Overview
„ What would be the impact of investing in
Investing in Children’
Children’s Health Care Quality
Improvement: Returns in Lives, Health, and
Dollars—
Dollars—An Illustration
Denise Dougherty, Ph.D.,
Presented by Anne Elixhauser, Ph.D.
June 24, 2006
CHSR, Seattle, WA
No Needless Deaths—
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*NICHQ*Cambridge, MA
„ Lisa C. White, MPH, NICHQ*NICHQ*-Seattle
improvements in health care quality for
children?
„ Two examples of preliminary studies:
– Child lives saved
– Morbidity avoided
– Dollars to Medicaid
Rationale and Methods
„ Rationale: draw attention to children’
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’
IOM’s To Err is Human figure of 98,000+ deaths due to
medical errors received attention.
„ Identified leading causes of death in children 00-17
„ 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
* National Initiative for Children’
Children’s Healthcare Quality
* Years of Potential Life Lost
Results—
Results—Needless Deaths
Prevented Through QI
Cause of Death
Improvement
Strategy
VLBW Neonatal NICU
Period
improvements
# of Deaths
Potential Life Years
Prevented Single
Gained with QI
Year ( 50(100%
50-100%
effectiveness)
effectiveness)
1,3291,329-2,658
SIDS mortality
B-W difference
“Back to sleep”
sleep” 161161-323
Medical errorserrorsinpatient
Patient safety
2,2422,242-4,483
Cancer mortality Improved
B-W difference cancer care
8-15
Total
3,7403,740-7,479
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
Other Evidence of Poor Quality
of Care for Children
Topic
Asthma care: Pediatric
hospitalizations (potentially
avoidable)
Immunizations up to date—
date—9-35
month olds
Timeliness: Care for illness or
injury as soon as desired
PatientPatient-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
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Improving Neonatal Outcomes of
MedicaidMedicaid-Covered Infants—
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 prepre- and postpost-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 1111-16
days
Source: AHRQ, Healthcare Cost and Utilization Project (HCUP) State
State Inpatient
Databases (SID), 7 States, 2002 data, extrapolated to national estimates
estimates
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)
Preliminary Results
Clinical
Improvement
Savings achieved
by
Smoking
cessation/pregnant
women
Antenatal
corticosteroids
Reduced NICU
admissions
Rough estimates of
national gross cost
savings
$48,300,000
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.
Conclusions
„ Conclusions:
– Needless deaths and substantial morbidity
can be prevented
– Substantial child life years gained
– Medicaid expenditures can potentially be
reduced
References available on request.
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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’
children’s health care quality and
costs
– Research on effectiveness of interventions (to
develop quality measures)
Informal Reactions from
Previous Reviewers
„ Needless deaths prepre-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’
don’t have these problems
– analysis doesn’
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?
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