'Stunning' Deficiencies in Kids' Health Care

The mother of 2-year-old Kristen Todd knows what it's like to go to a pediatrician's office.

"You probably get no more than 10 minutes with the doctor," she said. "And when you have a toddler and you go in there, and they're all screaming and hollering, and the physician's running 40 minutes behind ... it's kind of a pain."

But parents like Todd may have more to worry about than inconvenience when it comes to their kids' health care.

According to a new study released Wednesday in the New England Journal of Medicine, children across the country — even those covered by health insurance — receive less than half of the health care measures that pediatricians recommend.

Study authors said that while they expected to find deficiencies, they were surprised at the extent of the problem.

"Before this study was done, most people thought kids were getting reasonably good care," said lead author Dr. Rita Mangione-Smith, associate professor at the University of Washington School of Medicine. "I have to say that, as a pediatrician, I was surprised that things were as bad as they were."

Mangione-Smith and researchers at the RAND Corp. created a set of 175 quality indicators based on national guidelines and the opinions of an expert panel of pediatricians.

The indicators cover such common childhood health care needs as preventive care, acute medical care and care for chronic medical conditions.

They then examined medical records from 1,536 children, randomly selected from 12 major metropolitan areas across the country, looking at all types of outpatient pediatric care, received from 1996 to 2000.

What they found was that children received only 46.5 percent of recommended care measures overall.

When examined by category, children received only 67.6 percent of indicated care for acute illnesses, which includes measures such as hospitalization for a severe fever.

Care for chronic medical conditions — scheduling follow-up visits after changes in asthma medication — was delivered only 53.4 percent of the time.

And the worst news came in the area of care aimed at prevention of sickness — a category that includes immunizations and routine measurements of height and weight. In this category, only 40.7 percent of the recommended care was delivered.

Public health experts not involved with the study said the results are a call to action to address the country's failure to provide high-quality health care to its children.

"It is stunning, in many ways," said Jay Wolfson, distinguished service professor in the college of public health at the University of South Florida, "to glimpse the data from this study and realize that ... the care and nurturing and investment in the health of our children may have taken a back seat to Medicaid and commercial managed care and insurance plans."

An Indictment of the Health Care System?

Study co-author Elizabeth McGlynn, associate director of RAND Health, said the structure of the American health care system may play a large role in the deficiencies.

"If you look at the incentives in the systems, and how we organize medical care ... perhaps [the results] are not surprising," she said. "In a lot of ways, we're almost doing better than what one might think we would, given all the challenges in how medical care is organized and delivered today."

Indeed, many factors are likely at play — not the least of which is the pressure physicians face to see more and more patients in less time.

"We now often get 10-minute slots in the outpatient setting," said Mangione-Smith. "How can we possibly accomplish all the things we are supposed to do in that amount of time and also address questions from parents for a one-year checkup?"

Dr. Joseph Zanga, professor of pediatrics at the Brody School of Medicine at East Carolina University, estimated that physicians may need at least four times as much time as is often given to them.

"A few years ago, my colleagues and I sat down and listed the recommendations from the guidelines," said Zanga. "We tested them out with each other and our patients, and if we really spent the time performing preventive care and explaining everything to children's parents, it took about 45 to 60 minutes for a routine well-child check."

McGlynn noted that insurance companies may be driving part of this problem.

"The whole reimbursement scheme in this country is focused on the number of pieces of work you do, not the results that you get," said McGlynn. "We have to take a very serious look at how we're paying physicians and hospitals."

Another issue is a lack of organization — on the part of parents, physicians and health systems — that may be hampering efficiency during office visits.

"If you have a very short period of time, and you aren't that organized ... then you may not accomplish your goals," said McGlynn. "We also rely heavily in our health care system on the one-on-one patient-doctor visit to provide everything. We need to ask, are there different ways to organize that?"

Hints of an Even Bleaker Reality

As if the findings weren't discouraging enough, the authors noted that the limitations of the study leave room for an even bleaker picture of child health.

For one thing, only families from metropolitan areas, families with phones and children who had actually received some medical care during the study period were eventually eligible to be enrolled. As a result, the study population had a higher percentage of white patients and private insurance holders than the U.S. population as a whole. And all the children had seen at least one provider in the preceding two years.

But had uninsured, rural and minority children been factored in, the numbers could have been even worse.

"We had primarily white children with insurance from middle- to upper-middle income families," said Mangione-Smith. "This is probably a best-case scenario; this is as good as it's going to get."

The study also comes at a time when debate continues over the reauthorization and expansion of the State Children's Health Insurance Program. And while the study's authors said health care quality is largely a separate issue, the recently vetoed SCHIP reauthorization bill included some measures to assess and improve quality of care.

"The bill that was recently vetoed included a requirement for the Department of Health and Human Services to come up with a core set of quality measures," Mangione-Smith said. "Passage of this bill would not only improve access but also require that we routinely monitor and improve the quality of that care."

"The deficits in care [in this study] might be reduced if more patients had a regular source of care, and more continuity in relationships with providers," said R. Paul Duncan, chairman of the department of health services research at the University of Florida. "Insurance coverage is no guarantee of a medical home, or regular source of care, but it is an essential starting point."

Possibilities of Solutions

One conclusion the authors emphasized was that the political debate over improving health care needs to be expanded.

"Most of the debate has focused on how to deliver affordable health care, and how to ensure access to care," said McGlynn. "The third component should be how do we ensure that we are delivering care that is up to certain standards?"

Some solutions proposed by the authors included the development of automated checklists for physicians, greater use of health information technology and improved training of doctors in outpatient medicine during their residencies.

"Checklists — like what pilots have — would be very helpful to have," Mangione-Smith said. "People that have checklists that trigger them to do tasks do a better job, and do a more thorough job."

But researchers added that parents themselves may also have a role to play in improvements, stressing better preparation before taking their child to the pediatrician.

"In order to seriously look at how to change things, we need the public onboard with the idea that there is a problem that needs to be solved," McGlynn said.

Zanga added, "Parenting is not an easy job, but if we physicians are to do ours better, we need parents to be involved, interested, and knowledgeable of their children."