Investing in Children’s Health Care Quality
Improvement: Returns in Lives, Health, and
Dollars—An Illustration
Denise Dougherty, Ph.D.,
Presented by Anne Elixhauser, Ph.D.
June 24, 2006
CHSR, Seattle, WA
Overview
 What would be the impact of investing in
improvements in health care quality for
children?
 Two examples of preliminary studies:
– Child lives saved
– Morbidity avoided
– Dollars to Medicaid
No Needless Deaths—
Investigators
 Denise Dougherty, Ph.D., AHRQ
 Lisa Simpson, MB, BCh, MPH, FAAP,
University of South Florida
 Melissa Romaire, MPH, CMS (work
done at AHRQ)
 Charles Homer, MD, NICHQ*Cambridge, MA
 Lisa C. White, MPH, NICHQ*-Seattle
* National Initiative for Children’s Healthcare Quality
Rationale and Methods
 Rationale: draw attention to children’s healthcare
quality
– IHI 100,000 Lives Campaign on No Needless Deaths
– Woolf et al. report on deaths due to disparities got a lot
of attention
– IOM’s To Err is Human figure of 98,000+ deaths due to
medical errors received attention.
 Identified leading causes of death in children 0-17
 Among leading causes, identified those with
evidence that improved health care quality could
reduce child deaths
 Estimated # of deaths nationally that could be
prevented with improved healthcare quality
 Extrapolated life years gained using YPLL* method
* Years of Potential Life Lost
Results—Needless Deaths
Prevented Through QI
Cause of Death
Improvement
Strategy
VLBW Neonatal NICU
Period
improvements
# of Deaths
Prevented Single
Year ( 50-100%
effectiveness)
Potential Life Years
Gained with QI
(100%
effectiveness)
1,329-2,658
Child yrs: 47,844
Total yrs: 205,198
Child yrs: 5,491
Total yrs: 23,224
Child yrs: 40,347
Total yrs: 308,430
Child yrs: 150
Total yrs: 1,004
Child yrs: 93,832
Total yrs: 537,856
SIDS mortality
B-W difference
“Back to sleep” 161-323
Medical errorsinpatient
Patient safety
2,242-4,483
Cancer mortality Improved
B-W difference cancer care
8-15
Total
3,740-7,479
Other Evidence of Poor Quality
of Care for Children
Topic
Asthma care: Pediatric
hospitalizations (potentially
avoidable)
Immunizations up to date—9-35
month olds
Timeliness: Care for illness or
injury as soon as desired
Patient-centeredness: CAHPS
composite measure
Quality/Disparities
Findings (Nationally)
Children higher than adults
Black children 3x rate of white
children
31.6% not up to date
Lower among CSHCN than
children w/o SHCN
Lower among CSHCN than
children w/o SHCN
Source: AHRQ, National Healthcare Quality Report and National Healthcare Disparities Report, 2005
Improving Neonatal Outcomes of
Medicaid-Covered Infants—Investigators
 Denise Dougherty, Ph.D., AHRQ
 Bernard Friedman, Ph.D., AHRQ
 Vipul Mankad, MD, U MD (done while at
CMS)
 With assistance of:
– Jeannette Rogowski, Ph.D.
– Nikki Highsmith, MPA
– Neonatal Outcomes Improvement Group
Rationale and Methods
 Rationale: CMS Medicaid trying to stimulate
quality improvement and reduce costs
 Methods:
– Identified 4 illustrative perinatal areas with
evidence of the potential for improvement
– Detailed 2002 HCUP cost data on neonatal
special care units from 7 States
– Calculated differences between pre- and post-QI
admissions or LOS
– Extrapolated to national estimates using national
totals of deliveries and incidence of conditions
Results
 Average cost difference between a
Medicaid NICU stay and a Medicaid
regular nursery stay was $18,607
 Average difference in LOS was 11-16
days
Source: AHRQ, Healthcare Cost and Utilization Project (HCUP) State Inpatient
Databases (SID), 7 States, 2002 data, extrapolated to national estimates
Preliminary Results
Clinical
Improvement
Savings achieved
by
Rough estimates of
national gross cost
savings
$48,300,000
Smoking
cessation/pregnant
women
Antenatal
corticosteroids
Reduced NICU
admissions
Reduced NICU LOS
attributable to RDS
$48,727,854
Prophylactic
surfactant
Reduced NICU LOS
$55,822,000
Infection reduction in
NICU
Reduced NICU LOS
$72,093,193
Notes: 1) Gross mean costs of QI initiatives not included.
2) Medicaid programs may not be able to recoup all costs.
Other compelling reasons to
improve perinatal care
 Neonatal deaths prevented:
– 338 deaths prevented with smoking cessation
 Prevention of extremely low birth weight and
very low birth weight can potentially prevent:
– Intensive care admissions and ICU days during
the first year of life
– Low IQ
– Poor math and gross motor skills
– Other poor neurodevelopmental outcomes
(cerebral palsy, vision impairments)
References available on request.
Conclusions
 Conclusions:
– Needless deaths and substantial morbidity
can be prevented
– Substantial child life years gained
– Medicaid expenditures can potentially be
reduced
Caveats and Needed
Research
 Caveats:
– Figures are preliminary and illustrative due to
incompleteness of data sources
– Cost of QI interventions not included
– State Medicaid programs unlikely to recoup all
savings
 Research needed:
– Effectiveness of QI for other leading causes of
child deaths and morbidity
– National data on children’s health care quality and
costs
– Research on effectiveness of interventions (to
develop quality measures)
Informal Reactions from
Previous Reviewers
 Needless deaths pre-review
– Enthusiasm during presentations
– For potential publication:
 Numbers are small relative to other conditions and due
to QI focus
 Child life years gained not understood
 Neonatal care improvements
– Some States eager to discuss
– CMS to hold stakeholder meeting
– Some States say they don’t have these problems
– analysis doesn’t apply to them
Questions
 Is this enough to act on?
 If not, why not?
 What research strategies should be
used to create more data and frame the
issues?