1. 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

2. Overview What would be the impact of investing in improvements in health care quality for children? What would be the impact of investing in improvements in health care quality for children? Two examples of preliminary studies: Two examples of preliminary studies: – Child lives saved – Morbidity avoided – Dollars to Medicaid

3. No Needless Deaths— Investigators Denise Dougherty, Ph.D., AHRQ Denise Dougherty, Ph.D., AHRQ Lisa Simpson, MB, BCh, MPH, FAAP, University of South Florida Lisa Simpson, MB, BCh, MPH, FAAP, University of South Florida Melissa Romaire, MPH, CMS (work done at AHRQ) Melissa Romaire, MPH, CMS (work done at AHRQ) Charles Homer, MD, NICHQ*- Cambridge, MA Charles Homer, MD, NICHQ*- Cambridge, MA Lisa C. White, MPH, NICHQ*-Seattle Lisa C. White, MPH, NICHQ*-Seattle * National Initiative for Children’s Healthcare Quality

4. Rationale and Methods Rationale: draw attention to children’s healthcare quality 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 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 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 Estimated # of deaths nationally that could be prevented with improved healthcare quality Extrapolated life years gained using YPLL* method Extrapolated life years gained using YPLL* method * Years of Potential Life Lost

5. Results—Needless Deaths Prevented Through QI Cause of Death Improvement Strategy # of Deaths Prevented Single Year ( 50-100% effectiveness) Potential Life Years Gained with QI (100% effectiveness) VLBW Neonatal Period NICU improvements 1,329-2,658 Child yrs: 47,844 Total yrs: 205,198 SIDS mortality B-W difference “Back to sleep” 161-323 Child yrs: 5,491 Total yrs: 23,224 Medical errors- inpatient Patient safety 2,242-4,483 Child yrs: 40,347 Total yrs: 308,430 Cancer mortality B-W difference Improved cancer care 8-15 Child yrs: 150 Total yrs: 1,004 Total3,740-7,479 Child yrs: 93,832 Total yrs: 537,856

6. Other Evidence of Poor Quality of Care for Children Topic Quality/Disparities Findings (Nationally) Asthma care: Pediatric hospitalizations (potentially avoidable) Children higher than adults Black children 3x rate of white children Immunizations up to date—9-35 month olds 31.6% not up to date Timeliness: Care for illness or injury as soon as desired Lower among CSHCN than children w/o SHCN Patient-centeredness: CAHPS composite measure Lower among CSHCN than children w/o SHCN Source: AHRQ, National Healthcare Quality Report and National Healthcare Disparities Report, 2005

7. Improving Neonatal Outcomes of Medicaid-Covered Infants—Investigators Denise Dougherty, Ph.D., AHRQ Denise Dougherty, Ph.D., AHRQ Bernard Friedman, Ph.D., AHRQ Bernard Friedman, Ph.D., AHRQ Vipul Mankad, MD, U MD (done while at CMS) Vipul Mankad, MD, U MD (done while at CMS) With assistance of: With assistance of: – Jeannette Rogowski, Ph.D. – Nikki Highsmith, MPA – Neonatal Outcomes Improvement Group

8. Rationale and Methods Rationale: CMS Medicaid trying to stimulate quality improvement and reduce costs Rationale: CMS Medicaid trying to stimulate quality improvement and reduce costs Methods: 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

9. Results Average cost difference between a Medicaid NICU stay and a Medicaid regular nursery stay was $18,607 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 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

10. Preliminary Results Clinical Improvement Savings achieved by Rough estimates of national gross cost savings Smoking cessation/pregnant women Reduced NICU admissions $48,300,000 Antenatal corticosteroids Reduced NICU LOS attributable to RDS $48,727,854 Prophylactic surfactant Reduced NICU LOS $55,822,000 Infection reduction in NICU Reduced NICU LOS $72,093,193 Notes: 1) Gross mean costs of QI initiatives not included. 2) Medicaid programs may not be able to recoup all costs.

11. Other compelling reasons to improve perinatal care Neonatal deaths prevented: Neonatal deaths prevented: – 338 deaths prevented with smoking cessation Prevention of extremely low birth weight and very low birth weight can potentially prevent: 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.

12. Conclusions Conclusions: Conclusions: – Needless deaths and substantial morbidity can be prevented – Substantial child life years gained – Medicaid expenditures can potentially be reduced

13. Caveats and Needed Research Caveats: 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: 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)

14. Informal Reactions from Previous Reviewers Needless deaths pre-review Needless deaths pre-review – Enthusiasm during presentations – For potential publication: Numbers are small relative to other conditions and due to QI focus Numbers are small relative to other conditions and due to QI focus Child life years gained not understood Child life years gained not understood Neonatal care improvements 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

15. Questions Is this enough to act on? Is this enough to act on? If not, why not? If not, why not? What research strategies should be used to create more data and frame the issues? What research strategies should be used to create more data and frame the issues?