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PEDIATRICS Vol. 113 No. 1 January 2004, pp. 210-216

SUPPLEMENT ARTICLE

Risk Adjustment for Pediatric Quality Indicators

Karen Kuhlthau, PhD*, Timothy G. G. Ferris, MD, MPH*,{ddagger} and Lisa I. Iezzoni, MD, MSc§

* Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
{ddagger} Institute for Health Policy, Division of General Medicine, Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
§ Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, the Charles A. Dana, Research Institute, and the Harvard-Thorndike Laboratory, Boston, Massachusetts

The movement to measure medical care quality has been accelerating, spurred on by evidence of poor quality of care and trials of interventions to improve care. Appropriate measurement of quality of care is an essential aspect of improving the quality of care, yet some quality measures may be influenced by patients’ attributes unrelated to quality of care. Risk adjustment is the term commonly applied to those methods that account for patient-related attributes, making measurement of health care quality as comparable as possible across providers or organizations seeing different mixes of patients.

The measurement of quality of care for children poses specific challenges. In addition to these measurement challenges, analysts must ensure that quality comparisons among doctors, groups of doctors, hospitals, or health plans are not adversely affected by the likelihood that different types of patients seek care in different places. Although some techniques designed to adjust performance measures for case mix were developed for both adults and children, other systems are specific to childhood circumstances. The theoretical issues involved in risk-adjusting childhood outcomes measures for newborns in the neonatal intensive care unit were reviewed recently. Here, we go beyond the neonatal intensive care unit setting to consider risk adjustment for pediatric quality measures more broadly. In particular, we 1) review the conceptual background for risk-adjusting quality measures, 2) present policy issues related to adjusting pediatric quality measures, and 3) catalog existing risk-adjustment methodologies for pediatric quality measures. We conclude with an overall assessment of the status of risk adjustment for pediatric quality measures and recommendations for additional research and application.

Key Words: risk adjustment • pediatric quality indicators • child

Abbreviations: QI, quality indicators • ICU, intensive care unit • NICU, neonatal ICU • ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification • CDS, Chronic Disease Status • PICU, pediatric ICU • PRISM, Pediatric Risk of Mortality • HEDIS, Health Employer Data and Information Set • CAHPS, Consumer Assessment of Health Plans Study • HCUP, Health Care Cost and Utilization Project • APR, all patient-refined • DRG, diagnosis-related group

Received for publication May 13, 2003; Accepted Oct 2, 2003.




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