Quality and Value in Healthcare for Children

The Need for Improvement in Quality and Value

Adults and children only receive recommended evidence-based care about half the time. The gap between knowledge and practice widens to a chasm in part because of variations in practice and disparities in care from doctor to doctor, institution to institution, geographic region to geographic region, and socioeconomic group to socioeconomic group. Furthermore, it is estimated that it takes about 17 yr for new knowledge to be adopted into clinical practice.

In addition to appropriate care that patients do not receive, U.S. healthcare systems also deliver much care that is unnecessary and waste many resources in doing so. This overuse and waste is one key driver of the disproportionate costs of care in the United States compared with other developed countries’ delivery systems (in 2016, the United States spent about twice as much per capita, adjusting for gross domestic product (GDP), on healthcare compared to the average of peer wealthy nations). It is estimated that more than one quarter of all U.S. healthcare spending is waste. Gaps in appropriate care, combined with overuse and high costs, have driven conversations about the need to improve the value of care, which would mean better quality at lower overall costs. Choosing Wisely , an initiative initially sponsored by the American Board of Internal Medicine and subsequently endorsed by the American Academy of Pediatrics (AAP), asked medical societies to identify practices typically overused that clinicians could then make collective efforts to address.

Quality improvement (QI) science has become a predominant method utilized to close gaps and improve value. Initially focused on improving performance and reliability in care processes, more recently, in part inspired by the Institute for Healthcare Improvement's Triple Aim approach, QI is being used to improve value for populations of patients by focusing more on outcomes defined by patients’ needs. The Quadruple Aim approach adds the 4th dimension of healthcare worker experience or joy in work to focus delivery systems on the need to enhance the resiliency of the clinical workforce in order to sustain high-value care approaches.

What Is Quality?

The Institute of Medicine (IOM) defines quality of healthcare as “the degree to which healthcare services for individuals and populations increases the likelihood of desired health outcomes and are consistent with current professional knowledge.” This definition incorporates 2 key concepts related to healthcare quality: the direct relationship between the provision of healthcare services and health outcomes, and the need for healthcare services to be based on current evidence.

To measure healthcare quality, the IOM has identified Six Dimensions of Quality : effectiveness , efficiency , equity , timeliness , patient safety , and patient-centered care . Quality of care needs to be effective, which means that healthcare services should result in benefits and outcomes. Healthcare services also need to be efficient, which incorporates the idea of avoiding waste and improving system cost efficiencies. Healthcare quality should improve patient safety , which incorporates the concept of patient safety as 1 of the key elements in the Six Dimensions of Quality. Healthcare quality must be timely , thus incorporating the need for appropriate access to care (see Chapter 5 ). Healthcare quality should be equitable , which highlights the importance of minimizing variations as a result of ethnicity, gender, geographic location, and socioeconomic status (SES). Healthcare quality should be patient centered , which underscores the importance of identifying and incorporating individual patient needs, preferences, and values in clinical decision-making. In pediatrics, the patient-centered dimension extends to family-centeredness, so that the needs, preferences, and values of parents and other child caregivers are considered in care decisions and system design.

The IOM framework emphasizes the concept that all Six Dimensions of Quality need to be met for the provision of high-quality healthcare. Collectively, these concepts represent quality in the overall value proposition of quality per cost. From the standpoint of the practicing physician, these 6 dimensions can be categorized into clinical quality and operational quality . To provide high-quality care to children, both aspects of quality—clinical and operational—must be met. Historically, physicians have viewed quality to be limited in scope to clinical quality, with the goal of improving clinical outcomes, while considering improving efficiency and patient access to healthcare as the role of healthcare plans, hospitals, and insurers. Healthcare organizations, which are subject to regular accreditation requirements, viewed the practice of clinical care delivery as the responsibility of physicians and limited their efforts to improve quality largely to process improvement to enhance efficiencies.

The evolving healthcare system requires physicians, healthcare providers, hospitals, and healthcare organizations to partner together and with patients to define, measure, and improve the overall quality of care delivered. Concrete examples of the evolving U.S. perspective include the widespread adoption of Maintenance of Certification (MOC) requirements by medical-certifying bodies, which require providers to engage in activities that improve care in their practices, and the core quality measurement features and population health incentives of the Patient Protection and Affordable Care Act (ACA) of 2010. The ACA also established the Patient-Centered Outcomes Research Institute (PCORI) to develop a portfolio of effectiveness and implementation research that requires direct engagement of patients and families to partner in setting research priorities, formulating research questions, and designing studies that will directly impact the needs of patients to improve the value of the research.

Framework for Quality

Quality is broader in scope than QI. The approach to quality includes 4 building blocks. First , the standard for quality must be defined (i.e., developing evidence-based guidelines, best practices, or policies that guide the clinician for the specific clinical situation). These guidelines should change based on new evidence. In 2000–2001 the AAP had published guidelines for care of children with attention-deficit/hyperactivity disorder (ADHD). Subsequently, in 2011, these were updated to highlight a greater emphasis on behavioral interventions rather than pharmacologic options based on new evidence. Similarly, the AAP has emphasized that guidelines evolve to include greater consideration of value in care, an example being the update to the clinical practice guideline for urinary tract infection in 2011, which called for a decrease in the use of screening radiologic tests and prophylactic antibiotics in certain populations of children due to a lack of cost-effectiveness. Second , gaps in quality need to be closed. One key gap is the difference between the recommended care and the actual care delivered to a patient. Third , quality needs to be measured . Quality measures can be developed as measures for accountability and measures for improvement. Accountability measures are developed with a high level of demonstrated rigor because these are used for measuring and comparing the quality of care at the state, regional, or health system (macro) level. Often, accountability measures are linked to pay-for-performance (P4P) incentive arrangements for enhanced reimbursement at the hospital and individual physician level. In contrast, improvement measures are metrics that can demonstrate the improvement accompanying a discrete QI project or program. These metrics need to be locally relevant, nimble, and typically have not had rigorous field testing. Fourth , the quality measurement approach should be used to advocate for providers and patients. For providers, meeting quality goals should be a key aspect of reimbursement if the system is designed to incentivize high-value care. At the population level, quality measurement strategies should advocate for preventive and early childhood healthcare, improving the value of care by decreasing costs across a patient's life span.

Lastly, many quality measurement systems have attempted to be more transparent with clinicians and patients about costs of care. Because more direct costs have been shifted to patients and families through widespread adoption of high-deductible insurance plans (i.e., families experience lower up-front insurance coverage costs but pay for certain acute healthcare expenses out-of-pocket until the preset deductible is met), better awareness of costs has become a more effective driver of improvement in value, in part by reducing overuse.

Developing Guidelines to Establish the Standard for Quality

Guidelines need to be developed based on accepted recommendations, such as the Grading of Recommendations Assessment, Development and Evaluation ( GRADE ) system for rating the quality and strength of the evidence, which is crucial for guideline development. Guidelines must adopt a high level of transparency in the development process. This is particularly relevant in the pediatric setting, where there may be limited research using methods such as randomized controlled trials (RCTs), which would have a high level of rating from an evidence standpoint. Because guidelines and policies related to quality need to be interpreted for specific settings, they should not be interpreted as “standards of care.”

Improving Quality

The applied science of QI currently in use in healthcare is also firmly grounded in the classic scientific method of observation, hypothesis, and planned experimentation. There are 4 key features of the applied science of quality improvement: appreciation of systems, understanding variation, knowledge theory, and psychology of change. In addition to this theoretical framework, statistical analytic techniques evolved to better evaluate variable systems over time. While each derives key features from this applied scientific foundation, multiple QI methodologies are currently in use in healthcare. At their most parsimonious level, each method can be described as a 3-step model: Data → Information → Improvement. Quality needs to be measured. Data obtained from measurement needs to be converted into meaningful information that can be analyzed, compared, and reported. Information must then be actionable to achieve improvements in clinical practice and health systems’ processes.