PEDIATRICS Vol. 107 No. 1 January 2001, pp. 171

COMMENTARY:
Quality of Care: Time to Make the Grade

When the Institute of Medicine (IOM) reported in December 1999 that as many as 98 000 persons die each year because of medical errors, the media and the public "got it" with respect to the problems in health care quality. Yet for clinicians and researchers, much of the information in the IOM report was already familiar.¹ Errors of commission or omission are just one dimension of the quality challenge facing health care today. Decades of health services research have repeatedly demonstrated that the quality of health care often falls short of good, let alone ideal.^2-4 In the past 5 years, this extensive literature has been used to inform and galvanize action in both the public and private sectors. Several important milestones have occurred. In 1998, a presidential commission called for a national commitment to quality improvement in health care. In October 1999, in his keynote address to the American Academy of Pediatrics (AAP), Dr Berwick challenged pediatricians to rise to the quality challenge and laid out a 5-point strategy. In the same year, the federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (AHRQ) and charged with providing the science base for measuring and improving quality of care.⁵ Also included in the legislation was a new call to focus on children. Finally, last spring, Dr Berman challenged all of us in stating that, "In order to succeed, we need to reject the status quo and begin to inherently value change. We must be willing to recognize that the current standard of pediatric care, although good, is not good enough, and there are ample opportunities for improvement."⁶

The article by Ferris et al in this issue provides a much-needed baseline for our improvement efforts.⁷ This review of the state of quality improvement (QI) research in child health presents us with several important conclusions. First, substantial improvement is possible in the quality of care for children. Second, certain interventions have been well-demonstrated to be effective and are ready for widespread diffusion into pediatric practice. For example, reminder systems show improvements in physician immunization, screening, and counseling practices to a degree greater than all other interventions studied. Third, quality improvement for children appears from the research to be similar to adult QI despite the perception by experts in the field that it is more difficult. Finally, the number of studies being published has grown tremendously in the past few years, which bodes well for our future ability to respond to the challenges laid out by Drs Berwick and Berman.

However, this review also highlights a number of gaps in our research base. A majority of the studies reviewed were directed at children <5 years old and were located in a small number of cities. In most of the QI intervention categories assessed the authors found insufficient evidence to adequately inform clinicians and administrators. Fully 90% of studies of chronically ill children examined asthma and few included child health outcomes. All of these limitations reflect the emerging, but still inadequate, capacity for child and adolescent health services research in academic and office based settings. AHRQ's priorities for continued and expanded support for child health services research, training of new investigators, and the development of research networks, combined with the AAP's clinical leadership, should help to expand and implement the science base for public and private efforts to make the grade for quality for children.

Lisa Simpson, MB, BCh, MPH, FAAP
Agency for Healthcare Research and Quality
US Department of Health and Human Services
Rockville, MD 20852

FOOTNOTES

The views expressed in this article are those of the author and do not necessarily represent those of the Agency for Healthcare Research and Quality or the US Department of Health and Human Services.

PEDIATRICS (ISSN 0031 4005).

Received for publication Oct 10, 2000; accepted Oct 10, 2000.

Reprint requests to (L.S.) Agency for Healthcare Research and Quality, 2101 E Jefferson St, Suite 600, Rockville, MD 20852. E-mail: lsimpson{at}ahrq.gov

ABBREVIATIONS

IOM, Institute of Medicine; AAP, American Academy of Pediatrics; AHRQ, Agency for Healthcare Research and Quality; QI, quality improvement.

REFERENCES

1. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999
2. Schuster M, McGlynn E, Brook R How good is the quality of health care in the United States? Milbank Q. 1998; 76:517-563 [CrossRef][Medline]
3. Mangione-Smith R, McGlynn E Assessing the quality of healthcare provided to children. Health Serv Res. 1998; 33:1059-1090 [Medline]
4. Walker E. Quality of Care Research: Annotated. Washington, DC: Agency for Health Care Policy and Research; 1992
5. US Congress. Healthcare Research and Quality Act of 1999; 1999
6. Berman S Refocusing on quality furthers AAP access, reimbursement goals. AAP News. 2000; 16:28 [Free Full Text]
7. Ferris TG, Dougherty D, Blumenthal D, Perrin JM A report card on quality improvement for children's health care. Pediatrics. 2000; 107:143-155 [Abstract/Free Full Text]