Investing in Children’s Health Care Quality Improvement

Investing in Children’s Health Care Quality Improvement: Returns in Lives, Health, and Dollars—An Illustration Denise Dougherty, Ph.D., Presented by Anne Elixhauser, Ph.D. June 24, 2006 CHSR, Seattle, WA Overview  What would be the impact of investing in improvements in health care quality for children?  Two examples of preliminary studies: – Child lives saved – Morbidity avoided – Dollars to Medicaid No Needless Deaths— Investigators  Denise Dougherty, Ph.D., AHRQ  Lisa Simpson, MB, BCh, MPH, FAAP, University of South Florida  Melissa Romaire, MPH, CMS (work done at AHRQ)  Charles Homer, MD, NICHQ*Cambridge, MA  Lisa C. White, MPH, NICHQ*-Seattle * National Initiative for Children’s Healthcare Quality Rationale and Methods  Rationale: draw attention to children’s healthcare quality – IHI 100,000 Lives Campaign on No Needless Deaths – Woolf et al. report on deaths due to disparities got a lot of attention – IOM’s To Err is Human figure of 98,000+ deaths due to medical errors received attention.  Identified leading causes of death in children 0-17  Among leading causes, identified those with evidence that improved health care quality could reduce child deaths  Estimated # of deaths nationally that could be prevented with improved healthcare quality  Extrapolated life years gained using YPLL* method * Years of Potential Life Lost Results—Needless Deaths Prevented Through QI Cause of Death Improvement Strategy # of Deaths Prevented Single Year ( 50-100% effectiveness) 1,329-2,658 Potential Life Years Gained with QI (100% effectiveness) Child yrs: 47,844 Total yrs: 205,198 Child yrs: 5,491 Total yrs: 23,224 Child yrs: 40,347 Total yrs: 308,430 Child yrs: 150 Total yrs: 1,004 Child yrs: 93,832 Total yrs: 537,856 VLBW Neonatal Period NICU improvements SIDS mortality B-W difference Medical errorsinpatient ―Back to sleep‖ 161-323 Patient safety 2,242-4,483 Cancer mortality Improved B-W difference cancer care Total 8-15 3,740-7,479 Other Evidence of Poor Quality of Care for Children Topic Asthma care: Pediatric hospitalizations (potentially avoidable) Immunizations up to date—9-35 month olds Timeliness: Care for illness or injury as soon as desired Patient-centeredness: CAHPS composite measure Quality/Disparities Findings (Nationally) Children higher than adults Black children 3x rate of white children 31.6% not up to date Lower among CSHCN than children w/o SHCN Lower among CSHCN than children w/o SHCN Source: AHRQ, National Healthcare Quality Report and National Healthcare Disparities Report, 2005 Improving Neonatal Outcomes of Medicaid-Covered Infants—Investigators  Denise Dougherty, Ph.D., AHRQ  Bernard Friedman, Ph.D., AHRQ  Vipul Mankad, MD, U MD (done while at CMS)  With assistance of: – Jeannette Rogowski, Ph.D. – Nikki Highsmith, MPA – Neonatal Outcomes Improvement Group Rationale and Methods  Rationale: CMS Medicaid trying to stimulate quality improvement and reduce costs  Methods: – Identified 4 illustrative perinatal areas with evidence of the potential for improvement – Detailed 2002 HCUP cost data on neonatal special care units from 7 States – Calculated differences between pre- and post-QI admissions or LOS – Extrapolated to national estimates using national totals of deliveries and incidence of conditions Results  Average cost difference between a Medicaid NICU stay and a Medicaid regular nursery stay was $18,607  Average difference in LOS was 11-16 days Source: AHRQ, Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), 7 States, 2002 data, extrapolated to national estimates Preliminary Results Clinical Improvement Smoking cessation/pregnant women Antenatal corticosteroids Savings achieved by Reduced NICU admissions Reduced NICU LOS attributable to RDS Rough estimates of national gross cost savings $48,300,000 $48,727,854 Prophylactic surfactant Infection reduction in NICU Reduced NICU LOS Reduced NICU LOS $55,822,000 $72,093,193 Notes: 1) Gross mean costs of QI initiatives not included. 2) Medicaid programs may not be able to recoup all costs. Other compelling reasons to improve perinatal care  Neonatal deaths prevented: – 338 deaths prevented with smoking cessation  Prevention of extremely low birth weight and very low birth weight can potentially prevent: – Intensive care admissions and ICU days during the first year of life – Low IQ – Poor math and gross motor skills – Other poor neurodevelopmental outcomes (cerebral palsy, vision impairments) References available on request. Conclusions  Conclusions: – Needless deaths and substantial morbidity can be prevented – Substantial child life years gained – Medicaid expenditures can potentially be reduced Caveats and Needed Research  Caveats: – Figures are preliminary and illustrative due to incompleteness of data sources – Cost of QI interventions not included – State Medicaid programs unlikely to recoup all savings  Research needed: – Effectiveness of QI for other leading causes of child deaths and morbidity – National data on children’s health care quality and costs – Research on effectiveness of interventions (to develop quality measures) Informal Reactions from Previous Reviewers  Needless deaths pre-review – Enthusiasm during presentations – For potential publication:  Numbers are small relative to other conditions and due to QI focus  Child life years gained not understood  Neonatal care improvements – Some States eager to discuss – CMS to hold stakeholder meeting – Some States say they don’t have these problems – analysis doesn’t apply to them Questions  Is this enough to act on?  If not, why not?  What research strategies should be used to create more data and frame the issues?