Fact Sheet
This fact sheet presents information drawn from the 2009 National Healthcare Quality Report and National Healthcare Disparities Report for selected health care quality measures related to children. It complements work being carried out as a result of the Children's Health Insurance Program Reauthorization Act of 2009.
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Contents
Introduction
Children's Clinical Preventive Services
Access to Care
Behavioral Health
Management of Chronic Conditions
Family Experiences of Care
Most Integrated Health Care Settings
Introduction
In early 2009, Congress passed and
the President signed the Children's
Health Insurance Program
Reauthorization Act (CHIPRA; Public
Law 111-3). CHIPRA presents an
unprecedented opportunity to improve
health care quality measurement and
health care quality and outcomes for
the Nation's 75 million children,
beginning with the 38 million
enrolled in Medicaid and CHIP.
As a first step, a set of 24 initial
recommended evidence-informed and
feasible measures were posted for
public comment. The Centers for
Medicare & Medicaid Services
(CMS) will work with State Medicaid
and CHIP programs as the programs
consider whether to voluntarily report
these measures. The Agency for
Healthcare Research and Quality has
posted a funding announcement for
work to improve the initial core set to
measure the quality of both public and
private children's health care services.
CHIPRA requires identification of a
comprehensive set of measures,
across the spectrum of health care
services, settings, and providers that
work to improve children's health and
health care. In addition, CHIPRA
requires that the core measure set be
able to identify differences in care by
race, ethnicity, socioeconomic status,
and special health care needs.
This fact sheet complements the
CHIPRA work by providing
information from the 2009 National
Healthcare Quality Report (NHQR)
and National Healthcare Disparities
Report (NHDR) for selected measures
related to children. Included in this
fact sheet are data from measures
relevant to childhood immunizations,
obesity and overweight prevention,
dental care, quality of care for asthma,
and care for children with depression.
Data on race, ethnicity, insurance,
income, and special health care need
status are reported as available.i This
information can help maintain
momentum for action to improve children's health care quality across
the country.
Table 1
lists the initial recommended core set
of CHIPRA measures as posted for
public comment. Box 1 lists all the
children's health care quality measures
included in the NHQR and NHDR.
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Children's Clinical Preventive Services
Prevention of disease is a critical part
of children's health care. Two ways to
prevent disease are to ensure timely
immunization and to monitor
children's body mass index
(relationship of height to weight) to
avoid obesity-related illness.
Childhood immunizations
Recommended vaccines for children
by the age of 3 years include at least 4
doses of diphtheria-tetanus-acellular
pertussis (DTaP) vaccine, at least 3 doses of
polio vaccine, at least 1 dose of measles-mumps-rubella vaccine, at least 3 doses of
Haemophilus influenzae B vaccine, and at
least 3 doses of hepatitis B antigens.
- Although the gap between
Blacks and Whites who received
all recommended vaccines
decreased, in 2007, Black
children were less likely than White children to receive all
recommended vaccines (77.5%
compared with 80.9%).
- In 2007, the percentage of
children who received all
recommended vaccines was
lower for children from poor
(76.5%) and near-poor (77.8%)
families than for children from
high-income families (84.1%).
- Nationally, several groups
achieved the Healthy People
2010 objective of 80% of
children receiving all
recommended vaccines: White
(80.9%), American
Indian/Alaska Native (83.5%),
non-Hispanic White (81%),
middle income (81.8%), and
high income (84.1%).
The Centers for
Disease Control and Prevention's
National Immunization Program
survey is beginning to collect data on
insurance status. To the extent that
this information is shown to be valid,
it might be used by CMS to gather
information on immunization rates
for publicly insured children by State.
Prevention of obesity in children
Children enrolled in Medicaid are
more likely to meet criteria for
obesity than other children. The U.S.
Preventive Services Task Force
recently recommended screening for
overweight in children. One of the
CHIPRA core measures is a new
HEDIS® (Healthcare Effectiveness
Data and Information Set) measure
of documentation of body mass index
in children. A prerequisite to
calculating body mass index is
measurement of height and weight
(Figure 1).
- Children with any private or
public insurance, children from homes
where the primary language is
English, and children with
special health care needs were
more likely than their
counterparts to have had their
height and weight measured.
- The NHDR also reports on the
percentage of children who
received counseling from a
health provider on healthy eating
and physical activity (refer to
NHDR Figure 4.40 and Tables
6_4_5.1, 2, and 3).
Figure 1. Children who had their height and weight measured by a health provider, by health insurance, language spoken most often at home, and
special health care needs status, United States, 2006
Key: CSHCN = children with special health care
needs.
Source: AHRQ, Medical Expenditure Panel
Survey.
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Access to Care
Dental care
The CHIPRA initial core measures for
dental care are from data collected by
CMS's Early Periodic Screening,
Diagnosis, and Treatment (EPSDT)
Program. They include percentage of
eligible Medicaid-enrolled children
with a preventive care visit and
number of children who received
dental treatment services.
Performance data are available
nationally and by State at
http://www.cms.gov/MedicaidEarlyPeriodicScrn/.
The NHQR and NHDR report on the
percentage of children who had a
dental visit in the calendar year, by
family income, age group, gender,
race, ethnicity, residence, language
spoken at home, perceived health
status, special health care needs status,
and place of birth (United States or other).
Selected data are shown in Figure 2.
- Overall, the rate of dental visits
among children in the United
States is low, by recommended
standards. The Healthy People
2010 goal for dental visits was
56%.
- Younger children, uninsured
children, and children in a
household where English is not
the primary language are less
likely than their counterparts to
have had a dental visit.
- Children with special health care
needs are somewhat more likely
to have had a dental visit than
children without special health
care needs.
Figure 2. Children ages 2-17 who had a dental visit in the calender year, by age, insurance, language spoken at home, and special health care needs status, United States, 2007
![Figure 2, Bar chart depicts children aged 2-17 who had a dental visit in 2007: 38 percent ages 2-5; 58 percent ages 6-17; 60 percent any private coverage; 41 percent public coverage only; 28 percent uninsured; 56 percent English-speaking; 37 percent other language; 60 percent children with special health care needs; 52 percent non-special health care needs.](fig2.jpg)
Key: CSHCN = children with special health care needs.
Source: AHRQ, Medical Expenditure Panel Survey.
Usual primary care provider
Having a usual primary care provider
improves patient trust and provider-patient
communication, helping to
increase the chances of receiving appropriate
care. Among children ages 0-17, usual
primary care provider varies by
income. Data for 2006 show that
children in high-income families
(94.2%) are more likely than children
at other income levels (poor, 86.5%;
near poor, 85.6%; and middle income, 89.6%) to have a usual primary care
provider.
Children are more likely than adults
to have a usual source of care (90.1%
compared with 75.6%), but insurance
is a factor (Figure 3). Children with
private insurance are more likely to
have a usual source of care than
children with public insurance or
children who are uninsured (93.5%
compared with 87.8% and 67.9%,
respectively). A usual source of care
includes an urgent care or walk-in
clinic, doctor's office, clinic, health
center facility, hospital outpatient
clinic, health maintenance
organization or preferred provider
organization, military health care, or
some other place. A hospital
emergency department (ED) is also included.
Figure 3. People with a usual source of care (USC), by insurance, 2006
Source: Agency for Healthcare Research and
Quality, Medical Expenditure Panel Survey.
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Behavioral Health
Several initial core measures for
CHIPRA cover behavioral health
services (Table 1). For children with a
mental illness, the only measure
recommended was followup after
hospitalization, a HEDIS® measure for
which data are not currently available
by child age groups. The NHQR and
NHDR report data on a different
measure than that recommended for
the CHIPRA core set. The measure is
children ages 12-17 treated for
depression.
- In 2007, overall, less than 40% of
children ages 12-17 with a major
depressive episode received
treatment.
- Younger adolescents (41.4%), Whites (39.9%), non-Hispanics (41.0%), and adolescents living
in nonmetropolitan areas
(41.9%) were more likely to have
received care.
- Among income groups, near-poor
children were the least
likely to get care (36.9%
compared with poor, 39.4%;
middle income, 39.2%, and high
income, 40.0%).
Data are needed on the quality of the content of mental health care for children, by insurance status.
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Management of Chronic Conditions
One of the initial recommended core
CHIPRA measures in this category is ED visits for
asthma. Some unknown number of
ED visits for asthma is believed to be
avoidable with high-quality ambulatory care. The NHQR
measures pediatric hospital
admissions for asthma, which are similarly
believed to be avoidable to a large
extent. An ED visit is often a
precursor to a hospital admission for asthma.
- Within each racial and ethnic
group, children in the lowest
income quartile are most likely
to be admitted to the hospital for
asthma (Figure 4).
- Regardless of income, Black
children are most likely of all
racial and ethnic groups to be
admitted to the hospital for
asthma.
Data are needed on underlying child population with asthma by State and by race/ethnicity for all States; and about the quality of ambulatory care for children with asthma.
Figure 4. Pediatric asthma admissions per 100,000 population, ages 2-17, by race/ethnicity, stratified by income
![Figure 4, bar chart depicts pediatric (ages 2-17) hospital admissions for asthma per 100,000 population by race and income, from lowest (first) to highest (fourth) income: White 145, 99, 98, 97; Black 450, 340, 315, 195; Asian/Pacific Islander 70, 68, 67, 66; Hispanics, all races 235, 140, 135, 130.](fig4.jpg)
Source: AHRQ, Healthcare Cost and Utilization
Project, State Inpatient Databases, disparities
analysis file, 2006, and AHRQ Quality Indicators,
version 3.1. The disparities analysis file is
designed to provide national estimates on
disparities using weighted records from a
sample of hospitals from the following 25 States:
AR, AZ, CA, CO, CT, FL, GA, HI, KS, MA, MD,
MI, MO, NH, NJ, NY, OK, RI, SC, TN, TX, UT, VA,
VT, and WI.
Note: White, Black, and Asian or Pacific Islander are
non-Hispanic.
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Family Experiences of Care
Communication in children's health
care can be challenging, because
children often cannot express their
needs. They rely on other people, such
as their parents. Health provider
communication can have a major
effect on health care quality.
- From 2002 to 2006, the percentage of parents reporting poor communication decreased overall (from 6.7% to 4.8%). The percentage also decreased for parents of children with any private or public insurance (Figure 5).
- In all data years, parents of
children with public insurance
were more likely to report poor
communication with their health
providers compared with those
with private insurance.
Figure 5. Children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health
providers: Overall composite, by insurance, 2002-2006
![figure 5, graph depicts percent of children who had a doctor's office or clinic visit during the year (2002-2006) and parents reported poor communication with providers, by insurance status: 2002, total 6.5 percent, any private insurance 5 percent, public coverage only 11 percent, uninsured 7.5 percent; 2003, total 5 percent, private coverage 5 percent, public only 9.5 percent, uninsured 6.5 percent; 2004, total 6 percent, private 4 percent, public 8.5 percent, uninsured 10 percent; 2005, total 6 percent, private 4.5 percent, public 9 percent, uninsured 6.5 percent; 2006, total 5 percent, private 4 percent, public 8 percent; uninsured 6 percent.](fig5.jpg)
Source: Agency for Healthcare Research and
Quality, Medical Expenditure Panel Survey,
2002-2006.
Note: Parents who report that their child's
health providers sometimes or never listened
carefully, explained things clearly, showed
respect for what they had to say, or spent
enough time with them are considered to have
poor communication.
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Most Integrated Health Care Settings
Work to identify the initial core set of
CHIPRA measures did not yield a
comprehensive measure of the most
integrated health care setting. As
directed by CHIPRA, work to
develop such a measure will
continue. Care coordination, which
is covered in the NHQR and NHDR,
is an important element of integrated
health care.
The NHQR and NHDR report on
aspects of care coordination for
children measured by the 2007
Patient Experience Survey conducted
by Massachusetts Health Quality Partners. Among parents of pediatric
patients who were sent for a test,
69% reported that someone from the
doctor's office always followed up to
give the test results. Sixty-one percent
of parents reported that their child's
doctor always seemed informed and
up to date about the care the child
received from specialists. Among
parents of pediatric patients who saw
other doctors or nurses in the
practice, 59% reported that the other
providers always had all the
information they needed.
The NHQR also notes variation
among States in care coordination
based on the National Survey of
Children With Special Health Care
Needs. Overall, among children with
special health care needs who
required help with care coordination,
46.0% received the help they needed.
Among States, the percentage
receiving coordination ranged from
38.3% to 53.2%. The 13 States in the
best quartile (highest rates of
coordinated care) in 2005-2006 had a
combined average rate of 50.5%.
These States are primarily located in
New England and the Midwest.
Eleven States and the District of
Columbia were in the worst quartile
(lowest rates of coordinated care) in
2005-2006, with a combined average
rate of 41.5%. These States are
primarily located in the western
United States.
i The data included in this fact sheet do not always use the same data sources that are currently used
to report on CHIPRA measures. In many cases, the NHQR and NHDR measures are relevant to the
CHIPRA core measure topics but the measures themselves are different. The data in this fact sheet
do not come from Medicaid and CHIP programs. They are nationally representative when possible.
State-specific data are available for some measures.
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AHRQ Publication No. 10-P006
Current as of June 2010
Internet Citation:
Findings on Children's Health Care Quality and Disparities. Fact Sheet. AHRQ Publication No. 10-P006, June 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nhqrdr09/nhqrdrchild09.htm