Investing in Children’s Health Care Quality Investing in Children’s Health Care Quality Improvement: Returns in Lives, Health, and Improvement: Returns in Lives, Health, and

Dollars—An IllustrationDollars—An Illustration

Denise Dougherty, Ph.D., Denise Dougherty, Ph.D.,

Presented by Anne Elixhauser, Ph.D.Presented by Anne Elixhauser, Ph.D.

June 24, 2006June 24, 2006

CHSR, Seattle, WACHSR, Seattle, WA

OverviewOverview

What would be the impact of investing in What would be the impact of investing in improvements in health care quality for improvements in health care quality for children?children?

Two examples of preliminary studies:Two examples of preliminary studies:– Child lives saved Child lives saved – Morbidity avoided Morbidity avoided – Dollars to MedicaidDollars to Medicaid

No Needless Deaths—No Needless Deaths—Investigators Investigators

Denise Dougherty, Ph.D., AHRQDenise Dougherty, Ph.D., AHRQ Lisa Simpson, MB, BCh, MPH, FAAP, Lisa Simpson, MB, BCh, MPH, FAAP,

University of South FloridaUniversity of South Florida Melissa Romaire, MPH, CMS (work Melissa Romaire, MPH, CMS (work

done at AHRQ)done at AHRQ) Charles Homer, MD, NICHQ*-Charles Homer, MD, NICHQ*-

Cambridge, MACambridge, MA Lisa C. White, MPH, NICHQ*-SeattleLisa C. White, MPH, NICHQ*-Seattle

* National Initiative for Children’s Healthcare Quality* National Initiative for Children’s Healthcare Quality

Rationale and MethodsRationale and Methods Rationale: draw attention to children’s healthcare Rationale: draw attention to children’s healthcare

qualityquality– IHI IHI 100,000 Lives Campaign100,000 Lives Campaign on No Needless Deaths on No Needless Deaths– Woolf et al. report on deaths due to disparities got a lot Woolf et al. report on deaths due to disparities got a lot

of attentionof attention– IOM’s IOM’s To Err is HumanTo Err is Human figure of 98,000+ deaths due to figure of 98,000+ deaths due to

medical errors received attention.medical errors received attention. Identified leading causes of death in children 0-17Identified leading causes of death in children 0-17 Among leading causes, identified those with Among leading causes, identified those with

evidence that improved health care quality could evidence that improved health care quality could reduce child deathsreduce child deaths

Estimated # of deaths nationally that could be Estimated # of deaths nationally that could be prevented with improved healthcare qualityprevented with improved healthcare quality

Extrapolated life years gained using YPLL* methodExtrapolated life years gained using YPLL* method

* Years of Potential Life Lost* Years of Potential Life Lost

Results—Needless Deaths Results—Needless Deaths Prevented Through QIPrevented Through QI

Cause of DeathCause of Death Improvement Improvement StrategyStrategy

# of Deaths # of Deaths Prevented Single Prevented Single Year ( 50-100% Year ( 50-100% effectiveness)effectiveness)

Potential Life Years Potential Life Years Gained with QI Gained with QI

(100% (100% effectiveness)effectiveness)

VLBW Neonatal VLBW Neonatal PeriodPeriod

NICU NICU improvementsimprovements

1,329-2,658 1,329-2,658 Child yrs: 47,844Child yrs: 47,844

Total yrs: 205,198Total yrs: 205,198

SIDS mortality SIDS mortality B-W differenceB-W difference

““Back to sleep”Back to sleep” 161-323 161-323 Child yrs: 5,491Child yrs: 5,491

Total yrs: 23,224Total yrs: 23,224

Medical errors-Medical errors-inpatientinpatient

Patient safetyPatient safety 2,242-4,4832,242-4,483 Child yrs: 40,347Child yrs: 40,347

Total yrs: 308,430Total yrs: 308,430

Cancer mortality Cancer mortality B-W differenceB-W difference

Improved Improved cancer carecancer care

8-158-15 Child yrs: 150Child yrs: 150

Total yrs: 1,004Total yrs: 1,004

TotalTotal 3,740-7,479 3,740-7,479 Child yrs: 93,832Child yrs: 93,832

Total yrs: 537,856Total yrs: 537,856

Other Evidence of Poor Quality Other Evidence of Poor Quality of Care for Children of Care for Children

TopicTopic Quality/Disparities Quality/Disparities Findings (Nationally)Findings (Nationally)

Asthma care: Pediatric Asthma care: Pediatric hospitalizations (potentially hospitalizations (potentially avoidable)avoidable)

Children higher than adultsChildren higher than adults

Black children 3x rate of white Black children 3x rate of white childrenchildren

Immunizations up to date—9-35 Immunizations up to date—9-35 month oldsmonth olds

31.6% not up to date31.6% not up to date

Timeliness: Care for illness or Timeliness: Care for illness or injury as soon as desiredinjury as soon as desired

Lower among CSHCN than Lower among CSHCN than children w/o SHCNchildren w/o SHCN

Patient-centeredness: CAHPS Patient-centeredness: CAHPS composite measurecomposite measure

Lower among CSHCN than Lower among CSHCN than children w/o SHCNchildren w/o SHCN

Source: AHRQ, National Healthcare Quality Report and National Healthcare Disparities Report, 2005Source: AHRQ, National Healthcare Quality Report and National Healthcare Disparities Report, 2005

Improving Neonatal Outcomes of Improving Neonatal Outcomes of Medicaid-Covered Infants—InvestigatorsMedicaid-Covered Infants—Investigators

Denise Dougherty, Ph.D., AHRQDenise Dougherty, Ph.D., AHRQ Bernard Friedman, Ph.D., AHRQBernard Friedman, Ph.D., AHRQ Vipul Mankad, MD, U MD (done while at Vipul Mankad, MD, U MD (done while at

CMS)CMS) With assistance of:With assistance of:

– Jeannette Rogowski, Ph.D.Jeannette Rogowski, Ph.D.

– Nikki Highsmith, MPANikki Highsmith, MPA

– Neonatal Outcomes Improvement GroupNeonatal Outcomes Improvement Group

Rationale and MethodsRationale and Methods

Rationale: CMS Medicaid trying to stimulate Rationale: CMS Medicaid trying to stimulate quality improvement and reduce costsquality improvement and reduce costs

Methods:Methods:– Identified 4 illustrative perinatal areas with Identified 4 illustrative perinatal areas with

evidence of the potential for improvementevidence of the potential for improvement

– Detailed 2002 HCUP cost data on neonatal Detailed 2002 HCUP cost data on neonatal special care units from 7 Statesspecial care units from 7 States

– Calculated differences between pre- and post-QI Calculated differences between pre- and post-QI admissions or LOSadmissions or LOS

– Extrapolated to national estimates using national Extrapolated to national estimates using national totals of deliveries and incidence of conditionstotals of deliveries and incidence of conditions

Results Results

Average cost difference between a Average cost difference between a Medicaid NICU stay and a Medicaid Medicaid NICU stay and a Medicaid regular nursery stay was $18,607regular nursery stay was $18,607

Average difference in LOS was 11-16 Average difference in LOS was 11-16 days days

Source: AHRQ, Healthcare Cost and Utilization Project (HCUP) State Inpatient Source: AHRQ, Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), 7 States, 2002 data, extrapolated to national estimatesDatabases (SID), 7 States, 2002 data, extrapolated to national estimates

Preliminary Results Preliminary Results

Clinical Clinical ImprovementImprovement

Savings achieved Savings achieved byby

Rough estimates of Rough estimates of national gross cost national gross cost savingssavings

Smoking Smoking cessation/pregnant cessation/pregnant womenwomen

Reduced NICU Reduced NICU admissionsadmissions

$48,300,000$48,300,000

Antenatal Antenatal corticosteroidscorticosteroids

Reduced NICU LOS Reduced NICU LOS attributable to RDSattributable to RDS

$48,727,854$48,727,854

Prophylactic Prophylactic surfactantsurfactant

Reduced NICU LOSReduced NICU LOS $55,822,000$55,822,000

Infection reduction in Infection reduction in NICUNICU

Reduced NICU LOSReduced NICU LOS $72,093,193$72,093,193

Notes: 1) Gross mean costs of QI initiatives not included.Notes: 1) Gross mean costs of QI initiatives not included.2) Medicaid programs may not be able to recoup all costs.2) Medicaid programs may not be able to recoup all costs.

Other compelling reasons to Other compelling reasons to improve perinatal careimprove perinatal care

Neonatal deaths prevented:Neonatal deaths prevented:– 338 deaths prevented with smoking cessation338 deaths prevented with smoking cessation

Prevention of extremely low birth weight and Prevention of extremely low birth weight and very low birth weight can potentially prevent:very low birth weight can potentially prevent:– Intensive care admissions and ICU days during the Intensive care admissions and ICU days during the

first year of life first year of life – Low IQLow IQ– Poor math and gross motor skillsPoor math and gross motor skills– Other poor neurodevelopmental outcomes (cerebral Other poor neurodevelopmental outcomes (cerebral

palsy, vision impairments)palsy, vision impairments)

References available on request.References available on request.

ConclusionsConclusions

Conclusions:Conclusions:– Needless deaths and substantial morbidity Needless deaths and substantial morbidity

can be preventedcan be prevented

– Substantial child life years gainedSubstantial child life years gained

– Medicaid expenditures can potentially be Medicaid expenditures can potentially be reducedreduced

Caveats and Needed Caveats and Needed ResearchResearch

Caveats:Caveats:– Figures are preliminary and illustrative due to Figures are preliminary and illustrative due to

incompleteness of data sources incompleteness of data sources – Cost of QI interventions not includedCost of QI interventions not included– State Medicaid programs unlikely to recoup all State Medicaid programs unlikely to recoup all

savingssavings Research needed:Research needed:

– Effectiveness of QI for other leading causes of Effectiveness of QI for other leading causes of child deaths and morbiditychild deaths and morbidity

– National data on children’s health care quality and National data on children’s health care quality and costscosts

– Research on effectiveness of interventions (to Research on effectiveness of interventions (to develop quality measures)develop quality measures)

Informal Reactions from Informal Reactions from Previous ReviewersPrevious Reviewers

Needless deaths pre-reviewNeedless deaths pre-review– Enthusiasm during presentationsEnthusiasm during presentations

– For potential publication:For potential publication: Numbers are small relative to other conditions and due Numbers are small relative to other conditions and due

to QI focusto QI focus Child life years gained not understoodChild life years gained not understood

Neonatal care improvementsNeonatal care improvements– Some States eager to discussSome States eager to discuss

– CMS to hold stakeholder meetingCMS to hold stakeholder meeting

– Some States say they don’t have these problems Some States say they don’t have these problems – analysis doesn’t apply to them– analysis doesn’t apply to them

QuestionsQuestions

Is this enough to act on?Is this enough to act on? If not, why not?If not, why not? What research strategies should be What research strategies should be

used to create more data and frame the used to create more data and frame the issues?issues?