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How Does Pediatric Quality Measure Development Reflect the Real World Needs of Hospitalized Children?

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      What's New
      The Pediatric Quality Measures Program can support evaluation of many aspects of pediatric healthcare quality. This article describe recent advances in quality measurement in the context of current epidemiology of pediatric hospitalization in the United States.
      Infants, children, and adolescents experience more than 6 million hospitalizations each year in the United States (US), with health care costs exceeding 47 billion dollars annually.

      Moore B, Freeman W, Jiang H. Costs of Pediatric Hospital Stays, 2016. Healthcare Cost and Utilization Project Statistical Brief #250. Available at:Https://www.hcup-us.ahrq.gov/reports/statbriefs/sb250-Pediatric-Stays-Costs-2016.jsp. Accessed December 10, 2020.

      More than half of these hospitalizations occur at the time of birth, while the remaining represent medical, surgical, and mental health hospitalizations beyond the immediate neonatal period.

      Moore B, Freeman W, Jiang H. Costs of Pediatric Hospital Stays, 2016. Healthcare Cost and Utilization Project Statistical Brief #250. Available at:Https://www.hcup-us.ahrq.gov/reports/statbriefs/sb250-Pediatric-Stays-Costs-2016.jsp. Accessed December 10, 2020.

      The burden of pediatric hospitalization is disproportionately borne by children with chronic physical and mental health conditions, those insured by Medicaid, and those experiencing social risk factors including poverty and housing insecurity.
      • Leyenaar JK
      • Ralston SL
      • Shieh M
      • et al.
      Epidemiology of pediatric hospitalizations at General Hospitals and Freestanding Children’s Hospitals in the United States.
      • Beck AF
      • Riley CL
      • Taylor SC
      • et al.
      Pervasive income-based disparities in inpatient bed-day rates across conditions and subspecialties.
      • Beck AF
      • Florin T
      • Campanella S
      • Shah S
      Geographic variation in hospitalization for lower respiratory tract infections across one county.
      • Bardach N
      • Coker TR
      • Zima BT
      • et al.
      Common and costly hospitalizations for pediatric mental health disorders.
      • Torio CM
      • Encinosa W
      • Berdahl T
      • et al.
      Annual report on health care for children and youth in the United States : national estimates of cost, utilization and expenditures for children with mental health conditions.
      Recognizing the increasing complexity and costs of pediatric inpatient care, and the vulnerability experienced by children during hospitalization, a national focus on hospital-based quality improvement is well justified. Fortunately, funding provided by the Centers for Medicare and Medicaid Services (CMS) to support the Pediatric Quality Measures Program (PQMP) has enabled evaluation of many aspects of pediatric health care quality using robust and valid quality measures. But to what extent do these measures reflect the real world needs of hospitalized children? To address this question, we describe recent advances in pediatric quality measurement in the context of the current epidemiology of pediatric hospitalization in the US.
      The PQMP was launched in 2011, supported by Congress through the Children's Health Insurance Program Reauthorization Act (CHIPRA).

      Agency for Healthcare Research and Quality. Pediatric Quality Measure Program (PQMP) Measures. Available at:https://www.ahrq.gov/pqmp/measures/all-pqmp-measures.html. Accessed June 8, 2020.

      During the first phase (2011–2016), the Agency for Healthcare Research and Quality administered cooperative agreement grants to seven academic medical centers to support the development of an initial set of evidence-based quality measures designed to improve children's quality of care. Several of these quality measures are specific to pediatric hospitalization, including measures focused on access to high-risk obstetrical services, timely sepsis management, family experience of care, medication reconciliation, patient safety, transitions of care, mental health care, and readmission following hospital discharge.
      • Desai AD
      • Burkhart Q
      • Parast L
      • et al.
      Development and pilot testing of caregiver-reported pediatric quality measures for transitions between sites of care.
      • Parast L
      • Burkhart Q
      • Desai AD
      • et al.
      Validation of new quality measures for transitions between sites of care.
      • Toomey SL
      • Zaslavsky AM
      • Elliott MN
      • et al.
      The development of a pediatric inpatient experience of care measure: child HCAHPS®.
      • Toomey SL
      • Elliott MN
      • Zaslavsky AM
      • et al.
      Variation in family experience of pediatric inpatient care as measured by child HCAHPS.
      • Parast L
      • Bardach N
      • Burkhart Q
      • et al.
      Development of new quality measures for hospital-based care of suicidal youth.
      • Odetola FO
      • Freed G
      • Shevrin C
      • et al.
      In-hospital quality-of-care measures for pediatric sepsis syndrome.
      • Leyenaar JK
      • Desai AD
      • Burkhart Q
      • et al.
      Quality measures to assess care transitions for hospitalized children.
      • Bardach N
      • Burkhart Q
      • Richardson L
      • et al.
      Hospital-based quality measures for pediatric mental health care.
      • Landrigan CP
      • Stockwell D
      • Toomey SL
      • et al.
      Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) tool.
      (A comprehensive list of PQMP Measures is available at https://www.ahrq.gov/pqmp/measures/index.html).

      Agency for Healthcare Research and Quality. Pediatric Quality Measure Program (PQMP) Measures. Available at:https://www.ahrq.gov/pqmp/measures/all-pqmp-measures.html. Accessed June 8, 2020.

      In addition, the first phase of the PQMP supported the development of two algorithms based on International Classification of Diseases codes (9th and 10th revisions) to identify children with disabilities and chronic diseases, which enable the identification of children with special health care needs for focused quality improvement initiatives or for the purpose of risk stratification.
      • Simon TD
      • Haaland W
      • Hawley K
      • et al.
      Development and Validation of the Pediatric Medical Complexity Algorithm (PMCA) version 3.0.
      ,
      • Chien AT
      • Kuhlthau KA
      • Toomey SL
      • et al.
      Development of the children with disabilities algorithm.
      During the second phase of the PQMP (2016–2020), 6 institutions were funded to implement and disseminate these quality measures, with a goal of determining their feasibility and usability. The results of this second phase of work are forthcoming, and will provide valuable information about the application of these measures to improve pediatric health care delivery.
      To date, the majority of pediatric quality measure development and implementation efforts have occurred at large children's hospitals, where the majority of federal funding for pediatric research is received, and where high patient volumes enable relatively efficient data collection.
      • Good M
      • McElroy S
      • Berger J
      • et al.
      Name and characteristics of National Institutes of Health R01-Funded Pediatric Physician-Scientists : hope and challenges for the vanishing pediatric physician-scientists.
      However, the usability of quality measures must also take into account the diverse settings where hospital-based pediatric care is delivered. Of nonbirth pediatric hospitalizations in the United States, less than 30% occur at freestanding children's hospitals with the remainder occurring at more than 3000 general hospitals across the country.
      • Leyenaar JK
      • Ralston SL
      • Shieh M
      • et al.
      Epidemiology of pediatric hospitalizations at General Hospitals and Freestanding Children’s Hospitals in the United States.
      All freestanding children's hospitals in the United States are located in urban or suburban regions, leaving more than 1500 US rural hospitals underrepresented in quality measure field-testing and implementation.
      • Leyenaar JK
      • Ralston SL
      • Shieh M
      • et al.
      Epidemiology of pediatric hospitalizations at General Hospitals and Freestanding Children’s Hospitals in the United States.
      One-in-five American children live in rural areas, and one-quarter of these children – 2.95 million – have chronic health conditions.
      • Probst JC
      • Barker JC
      • Enders A
      • et al.
      Current state of child health in rural America : how context shapes children's health.
      Survey data indicate several urban-rural disparities in health care quality: rural-residing children are more likely to report unmet healthcare needs and less likely to receive preventive health care than children who live in urban areas.
      • Probst JC
      • Barker JC
      • Enders A
      • et al.
      Current state of child health in rural America : how context shapes children's health.
      • Skinner AC
      • Slifkin RT
      Rural/urban differences in barriers to and burden of care for children with special health care needs.
      • Kelleher K
      • Gardner W
      Out of sight, out of mind - behavioral and developmental care for rural children.
      In a study of freestanding children's hospitals, rural-residing children had a higher prevalence of complex chronic conditions, higher inpatient costs, and greater risk of readmission than their urban-residing peers.
      • Peltz A
      • Wu CL
      • White L
      • et al.
      Characteristics of rural children admitted to pediatric hospitals.
      Studies of health care quality in rural hospitals are needed to inform quality improvement efforts and the decisions of families and health care providers about where they seek or refer for hospital-based care.
      Although, in aggregate, the majority of hospitalized children receive their care at general hospitals, meaningful pediatric quality measurement in this setting is challenged by the relatively low volume of pediatric hospital admissions at any one hospital. Across all general hospitals that admit children, 80% have pediatric volumes of less than 375 hospitalizations a year.
      • Leyenaar JK
      • Ralston SL
      • Shieh M
      • et al.
      Epidemiology of pediatric hospitalizations at General Hospitals and Freestanding Children’s Hospitals in the United States.
      These relatively low numbers juxtapose with the need for sufficient patient volumes and statistical power to detect clinically meaningful differences in quality measure performance. Past analyses have shown that more than 85% of pediatric hospitalizations occur at hospitals with sufficient volumes to detect meaningful differences in several all-condition quality measures over a three year study period, while relatively few hospitals have volumes to meaningfully evaluate differences in condition-specific measures.
      • Berry JG
      • Zaslavsky AM
      • Toomey SL
      • et al.
      Recognizing differences in hospital quality performance for pediatric inpatient care.
      This calls for unique strategies at general hospitals to evaluate healthcare quality, including a focus on all-condition quality measures that may be applicable to both neonatal and general pediatric populations, collating data across longer periods of time, or joint measurement across several hospitals in a health care system. Illustrating the feasibility of multi-site collaboration and performance measurement, a number of recent quality improvement collaboratives representing both children's hospitals and general hospitals have demonstrated significant improvements in quality of care for several common conditions, including bronchiolitis, asthma, and community acquired pneumonia.
      • Parikh K
      • Biondi E
      • Nazif J
      • et al.
      A multicenter collaborative to improve care of community acquired pneumonia in hospitalized children.
      • Mussman G
      • Lossius M
      • Wasif F
      • et al.
      Multisite emergency department inpatient collaborative to reduce unnecessary bronchiolitis care.
      • Kaiser S V
      • Jennings B
      • Rodean J
      • et al.
      Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): a multicenter, national study.
      Ongoing support for such quality improvement collaboratives is one means to support general hospitals’ quality improvement efforts.
      Several recent studies also demonstrate that a growing number of children who present for care at smaller general hospitals are transferred to children's hospitals for ongoing management of their condition.
      • Franca UL
      • McManus M
      Availability of definitive hospital care for children.
      ,
      • Franca UL
      • McManus ML
      Trends in regionalization of hospital care for common pediatric conditions.
      Our knowledge of health care quality associated with interhospital transfer and regionalization of pediatric health care delivery is limited, as many studies of health care quality exclude transferred patients due to the inability to evaluate their full course of disease management. Of studies focused specifically on children experiencing interhospital transfer, some suggest that the majority of interhospital transfers are potentially unnecessary, given high rates of rapid discharge from the accepting facilities.
      • Rosenthal J
      • Lieng M
      • Marcin J
      • et al.
      Profiling pediatric potentially avoidable transfers using procedure and diagnosis codes.
      ,
      • Richard KR
      • Glisson KL
      • Shah N
      • et al.
      Predictors of potentially unnecessary transfers to pediatric emergency departments.
      Other studies indicate that inter-hospital transfer is associated with longer lengths of hospitalization, greater odds of receipt of critical care services, and higher risk of in-hospital mortality.
      • Evans JM
      • Dayal P
      • Hallam DL
      • et al.
      Illness severity of children admitted to the PICU from referring emergency departments.
      ,
      • White MJ
      • Sutton AG
      • Ritter V
      • et al.
      Interfacility transfers among patients with complex chronic conditions.
      Accordingly, evaluation of health care quality related to interhospital transfer of care is needed, and should be responsive to families’ experiences and priorities as well as those of health care providers in lower-volume hospitals. Recognizing that interhospital transfer may result in substantial hardships for many families related to direct costs, lodging, transportation and childcare, quality measurement should also address financial burdens and social complexity.
      • Rosenthal JL
      • Li ST
      • Hernandez L
      • et al.
      Familial Caregiver and physician perceptions of the family-physician interactions during interfacility transfers.
      Families of rural-residing children may experience particular financial hardships, given the often substantial distances from their homes to regional referral centers, and the relatively higher rates of poverty experienced by rural-residing children.
      • Probst JC
      • Barker JC
      • Enders A
      • et al.
      Current state of child health in rural America : how context shapes children's health.
      ,

      United States Department of Agriculture Economic Research Service. Child poverty. Available at:https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/child-poverty/. Accessed May 28, 2017.

      In conclusion, the PQMP has greatly advanced the field of pediatric quality measurement for hospitalized children, providing clinicians, researchers, and health care administrators access to a large number of quality measures to evaluate all phases of pediatric hospitalization, from admission through hospital discharge. Important next steps include the application of these measures across the structurally diverse hospitals where children receive their care, and attention to how interhospital transfer and regionalization of care are associated with health care quality. Future quality measure development and implementation efforts should also take into account the growing recognition of associations between social complexity and pediatric hospitalization, the financial burden of hospitalization on families, and the consequences of systemic racism in pediatric health care delivery. Recognizing and addressing social complexity and health disparities within a quality improvement framework will further advance the quality of pediatric hospital-based care.

      Acknowledgments

      Funding Statement: The authors were supported by funding from a cooperative agreement with the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services, grant number U18HS025291 , principal investigator, Rita Mangione-Smith. The funders had no role in the writing of the report; nor in the decision to submit the article for publication.
      The views expressed in this article are those of the authors, and no official endorsement by the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid Services (CMS), or the Department of Health and Human Services (DHHS) is intended or should be inferred.
      This article is published as part of a supplement sponsored by the US Department of Health and Human Services, the Centers for Medicare and Medicaid Services, and the Agency for Healthcare Research and Quality.

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