Mar 1 2013
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RWJF Clinical Scholars Survey Child Health Quality

Lawrence Kleinman, MD, MPH, is vice chair and associate professor of health evidence and policy and associate professor of pediatrics at Mount Sinai Hospital. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (1990-1992) and helped guide a special supplement of studies by RWJF Clinical Scholars into publication in Pediatrics this month.

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Human Capital Blog: How did this special supplement come to be and what impact do you expect and hope it will have? 

Kleinman: Des Runyan, MD, DrPH, director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, called to ask me what I thought about the idea and whether I would be willing to shepherd the issue. Des had observed the historical and seminal role of RWJF Clinical Scholars in the emergence of the field of quality of health care, the work of Bob Brook, MD, ScD, chair in health care services at the RAND Corp., a professor of health policy and management, and of medicine, at the University of California at Los Angeles (UCLA), and an RWJF Clinical Scholar alumnus, and of many others, and also the more recent emergence of Clinical Scholars as leaders in the field of children’s health care. 

He also recognized that five of seven centers of excellence funded by the Agency for Healthcare Research and Quality (AHRQ) as part of its flagship Pediatric Quality Measures program (PQMP) were led by alumni of the Clinical Scholars program. I think Des viewed that as a seminal moment that showed that Clinical Scholars alumni had achieved similar leadership in child health that they had achieved in the area of adult health. He recognized the opportunity to celebrate that in a collection of work on children’s health quality by RWJF Clinical Scholars and alumni.

HCB: What are the key messages readers should take away from the series?

Kleinman: This supplement demonstrates the capacity and power of using conceptual models to inform quality and quality improvement research, suggests an approach to developing these kinds of conceptual models, and illustrates that a span of approaches—ranging from evidence synthesis to a highly reductionist analysis of existing data to an extremely generative qualitative analysis to the thoughtful integration of ideas by colleagues—may all inform the field in important ways. 

Further, the field of pediatric quality of care is blossoming; it truly needs studies that incorporate and extend its range. Finally RWJF Clinical Scholars are still thought leaders and change agents who as a group demonstrate remarkable versatility in their methods and prove notably capable of provoking progress in children’s health and quality research.

Pediatrics Supplement

Human Capital Blog: How did this special supplement come to be and what impact do you expect and hope it will have? 

Kleinman: Des Runyan, MD, DrPH, director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, called to ask me what I thought about the idea and whether I would be willing to shepherd the issue. Des had observed the historical and seminal role of RWJF Clinical Scholars in the emergence of the field of quality of health care, the work of Bob Brook, MD, ScD, chair in health care services at the RAND Corp., a professor of health policy and management, and of medicine, at the University of California at Los Angeles (UCLA), and an RWJF Clinical Scholar alumnus, and of many others, and also the more recent emergence of Clinical Scholars as leaders in the field of children’s health care. 

He also recognized that five of seven centers of excellence funded by the Agency for Healthcare Research and Quality (AHRQ) as part of its flagship Pediatric Quality Measures program (PQMP) were led by alumni of the Clinical Scholars program. I think Des viewed that as a seminal moment that showed that Clinical Scholars alumni had achieved similar leadership in child health that they had achieved in the area of adult health. He recognized the opportunity to celebrate that in a collection of work on children’s health quality by RWJF Clinical Scholars and alumni.

HCB: What are the key messages readers should take away from the series?

Kleinman: This supplement demonstrates the capacity and power of using conceptual models to inform quality and quality improvement research, suggests an approach to developing these kinds of conceptual models, and illustrates that a span of approaches—ranging from evidence synthesis to a highly reductionist analysis of existing data to an extremely generative qualitative analysis to the thoughtful integration of ideas by colleagues—may all inform the field in important ways. 

Further, the field of pediatric quality of care is blossoming; it truly needs studies that incorporate and extend its range. Finally RWJF Clinical Scholars are still thought leaders and change agents who as a group demonstrate remarkable versatility in their methods and prove notably capable of provoking progress in children’s health and quality research.

  • Tumaini Coker, MD, MBA, and her UCLA colleagues provide a sophisticated review of the evidence for how to improve the well-child care that pediatricians deliver every day. 
  • Marielena Lara, MD, MPH, and her colleagues provide a thoughtful case study of work that succeeded in reducing disparities for asthmatic children in Puerto Rico. 
  • Bonnie Zima, MD, MPH, offers us two glimpses into mental health for kids: a conceptual framework on mental health and measurement that integrates the work of several colleagues working on mental health measures for PQMP Centers, and a study of continuity of care for children with attention deficit hyperactivity disorder. 
  • Michael Leu, MD, tells the fascinating case history of implementing and updating information technologies at Seattle Children’s Hospital. 
  • Stephen Patrick, MD, MPH, MSc, and his colleagues provide us first with a thoughtful methodological review of the use of “risk adjustment” methods in neonatal intensive care units and also with an insightful critique of standard methods to identify central line associated bloodstream infections, a common patient safety indicator. 
  • Sophia Jan, MD, and her team bring sophisticated analytic methods to a secondary data set to inform us about the importance of structural attributes in surgical outcomes for adolescents. 
  • Jennifer Walter, MD, PhD, MS, and colleagues combine qualitative methods and the power of the electronic medical record to offer new insights into end-of-life care for very sick children. 
  • Patrick Conway, MD, MSc, is senior author of the reflective analysis of quality improvement efforts to improve the care of children with gastroenteritis in one community. 
  • Lara Johnson, MD, and her colleagues used a nationally representative database to assess the effectiveness of national guidelines intended to reduce services used for children who are seen in emergency departments with bronchiolitis. She found less imaging but no change in treatment. 

Finally, along with Denise Dougherty, PhD, at AHRQ, I present an innovative model that offers an alternative approach to conceptualizing quality, building from Donabedian’s Structure-Process-Outcome model, which was designed to support quality measurement, to a more operations-based model, which is designed to serve the study of quality improvement.

As terrific as each of these papers is, the sum total demonstrates an expanse of methods, topics, and approaches to studying the quality of children’s health that serves as a survey of contemporary contributions to the field made by RWJF Clinical Scholars and alumni. 

HCB: What can researchers and policy-makers learn from them?

Kleinman: Coker’s article reminds us that out-of-the-box thinking can sometimes get us closer to where we want to go. Leu reminds us that health information technology is not a panacea, but requires hard and thoughtful work that must be ongoing and revised if it is to serve our clinical goals. Patrick offers a harsh critique of current approaches to use data to find central line infections. 

Walter reminds us that communication is central to quality. Conway illustrates how we can make care better by combining thoughtful recommendations with a robust improvement process. Johnson both reminds us of the value of national data sets to study changes in practice, and that publishing a guideline is unlikely to be sufficient to effect change. Jan reminds us of the importance of structural attributes as markers for clinical performance. 

And several of the articles (Zima, Murphy, Scholle et al; Patrick, Schumacher & Davis; Kleinman & Dougherty) remind us of the importance of articulating a thoughtful and explicit model as foundational to the measurement, study, or improvement of practice. 

One critical task of the policy-maker and analyst alike is to align the question being asked with the substantive need, the measurement strategy with the analysis, and all of them together. The most sophisticated methods won’t save someone who doesn’t recognize either that they have asked the wrong question, or that the methods answer a different question than is being asked.

HCB: Did any of the studies reach findings that surprised you? Which were they?

Kleinman: What I found most surprising was how well this group of articles held together as a body of work. I did not find any of the studies themselves particularly surprising. These articles were written by physicians from a diversity of clinical disciplines, trained across the country in locally distinct programs, over a span of years.  They used different approaches, varied data sources, and contrasting methods. 

Nonetheless, the supplement communicates a narrative that tells a number of the key stories of pediatric quality measurement and improvement. Data matters. Choices for measurement matter. The age of the patient matters. Clinicians introduce variation.  Efforts designed to reduce variations in practice may succeed, but not always. Quality improvement is work. Understanding how to measure something is really hard work.  One’s findings depend upon measurements. Children and their health care are distinct components in the health care system. Thoughtful modeling adds the capacity for the next study to improve clarity of understanding.  

This supplement clearly demonstrates a breadth of work. It offers a survey of the state of the field of child health quality as we head into 2013. RWJF Clinical Scholars and alumni are among the small group of thought leaders among those investigators committed to improving health and health care for children.

Read the supplement (subscription required).
Learn more about the RWJF Clinical Scholars program.

Tags: Pediatric care, Quality of care, Research, Clinical Scholars