AHCPR Research on Children's Health

2. Highlights of AHCPR-Sponsored Research on Children's Health

Childbirth/Infant Health

Home care of very low birthweight infants with chronic lung disease.¹ A randomized controlled trial is assessing and comparing the outcomes and costs of two interventions to facilitate the home care of oxygen-dependent infants with chronic lung disease. These two potential alternatives to prolonged hospitalization involve multi-disciplinary center-based followup care versus community-based followup care by a nurse. Thomas O'Shea, Principal Investigator (Grant No. HS-07928) (7/1/96-6/30/01).

Strategies for care of very low birthweight infants.¹ This study will evaluate outcomes in school-aged children who were very low birthweight infants, using three population-based data sets from the Netherlands, Canada, and the United States. Recommendations will be made for the development of ethical, cost effective, and appropriate strategies for clinical management and resource allocation. Nigel S. Paneth, Principal Investigator (Grant No. HS-08385) (9/30/96-9/29/99).

Family Linkages supporting hyperbilirubin (neonatal jaundice) guidelines.¹ This effort will develop and implement a computer-based decision-support system to help different types of providers identify and treat infants at risk for developing neonatal jaundice (hyperbilirubinemia) by providing better access to patient records and guidelines. More than half of all infants born in hospitals develop jaundice within 48 hours of discharge. Charles J. Homer, Principal Investigator (Grant No. HS-09390) (9/30/96-9/29/99).

Impact of prenatal Medicaid program on newborns' health.¹ This effort will examine how the Medicaid program affects newborns' health. Specifically, it will isolate the impact of individual Medicaid program components on birth outcomes. Christopher Trenhom, Principal Investigator (Grant No. 9332) (9/1/96-8/31/97).

Estimated costs and benefits of the postpartum mandate.¹ This study will evaluate the costs and health consequences of mandates requiring insurers to pay for a minimum 48-hour hospital stay for mothers and newborns after a vaginal delivery or 96 hours following a cesarean section. Three related policy questions will be addressed: 1) How will the mandate affect health? 2) How much will the mandate cost? 3) Is the mandate cost effective? Jesse Malkin, Principal Investigator (Grant No. HS-09342) (9/1/96-8/31/97).

Variations in management of childbirth and patient outcomes. An expert Patient Outcomes Research Team (PORT) is examining the use and outcomes of cesarean section as compared to alternatives. Variations and correlates of specific diagnostic and treatment procedures used during labor and delivery also are analyzed. For example, based on a meta-analysis of nine studies, researchers found a significantly higher risk of fetal injury or death in term breech infants whose mothers were allowed a trial of labor prior to undergoing cesarean section. While in either case the risk for infant injury or death was small, the researchers recommended that the respective risks of each mode of delivery be considered. Gifford DS, Morton SC, Fiske M, Kahn K. A meta-analysis of infant outcomes after breech delivery. Obstet Gynecol 85(6):1047-1054, 1995. (Contract No. 282-90-0039).

Low birthweight in babies of minority and high-risk women. This PORT examines ways to prevent low birthweight and improve the outcomes of low birthweight infants. (Contract No. 282-92-0055). For example:

• In a controlled trial, researchers found that zinc supplements in pregnant women whose blood zinc levels were low early in pregnancy resulted in heavier babies with larger head circumferences. Goldenberg RL, Tamura T, Neggers Y, et al. The effect of zinc supplementation on pregnancy outcome. JAMA 274(6):463-468, 1995.
• Based on an evaluation of the literature, researchers found that while bed rest is used extensively to treat a wide variety of pregnancy conditions, there is little proof of effectiveness. They suggest that the use of bed rest be curtailed until specific benefits are established through a randomized clinical trial. Goldenberg RL, Cliver SP, Bronstein J, et al. Bed rest in pregnancy. Obstet Gynecol 84(1):131-136, 1994.

Safety and effectiveness of homemade cereal-based oral rehydration therapy for infants (PORT-II). Diarrhea with dehydration among children younger than age 5 accounts for more than 10 percent of hospitalizations for that age group, and for about 500 deaths each year. The condition is preventable and treatable with oral rehydration therapy—the administration of a balanced solution of electrolytes and glucose or starch. This controlled experimental study will evaluate the safety and effectiveness of low-cost, homemade, cereal-based oral rehydration solutions. Alan Meyers, Principal Investigator (Grant No. HS-08335) (8/1/94-9/30/96).

Impact of variations in diagnosis and treatment on outcomes and costs for infants with high fever. This study is examining variations in diagnosis and treatment of febrile infants with an emphasis on infants younger than 2 months. Differences affecting outcomes and costs will be assessed. Robert Pantell, Principal Investigator (Grant No. HS-06485) (5/1/93-1/31/98).

Illness severity and practice variations in newborn intensive care units. This project is identifying variability in outcomes from neonatal intensive care units that are not attributable to illness severity, and also is identifying variations in practice that may increase costs without improving outcome. Douglas Richardson, Principal Investigator (Grant No. HS-07015) (4/1/94-3/31/98).

Lower mortality rates of high-risk infants born in hospitals with advanced neonatal intensive care units. Researchers from the low birthweight PORT published research showing that high-risk infants born in hospitals with advanced neonatal intensive care units (level III NICUs) have a 38 percent lower death rate than similar infants born in hospitals without NICUs. Infants born in hospitals with intermediate-level NICUs had a risk of dying comparable to that of infants born in hospitals without NICUs. The researchers recommend that urban areas concentrate high-risk deliveries in a small number of hospitals with level III NICUs. Phibbs CS, Bronstein JM, Buxton E, Phibbs RH. The effects of patient volume and level of care at the hospital of birth on neonatal mortality. JAMA 276(13):1054-1059, 1996.

Health Care Services Organization, Access, Use, Quality, and Costs

Patterns of referral and care for children on Medicaid.¹ This study focuses on the consequences of the referral of children enrolled in Medicaid to pediatric specialists, compared with specialists for adults, for common and uncommon pediatric chronic conditions. James Perrin, Principal Investigator (Grant No. HS-09416) (9/30/96-9/29/98).

Effective organization of adolescent health services.¹ This study will analyze how the organization of adolescent health services affects teenagers' access to care. Jonathan B. Klein, Principal Investigator (Grant No. HS-08192) (9/30/96-9/29/98).

Primary care services for low-income children in health maintenance organizations (HMOs).¹ This effort will assess the performance of different types of managed care organizations in the organization and delivery of primary care services to children. It will take into account plan features that affect provider and consumer behavior; examine possible variations in the attainment of primary care among enrollees with different racial, ethnic, economic, and family characteristics; and contribute to the development of better tools to measure primary care from the consumer perspective. Margarita Patricia Hurtado, Principal Investigator (Grant No. HS-09339) (9/1/96-8/31/97).

Research agenda conference on quality of pediatric care.¹ The purpose of the conference is to develop and disseminate a national research agenda on quality of care measures for children, and to set priorities for issues that demand immediate and long-term attention from the research community and from policymakers. The conference will be convened in May 1997 by the Association for Health Services Research (AHSR), with cosponsorship from AHCPR, the Centers for Disease Control and Prevention, the National Institutes of Health, the Health Resources and Services Administration, the Health Care Financing Administration, the David and Lucille Packard Foundation, and Pfizer, Inc. Background papers for the conference will be published as a supplement to AHSR's official journal, and a resulting research agenda will be widely disseminated. Alice Hersh, Principal Investigator (Grant No. HS-09323) (8/1/96-7/31/97).

Adjusting capitation rates may not prevent discrimination against chronically ill children. If a plan or provider is paid the same rate for a patient with chronic health problems as for a generally healthy patient, there is a financial incentive to discriminate against patients with more serious illnesses. Capitation adjustment methods, which adjust capitated rates to compensate plans for increased costs associated with chronic medical problems, is one approach to eliminating the incentive to discriminate against children with chronic conditions. This study tested several capitation methods and found that none would eliminate the disincentive to enroll children with costly conditions, and special health care needs would not be eliminated by any of the capitation methods tested. Fowler EJ, HealthSystem Minnesota, and Anderson GF. Capitation adjustment for pediatric populations. Pediatrics 98(1), pp. 10-17, July 1996.

Multiple factors influence pediatric hospitalization rates. Researchers found that access to primary care per se did not appear to explain variations in rates of pediatric hospitalization in three cities. Eighty-five percent of the children in cities with wide variations in hospitalizations had a usual primary care source. Variations were found to be associated with area-specific admission practices, and patterns of primary care involvement. Perrin J. Variations in pediatric hospitalization rates: Why do they occur? Pediatr Ann 23(12):676-683, 1994; Homer CJ, Perrin JM, Kemper K, et al. Effect of socioeconomic status on variation in pediatric hospitalization. Ambulatory Child Health 1:33-43, 1995; Perrin JM, Greenspan P, Bloom SR, et al. Primary care involvement among hospitalized children. Arch Pediatr Adolesc Med 150:479-486, 1996; Homer CJ, Szilagyi P, Rodewald L, et al. Does quality of care affect rates of hospitalization for childhood asthma? Pediatrics 98(1), pp. 18-23, 1996. (Grant No. HS-06060) (9/1/90-8/31/94).

Gatekeeping fails to prevent unnecessary emergency room use by pediatric Medicaid patients. Researchers found that Medicaid managed care patients who were denied the use of emergency rooms (ERs) via gatekeeping functions did not necessarily change their health care-seeking behavior. Children denied an ER visit continued to use the ER at a significantly higher rate than other children. Gadomski A. Diverting managed care Medicaid patients from pediatric emergency department use. Pediatrics 95(2):170-178, 1995.

Generous Medicaid physician fees result in lower expenses for outpatient pediatric care. Researchers found that low Medicaid reimbursement rates discourage physician participation in the program and cause children to be seen in more expensive hospital emergency rooms and outpatient departments. Analysis of 1987 national expenditure data indicates that average outpatient health care expenditures for children on Medicaid were highest in the States with the lowest payment rates. Cohen JW, Cunningham PJ. Medicaid physician fee levels and children's access to care. Health Aff (Millwood) 14(1):255-262, 1995. (AHCPR Pub. No. 95-R003).

Physicians encouraged to learn about community resources in order to address nonfinancial barriers to care. In assessing barriers to health care, researchers found economic factors to be only one barrier. Other roadblocks included lack of knowledge about health care, language problems, inability to obtain child care, transportation, long waiting times, and limited clinic hours. It was recommended that physicians learn more about integrating community resources with health care resources to address barriers. Margolis P. The rest of the access-to-care puzzle: addressing structural and personal barriers to health care for socially disadvantaged children. Arch Pediatr Adolesc Med 149:541-545, 1995. (Grant No. HS-07106) (8/1/92-1/31/95).

Racial and ethnic differences found in the use of prescription medications. Descriptive statistics indicated that, even when controlling for other factors, such as socioeconomic conditions, black and Hispanic children received fewer medications than did white children. The researchers concluded that the relationship between racial and ethnic status and the use of prescription medication mirrors other types of services, such as physician visits, and affirms that minorities receive fewer health services than do whites. Hahn B. Children's health: racial and ethnic differences in the use of prescription medications. Pediatrics 956:727-732, 1995. (AHCPR Pub. No. 95-R006).

Measures of Children's Health Status

Developmentally sensitive instruments for valid assessment of child health status to be developed.¹ A new project will produce child health status instruments that reliably measure the health and illness profile of children ages 5 to 11. After development of the parent version and a pictorial version to obtain childrens perspectives of their own health, the instrument sets will be tested systematically in geographically distinct populations with different racial and ethnic backgrounds. Barbara Starfield, Principal Investigator (Grant No. HS-08829) (8/1/96-7/31/00).

Development of an adolescent health status measure. This project developed and validated an instrument to comprehensively assess adolescent health status. The instrument is being used to assess the health status of populations and subpopulations of adolescents in government-funded research projects and managed care organizations. Starfield B, Riley AW, Green BF, et al. The adolescent child health and illness profile. A population-based measure of health. Med Care 33(5):553-66, 1995.

Pediatric Asthma

Cost effectiveness of practice guidelines to reduce asthma morbidity among children.¹ This large, 5-year randomized clinical trial will test the cost-effectiveness of recently developed practice guidelines designed to reduce asthma morbidity among children. In addition, researchers will test new educational and organizational approaches to deliver pediatric asthma care in managed care settings. The National Heart, Lung, and Blood Institute, which developed the guideline to be used in the study, is contributing to this study. Kevin B. Weiss, Principal Investigator (Grant No. HS-08368) (9/30/96-9/30/01).

Measuring quality of life in children with asthma.¹ This study will examine the relationship between a general multi-dimensional approach and a disease-specific approach to measuring quality of life in children with asthma. The two different approaches will be assessed by administering the Pediatric Quality-of-Life Questionnaire to 600 asthmatic children and their parents who are participating in an asthma management program. Robert D. Annett, Principal Investigator (Grant No. HS-09123) (6/1/96-5/31/98).

Medicaid managed care for asthma: Does plan type matter?¹ This study explores potential differences in the patterns of clinical care provided to Massachusetts Medicaid asthma patients enrolled in two different delivery systems. One is a modified fee-for-service plan which uses a physician gatekeeper model and is managed by the State Medicaid program. The other is a staff model HMO with the largest Medicaid enrollment among participating HMOs in the State. Alexandra Shields, Principal Investigator (Grant No. HS-09327) (9/1/96-5/31/97).

Patient outcomes and cost effectiveness of pharmaceutical care for pediatric asthma patients. This 4-year randomized controlled trial will compare the impact of pharmacy-based interventions with that of usual services on pediatric patients with asthma. Patients will be tracked and monitored in terms of lung function and health status, school attendance, and asthma-related costs to determine the cost-effectiveness of pharmaceutical care. Andreas Stergachis, Principal Investigator (Grant No. HS-07834) (3/1/93-10/31/97).

Preventive treatment for asthma in minority children. Currently available treatments can prevent most hospitalizations for asthma episodes. However, this study found that black and Hispanic preschoolers hospitalized for acute asthma episodes are less likely than are white preschoolers to receive the most effective preventive therapy, either before hospital admission or after discharge. Finkelstein J. Quality of care for preschool children with asthma: the role of social factors and practice setting. Pediatrics 95(3): 389-394, 1995. (National Research Service Award Training Grant No. HS-00020).

Pediatric HIV/AIDS

Consumer information on use of AZT to reduce perinatal HIV transmission. In 1994, an NIH-sponsored clinical trial found that the use of AZT by asymptomatic HIV-positive women during pregnancy, labor, and childbirth, and by the newborn for 6 weeks following birth, reduces the risk of perinatal HIV transmission from an average of 25 percent to 8 percent. In collaboration with other U.S. Department of Health and Human Services agencies and outside organizations, AHCPR developed consumer education materials in multiple languages and formats (brochures, audiotapes, and videotapes) for educating HIV-infected pregnant women about the benefits of treatment with AZT. HHS Pub. No. 96-0007, December 1995.

Emergency Medical Services for Children

Emergency medicine initiative with HRSA. In 1995, AHCPR and HRSA jointly awarded grants totaling $2.5 million for research leading to improvements in emergency medical services for children. Projects include:

• Investigation of the relationship between cost containment and the quality of care in pediatric intensive care units.
• Assessment of emergency medical services and patient outcomes in children.
• Development of improved methods for assessing injuries to assist selection of treatments.
• Comparison of the effectiveness of alternative emergency respiratory care technologies.

Pain Management

Clinical practice guideline: Acute Pain Management. This AHCPR-supported guideline recommends that health care providers be careful to assess the extent of pain in children because children may not be able to communicate their pain, or may hide pain to avoid injections or other unpleasant procedures. Since children vary greatly in their cognitive and emotional development, the guideline encourages a flexible approach to pain management. AHCPR Pub. No. 92-0032, February 1992.

Clinical practice guideline: Management of Cancer Pain. The AHCPR guideline on cancer pain indicates that an aggressive approach to pain management in children is necessary, but that clinicians should tailor assessment and management strategies to each child's developmental level, personality style, and emotional and physical resources. Clinicians should seek to form a therapeutic alliance with parent(s) and child. AHCPR Pub. No. 94-0592, March 1994.

Immunization/Disease Prevention for Children

Office systems to improve preventive care for children.¹ This study will determine whether pediatric practices that use office systems for prevention have higher rates of immunizations and screening for anemia, tuberculosis, and lead, and if rates vary in relation to the number of system components used. Peter Margolis, Principal Investigator (Grant No. HS-08509) (9/30/96-9/29/00).

Evaluating computer decision support for preventive care.¹ This study will expand and modify for everyday use in pediatric office practices an existing guideline-based computerized decision service for childhood preventive services. The study will evaluate the effects of the system on process of care and outcomes of patients. Stephen M. Downs, Principal Investigator (Grant No. HS-09507) (9/30/96-9/29/99).

Barriers to the immunization of children in the United States. Using a nationwide sample of 3,600 physicians in general and family practice and pediatrics, this study will identify and quantify the knowledge, attitudes, and practices of the surveyed physicians regarding immunization. Physicians responses will be validated through an audit of the actual practices of selected study participants. Richard Zimmerman, Principal Investigator (Grant No. HS-08068) (7/1/94-6/30/97).

Similarly, two AHCPR-supported rural health research centers are studying barriers to childhood immunizations in rural America: the Colorado Center for Health Policy Research (Denver, CO) (Contact No. 290-93-0039 and the Sheps Center for Health Services Research (Chapel Hill, NC) (Contact No. 290-93-0038). Both centers are analyzing secondary data to assess gaps in rural health provider practices in the immunization of children.

Adoption of children's vaccine guidelines. This study is designed to improve physicians' use of pediatric vaccine guidelines. The degree to which pediatricians and family physicians are aware of immunization guidelines for selected pediatric diseases, as well as whether they agree with and adhere to recommended schedules, will be assessed. Researchers will identify factors that influence the visibility of guidelines, barriers to dissemination and implementation, and recommend strategies for improvement. One report from this project found that, in 1994, less than two-thirds of family physicians were following recommendations to routinely vaccinate infants against hepatitis B. Physicians' reluctance stemmed from doubts about the efficacy of the vaccine.

Freed GL, Freeman VA, Clark SJ, et al. Pediatrician and family physician agreement with and adoption of universal hepatitis B immunization. J Fam Pract 42(6), pp. 587-592, 1996; and Stevens C, Freeman V, Konrad T, et al. Calculating a clinic's childhood immunization rate: costs and returns [letter]. Arch Fam Med 5, p. 323, 1996. (Grant No. HS-07286) (7/1/92-6/30/96).

Pediatric preventive care incentives in a Medicaid HMO. This randomized controlled trial will assess the impact of a system of periodic feedback and financial incentives on the compliance of a multi-site, mandatory Medicaid HMO with pediatric preventive care clinical guidelines. Alan Hillman, Principal Investigator (Grant No. HS-07634) (4/1/93-9/30/96).

Clinical practice guideline: Sickle Cell Disease. An AHCPR-supported guideline recommends screening of all newborns for sickle cell disease, administering protective doses of penicillin to ward off infection in infants whose initial test reveals presence of the disease, and improving genetic counseling for couples with the sickle cell trait. AHCPR Pub. No. 93-0562, April 1993.

Otitis Media

Child development in relation to early otitis media. This 5-year study examines whether persistent otitis media with effusion (fluid in the middle ear without infection) during the first 3 years of life results in lasting impairments of speech, language, and cognitive or psychosocial development and, if so, whether prompt insertion of tympanotomy tubes will prevent or lessen impairment. The study also will determine whether longer waiting periods can reduce the number of operations without adverse effects. Jack L. Paradise, Principal Investigator (Grant 92-112-F).

Outcomes associated with therapy for otitis media. This study will describe the practice patterns and expenditures for management of pediatric otitis media in Medicaid patients. Also, it will assess the effectiveness of pharmaceutical therapies and other interventions in the prevention and management of persistent middle ear effusions and/or recurrent otitis media in children. Stephen Berman, Principal Investigator (Grant No. HS-07816) (7/1/93-6/30/97).

A comparative study of provider practices and outcomes in otitis media in three Nations. This study is comparing provider practices and outcomes for childhood otitis media in England, the Netherlands, and the United States, where use of antibiotics differs substantially. Jack Froom, Principal Investigator (Grant No. HS-07035) (9/1/93-8/31/97).

Clinical practice guideline: Otitis Media With Effusion in Young Children. This AHCPR-supported guideline recommends "watchful waiting" for most young children with otitis media with effusion because the condition usually disappears without treatment within 3 to 6 months. The guideline notes that there are treatment options, but that when resulting improvements are weighed against side effects and costs, antibiotic therapy may not be preferable to waiting. The guideline also recommends lancing of the ear drum or insertion of tubes if the condition has lasted more than 4 months and there is hearing loss in both ears. AHCPR Pub. No. 94-0622, July 1994.

Mental Health and Substance Abuse¹

Development of a child mental health and substance abuse agenda. AHCPR has begun to develop and carry out a health services research agenda for improving mental health and substance abuse services for children and youth focusing on services provided in the general health sector.

Factors affecting children's access to mental health services. Children who had public insurance were found to be more likely than children who were either uninsured or privately insured to have had at least one ambulatory visit to any medical provider for a mental health problem. The greatest predictor of whether children with a problem had a mental health visit was their mothers' use of mental health services. Cunningham PJ, Freiman MP. Determinants of ambulatory mental health services use for school-age children and adolescents. Health Serv Res, 31(4):409-427, 1996.

Conference Grants

The Efficacy of Prenatal Care for Women and Children's Health. This conference, scheduled for June 26-27, 1997, will examine prenatal care interventions and their effectiveness in enhancing both immediate and long-term health and development of women and children. Conference participants will summarize and synthesize the current research on prenatal care, develop recommendations for a research agenda that addresses gaps in the literature, and disseminate findings to health care providers, managers, and policymakers. Marie McCormick, Principal Investigator (Grant No. HS-09528) (1/1/97-12/31/97).

Taking Action With Children and Families. This conference, held March 13-14, 1997, examined health services and outcomes research for children and adolescents, especially as applied to Medicaid settings. Research and demonstration projects and community-based model programs were discussed in three symposia: 1) service systems for at-risk infants and very young children; 2) community interventions to reduce asthma morbidity in elementary school children; and 3) health promotion interventions to reduce risk-taking behaviors among adolescents. Small working groups were also convened to summarize findings and recommend future initiatives in each of the three topical areas. Ardene Brown, Principal Investigator (Grant No. HS-09362) (2/1/97-1/31/98).

Evidence Reports

AHCPR's newest endeavor as a "science partner" with both public- and private-sector organizations is the Evidence-based Practice Center (EPC) program. AHCPR will fund 8-10 Evidence-based Practice Centers (EPCs). These centers will work closely with professional societies, health plans, and others to develop evidence reports and technology assessments. These reports will form the scientific foundation for use by AHCPR science partners in developing their own quality improvement tools. Applicants were asked to include evidence of their expertise in child health. AHCPR is already working on two pilot evidence reports that concern children. One report is on attention deficit hyperactivity disorder (ADHD), in coordination with the American Academy of Pediatrics, and the other is on valvular heart disease with the American College of Cardiology and the American Heart Association.

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1. Indicates projects newly funded in Fiscal Year 1996.

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3. Additional Information

For more information on the above projects, contact:

Denise Dougherty, Ph.D.
Senior Advisor, Child Health
Agency for Healthcare Research and Quality
540 Gaither Road, Suite 2000
Rockville, MD 20850
Phone: (301) 427-1868
Fax: (301) 427-1561
E-mail: Denise.Dougherty@ahrq.hhs.gov

U.S. Department of Health and Human Services
Public Health Service
Agency for Health Care Policy and Research
2101 E. Jefferson Street
Executive Office Center, Suite 501
Rockville, MD 20852

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Current as of November 1998