Measuring quality in pediatrics: Once again, children aren't little adults

There has been a great deal of interest recently in measuring quality in medical care. Two Institute of Medicine reports-"To Err Is Human: Building a Safer Health System," issued in 2000, and "Crossing the Quality Chasm: A New Health System for the 21st Century," a year later-catalyzed calls to improve both patient safety and measurements of the quality of medical care. More recently, health-care insurers, and other interested parties, have proposed that reimbursement to physicians be tied to their performance, which would be measured by how effectively and efficiently they deliver care-a practice known as pay for performance or, simply, "P4P."

Efforts to apply these principles to pediatrics have been stymied by a near-absence of agreed-on measures of quality in pediatric care. Certainly, we know that many patients with asthma benefit from a controller medication, and that timely administration of recommended immunizations results in a healthier population, but it is difficult to find other examples of evidence-based intervention that warrant use as yardsticks of quality.*

Published measures of quality care for adults primarily include interventions to treat disease-most often, chronic conditions. There are, to name a few, established standards for treating hypertension, diabetes, and cardiac and pulmonary disease. If we were to design a mechanism for assessing quality of care in pediatrics, however, it would be most appropriate to measure interventions that have been designed to prevent those conditions of adulthood from ever developing. We might agree with quality measures that reward pediatricians for withholding unnecessary antibiotics or for making the effort to provide the influenza vaccine to every patient for whom it is recommended, but if we really want to encourage quality in the delivery of pediatric care we would find ways to recognize the pediatrician who provides effective counseling to prevent, say, obesity or tobacco use.

Children are not just little adults, and measures of the quality of their medical care should acknowledge that fact.

*For a more complete discussion of this issue, see: Miller MR, Gergen P, Honour M, et al: Burden of illness for children and where we stand in measuring the quality of this health care. Ambul Pediatrt 2005;5:268