childhood ailments. "We share the vision that many other organizations have also — the Foundation for Accountability, U.S. Congress, the [Clinton] administration — of having a robust set of measures that provide information on quality of children’s health," says Thompson.
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