Advertisement

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.
      Beal et al., in 2004 identified 19 measure sets and 396 individual measures available to assess the quality of children’s health care.
      • Beal A.C.
      • Co J.P.
      • Dougherty D.
      • et al.
      Quality measures for children’s health care.
      These measures spanned multiple domains—safety, 14.4%; effectiveness, 59.1%; patient centeredness, 32.1%; and timeliness, 33.3%.
      • Beal A.C.
      • Co J.P.
      • Dougherty D.
      • et al.
      Quality measures for children’s health care.
      Despite a number of measures being available, there were relatively few measures that captured specific age categories, equity, and disparities.
      • Beal A.C.
      • Co J.P.
      • Dougherty D.
      • et al.
      Quality measures for children’s health care.
      Since then, the passage of the Children’s Health Insurance Program Reauthorization Act in 2009 (CHIPRA) has provided the necessary legislative support for the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS) to implement the Pediatric Quality Measurement Program (PQMP). This landmark step to improve the quality of health care for children supports 7 Centers of Excellence in developing, testing, and recommending quality measures that will span the breadth of primary care, specialty care, and hospital-based pediatric care. A critical step now is to assure that substantial numbers of these measures are adopted into the clinical practice of practicing pediatricians. As noted by Perrin in 2012, most quality measures and improvement efforts address children without chronic conditions, and only a “few measures of chronic conditions go beyond examining what kinds of monitoring children with specific conditions receive. Only limited attention is paid to how well the children are functioning.”
      • Perrin J.M.
      How can quality improvement enhance the lives of children with disabilities?.
      As attempts are made to address these gaps, it will also be important to expand the measurement activity to include outcomes of care.
      • Porter M.E.
      What is value in health care?.
      • Casciato A.
      • Angier H.
      • Milano C.
      • et al.
      Are pediatric quality care measures too stringent?.
      Future efforts at quality measure development should also aim to incorporate the approach identified by Porter and Lee in an article in the Harvard Business Review.
      • Porter M.E.
      • Lee T.H.
      The strategy that will fix health care.
      This approach recommends an incremental tiered approach for outcomes assessment based on the notion of creating value for patients and families. Tier 1 pertains to the health status that is achieved or retained; tier 2 looks at the care cycle and the process of recovery; and tier 3 relates to the overall sustainability of health.
      • Porter M.E.
      • Lee T.H.
      The strategy that will fix health care.
      Several centers within the PQMP are exploring opportunities to develop outcome measures that will allow building further on the strategy proposed in the tiered approach.
      Practicing primary care pediatricians and pediatric subspecialists are currently attempting to understand the many efforts related to quality measure development and improvement initiatives. Maintenance of Certification requirements from the American Board of Pediatrics has driven much interest in quality measurement and improvement in the pediatric community. Beyond the activities of the PQMP, the National Committee on Quality Assurance (NCQA) and the Children’s Hospital Association are involved in measure development, along with many home-grown measures developed by health systems. Although the National Quality Forum has endorsed some of these measures, many others without endorsement are being used in practice.
      It will be important to provide the necessary education for pediatricians to better understand the differences between measures for accountability and measures for improvement.

      Sachdeva RC. Quality and safety in health care for children. In: Nelson’s Textbook of Pediatrics 2014. In press.

      Ideally, quality measures should serve both purposes; however, in reality, few measures can effectively meet both objectives. Measures for accountability are developed using a thorough process grounded in measurement science that allows evaluation of quality at a macro level, such as a health plan or a state. In contrast, measures for improvement are typically highly process driven and aim to capture the impact of discrete incremental quality improvement initiatives at a local level. It would be important to attempt to link measures for improvement with measures for accountability so that the quality measures are clinically relevant to practicing pediatricians and so that they will also allow measuring the quality of care at a more macro level, such as a health system or health plan at state and national levels.
      In order for quality measures to lead to improvement in health care, these measures must have clinical relevance to both pediatricians and families.
      • Sachdeva R.C.
      • Jain S.
      Making the case to improve quality and reduce costs in pediatric health care.
      Efforts to link some measures from PQMP with the Maintenance of Certification Performance Improvement Modules is a step in this direction; this will enhance the adoption of these quality measures into clinical practice and will lead to improvements in quality of care. Expanding strategic partnerships among the national pediatric organizations to develop and implement a comprehensive quality approach should support reconciliation of existing and emerging quality measures with the goal of rapid adoption into clinical practice.
      Recent efforts related to the notion of patient-reported outcomes are being explored within the PQMP centers of excellence and hold promise to allow expanding the traditional process measures to meaningful outcome measures that will have relevance to patients and families. Such efforts can achieve an even greater impact by strengthening partnerships with other initiatives such as the Child and Adolescent Health Measurement Initiative (CAHMI), which has developed several quality measurement survey tools that are crucial for pediatricians including the medical home, cultural competency, and standardized developmental screening.

      References

        • Beal A.C.
        • Co J.P.
        • Dougherty D.
        • et al.
        Quality measures for children’s health care.
        Pediatrics. 2004; 113: 199-209
        • Perrin J.M.
        How can quality improvement enhance the lives of children with disabilities?.
        Future Child. 2012; 22: 149-168
        • Porter M.E.
        What is value in health care?.
        N Engl J Med. 2010; 363: 2477-2481
        • Casciato A.
        • Angier H.
        • Milano C.
        • et al.
        Are pediatric quality care measures too stringent?.
        J Am Board Fam Med. 2012; 25: 686-693
        • Porter M.E.
        • Lee T.H.
        The strategy that will fix health care.
        Harvard Business Rev. 2013; 91: 50-70
      1. Sachdeva RC. Quality and safety in health care for children. In: Nelson’s Textbook of Pediatrics 2014. In press.

        • Sachdeva R.C.
        • Jain S.
        Making the case to improve quality and reduce costs in pediatric health care.
        Pediatr Clinic North Am. 2009; 56: 731-743