Beal Anne C, Co John Patrick T, Dougherty Denise, Jorsling Tanisha, Kam Jeanelle, Perrin James, Palmer R Heather
Center for Child and Adolescent Health Policy, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
Pediatrics. 2004 Jan;113(1 Pt 2):199-209.
The ability to measure and improve the quality of children's health care is of national importance. Despite the existence of numerous health care quality measures, the collective ability of measures to assess children's health care quality is unclear. A review of existing health care quality measures for children is timely for both assessing the current state of quality measures for children and identifying areas requiring additional research and development.
To identify and collect current health care quality measures for child health and then to systematically categorize and classify measures and identify gaps in child health care quality measures requiring additional development.
DESIGN/METHODS: We first identified child health care quality instruments with assistance from staff at the Agency for Healthcare Research and Quality, experts in the field, the Computerized Needs-oriented Quality Measurement Evaluation System, the Child and Adolescent Health Measurement Initiative, and a medical literature review. From these instruments, we then selected clinical performance measures applicable to children (aged 0-18 years). We categorized the individual measures into the Institute of Medicine's framework for the National Health Care Quality Report. The framework includes health care quality domains (patient safety, effectiveness, patient-centeredness, and timeliness) and patient-perspective domains (staying healthy, getting better, living with illness, and end-of-life care). We then determined the balance of the measures (how well they assess care for all children versus children with special health care needs) and their comprehensiveness (how well the measures apply to the developmental range of children). Finally, we analyzed the ability of the measures to assess equity in care.
We identified 19 measure sets, and 396 individual measures were used to assess children's health care quality. The distribution of measures in the health care quality domains was: safety, 14.4%; effectiveness, 59.1%; patient-centeredness, 32.1%; and timeliness, 33.3%. The distribution of measures in the patient-perspective domains was: staying healthy, 24%; getting better, 40.2%; living with illness, 17.4%; end of life, 0%; and multidimensional, 23.5% (measures were multidimensional if they applied to >1 domain). Most of the measures were meant for use in the general pediatric population (81.1%), with a significant proportion designed for children with special health care needs (18.9%). The majority (>or=79%) of the measures could be applied to children across all age groups. However, there were relatively few measures designed specifically for each developmental stage. Regarding the use of measures to study equity in health care, 6 of the measure sets have been used in previous studies of equity. All the survey measure sets contain items that identify patients at risk for poor outcomes, and 4 are available in languages other than English. However, only 1 survey (Consumer Assessment of Health Plans) has undergone studies of cross-cultural validation. Among the measure sets based on administrative data, 3 included infant mortality, a well-known measure of health disparity.
There are several instruments designed to measure health care quality for children. Despite this, we found relatively few measures for assessing patient safety and living with illness and none for end-of-life care. Few measures are designed for specific age categories among children. Although equity is an overarching concern in health care quality, the application of current measures to assess disparities has been limited. These areas need additional research and development for a more complete assessment of health care quality for children.
衡量并改善儿童医疗保健质量的能力具有国家层面的重要意义。尽管存在众多医疗保健质量衡量指标，但这些指标评估儿童医疗保健质量的总体能力尚不清楚。对现有的儿童医疗保健质量指标进行综述，对于评估儿童质量指标的当前状况以及确定需要进一步研究和开发的领域而言，正逢其时。
识别并收集当前用于儿童健康的医疗保健质量指标，然后对这些指标进行系统分类，并找出儿童医疗保健质量指标中需要进一步开发的差距。
设计/方法：我们首先在医疗保健研究与质量局的工作人员、该领域的专家、计算机化的需求导向型质量测量评估系统、儿童与青少年健康测量倡议以及医学文献综述的协助下，识别儿童医疗保健质量工具。然后，从这些工具中，我们挑选出适用于儿童（0至18岁）的临床绩效指标。我们将各个指标归类到医学研究所的《国家医疗保健质量报告》框架中。该框架包括医疗保健质量领域（患者安全、有效性、以患者为中心和及时性）以及患者视角领域（保持健康、好转、带病生存和临终关怀）。然后，我们确定这些指标的平衡性（它们评估所有儿童与有特殊医疗保健需求儿童的医疗服务的程度）及其全面性（这些指标适用于儿童发育范围的程度）。最后，我们分析这些指标评估医疗服务公平性的能力。
我们识别出19套指标集，396项个体指标用于评估儿童医疗保健质量。医疗保健质量领域中指标的分布情况为：安全性，14.4%；有效性，59.1%；以患者为中心，32.1%；及时性，33.3%。患者视角领域中指标的分布情况为：保持健康，24%；好转，40.2%；带病生存，17.4%；临终，0%；多维，23.5%（如果指标适用于多个领域，则为多维指标）。大多数指标旨在用于普通儿科人群（81.1%），相当一部分是为有特殊医疗保健需求的儿童设计的（18.9%）。大多数（≥79%）指标可应用于所有年龄组的儿童。然而，专门针对每个发育阶段设计的指标相对较少。关于使用指标研究医疗服务公平性，6套指标集曾用于先前的公平性研究。所有调查指标集都包含识别预后不良风险患者的项目，4套指标集有英语以外语言的版本。然而，只有1项调查（健康计划消费者评估）经过了跨文化验证研究。在基于行政数据的指标集中，3套包括婴儿死亡率，这是一个众所周知的健康差距衡量指标。
有几种工具旨在衡量儿童医疗保健质量。尽管如此，我们发现评估患者安全和带病生存的指标相对较少，且没有用于临终关怀的指标。针对儿童特定年龄类别的指标设计很少。虽然公平性是医疗保健质量的一个总体关注点，但当前用于评估差异的指标应用有限。这些领域需要进一步研究和开发，以便更全面地评估儿童医疗保健质量。
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