Introduction 

Children and adolescents are growing

and developing, and their health care

needs, use of services, and outcomes are

very different from those of adults.

Unlike adults, children and adolescents

usually are dependent on parents and

others for access to care and evaluations

of the quality of that care. Furthermore,

adolescents differ from younger

children; they are moving from

childhood to adulthood and have their

own unique health care needs,

preferences, and patterns of use. For

these and many other reasons, a special

research focus is needed to increase

understanding of the issues involved in

improving the delivery of health care to

children and adolescents. 

In 1997, Christopher B. Forrest, M.D.,

Ph.D., of the Johns Hopkins School of

Public Health, Lisa Simpson, M.B.,

B.Ch., Deputy Director of the Agency

for Healthcare Research and Quality

(AHRQ), and Carolyn Clancy, M.D.,

Director of AHRQ’s Center for

Outcomes and Effectiveness Research

(now Acting Director of AHRQ),

proposed six strategies for increasing the

quantity and quality of child health

services research (CHSR). In an article

published in the June 11, 1997 issue of

the Journal of the American Medical

Association, they explained the need to

(1) expand the disease orientation of

health services research to include a

focus on child health development; (2)

establish child-sensitive standards for

setting research priorities; (3) increase

the size and capacity of the CHSR

workforce; (4) develop appropriate

laboratories to study child health care;

(5) improve coordination of research

funding across the Federal Government,

foundations, and the private sector; and

(6) enhance the research function of

health care delivery in the private sector.

Finding ways to improve outcomes,

quality, and access to health care for

America’s 70 million children and

adolescents is a critical goal of health

services research and a continuing

priority for AHRQ (see Dougherty, D.,

Simpson, L., and Eisenberg, J., in the

April 2000 issue of Health Services

Research, pp. xi- xix). For many years,

AHRQ has supported and conducted

research on children’s health issues.

These activities are coordinated across

the Agency’s health services research

portfolio to ensure that projects are

appropriately addressed in all program

areas. 

In FY 2001, AHRQ announced $16

million in total support for new research

and training grants, contracts, and

interagency agreements relating directly

to health care issues concerning children

and adolescents.

This program brief provides an overview

of current AHRQ programs, activities,

and priorities in health care research for

children and adolescents, as well as

summaries of selected findings from

recent AHRQ-supported research

projects. It reflects AHRQ’s

AHRQ is the lead Federal agency

charged with supporting research

designed to improve the quality of

health care, reduce its cost, address

patient safety and medical errors, and 

broaden access to essential services.

AHRQ sponsors and conducts research

that provides evidence-based

information on health care outcomes;

quality; and cost, use, and access. The

information helps health care

decisionmakers—patients and

clinicians, health system leaders, and

policymakers—make more informed

decisions and improve the quality of

health care services.

Children’s Health

Highlights 

Agency for Healthcare Research and Quality • 2101 East Jefferson Street • Rockville, MD 20852

PROGRAM BRIEF

U.S. Department of Health 

and Human Services

Public Health Service
2

commitment to build the

infrastructure and capacity for child

health services research and ensure

that practitioners and policymakers

have the knowledge and tools they

need to:

• Improve child health outcomes.

• Enhance the quality of care

children receive.

• Address access, use, and costs.

• Translate evidence-based research

into improved clinical practice.

An asterisk (*) following a summary

indicates that reprints of an

intramural study or copies of other

publications are available from

AHRQ. Two asterisks (**) identify

materials that are available from the

National Technical Information

Service. Ordering information

appears on page 28, as well as

contacts for more information about

AHRQ’s research programs,

including grant announcements and

application kits. Visit AHRQ’s Web

site at www.ahrq.gov and click on

“Child Health” to find updates on

child health initiatives at AHRQ, relevant conferences and workshops,

funding announcements, and much

more.

Acute Care/Injuries

In 2000, children and adolescents

under age 18 had over 212 million

ambulatory health care visits,

including 49 million visits to

hospital outpatient and emergency

departments. Only 15 percent of

visits to physicians’ offices were for

well-child care, while a high number

of visits were for acute care. Fifty- four percent of visits to

hospital emergency departments by

5-14 year olds are due to injuries,

and injuries are the leading cause of

death among those 1-24 years old in

the United States. AHRQ’s research

portfolio on acute care and injuries

focuses on the effectiveness, quality,

and costs of care for children and

adolescents.

Research in Progress • Study focuses on using evidence to

enhance care for childhood

illnesses.

Investigators are examining whether

providing evidence at the point of

ambulatory pediatric care will

improve antibiotic use in pediatric

disorders, reduce duration of therapy

for acute sinusitis, reduce use of

bronchodilators, and increase the

use of intranasal steroids for allergic

rhinitis. Robert L. Davis, Principal

Investigator (AHRQ grant

HS10516). • Researchers are developing decision rules for use of chest x-ray to

diagnose pneumonia in young

children.

Although a relatively low proportion

of chest x-rays reveal radiographic

pneumonia, many young children

are referred for chest-rays, resulting

in unnecessary exposure to radiation

and additional cost. The goal of this

study is to develop decision rules

that will help clinicians predict when

children with lower respiratory tract

infections should be sent for chest 

x-rays. Melinda Mahabee-Gittens, Principal Investigator (AHRQ grant

HS11038).

Recent Findings • One in five childhood injuries may

be caused by abuse.

Investigators examined data from

12,510 office visits during which

primary care physicians (PCPs)

evaluated 659 injuries, assessed the

causes of the injuries, and

determined their level of suspicion

that the injuries were caused by

abuse. The PCPs had “some

suspicion” of abuse for 21 percent of

the injuries. Flaherty, Sege, Mattson,

et al., Ambulatory Pediatrics

2(2):120-126, 2002 (AHRQ grant

HS09811). • Analysis affirms current guidelines

for treating high fever.

An analysis of six management

strategies for a hypothetical group of

100,000 3- to 36-month-old
children was conducted. Findings

show that current guidelines for

treating children up to age 3 who

have a high fever and no obvious

source of infection are the most cost

effective (i.e., obtain complete blood

counts and cultures, and treat

children with antibiotics if the white

blood cell count is equal to or greater

than 15 x 109/L). Lee, Fleisher, and

Harper, Pediatrics 108(4):835-844,

2001 (NRSA grant T32 HS00063).

• Criteria reduce unnecessary x-rays

for blunt trauma victims.

Researchers evaluated the use of

National Emergency X-Radiography

Utilization Study criteria for

identifying which of over 3,000

children were at low risk for cervical

spine injury (CSI). Five criteria can

identify pediatric blunt trauma

victims who are at low risk for CSI,

thereby reducing unnecessary x-rays

by 20 percent. Viccellio, Simon,

Pressman, et al., Pediatrics Electronic

Pages 108(2):E20

http://www.pediatrics.org, 2001

(AHRQ grant HS08239).

• Researchers synthesize evidence on

diagnosis and treatment of sinusitis

in children.

Researchers found little evidence on

how to accurately diagnose acute

sinusitis in children and note a lack of

consensus on which clinical signs and

symptoms are most useful for

diagnosis. The various antibiotics

used to treat pediatric sinusitis are

equally effective; no convincing

evidence supports the use of ancillary

decongestants and antihistamines,

and limited evidence supports the use

of steroids. A summary of this

evidence report (AHRQ Publication

No. 01-E007) and the full report,

Diagnosis and Treatment of

Uncomplicated Acute Sinusitis in

Children (AHRQ Publication No. 01-

E005), are available from AHRQ*

(AHRQ contract 290-97-0019).

Adolescent Health

Researchers have begun to target

studies at the distinctive health care

needs of adolescents. Establishing

healthy behaviors early can reduce

risks of acquiring many diseases.

Recent AHRQ-funded studies have

focused on such adolescent

prevention topics as screening for

sexually transmitted diseases and

smoking cessation.

Research in Progress

• Study focuses on eliminating

barriers to implementation of

adolescent preventive health

guidelines.

This quality improvement (QI)

intervention addresses provider and

system-level barriers to delivery of

preventive services to adolescents

during primary care visits. The goal is

to determine whether a systems

intervention in a managed health care

organization—including provider

training and customized screening

and charting tools—results in

increased delivery of clinical

preventive services to adolescents than

the usual standard of care. Charles E.

Irwin, Principal Investigator (AHRQ

grant HS11095).

• Researchers examine the role of a

regular source of care for at-risk

youth.

This study focuses on disparities in

the use of physician services, the role

of having a usual source of care, and

the characteristics likely to result in

greater use of services. Tanisha V.

Carino, Principal Investigator (NRSA

fellowship F31 HS00150).

• Internet learning modules for

physicians may improve

chlamydia screening for

adolescents.

Study physicians will complete a yearlong series of Internet learning

modules that integrate case-based

education with audit, feedback, and

benchmarking of practice profiles.

The goal is to improve chlamydia

screening and treatment rates among

patients aged 16-26, which should

result in lower rates of pelvic

inflammatory disease. Jeroan Allison,

Principal Investigator (AHRQ grant

HS11124).

• Researchers are testing an

intervention for smoking cessation

among rural teens.

The goal is to determine the

usefulness of a theory-based

motivational tobacco intervention for

rural smokers ages 14 to 18 who seek

emergency care. Researchers will

develop a transportable version of the

intervention for emergency facilities.

Kimberly A. Horn, Principal

Investigator (AHRQ grant

HS10736).

• Investigators seek to improve STD

screening for asymptomatic teens.

This QI intervention involves a

small-group educational program for

clinic personnel on sexually

transmitted diseases, including

chlamydia. The sessions will be

augmented with weekly supervision

and followup to reinforce the

educational content. Mary-Ann

Shafer, Principal Investigator (AHRQ

grant HS10537).

Recent Findings

• Premature birth does not affect

adolescent self-esteem.

Premature infants who weighed less

than 2 pounds were at high risk for

neurodevelopmental, cognitive,

behavioral, and emotional difficulties.

However, once they reached

adolescence, their self-esteem was

similar to that of other adolescents.

Saigal, Lambert, Russ, et al.,

Pediatrics 109(3):429-433, 2002

(AHRQ grant HS08385).

• Delivery of smoking

prevention/cessation services differs.

Researchers analyzed survey responses

from pediatricians and family

physicians and found that doctors

used more tobacco interventions

when they were familiar with the

Public Health Service guidelines,

spent more time with adolescent

3
patients, and spent more time alone

with patients. Klein, Levine, and

Allan, Arch Pediatr Adolesc Med

155:597-602, 2001 (AHRQ grant

HS08192).

• Not all teens receive reproductive

health services.

In a survey of 354 family physicians,

respondents reported asking 79

percent of their adolescent patients

about contraceptive use, 73 percent

about condom use, 72 percent about

sexual relationships, and 61 percent

about sexual behavior. Female doctors

and younger doctors are among those

more likely to provide reproductive

health screening and counseling

during adolescent visits. Kelts, Allan,

and Klein, Fam Med 33(5):376-381,

2001 (AHRQ grant HS08192). 

• Providers’ role in preventing alcohol

problems is unclear.

This article summarizes what is

known about adolescent alcohol use

and how it can be addressed in

primary care settings. Studies show

that few primary care doctors follow

existing guidelines that recommend

yearly screening of adolescents for

alcohol problems. Knight,

Ambulatory Pediatr 1(3):150-161,

2001 (AHRQ/NIAAA interagency

agreement).

• Adolescents accurately characterize

the care they receive.

To develop quality measures for

adolescent care, researchers recruited

400 adolescents, audiotaped their

visits with physicians, and conducted

phone surveys to assess their

recollection of the preventive health

care they received. Adolescents’ recall

of the care they received was good.

Klein, Graff, Santelli, et al., Health

Serv Res 34(1):391-404, 1999

(AHRQ grant HS08192).

• Researchers develop and test a

taxonomy of adolescent health.

Researchers used four domains of

health to group adolescents into 13

profile types. They also identified

combinations of problems that

characterize different subgroups of

adolescents to develop a taxonomy of

adolescent health and tested the

taxonomy in four ethnically diverse

groups of urban and rural youths ages

11 to 17. Riley, Forrest, Starfield, et

al., Med Care 36(8):1228-1236, 1998

and Riley, Green, Forrest, et al., Med

Care 36(8):1237-1248, 1998

(AHRQ grant HS07045).

Asthma

Asthma is a chronic inflammatory

disease of the airways that affects

approximately 5 million U.S.

children a year. An estimated

400,000 of these children have

moderate to severe asthma. It is the

most common chronic disease of

childhood, with about one-fourth of

those affected being less than 5 years

of age. Illness associated with asthma

is on the rise, and reducing asthmarelated morbidity continues to be a

major objective for the U.S. Public

Health Service. 

Research in Progress

• Study examines underuse of

preventive care among black

children.

This study is exploring the factors

that contribute to the disparity

between black and white children in

preventive asthma care. Factors

include insurance coverage, access to

preventive health care, financial

resources, and health beliefs. Andrea

Ireland, Principal Investigator

(AHRQ grant HS11929).

• Researchers study treatment

adherence among children with

cystic fibrosis and asthma.

The aims of this study are three-fold:

(1) assess the extent of adherence

problems in children with cystic

fibrosis and asthma, (2) compare

patterns of adherence in two pediatric

pulmonary populations, and (3)

identify key barriers associated with

poor adherence. Avani Modi,

Principal Investigator (AHRQ grant

HS11768).

• Researchers explore the family effects

of having a child with asthma.

This project will extend previous

research on the impact of having a

child with asthma and the burden

asthma places on the family’s

resources, availability of care, and

barriers to care. Nazil Baydar,

Principal Investigator (AHRQ grant

HS13110).

• Project underway to test the costeffectiveness of recently developed

practice guidelines for pediatric

asthma.

This 5-year study is being conducted

in three unrelated, geographically

dispersed managed care settings. The

researchers are evaluating educational

and organizational approaches to QI

for pediatric asthma care, focusing

primarily on symptom assessment.

They also will examine other

outcomes, including functional

status, health care use, and patient

satisfaction. Kevin Weiss, Principal

Investigator (AHRQ grant

HS08368).

• Effects of Medicaid enrollment gaps

on asthma outcomes are being

studied.

Researchers are evaluating the effect

of gaps in enrollment in Tennessee’s

Medicaid program for children with

asthma by studying two markers for

use of asthma care—emergency room

visits and hospitalizations. William

O. Cooper, Principal Investigator

(AHRQ grant HS10249).

• Two studies explore the effects of

managed care on the quality of

pediatric asthma care.

The first study is investigating the

impact of the transition from fee-forservice to managed care on quality of

treatment, quality of life, and health

outcomes for indigent children with

asthma, as well as the impact of

organizational policies on quality and

outcomes. Bruce Stuart, Principal

Investigator (AHRQ grant

HS09950). The second study

involves 2,700 children with asthma

who are enrolled in nine Medicaid

4
managed care organizations in

California, Washington, and

Massachusetts. Researchers are

studying health plan payment

mechanisms, provider profiling and

incentives, and disease management

programs; patient-level features; and

other variables. Tracy Lieu, Principal

Investigator (AHRQ grant

HS09935).

• Evaluation of school-based asthma

care is underway.

Children’s functional status, school

days missed, and resource use are

among the indicators researchers are

using to evaluate the impact of using

school-based health centers to deliver

care for asthma. Mayris P. Webber,

Principal Investigator (AHRQ grant

HS10136).

• Researchers are assessing the use of

telecommunications in asthma care.

The researchers are assessing the

effectiveness of Telephone-Linked

Communications for Asthma, a

computer-based system that

monitors, educates, and counsels

parents and children who have

asthma. Robert Friedman, Principal

Investigator (AHRQ grant

HS10630).

• Study compares two pediatric

asthma management programs.

Researchers are comparing a modified

“easy breathing” program with a

disease management program being

used by 66 providers in 18

communities. Outcome measures will

include adherence to guidelines,

antiinflammatory prescription and

use rates, hospitalization and ER

visits, patient/family satisfaction, and

quality of life. Michele M. Cloutier,

Principal Investigator (AHRQ grant

HS11147).

• Multisite intervention project for

children with asthma may lead to

improved outcomes and reduced

costs.

Using a family-focused QI

intervention for children with

asthma, this study is targeting

providers of care to poor, inner-city,

minority youths ages 5-18 who are

enrolled in a community health

center-based Medicaid managed care

organization. The goals are to develop

a method to deliver patient-linked

guideline prompts at the point of care

using affordable information

technology; evaluate the system’s

effects on the process and outcomes

of pediatric asthma care; and evaluate

the effects on patient outcomes of a

family-focused education intervention

delivered by a community health

worker. Judith Fifield, Principal

Investigator (AHRQ grant

HS11068).

• Study findings will build an asthma

case-management model for Head

Start.

The researchers are developing a

pediatric asthma management model

for Head Start personnel using

evidence-based asthma management

criteria. The goal is to improve the

asthma management practices of

children, parents, and staff, as well as

reduce school absences and use of

acute care services. Perla A. Vargas,

Principal Investigator (AHRQ grant

HS11062).

• Researchers are evaluating quality

improvement strategies.

These researchers will compare the

effects of office-based QI with regular

practice on processes and outcomes

of care for children with asthma ages

2 to 18. Effectiveness and costeffectiveness will be evaluated in this

managed care setting. Charles J.

Homer, Principal Investigator

(AHRQ grant HS10411).

Recent Findings

• Experts develop policy

recommendations for pediatric

asthma.

Experts and leaders in childhood

asthma outline policy

recommendations for ensuring

children are quickly diagnosed and

treated, agencies are prepared to

address needs, and children are safe

from environmental risks that worsen

asthma. Lara, Rosenbaum,

Rachelefsky, et al., Pediatrics

109(5):919-930, 2002 (AHRQ grant

K08 HS00008).

• Improving medication use will

reduce racial/ethnic disparities.

Study findings show that despite

having worse asthma than white

children, black and Hispanic children

with similar insurance and

sociodemographic characteristics are

31 and 42 percent less likely to be

using inhaled antiinflammatory

medication to prevent the onset or

worsening of an asthma episode.

Lieu, Lozano, Finkelstein, et al.,

Pediatrics 109(5):857-865, 2002

(AHRQ grant HS09935).

• Few parents are reducing household

asthma triggers.

In a study of 638 children with

asthma, 45 percent of the parents had

received written instructions about

avoiding asthma triggers in their

homes. Providing parents with these

instructions was not associated with

their efforts to do so. Finkelstein,

Fuhlbrigge, Lozano, et al., Arch

Pediatr Adolesc Med 156:258-264,

2002 (AHRQ grant HS08368).

• Minority children get fewer

medications than white children.

Investigators analyzed responses to

questionnaires, as well as prescription,

demographic, provider, and other

data on 1,000 asthmatic children and

their families. Black and Hispanic

children received fewer

bronchodilators, and Hispanic

children received fewer inhaled

steroids than white children. Ortega,

Gergen, Paltiel, et al., Pediatrics

Electronic Pages 109(1):E1

http://www.pediatrics.org, 2002

(AHRQ Publication No. 02-R046)*

(Intramural).

• Mild asthma does not significantly

affect quality of life.

Researchers analyzed asthma

symptom data (based on parent and

child daily logs); child-reported

health status and quality-of-life

(QOL) scores; and child-reported

anxiety scale, depression inventory,

5
and behavior checklist data for 339

children. Children with mild or

moderate asthma do not differ in

emotional functioning, symptoms, or

total QOL scores, but those with

moderate asthma report more activity

limitations. Annett, Bender, Lapidus,

et al., J Pediatr 139(6):854-861, 2001

(AHRQ grant HS09123).

• Tobacco smoke increases risk of

respiratory diseases.

A literature review reveals the

following: environmental tobacco

smoke (ETS) increases the risk of

respiratory diseases (including

asthma) in children, and the home is

the most important source of ETS

exposure. The impact of ETS on

respiratory symptoms is strongest in a

child’s first 2 years. Gergen, Respir

Physiol 128:39-46, 2001 (AHRQ

Publication No. 02-R022)*

(Intramural). 

• Comorbidities led to higher use and

cost of health care.

Records of 71,818 children enrolled

in a health care group plan revealed

that children with asthma were three

times more likely than those without

asthma to have coexisting problems.

The problems (sinusitis, otitis media,

and allergic rhinitis) led to higher

health care use and costs. GruppPhelan, Lozano, and Fishman, J

Asthma 38(4):363-373, 2001 (NRSA

training grant T32 HS00034).

• Medicaid children use emergency

departments most often.

Investigators studied health care use

and asthma symptoms of 804

children. Medicaid children used the

emergency department almost twice

as often for asthma care as privately

insured children. Ortega, Belanger,

Paltiel, et al., Med Care 39(10):1065-

1074, 2001 (NRSA training grant

T32 HS00034).

• Rates of diagnosis vary despite

similarities in symptoms.

An asthma screening survey

administered to a metropolitan and a

nonmetropolitan group of American

Indian and Alaska Native students

found similar rates of asthma

symptoms and medical visits for these

symptoms. However, the students’

locale, ethnicity, and socioeconomic

status had a stronger effect on

physician diagnosis of asthma than

prevalence of asthma symptoms.

Stout, White, Redding, et al., Public

Health Rep 116:51-57, 2001 (AHRQ

Publication No. 02-R005)*

(Intramural). 

• Few children with asthma use

controller medication despite

guidelines.

Researchers conducted a 1-year study

of 13,352 children with asthma who

were cared for in three managed care

organizations. They found that

despite national guidelines

recommending use of inhaled

corticosteroids, few children with

persistent asthma symptoms used

them regularly. Adams, Fuhlbrigge,

Finkelstein, et al., Arch Pediatr Adolesc

Med 155:501-507, 2001 (AHRQ

grant HS08368).

• Bilingual scale helps clinicians assess

asthma symptoms.

A new Spanish-English scale for

measuring the control of asthma in

Latino children from low-income

families has been developed and

tested with parents of 234 inner-city

Hispanic children with asthma. Lara,

Sherbourne, Duan, et al., Med Care

38(3):342- 350, 2000 (AHRQ

Publication No. 00-R021)*

(Intramural).

• Factors that predict hospitalization

of children with asthma have not

changed over time.

Researchers found that teenagers and

boys were more likely than children

aged 5 to 12 and girls to be

hospitalized for severe respiratory

distress or failure. Region of the

country and hospital teaching status

also were significantly associated with

differences in severity of asthma

among hospitalized children. The

research team reviewed hospital

records of more than 168,000

children in 746 hospitals in 1990 and

more than 174,000 children in 811

hospitals in 1995. Meurer, George,

Subichin, et al., Arch Pediatr Adolesc

Med 154:143-149, 2000 (AHRQ

grant HS09564).

• Children with asthma did not

improve following a pharmacistdelivered intervention.

Researchers assessed changes in

disease control, functional status, and

cost associated with a structured

program of pharmacist-delivered care

for children with asthma and found

no evidence that they improved in

pulmonary function, functional

status, quality of life, asthma

management, or satisfaction with

care. Stergachis, Gardner, Anderson,

and Sullivan, J Am Pharm Assoc

42(5):743-752, 2002 (AHRQ grant

HS07834). 

• Asthma affects Puerto Rican

children more severely than it does

other Latino children.

Puerto Rican children with asthma

are affected by their illness

significantly more than Cuban

American or Mexican American

children. Puerto Rican children

usually have a smaller airway size,

more severe inflammatory reactions,

and lower birthweight than other

Latino children, and their mothers

are more likely to smoke cigarettes

than other Hispanic mothers. Lara,

Morgenstern, Duan, et al., West J

Med 170:75-84, 1999 (NRSA

training grant T32 HS00007).

• Environmental tobacco smoke

contributes to early childhood

asthma.

Data from the Third National Health

and Nutrition Examination Survey

(NHANES) reveal that almost half of

the cases of early childhood asthma,

chronic bronchitis, and wheezing

result from secondhand cigarette

smoke. Gergen, Fowler, Maurer,

Pediatrics Electronic Pages 101(2):E8,

http://www.pediatrics.org (AHRQ

Publication No. 98-R033)*

(Intramural). 

6
Attention

Deficit/Hyperactivity

Disorder

Attention deficit/hyperactivity

disorder (ADHD) is a psychiatric

disorder distinguished by symptoms

of inattention, hyperactivity, and

impulsivity, and it may be

accompanied by learning disabilities,

depression, anxiety, conduct disorder,

and oppositional defiant disorder.

ADHD is one of the most common

childhood-onset disorders, with a

prevalence rate of approxiately 4

percent to 12 percent for school-aged

children. AHRQ has supported the

development of evidence reports on

the diagnosis and treatment of

ADHD, research on the costs

associated with the disorder, and

efforts to improve quality of care for

ADHD.

Research in Progress

• Workshops will facilitate

applications of research to practice.

This conference grant supports a

series of learning opportunities to

improve care for children with

attention-deficit/hyperactivity

disorder (ADHD). The goal is to

promote the translation of the

evidence about the diagnosis and

treatment of ADHD into clinical

practice. Charles Homer, Principal

Investigator (AHRQ grant

HS12070).

• Study examines use of computers in

caring for children with ADHD.

The researchers will develop and

evaluate a computerized system for

laptop use in the examining room to

improve the care of children with

ADHD. Paula Lozano, Principal

Investigator (AHRQ grant

HS11859).

• New tools are being developed to

help families cope with ADHD.

Researchers are developing tools for

families with children who have

ADHD to help them coordinate the

child’s care and inform parents,

teachers, and health providers.

Clinical Tools, Inc., Chapel Hill, NC

(AHRQ contract 290-99-0008).

Recent Findings

• Costs are similar for ADHD and

asthma.

Data from the 1996 Medical

Expenditure Panel Survey reveal

annual health care costs for children

with ADHD and asthma were $479

and $437 more than the those of the

general population of children. Chan,

Zhan, and Homer, Arch Pediatr

Adolesc Med 156:504-511, 2002

(AHRQ Publication No. 02-R074).*

• Evidence report focuses on children

with ADHD.

Researchers assessed the effectiveness

and long- and short-term safety of

pharmacological and

nonpharmacological interventions for

ADHD. Copies of the report

summary (AHRQ Publication No.

99-E0017) and full report, Treatment

of Attention-Deficit/Hyperactivity

Disorder (AHRQ Publication No. 00-

E005), are available from AHRQ*

(AHRQ contract 290-97-0017).

• AHRQ technical review focuses on

the screening tests used to diagnose

ADHD.

The researchers identified several

rating scales that effectively

discriminate between ADHD

children and normal controls. Broadband behavior rating scales were

ineffective in identifying ADHD

children, as were imaging procedures

(CT, CAT scan, MRI) and

neurological screening tests. Copies of

the summary (AHRQ Publication

No. 99-0049) and technical review,

Diagnosis of AttentionDeficit/Hyperactivity Disorder (AHRQ

Publication No. 99-0050), are

available from AHRQ* (AHRQ

contract 290-94-2024).

Chronic Illnesses

Approximately 20 million children

suffer from at least one chronic health

condition. Of the 200 chronic

conditions and disabilities that affect

young people, AHRQ’s current

research focuses most predominantly

on diabetes, cerebral palsy, respiratory

problems, and traumatic brain injury.

For a description of projects and

findings on other chronic illnesses, see

the sections on asthma, ADHD, and

mental health in this program brief.

Recent Findings

• Palliative care services should be

partially hospital based.

In examining the characteristics of

deaths occurring in children’s

hospitals, researchers find that

children with complex chronic

conditions are in the hospital longer

and spend longer periods on

mechanical ventilation than other

children and could benefit from

hospital-based palliative care services.

Feudtner, Christakis, Zimmerman, et

al., Pediatrics 109(5):887-893, 2002

(AHRQ grant K08 HS00002).

• Multidisciplinary care did not

prevent adverse outcomes among

children with type-1 diabetes.

Researchers assessed how glycemic

control and the frequency of glycemic

monitoring affected the incidence of

adverse events, hospitalizations, and

emergency room visits of 300

youngsters with type-1 diabetes.

Despite multidisciplinary care,

glycemic control did not improve

during the 1-year study period, and

participants were hospitalized three

times as often as the general pediatric

population. Levine, Anderson, Butler,

et al., J Pediatr 139:197- 203, 2001

(NRSA training grant T32

HS00063).

• Children with diabetes can learn to

live well, despite the ever-present

risk of serious illness and death. 

Attitudes of juvenile diabetes patients

toward their illness early in its course

can lead to emotional and ethical

predicaments involving issues of

control, stigma, risk, and

responsibility. Because advances in

medical therapy will keep patients

with chronic diseases living longer in

7
states of “dangerous safety,” the

inescapable threat of illness and death

needs to be integrated into the

concept of a well-lived life. Feudtner,

Cult Med 173:64-67, 2000 (AHRQ

training grant T32 HS00009 and

HS07476).

• Medicaid-insured children with

chronic diseases receive most of their

care from generalist physicians.

To calculate annual rates of generalist,

subspecialist, and pediatric

subspecialist use, investigators

analyzed Medicaid claims data for

over 57,000 children and adolescents

with 11 chronic conditions. Findings

show that Medicaid-insured children

with chronic diseases received most of

their care from generalists. Kuhlthau,

Ferris, Beal, et al., Pediatrics

108(4):906-912, 2001 (AHRQ grant

HS09416).

• Evidence report discusses

rehabilitation for traumatic brain

injury (TBI) in children.

Researchers examined the

effectiveness of early, intensive

rehabilitation; the use and outcomes

of special education; the role of

developmental stage as a predictor of

problems resulting from TBI; and the

ability of support services to improve

family coping and alleviate the

burden of illness. The report

summary (AHRQ Publication No.

99-E025) and full report,

Rehabilitation of Traumatic Brain

Injury in Children and Adolescents

(AHRQ Publication No. 00-E001),

are available from AHRQ* (contract

290-97-0018).

• Medications are the third-largest

health care expense for children

infected with HIV.

An analysis of medical costs for 100

children with AIDS and 41 children

with HIV revealed that medications

constitute the third-largest expense.

The largest expenses are for hospital

stays and outpatient services. Hsia,

AIDS Care 10(6):761-770, 1998

(AHRQ Publication No. 99-R031)*

(Intramural). 

• Costs are high for families that have

children with diabetes.

Questionnaires were sent to 197

families with a diabetic child and 142

families with no diabetic children.

More than 60 percent of affected

families reported having to pay a

deductible for either insulin, syringes,

or blood-testing strips; more than 85

percent paid a copayment for these

items. Songer, LaPorte, Lave, et al.,

Diabetes Care 20(4):577-584, 1997

(NRSA Fellowship F32 HS00038). 

Costs, Use, and Access to

Care

AHRQ’s research indicates that as

many as 11 million U.S. children

ages birth to 18 are uninsured.

Obtaining adequate access to care

and maintaining a usual source of

care are special challenges for these

young people and their families.

There also are significant racial and

ethnic differences in children’s access

to health care that cannot be

explained by insurance and

socioeconomic factors alone.

Research in Progress

• Barriers faced by vulnerable

children are being identified.

Researchers aim to measure

modifiable barriers to care that affect

the link between vulnerability factors

and health care structures, processes,

and outcomes for children with

special health care needs. English and

Spanish versions of a Barriers to Care

Questionnaire also will be developed.

Michael Seid, Principal Investigator

(AHRQ grant HS13058). 

• Study will examine family status

and child mental health.

This project will examine the

socioeconomic status of families,

mental health conditions of children,

and related services for children.

Michael Ganz, Principal Investigator

(AHRQ grant HS13047).

• Project assesses family experiences in

managing health needs.

The goal of this project is to provide

qualitative information about

managing the health care needs of

vulnerable children in San Diego.

The focus will be on health needs,

use of services, problems in using

care, and proposals for improving

health care services. Michael Seid,

Principal Investigator (AHRQ grant

HS11751).

• Study will evaluate risk-assessment

instruments.

Investigators will determine the

sensitivity of risk assessment models

that identify expected costs and use of

managed care plans, if disincentives

for enrollment exist, and whether

additional information improves the

predictive performance of risk

assessment instruments. Paul

Fishman, Principal Investigator

(AHRQ grant HS11314).

• Studies in the Child Health

Insurance Research Initiative

(CHIRI) are focusing on ways that

public health insurance programs

and health care delivery systems can

improve quality and access for lowincome children.

In 1999, AHRQ in partnership with

the Health Resources and Services

Administration and the David and

Lucile Packard Foundation funded

nine 3-year projects to examine ways

to improve health care for lowincome children receiving care

through publicly funded programs,

including the State Children’s Health

Insurance Program (SCHIP).

Funding for these projects will total

$9.1 million over 3 years. The

projects, which are dispersed around

the country, will identify which

health insurance and delivery features

work best for low-income, minority,

and special-needs children. The

projects and principal investigators

are:

– Access and Quality of Care for

Low-Income Adolescents, 

Elizabeth Shenkman, University

of Florida, Gainesville.

8
– Analysis of Fee-for-Services vs. Managed Care for Children with Special Health Care Needs, Elaine Beane, Michigan Public Health Institute, Ann Arbor.

– Evaluation of Kansas Healthwave, Robert St. Peter,

Kansas Health Institute, Topeka.

– Health Care Access, Quality, and Insurance for Children with Special Health Care Needs, Nancy Swigonski, Indiana University, Indianapolis.

– Impact of Publicly Funded

Programs on Child Safety Nets, Peter Budetti, Northwestern University, Evanston, IL.

– Medicaid vs. Premium Subsidy:

Oregon’s CHIP Alternatives, Janet Mitchell, Center for Health Economics Research, Waltham, MA.

– New York’s SCHIP: What

Works for Vulnerable Children,

Peter Szilagyi, University of Rochester, Rochester, NY.

– Provider Participation and Access

in Alabama and Georgia, Janet

Bronstein, University of Alabama

at Birmingham.

– Responsiveness of SCHIP to

Children with Special Health

Care Needs, Sara Rosenbaum, George Washington University, Washington, DC (funded by

HRSA’s Maternal and Child Health Bureau).

Recent Findings • Adolescents in skipped-generation

families are most likely to be

uninsured.

A study of the health insurance

status of a nationally representative

sample of 17,670 middle and high

school students reveals that

adolescents who live outside of twoparent families are significantly more

likely to have been uninsured than

adolescents in two-parent families. Adolescents living in households

headed by grandparents are most

likely to be uninsured. Kirby and

Kaneda, Med Care Res Rev

59(2):146-165, 2002 (AHRQ Publication No. 02-R073)*

(Intramural). • Limited English proficiency

hinders enrollment in State Medicaid programs.

Families who are not proficient in

the English language have more

difficulty enrolling in State Medicaid health insurance

programs, according to a survey of

1,055 parents. Compared with English-proficient families, they

were more likely not to know if they

were eligible or how to enroll in Medicaid and to find the enrollment

forms too difficult. Feinberg, Swartz, Zaslavsky, et al., Maternal and Child Health Journal 6(1):5-18, 2002

(AHRQ grant HS10207). • Georgia’s SCHIP enrollees have

better access to care than its Medicaid-insured children.

Based on responses to the

Consumer Assessment of Health Plans Study Medicaid-Managed

Care Child Survey, researchers report that children enrolled in Georgia’s Medicaid program have

worse access to health care than

children enrolled in Georgia’s

SCHIP. Both programs have nearly

identical rules and providers, and results were corroborated by focus

groups with physicians and parents. Edwards, Bronstein, and Rein, Health Affairs 21(3):240-248, 2002

(AHRQ grant HS10435). • Passive reenrollment policies

contribute to a lower SCHIP

disenrollment rate.

Kansas, New York, and Oregon require parents to periodically verify

their children’s eligibility. Florida’s

passive policy requires notification

only if changes occur that affect

eligibility for SCHIP. At reenrollment, this study found only

5 percent of children in Florida’s

SCHIP were disenrolled compared

with one-third to one-half of those

in the other States. Dick, Allison, Haber, et al., Health Care Financing

9
Review 23(3):65-88, 2002 (AHRQ Publication No. 02-R070)*

(Intramural). • Expanding income eligibility does

not increase unmet needs.

Researchers evaluated a Statefinanced health insurance program

that provided coverage to children regardless of income before

implementation of SCHIP. They

found inclusion of higher income

children benefits a larger group of

children without substantially

changing health service use in the

program. Feinberg, Swartz, Zaslavsky et al., Pediatrics

109(2):2002, online at

www.pediatrics.org/cgi/content/full/

109/2/e29 (AHRQ grant

HS10207). • State insurance does not “crowd

out” private insurers. 

Telephone surveys of 996

parent/guardians of children

enrolled in the Massachusetts

Children’s Medical Security Plan

(CMSP) revealed that access to

employer-sponsored insurance (ESI)

was limited (19 percent), and

uptake was low (13 percent). Few

children who had ESI at enrollment

dropped this coverage to enroll in

CMSP. Feinberg, Swartz, Zaslavsky,

et al., Health Serv Res 36(6) (online

only), 2001 (AHRQ grant

HS10207). • Medicaid expansions were relatively inexpensive. Researchers analyzed 1984 to 1994 State Medicaid spending to

determine the cost of Medicaid

expansions for children. They found

that the expansions had relatively

low incremental costs per enrollee

and were substantially below the

average Medicaid expenditure for

children. Gordon and Selden, Med

Care Res Rev 58(4):482-495, 2001

(AHRQ Publication No. 02-R033)*

(Intramural). • Market forces prompt evolution of

children’s hospitals.

Chief executive officers of 29

children’s hospitals responded to a

survey on the impact of market

changes from 1991 through 1996.

They note that hospitals experienced

changes in mission, movement

toward more outpatient care, a

decline in lengths of stay, and an

increase in marketplace competition. Yee, Shelton, Girouard, et al., Ambulatory Pediatr 1(2):117-121,

2001 (NRSA training grant T32

HS00063). • A regular source of care helps to

ensure appropriate service.

Middle and high school students in rural areas were surveyed regarding

their health status and use of health

care services. Those with no regular

source of care were much less likely

to obtain preventive or acute care

than those with a regular source of

care. Ryan, Riley, Kang, et al., Arch Pediatr Adolesc Med 155:184-190,

2001 (AHRQ grant HS07045). • Use of health services involves

significant out-of-pocket

expenditures for some families.

Data from AHRQ’s 1996-1998 Medical Expenditure Panel Survey

(MEPS) were used to analyze

insurance coverage and health

expenditures for children and youths, newborn to age 17.

Although private health insurance

was the largest payer, nearly 21

percent of expenditures were covered

directly by families. McCormick, Weinick, Elixhauser, et al., Ambulatory Pediatrics 1(1):3-15,

2001 (AHRQ Publication No. 01-

R036)* (Intramural). • Children who are eligible for

public insurance programs often

are not enrolled.

Although nearly 90 percent of

children had some form of health

insurance in 1996, 15.4 percent of

children were uninsured at any

given point in time. White children

were more likely to have insurance

than minority children; Hispanic

children were least likely to be

insured. Many children who were

eligible for public insurance (e.g., Medicaid) were not enrolled.

10

McCormick, Kass, Elixhauser, et al.,
Pediatrics 105:219-230, 2000

(AHRQ Publication No.00-R014)*

(Intramural).

• Costs of treating Medicaid-insured

and commercially insured children

are similar.

Researchers compared the use of

services and costs for treating

Medicaid-insured children and

commercially insured children in a

large nonprofit health maintenance

organization. They concluded that

treatment costs did not differ

significantly between the two groups,

and that States enrolling Medicaid

recipients in managed care plans may

need to adopt reimbursement levels

comparable to rates for commercially

insured patients. Ray, Lieu, Weinick,

et al., Am J Managed Care 6:753-760,

2000 (AHRQ Publication No. 00-

R044)* (Intramural).

• Changes in State rules and processes

for public insurance could improve

coordination and outreach.

Two reports examine efforts to

increase enrollment in public health

insurance programs that serve

children. The first report describes

administrative strategies that could

promote coordination between

Medicaid and SCHIP. Mann, Cox,

and Cohen-Ross, Making the Link:

Strategies for Coordinating Publicly

Funded Health Care Coverage for

Children (AHRQ Publication No.

00-0014)* (AHRQ contract 290-98-

0009). The second report presents

the results of a review of evidence on

pre-SCHIP outreach efforts. Barents

Group, Review of the Literature on

Evaluations of Outreach for Public

Health Insurance and Selected Other

Programs (AHRQ Publication No.

OM 00-0006)* (AHRQ contract

290-96-0004).

• Proportion of privately insured

children declined between 1977

and 1996.

Between 1977 and 1996, the

proportion of publicly insured

children grew from 13.5 to 19.7

percent, the proportion with no

insurance increased from 12.7 to

15.1 percent, and the proportion of

children with private coverage

decreased from 73.8 to 65.2 percent.

Weinick and Monheit, Med Care Res

Rev 56(1):55-73, 1999 (AHRQ

Publication No. 99-R051)*

(Intramural).

• The daily practice of children’s

primary care is changing.

Using data from the National

Ambulatory Care Surveys from 1979

to 1994 (58,000 visits), investigators

concluded that primary care

physicians were spending slightly

more time with young patients in

1994 than they did in 1979. They

also are providing increased

preventive services and counseling

and are prescribing antibiotics and

the stimulant Ritalin more often.

Ferris, Saglam, Stafford, et al., Arch

Pediatr Adolesc Med 152:227-233,

1998 (AHRQ grant HS07892).

• Outpatient capacity and access to

primary care play a role in out-ofarea hospitalizations.

Children who live in areas with more

primary care physicians and hospitalbased outpatient services are less

likely to go to hospitals outside their

local area for ambulatory-caresensitive conditions such as asthma

and diabetes. Greater severity of

illness, distance to a metropolitan

area, and a higher county median

income increase the likelihood of outof-county care. Basu and Friedman,

Health Econ 10:67-78, 2001 (AHRQ

Publication No. 01-R033)*

(Intramural).

• Parental inability to speak English

creates a substantial barrier to

health care.

Researchers found that parents’

inability to speak English well

enough to fully interact with health

care providers creates disadvantages

for their children in accessing care.

Interpreters or bilingual providers

and office staff would help to help

reduce disparities. Weinick and

Krauss, Am J Public Health 90:11-14,

2000 (AHRQ Publication No. 01-

R008)* (Intramural).

• Doctors with many patients in

gatekeeping plans tend to refer their

patients to specialists.

Researchers found that gatekeeping

arrangements nearly double the odds

of patient referrals from pediatricians’

offices to specialty care, even though

coordinating referrals made during

office visits is more difficult for

patients in gatekeeping plans. Forrest,

Glade, Starfield, et al., Pediatrics

104(1):28-34, 1999 (AHRQ grant

HS08430).

Emergency

Care/Hospitalization

Current studies are focused on

evaluating specific units within

hospitals and identifying

commonalities between frequent

users of these facilities. Researchers

also hope to expedite decisionmaking

by providing evidence-based

solutions.

Research in Progress

• Conference aims to improve practice

through research.

Pediatric emergency medicine

investigators learned about concepts

in outcomes research, reviewed

measures, determined their

applicability, identified where new

measures are needed, and promoted

dialogue with researchers of other

disciplines. Several conference papers

were published in Ambulatory

Pediatrics, July 2002, volume 2,

number 4, including the paper “The

importance of outcomes research in

pediatric emergency medicine”

(AHRQ Publication No. 02-R087)

by AHRQ’s Carolyn Clancy, Denise

Dougherty, and Elinor Walker.**

Ellen Crain, Principal Investigator

(AHRQ grant HS10942).

• Researchers are developing a triage

instrument.

The Pediatric Emergency Assessment

Tool, now under development, is

intended to help emergency room

11
clinicians triage pediatric patients to

the appropriate level of emergency

care. Marc Gorelick, Principal

Investigator (AHRQ grant

HS11028).

• Findings on quality and severity are

being applied in a pediatric

emergency setting.

A pediatric emergency department

severity system is being validated and

applied to a quality-of-care

evaluation. Murray M. Pollack,

Principal Investigator (AHRQ grant

HS10238).

• Researchers examine adolescents’

functional outcomes after trauma.

This study is identifying risk factors

for functional limitations after major

trauma in adolescents and assessing

their degree of disability, quality of

life, and psychological well-being.

Troy Holbrook, Principal Investigator

(AHRQ grant HS09707).

Recent Findings

• Three factors predict severity of car

crash injuries.

Emergency medical technicians can

identify seriously injured children and

properly triage them to trauma

centers if at the car crash site they

evaluate a child’s degree of

consciousness, extent of passenger

space intrusion, and appropriate use

of a seatbelt or other restraint.

Newgard, Lewis, and Jolly, Ann

Emerg Med 39(1):481-491, 2002

(NRSA grant F32 HS00148). 

• Nurses can be trained to recognize

suicide risk in an emergency

department.

After attending educational sessions

on psychiatric issues and learning

about the Suicide Risk

Questionnaire, nurses were better

equipped to manage potentially

suicidal children in the emergency

department. Horowitz, Smith, Levin,

et al., Pediatr Emerg Care 17(4):306-

309, 2001 (NRSA training grant T32

HS00063). Four simple questions

based on a standard 30-item Suicide

Ideation Questionnaire helped the

ER triage nurses identify 98 percent

of children at risk for suicide.

Horowitz, Wang, Koocher, et al.,

Pediatrics 107(5):1133-1137, 2001

(NRSA training grant T32

HS00063).

• Quality and research are key themes

of conference.

This report describes a national

conference on childhood

emergencies. Participants emphasized

quality improvement and research.

Jane Ball, Principal Investigator

(AHRQ grant HS10084), National

Congress on Childhood Emergencies,

2000 (Final Report, NTIS Accession

No. PB2001-102808).**

• Children with special health care

needs are much more likely to use

emergency medical services than

other children.

A study of how Utah children used

emergency medical services (EMS)

and related hospital care found that

children with special health care

needs—for example, congenital

anomalies or birth-related

conditions—use more EMS than

other children, are more likely to be

admitted to the hospital and have

longer stays, and usually incur greater

hospital charges. Suruda, Vernon,

Diller, et al., Prehosp Emerg Care

4(2):131-135, 2000 (AHRQ grant

HS09057).

• No significant differences in

outcomes were found between two

emergency breathing procedures—

endotracheal intubation (ETI) and

bag-valve-mask ventilation.

Nearly all (97 percent) paramedic

training programs teach ETI. Until

this study, however, there were no

data associating improved patient

survival or other positive outcomes

with its use. These researchers

compared pediatric ETI with bagvalve-mask ventilation in 830

children and found no significant

differences in survival or neurological

outcome between the two

approaches. Gausche-Hill, Lewis,

Gunter, et al., Ann Emerg Med

36(4):356-365, 2000 and Gausche,

Lewis, Stratton, et al., JAMA

283(6):783-790, 2000 (AHRQ grant

HS09166).

• Mortality and functional outcomes

data are needed to evaluate

pediatric intensive care units

(PICUs).

Researchers examined the

relationships between illness severity,

length of stay, and functional

outcomes among 11,106 patients at

16 PICUs across the United States.

Because mortality is a relatively rare

event, by itself it probably is not a

sufficient indicator of outcomes for

PICUs but should be combined with

other findings. Fiser, Tilford, and

Roberson, Crit Care Med 28(4):1173-

1179, 2000 (AHRQ grant

HS09055).

• High-volume PICUs have better

outcomes than low-volume units.

A study of patient volume and its

relationship to risk of death and

length of stay in 16 PICUs revealed

that higher patient volume is

consistent with lower mortality rates

and shorter stays. Tilford, Simpson,

Green, et al., Pediatrics 106:289-294,

2000 (AHRQ grant HS09055).

• Handlebars cause major abdominal

injuries in minor bicycle falls.

Researchers studied the records of

children age 18 and younger who had

been treated for serious bicyclerelated injuries at an urban pediatric

trauma center. About 77 percent of

the handlebar-related injuries resulted

from minor crashes. Winston, Shaw,

Kreshak, et al., Pediatrics 102(3):596-

601, 1998 (AHRQ grant HS09058).

Mental Health

Despite the debilitating nature and

prevalence of mental health problems

in children, many disorders continue

to be under-diagnosed and

inadequately treated. AHRQ-funded

research focuses on improving

delivery of mental health care in

general health care.

12
Research in Progress

• Study evaluates an intervention for

oppositional defiant disorder.

Researchers are evaluating the

effectiveness of using a psychological

intervention in primary care pediatric

settings to help identify and treat

preschool children with oppositional

defiant disorder (ODD). The study

also will evaluate how well a 10-week

training program on parenting skills

reduces the incidence of ODD and

the use of ambulatory and ER care.

John V. Lavigne, Principal

Investigator (AHRQ/NIMH grant

MH59462).

• Investigators explore better ways to

treat depressed teens.

This study is testing whether

adolescents who receive

psychotherapy and medication are

more likely than those given

medication alone to adhere to

medication instructions, recover faster

from initial depression, stay in

remission longer, function better

socially and academically, and be

more satisfied with their treatment.

Gregory N. Clarke, Principal

Investigator (AHRQ grant

HS10535).

• Researchers evaluate an intervention

for depressed youths.

This study involves an intervention to

treat depression in adolescents and

young adults in primary care settings.

Effects are being compared for

indicators including usual care,

quality of care, satisfaction with care,

clinical symptoms, daily functioning,

service use and cost, and parental

psychological distress. Joan Asarnow,

Principal Investigator (AHRQ grant

HS09908).

Recent Findings

• More primary care physicians are

prescribing psychotropic

medications.

An analysis of 1995-1999 claims data

and calculation of the prevalence of

antidepressant use for children with

depression or attention

deficit/hyperactivity disorder reveal an

increase in use of serotonin selective

reuptake inhibitors and central

nervous system stimulants, a decrease

in use of tricyclic antidepressants, and

an increase in other antidepressants.

Also, more pediatricians and family

doctors are prescribing these drugs,

despite their limited training in this

area. Shatin and Drinkard,

Ambulatory Pediatrics 2:111-119,

2002 (AHRQ grant HS10397).

• Affective disorders in children often

go undetected and untreated in

primary care.

Researchers examined how primary

care providers treat affective disorders

in children and adolescents. They

found that pediatricians identified

mental health needs in only 1 to 16

percent of children, even though 17

to 27 percent of pediatric primary

care patients may need care. Wells,

Kataoka, and Asarnow, Biol Psychiatry

49(12):1111-1120, 2001 (AHRQ

grant HS09908).

• Family stress contributes to the use

of services.

In this study, mothers of 4,000

disabled children ages 6-17 reported

on their children’s health,

psychosocial problems, and mental

health services use, as well as the

services provided by health care

coordinators. Family stressors were

found to be strongly associated with

children’s poor psychosocial

adjustment and mental health care

use. Whitney P. Witt, Principal

Investigator (AHRQ grant

HS11254), Family Influences on

Children’s Health and Health Care

(Final Report, NTIS Accession No.

PB2002-100381).**

• Youths with dual diagnoses need a

specialized approach. 

An analysis of data on 564 youths in

residential treatment and State

custody examined clinical

characteristics and placement

outcomes. Researchers recommend

screening youths entering residential

treatment for type and severity of

substance use problems and tailored

services to ensure close supervision

and monitoring of high-risk

behaviors. Weiner, Abraham, and

Lyons, Psychiatr Serv 52(6):793-799,

2001 (NRSA training grant T32

HS00078).

• Monographs cover children’s mental

health issues.

Two monographs, produced by the

Children’s Mental Health Alliance,

focus on children’s mental health

issues. The first covers best practices,

approaches, outcomes, and

professional responsibilities across

systems of care. Steinberg, Children’s

Mental Health: The Changing

Interface Between Primary and

Specialty Care (AHRQ grant

HS09813). (AHRQ Publication No.

00-R040).* The second monograph

examines children’s access to and use

of mental health services. Leonard

Davis Institute of Health Economics

Issue Brief—Children’s Mental Health:

Recommendations for Research,

Practice, and Policy 7(5), 2000

(AHRQ grant HS09813) (AHRQ

Publication No. 00-R042).*

• Children who suffer traffic injuries

may develop posttraumatic stress

disorder (PTSD). 

Data show that even with minor

injuries following a traffic accident,

children and their parents are at risk

for developing PTSD. Researchers

interviewed parents from 102 families

in which children had suffered trafficrelated injuries; 25 percent of the

children and 15 percent of parents

suffered PTSD. De Vries, KassamAdams, Cnaan, et al., Pediatrics

104(6):1293-1299, 1999 (AHRQ

grant HS09058).

Newborns and Infants

Four million babies are born each

year in the United States. AHRQ’s

current research focuses on improving

the babies’ health outcomes,

preventing jaundice, and reducing

racial and ethnic disparities in access

to care.

13
Research in Progress

• Researchers are assessing the

economic impact of breastfeeding

promotions.

Using a randomized controlled trial,

researchers are comparing the effects

of pre- and postnatal breastfeeding

promotions on child health care costs,

breastfeeding practices, and

outcomes. Karen A. Bonuck,

Principal Investigator (AHRQ grant

HS10900).

• Study will test the transferability of

a simulation program.

Investigators will determine whether

the skills acquired in a simulated

environment can be practiced in

delivery rooms. Findings will be used

to improve the technical and

behavioral performance of health

professionals caring for mothers and

babies. Louis P. Halamek, Principal

Investigator (AHRQ grant

HS12022).

• Two studies focus on racial/ethnic

variations in managing prematurity

and infant mortality.

In the first study, the researchers are

using vital statistics to determine the

relationship between newborn

ethnicity, obstetric volume, and

neonatal intensive care unit volume

in the hospital of birth. Mark

Chassin, Principal Investigator

(AHRQ grant HS10859). In the

second study, the researchers are using

linked birth records, death records,

and hospital discharge abstract data,

to examine racial/ethnic differences in

infant mortality. Martin Shapiro,

Principal Investigator (AHRQ grant

HS10858). 

• Researchers seek to improve quality

of care for newborns with jaundice.

The impact of a QI intervention on

adherence to the American Academy

of Pediatrics’ guidelines for jaundice

management is being assessed. R.

Heather Palmer, Principal Investigator

(AHRQ grant HS09782).

• Standardizing surfactant therapy

for preterm infants.

One of the goals of this QI study is

to reduce morbidity and mortality

among preterm infants by

standardizing use of surfactant

therapy. Jeffrey D. Horbar, Principal

Investigator (AHRQ grant

HS10528).

• Study of neonatal intensive care

addresses regionalization, market

forces, and mortality.

Researchers are assessing differences

in neonatal mortality over time,

focusing on assessing the volume of

newborns in high-risk groups,

comparing insurance coverage with

mortality, and assessing how

competition affects the diffusion of

units into community hospitals.

Ciaran S. Phibbs, Principal

Investigator (NIH/AHRQ grant

HD36914).

• Quality of care measures for highrisk infants are being developed.

This project has three objectives: (1)

develop new methods for measuring

quality of care for very low

birthweight infants, (2) apply the

methods to estimating past and

future quality of care, and (3) apply

measures that summarize quality

differences and economic

performance across time and place.

Jeanette A. Rogowski, Principal

Investigator (AHRQ grant

HS10328).

• Researchers examine outcomes for

moderately premature newborns.

This study focuses on the

epidemiology, treatment, and

outcomes of moderately premature

newborns who are admitted to an

intensive care setting during the birth

hospitalization. Douglas K.

Richardson, Principal Investigator

(AHRQ grant HS10131).

Recent Findings

• Survival of low birthweight infants

is linked to care in neonatal

intensive care units (NICUs).

Birth certificates for 16,732 infants

who weighed less than 4.2 pounds at

birth were linked with hospital

discharge abstracts and death

certificates. Those who were born at

hospitals with no NICUs or

intermediate NICUs had almost

twice the risk of dying of babies born

at hospitals with regional NICUs.

Cifuentes, Bronstein, Phibbs, et al.,

Pediatrics 109(5):745-751, 2002

(AHRQ contract 290-92-0055). 

• Selective testing finds most urinary

tract infections (UTIs).

A study of the urine testing practices

of 573 pediatricians shows many test

the urine of young febrile infants

according to their clinical judgment

rather than the recommended routine

testing. Over half of the 3,066 infants

had their urine tested, and 10 percent

of those had UTIs. Of the 807

infants not initially tested, only 2 had

subsequent documented UTIs.

Newman, Bernzweig, Takayama, et

al., Arch Pediatr Adolesc Med 156:44-

54, 2002 (AHRQ grant HS06485). 

• Market factors are not related to the

offering of neonatal intensive care

(NIC).

Researchers examined how strongly a

hospital’s decision to offer NIC is

associated with teaching status and

market factors. A high hospital

market share of births is not

associated with a higher likelihood of

offering NIC, although the effect of

market share is confounded with

hospital teaching status. Friedman,

Dever, Steiner, et al., J Health Polit

Policy Law 27(3):441-464, 2002

(AHRQ Publication No. 02-R078)*

(Intramural).

• Authors urge the discontinuation of

a biased index. 

The Adequacy of Prenatal Care

Utilization (APNCU) Index, used to

measure resource use, demonstrates

bias with the finding that more

intensive resource use is associated

with poorer birth outcomes.

Investigators recommend

discontinuing use of the APNCU

index because it yields misleading

results. Koroukian and Rimm, J Clin

Epidemiol 55:296- 305, 2002 (NRSA

14 training grant T32 HS00059).
• The long-term health of low

birthweight survivors may be

compromised.

The physical growth and health status

of 154 adolescents who were

extremely low birthweight (ELBW)

infants were examined and compared

with 125 sociodemographically

matched controls. Despite some

catch-up growth, fewer acute health

problems, and less use of medical

services, the former group’s physical

growth continues to be compromised.

Saigal, Stoskoph, Streiner, et al.,

Pediatrics 108(2):407-415, 2001

(AHRQ grant HS08385).

• Method of delivery affects bleeding

problems.

Researchers studied the incidence of

neonatal thrombocytopenia (NT);

incidence of intraventricular

hemorrhage (IVH); and method of

delivery for 1,283 low birthweight

infants. Vaginal delivery involved

nearly three times the risk of IVH

and 11 times the risk of severe NT

during an infant’s first day in the

neonatal intensive care unit. Kahn,

Richardson, and Billett, Amer J

Obstet Gynecol 186:109-116, 2002

(AHRQ grant HS07015).

• Ventilation increases risk of

disabling cerebral palsy (DCP) in

some low birthweight infants.

With a population of 1,105 low

birthweight newborns, researchers

examined ventilatory practices as risks

for cerebral palsy. Results show that

ventilated newborns with low levels

of carbon dioxide in the blood, high

levels of oxygen in the blood, or

unusually prolonged duration of

ventilation support have a two- to

three-fold increased risk of being

diagnosed with DCP by age 2.

Collins, Lorenz, Jetton, et al., Pediatr

Res 50(6):712-719, 2001 (AHRQ

grant HS08385).

• Use of intensive care can pose a

moral dilemma.

Researchers examined two groups of

extremely premature infants in New

Jersey and the Netherlands. Near

universal care in New Jersey (versus

selective initiation of intensive care in

the Netherlands) was associated with

an additional 24.1 survivors, 7.2 cases

of disabling cerebral palsy, and 1,372

ventilator days per 100 live births.

Lorenz, Paneth, Jetton, et al.,

Pediatrics 108(6):1269-1274, 2001

(AHRQ grant HS08385).

• Prevalence of hypotension and

vasopressor use varies.

Researchers evaluated differences in

the prevalence of hypotension and

hypertension among 1,288 very low

birthweight infants at six neonatal

intensive care units (NICUs).

Hypotensive prevalence ranged from

24 to 45 percent, and NICUs varied

nine-fold in their use of vasopressors.

Al-Aweel, Pursley, Rubin, et al., J

Perinatol 21:272-278, 2001 (AHRQ

grant HS07015).

• Care differs widely despite similarity

of illness.

Researchers used the Pediatric

Comprehensive Severity Index and

patient charts of 601 infants less than

a year old with viral lower respiratory

illness (VLRI) to examine practice

variations in 10 medical centers. They

found that infants with similar illness

severity receive very different care at

different hospitals. A more

conservative approach to treatment of

VLRI in hospitalized infants would

not affect recovery but could reduce

resource use and related costs.

Wilson, Horn, Hendley, et al.,

Pediatrics 108(4):851-855, 2001

(AHRQ contract 290-95-0042).

• Study associates maternal fever with

death of newborns.

Investigators retrospectively analyzed

data from more than 11 million

single live births from 1995 to 1997.

The data show that maternal fever

during labor is strongly associated

with neonatal and infant death.

Petrova, Demissie, Rhoads, et al.,

Obstet Gynecol 98:20-27, 2001

(AHRQ grant HS09788).

• Researchers examine attitudes on

treating extremely premature

newborns.

Researchers examined the attitudes of

parents of ELBW children and

doctors about the desirability of

saving ELBW children. Findings

underscore the importance of parentdoctor decisionmaking. Steiner,

Saigal, Burrows, et al., Pediatrics

108(1):152-157, 2001 (AHRQ grant

HS08385).

• Hospital sepsis evaluations for

infants vary substantially.

Researchers analyzed medical records

of 303 infants. After controlling for

illness severity, infant age, and

pediatric ICU stay, 10 hospitals were

found to vary 46-fold in the

likelihood that an infant would

undergo a sepsis evaluation.

Antonow, Smout, Gassaway, et al., J

Nurs Care Qual 15(3):39-49, 2001

(AHRQ contract 290-95-0042).

• Biological mechanisms contribute to

behavioral problems.

A four-country study of ELBW

babies reveals that 8 to 10 years after

birth, these children suffer from

behavioral difficulties. Central

nervous system insult due to prenatal

or neonatal complications can explain

some of the problems. Hille, den

Ouden, Saigal, et al., Lancet

357:1641-1643, 2001 (AHRQ grant

HS08385).

• Similar patterns of disorders are

found in LBW infants

internationally.

Researchers examined cohorts of very

low birthweight infants in the United

States, Canada, Holland, Germany,

and Jamaica. At school age, all groups

had high rates of disabling cerebral

palsy, mental retardation, school

problems, and behavioral difficulties.

Nigel S. Paneth, Principal Investigator

(AHRQ grant HS08385), Strategies

for Care of the Very Low Birthweight

Infant (Final Report NTIS Accession

No. PB2001-105904).**

15
• Relationship between method of

infant feeding and health care

costs and use depends on several

factors.

A study of 1,374 infants enrolled

in Medicaid found no specific

relationship between method of

feeding—breastfeeding or formula

feeding—and use of health care

services. Although breastfeeding

initially appeared to lower costs

and use of care, preexisting illnesses

and more severe conditions

affected this relationship. Aylin A.

Riedel, Principal Investigator

(AHRQ grant HS10163), Impact

of Infant Feeding Method on Health

Services Costs and Utilization in a

Medicaid Population (Final Report,

NTIS Accession No. PB2000-

107824)**.

• Many low birthweight babies

have learning and behavioral

problems in adolescence.

A review of studies of six cohorts

of infants born in the United

States, Canada, Australia, and the

United Kingdom found that

adolescents who weighed only 2

pounds or less at birth (very low

birthweight) suffer from more

school difficulties and behavioral

problems than their normal

birthweight peers. Extremely low

birthweight (less than 1.6 pounds

at birth) adolescents fared the

worst. Saigal, Semin Neonatology

5:107-118, 2000 (AHRQ grant

HS08385).

• Children with very low

birthweight remain smaller than

their normal-birthweight peers.

Researchers found that adolescents

who weighed 2 pounds or less at

birth, even if they survived without

major neurodevelopmental

disability, continued to be smaller

in height, weight, and head

circumference than peers of normal

birthweight. Peralta-Carcelen,

Jackson, Goran, et al., J Pediatr

136:633-640, 2000 (PORT

contract 290-92-0055). 

• Home visits to low-risk mothers

and newborns cost more than

clinic visits but are equally

effective and increase mother’s

satisfaction.

In a randomized study of 1,163

medically and socially low-risk

mother-newborn pairs, researchers

assigned the pairs to receive either

70-minute home visits by nurses or

20-minute clinic visits with nurse

practitioners or physicians on the

third or fourth postpartum day.

No significant differences were

seen in clinical outcomes between

the groups, but the mothers were

much more satisfied with the

home visits. Lieu, Braveman,

Escobar, et al., Pediatrics

105(5):1058-1065, 2000 (AHRQ

grant HS07910).

• Increasing postpartum hospital

stays may reduce newborn

readmissions and deaths.

In the first of two studies,

researchers compared the

probability of readmission for

newborns who had 39-hour stays

with those who had 51-hour stays.

They found that the 12-hour

increase in length of hospital stay

could reduce the newborn

readmission rate by 0.6 percentage

point. Malkin, Broder, and Keeler,

Health Serv Res 35:1071-1091,

2000. In the second study, the

researchers examined birth, death,

and hospital discharge records of

47,879 newborns and found a

significant association between

early discharge and newborn death.

Delayed diagnosis of curable but

life-threatening conditions was a

major factor in their finding that

infants discharged within 30 hours

of birth were at greater risk of

death than those discharged within

30 to 78 hours. Malkin, Garber,

Broder, et al., Obstet Gynecol

96:183-188, 2000 (AHRQ grant

HS09342).

• Clinicians should give high

priority to parents’ wishes in

decisions about neonatal care.

A study of ELBW adolescents and

their parents found that despite

severe disabilities, parents—and

ELBW adolescents themselves—

believe these young people have a

decent quality of life. Saigal, Clin

Perinatology 27(2):403-419, 2000

(AHRQ grant HS08385).

• Physicians may underestimate

preterm infants’ outcomes.

Pediatricians and obstetricians who

are pessimistic about the outcomes

of premature infants tend to

underestimate their actual chances

of survival and freedom from

serious handicap and may be less

likely to use potentially lifesaving

therapies. Morse, Haywood,

Goldenberg, et al., Pediatrics

105(5):1046-1050, 2000 (PORT

contract 290-92-0055).

• Comprehensive followup care

reduces life-threatening illnesses

and improves outcomes.

When high-risk inner-city infants

received comprehensive followup

care, 47 percent fewer of them

died or developed life-threatening

illnesses that required admission

for pediatric intensive care,

compared with infants who did

not receive comprehensive

followup care. Broyles, Tyson,

Heyne, et al., JAMA 284:2070-

2076, 2000 (AHRQ grant

HS06837).

• Longer hospital stays for

newborns may not affect

readmission rates for jaundice.

This study found that current laws

mandating insurance coverage for

48-hour maternal and infant stays

may not be the most effective way

to prevent hospital readmission for

jaundice and its complications.

Grupp-Phelan, Taylor, Liu, et al.,

Arch Pediatr Adolesc Med

153:1283-1288, 1999 (NRSA

training grant T32 HS00034). 

16
•

Researchers develop model for

treating infants with high fevers.

These researchers documented

clinical practices and costs of care

for infants with fever, and developed

an optimal clinical prediction

model. They used data collected by

577 pediatricians on 3,066 infants

less than 3 months old who had a

fever of at least 100.2 ̊F. Robert H. Pantell, Principal Investigator

(AHRQ grant HS06485), PROs Febrile Infant Study (Final Report,

NTIS Accession No. PB2000-

100683).**

Oral Health

In order to reverse trends of under

use and disparities in oral care for

children, researchers are studying

incentives to improve access to and

delivery of care.

Research in Progress • Study assesses effects of public

insurance on use of pediatric

dental services.

This researcher is studying the

dental health status, use of dental

services, and effectiveness of

established pediatric oral health

performance measures for children

enrolled in the North Carolina

Medicaid or State Children’s Health Insurance Program. Tegwyn L. Hughes, Principal Investigator

(AHRQ grant HS11514). • How do Federal programs affect

use and cost of services?

This dissertation research project

involves costs to the Medicaid

program and use of dental health

services for children and the role of

the Women, Infants, and Children’s

(WIC) Supplemental Food Program

in helping to help increase oral

health access for Medicaid children. Jessica Y. Lee, Principal Investigator

(AHRQ grant HS11607).

Recent Findings • Dental expenses of poor and

minority children are low

compared with other population

groups.

Data from the 1996 Medical Expenditure Panel Survey show that

white children make up to 66

percent of the child population and

incur 86 percent of dental

expenditures. Black and Hispanic

children each make up 17 percent of

the population and incur about 6

and 8 percent of dental

expenditures, respectively. Dental

expenses for poor, middle-income,

and high-income children account

for 8, 43, and 41 percent respectively. Edelstein, Manski, and

Moeller, Pediatr Dent 24(2):11-17,

2002 (AHRQ Publication No. 02-

R062)* (Intramural). • Researchers characterize 10 years

of dental expenditures for children.

A comparison of data from the

1987 National Medical Expenditure

Survey and the 1996 Medical Expenditure Panel Survey indicates

that disparities in dental care

expenses between poor and higher

income children and among

minority and white children are

shrinking. Wall, Brown, and Manski, J Am Dent Assoc 133:474-

482, 2002 (AHRQ Publication No.

02-R069)* (Intramural). • School-based dental sealant

program reduces decay and tooth

loss among poor children.

A cost-effectiveness analysis was

conducted on a school-based dental

sealant program for lowsocioeconomic-status children in

New York. Despite having more

untreated cavities than the control

group (78 vs. 66 percent), the

sealant group experienced fewer

cavities (2.2 vs. 6.8), no loss of

permanent teeth (0 vs. 6), and fewer

decayed and filled surfaces (62 vs.

159). Zabos, Glied, Tobin, et al., J

Health Care Poor Underserved

13(1):38-48, 2002 (AHRQ and

HRSA interagency agreement).

17
• Ca

regivers recount barriers to

obtaining care.

Researchers examined comments

about dental care from an ethnically

diverse group of 77 caregivers who

participated in 11 focus groups.

Participants identified barriers to

making appointments for their

Medicaid-insured children, as well

as barriers at the dental setting, such

as long waiting times and

judgmental, disrespectful, and

discriminatory behavior from staff

and providers. Mofidi, Rozier, and

King, Am J Public Health 92(1):53-

58, 2002 (NRSA training grant T32

HS00032). • Poor and minority children

experience substantial service

disparities in dental care.

Investigators analyzed dental visits

among U.S. children by category of

service and sociodemographic

factors using 1996 Medical Expenditure Panel Survey data. For

every type of dental service, use was

higher among white children than

among black and Hispanic children

and among non-poor children than

among poor children. Macek, Edelstein, and Manski, Pediatr Dent

23(5):383-389, 2002 (AHRQ Publication No. 02-R045)*

(Intramural). • Consuming sugared soda does not

increase cavities in children and

teens. 

Using data from the 1988-1994

Third National Health and Nutrition Examination Survey, researchers examined associations

between dental cavities and soda

consumption. Children aged 12 to

16 drank an average of 9 to 12

ounces of soda a day, those aged 6

to 11 drank about 6.5 ounces a day,

and those aged 2 to 5 drank an

average of 2.3 ounces a day. No

differences in decayed, missing, and

filled permanent tooth surfaces were

found. Heller, Burt, and Eklund, J

Dent Res 80(10):1949-1953, 2001

(AHRQ grant HS09554). 

•Income affects the number of

preventive dental visits made. 

These researchers calculated national

estimates for preventive dental visits

by poor and near-poor youths. Such

visits were only about half as likely

among poor and near-poor youngsters as they were among young people in middle or high

income families across racial/ethnic

groups. Watson, Manski, and Macek, J Am Dent Assoc 132:1580-

1587, 2001 (AHRQ grant

HS10129) (AHRQ Publication No.

02- R034)* (Intramural). • Sealants save Medicaid money for

children prone to cavities.

Researchers assessed dental

experiences of 15,438 children

enrolled in the North Carolina Medicaid program from 1985 to

1992. They found savings in Medicaid expenditures related to

sealant use within 2 years of

application for children with two or

more prior caries-related services

involving the occlusal surface. Weintraub, Stearns, Rozier, et al.,

Am J Public Health 91(11):1877-

1881, 2001 (AHRQ grant

HS06993). • Study reveals the impact of

insurance on dental visits.

Using data from the 1996 Medical Expenditure Panel Survey, researchers found that Medicaidinsured children are more likely

than uninsured children to visit a

dentist but not as likely as privately

insured children. Manski, Edelstein,

and Moeller, J Am Dent Assoc

132:1137-1145, 2001 (AHRQ Publication No. 01-R083)*

(Intramural). • Age and sociodemographic

differences exist in dental visits.

An analysis of data on the civilian,

community-based U.S. population

during 1977, 1987, and 1996 was

conducted. Children aged 6 to 18

had higher dental use rates than any

other age group. Manski, Moeller,

and Maas, J Am Dent Assoc

132:655-664, 2001 (AHRQ

18
Publication No. 01-R068)*

(Intramural).

• Review demonstrates benefits of

preventive oral care in children.

Studies show that by mid-childhood,

more than 50 percent of children

have dental caries; by late adolescence

about 80 percent have caries.

Researchers say the infectious nature

of dental caries, their early onset, and

the potential of early interventions

require an emphasis on preventive

oral care in primary pediatric care to

complement existing dental services.

Mouradian, Wehr, and Crall, JAMA

284(20):2625-2631, 2000 (AHRQ

purchase order R40281601D).

• Applying fluoride during dental

checkups does not affect restorative

care. 

Researchers correlated the application

of topical fluoride with dental fillings

and found that children who receive

topical fluoride most frequently are at

least as likely to receive fillings as

children who receive little or no

topical fluoride. Eklund, Pittman,

and Heller, J Public Health Dent

60(1):33-38, 2000 (AHRQ grant

HS09554).

• Study suggests that increasing

reimbursement will not

substantially improve access to

dental care for children.

Expanding Medicaid eligibility in

North Carolina between 1985 and

1991 and increasing payments to

providers between 1988 and 1991

only marginally increased access to

dental services for Medicaid-insured

children in the State. Pediatric

dentists were more likely to

participate in Medicaid than general

dentists, as were dentists in solo

rather than group practices. Mayer,

Stearns, Norton, et al., Inquiry 37:33-

44, 2000 (AHRQ grant HS09330).

• Data reveal disparities in dental

care.

Data from AHRQ’s Medical

Expenditure Panel Survey were

analyzed to determine the percentage

of children who made a dental visit

and the number of visits they made.

Low income, low education, and

minority race were associated with

lower odds of visiting the dentist and

a lower number of visits per child.

Edelstein, Manski, and Moeller,

Pediatr Dent 22(1):17-20, 2000

(AHRQ Publication No. 00-R024)*

(Intramural).

• Half of Medicaid-insured children

do not use dental services.

Despite Federal law requiring dental

care for Medicaid-eligible children,

researchers found that half of such

children never used dental services.

Robison, Rozier, and Weintraub, Am

J Public Health 88(11):1669-1673,

1998 (AHRQ grant HS06993 and

NRSA training grant T32 HS00032).

Otitis Media

Otitis media (middle ear infection) is

a common childhood illness that

affects more than half of children

under age 5 each year. Current debate

revolves around antibiotic use and the

long-term effects of ear infection on

functioning, behavioral problems,

and parental stress.

Research in Progress

• Conference attendees focused on the

effects of otitis media on language

and learning.

Aims of this interdisciplinary

conference included addressing

research and controversies on the

linkage of otitis media in early

childhood with hearing, speech and

language development, behavior, and

academic achievement. Joanne

Roberts, Principal Investigator

(AHRQ grant HS12072).

• Investigators are developing and

validating quality measures related

to insertion of tympanostomy tubes.

Researchers are assessing the

usefulness of tympanostomy tubes in

children with recurring otitis media

with effusion and developing quality

measures and evidence-based criteria

to identify appropriate candidates for

tube placement. Mark R. Chassin,

Principal Investigator (AHRQ grant

HS10302).

• Study focuses on use of

nonantibiotic treatments for otitis

media.

These researchers are examining the

safety, effectiveness, cost, and

acceptability of withholding

antibiotics from children with mild

acute otitis media (AOM). They are

using nonantibiotic symptomatic

treatment, parent education, and

followup to manage the condition.

David P. McCormick, Principal

Investigator (AHRQ grant

HS10613).

Recent Findings

• Parents influence pediatricians’

treatment decisions.

An analysis of audiotapes and

videotapes of 295 acute care visits

reveals that parents often pressure

pediatricians to prescribe antibiotics

for their children. The doctors

prescribed antibiotics in 15 of the 31

cases involving overt pressure. Stivers,

Soc Sci Med 54(7):1111-1130, 2002

(AHRQ grant HS10577).

• Researchers describe complications

associated with tympanostomy-tube

placement.

Investigators prospectively monitored

the middle ear status of 173 children

who underwent bilateral

tympanostomy tube placement. They

found that tube otorrhea (discharge

of pus through the tube) is a

common and recurring complication

in young children who undergo tube

placement for persistent middle-ear

effusion. Ah-Tye, Paradise, and

Colborn, Pediatrics 107(6):1251-

1258, 2001 (AHRQ and NICHD

grant HD26026).

• Antibiotics offer only modest benefits

to children with uncomplicated

otitis media.

Data show that most children with

uncomplicated AOM who were not

initially treated with antibiotics (78

percent) no longer had pain or fever

within 4 to 7 days and suffered no

complications. Takata, Chan,

Shekelle, et al., Pediatrics 108(2):

239-247, 2001 (AHRQ contract

290-97-0001). 19
• Expert panel labels literature on

otitis media “uneven.”

Reviewers screened 3,461 abstracts

and titles of AOM studies from 1966

to 1999, reviewed 760 full-length

articles, and used 80 studies in 85

articles. The experts concluded that

there is a large body of research

literature; however, its quality is

uneven and not generalizable. Chan,

Takata, Shekelle, et al., Pediatrics

108(2):248-254, 2001 (AHRQ

contract 290-97-0001).

• Ear tube placement in children

with persistent otitis media does not

measurably improve development at

age 3.

Children under age 3 in this study

did not have improved developmental

outcomes—speech, language,

cognitive, or psychosocial

development—as a result of

tympanostomy tube placement for

persistent fluid in the middle ear,

regardless of whether tube insertion

was prompt or delayed. Paradise,

Feldman, Campbell, et al., N Engl J

Med 344:1179-1187, 2001

(AHRQ/NICHD grant HD26026).

• Report summarizes available

scientific evidence on managing

AOM.

This report presents a synthesis of

available scientific evidence on

treating AOM. The researchers

discuss the natural history of AOM,

assess whether antibiotics are effective

in treating the condition, and

compare the effectiveness of specific

antibiotic regimens. The summary

(AHRQ Publication No. 00-E008)

and full report, Management of Acute

Otitis Media (AHRQ Publication No.

00-E009), are available from AHRQ*

(AHRQ contract 290-97-0001).

• Primary care physicians can use

tympanometry to diagnose middle

ear infections.

Primary care physicians who have

been trained in using a hand-held

tympanometer to diagnose otitis

media can interpret tympanograms as

accurately as experts, according to

this study. In addition, their readings

can provide high-quality data for

research purposes. Green, Culpepper,

De Melker, et al., J Fam Pract

49(10):932-936, 2000 (AHRQ grant

HS07035).

• Researchers examine effects of

persistent middle-ear inflammation

in the first 3 years of life.

Two studies from the University of

Pittsburgh School of Medicine

involved 2,278 children to examine

the effects of persistent otitis media in

the first 3 years of life on later

functioning and behavior. The first

study found that problems with

impaired hearing, language, speech,

and cognitive development correlated

more with socioeconomic status than

with otitis media. The second study

found no substantial relationship

between parents’ ratings of parentchild stress or children’s behavioral

problems and the duration of middleear effusion. Paradise, Dollaghan,

Campbell, et al., Pediatrics

105(5):1119-1130, 2000

(AHRQ/NICHD grant HD26026)

and Paradise, Feldman, Colborn, et

al., Pediatrics 104(6):1264-1273,

1999 (AHRQ grant HS07786).

• Using less expensive antibiotics to

treat children’s ear infections could

save money without compromising

care.

Researchers found that more

expensive antibiotics accounted for

only 30 percent of the prescriptions

written but up to 77 percent of the

more than $2 million spent on

medications for AOM in the

Colorado Medicaid program. Less

expensive antibiotics, which worked

just as well, accounted for 67 percent

of the prescriptions but only 21

percent of the costs. Berman, Byrns,

Bondy, et al., Pediatrics 100(4):585-

592, 1997 (AHRQ grant HS07816).

Preventive Services

The majority of injuries and deaths in

children and adolescents are

preventable. Although the

importance of preventive services has

been identified, there still are barriers,

flaws, and disparities in the content

and delivery of clinical preventive

services.

Research in Progress

• Intervention to improve delivery of

adolescent preventive health services.

Researchers are analyzing the value of

a QI strategy to enhance delivery of

office-based clinical preventive

services for adolescents during routine

well-care visits. Charles E. Irwin,

Principal Investigator (AHRQ grant

HS11095).

• Will enhanced services alter future

parental practices?

Investigators will assess whether

enhanced delivery of behavioral and

developmental services in children’s

first 3 years of life changes parental

attitudes and practices when their

children reach 5 years of age. Cynthia

Minkovitz, Principal Investigator

(AHRQ grant HS13086). 

Recent Findings

• QI systems improve service delivery.

Researchers had project teams work

with QI teams in eight primary care

practices to develop systems to assess

and improve the delivery of

immunizations and screening (for

anemia, tuberculosis, and lead

exposure). The proportion of children

with complete immunizations

improved 7 percent within 1 year and

12 percent after 2 years. Bordley,

Margolis, Stuart, et al., Pediatrics

Electronic Pages 108(3):E41,

http://www.pediatrics.org, 2001

(AHRQ grant HS08509).

• Long-term benefits of routine

newborn hearing screening are

unclear.

Evidence suggests that universal

screening leads to earlier

identification and treatment of

infants with hearing loss. However,

the evidence is inconclusive about

whether earlier treatment as a result

of screening leads to long-term

20
improvements in language skills.

Thompson, McPhillips, Davis, et al.,

JAMA 286(16):2000-2010, 2001

(AHRQ contract 290-97-0018).

• Study finds lower than expected risk

of intussusception.

The claim that the rotavirus vaccine

Rotashield increases risk of

intussusception by approximately 20-

fold were not confirmed, say

researchers. Based on an analysis of

hospital discharge data from 10

States, no increase in hospital infant

admission rates for intussusception

followed vaccination with Rotashield.

Simonsen, Morens, Elixhauser, et al.,

Lancet 358:1224-1229, 2001

(AHRQ Publication No. 02-R016)*

(Intramural).

• Survey uncovers discrepancies in

immunization practices.

Researchers conducted a national

survey of 252 pediatric nurse

practitioners. Although 44 percent

were less likely to vaccinate a child

during an acute care visit, 56 percent

treated this situation the same as a

routine, well-child visit. Richard K.

Zimmerman, Principal Investigator

(AHRQ grant HS09527),

Immunization Barriers: A Study of

Pediatric Nurse Practitioners (Final

Report, NTIS Accession No.

PB2002-100268).**

• Availability of free vaccines affects

clinicians’ referrals.

Researchers surveyed primary care

pediatric nurse practitioners (PNPs)

about their use of free vaccines

provided by the Federal Vaccines for

Children Program. PNPs who

received free vaccine supplies were

less likely than those who did not to

refer children to public clinics for

vaccinations. Zimmerman, VanCleve,

Medsger, et al., Matern Child Health

J 4(1):53-58, 2000 (AHRQ grant

HS09527).

• Medicaid managed care enrollment

improves use of well-child care.

Researchers examined the impact of

mandatory Medicaid managed care

enrollment on access to and use of

health care services by 488 motherinfant pairs and found that managed

care enrollment had a positive effect

on use of well-child care when

compared with private insurance and

lack of insurance. Laurel K. Leslie,

Principal Investigator (AHRQ grant

HS09563), Medicaid Changes: Impact

on at-Risk Children (Final Report,

NTIS Accession No. PB2000-

105025).**

• Economic barriers prevent timely

immunizations.

According to this study, children are

vaccinated later in the practices of

providers who do not receive free

vaccine supplies, those that refer

uninsured children to a public

vaccine clinic, and providers who

over-interpret contraindications to

vaccinations. Zimmerman,

Mieczkowski, and Michel, Fam Med

31(5):317-323, 1999 (AHRQ grant

HS08068).

• A majority of clinicians consider

early childhood hepatitis B

vaccination to be important.

In a 1995 telephone survey, 78

percent of 1,236 primary care

physicians rated vaccination against

the hepatitis B virus as important, 7

percent rated it as unimportant, and

15 percent gave it an intermediate

rating. Zimmerman and

Mieczkowski, J Fam Pract 47(5):370-

374, 1998 (AHRQ grant HS08068).

• Demographics, rather than

geographics, account for disparities

in immunization rates.

Analysis of the 1991 National

Maternal and Infant Health Survey

and the 1993 National Health

Interview Survey revealed no

significant differences in

immunization rates of rural and

urban 2-year-old children. Low

family income and education,

minority race, parental

unemployment, and female sex were

associated with underimmunization.

Lowery, Belansky, Siegel, et al., J Fam

Pract 47(3):221-225, 1998 (AHRQ

contract 290-93-0039).

• Reasons for low immunization rates

include referral practices and cost.

A survey of 1,236 physicians found

that uninsured children are not as

likely as insured children to be

immunized when they see their

primary care physicians, particularly

when the doctor does not receive free

vaccines. Zimmerman, Medsger,

Ricci, et al., JAMA 278(12):996-

1000, 1997 (AHRQ contract

HS08068).

• Feedback and financial incentives

do not improve pediatric preventive

care.

In this study, providing pediatricians

in Medicaid managed care

organizations with feedback on

compliance with preventive health

services and financial bonuses did not

increase their provision of these

services. Hillman, Ripley, Goldfarb,

et al., Pediatrics 104(5):931-935,

1999 (AHRQ grant HS07634).

• Providers often do not address

major injury-prevention issues

during well-child visits.

A survey of 465 pediatricians, family

physicians, and pediatric nurse

practitioners found that attitudes

about certain childhood injuries,

rather than knowledge about the

prevalence of particular injuries,

affected which counseling topics the

clinicians discussed with their

patients. Barkin, Fink, and Gelberg,

Arch Pediatr Adolesc Med 153:1226-

1231, 1999 (NRSA training grant

T32 HS00046).

• Clinicians often do not counsel

parents on drowning prevention.

Despite the high incidence of

drowning injuries in Los Angeles

County, only one-third of a random

sample of primary care providers

counseled parents about drowning

prevention. Two-thirds of the PCPs

surveyed did not know that deaths of

young children due to drowning are

more common than deaths due to

poisoning and firearm injury. Barkin

21
and Gelberg, Pediatrics 104(5):1217-

1219, 1999 (NRSA training grant

T32 HS00046).

Quality of Care/Patient

Safety

In order to assess quality of care and

patient safety, researchers are

developing quality measures,

analyzing medical injuries, and

assessing the usefulness of guidelines

and other strategies to improve care.

Research in Progress

• Investigation focuses on choosing

managed care plans for children

with special needs.

This study will examine the factors

used in selecting managed care plans

by the parents of children with special

health care needs, the difficulties they

face in obtaining access to care, and

indicators of quality of care. Jean

Mitchell, Principal Investigator

(AHRQ grant HS10912).

• Study focuses on the impact of

electronic prescribing on patient

safety.

After determining an institution’s

baseline medication error rate,

investigators will compare handheld

implements for electronic

prescription writing and determine

the effect of the instruments on error

rates and prescribing practices. Kevin

B. Johnson, Principal Investigator

(AHRQ grant HS11868).

• Two centers for pediatric patient

safety are being established. 

One project will establish a

Developmental Center for Evaluation

and Research in Patient Safety

(DCERPS) at the University of

Washington Children’s Hospital

Regional Medical Center. The goal is

to reduce and prevent medical errors.

James A. Taylor, Principal Investigator

(AHRQ grant HS11590). The

second project involves collaboration

between the University of Vermont,

Harvard University, and Dartmouth

University to establish a DCERPS in

neonatal intensive care. Center

programs will work to reduce medical

errors, enhance patient safety, and

determine how to learn most

effectively from errors and

communicate the information to

families. Jeffrey D. Horbar, Principal

Investigator (AHRQ grant

HS11583).

• Study examines effects of intensive

care unit (ICU) errors.

The goal is to calculate the increase in

resource use attributable to

medication errors in the pediatric

ICU, determine the risk of death

from errors, and determine the risk of

requiring inpatient rehabilitation or

technology dependence associated

with exposure to medication errors.

Joel D. Portnoy, Principal Investigator

(AHRQ grant HS11636).

• Researchers are validating qualityof-care measures for vulnerable

children.

In the context of a school health

initiative, this project will validate a

health-related quality-of-life

instrument and examine the

relationships among structures and

processes of care, health-related

quality of life, and outcomes. The

project will include children and

families who speak English, Spanish,

Tagalog, and Vietnamese. Michael

Seid, Principal Investigator (AHRQ

grant HS10317).

• Injury analysis will assess

management of suspected abuse.

This study will analyze practitioner

management of 16,000 childhood

injuries and provide the first

comprehensive analysis of the

management of suspected child abuse

in primary care practices. Emalee G.

Flaherty, Principal Investigator

(AHRQ grant HS10746).

• Effects of teamwork on errors in

neonatal intensive care units.

Researchers are testing the hypothesis

that specific behaviors in teamwork

correlate with errors in delivering care

to preterm infants during initial

resuscitation and in the first 90

minutes of care. Eric J. Thomas,

Principal Investigator (AHRQ grant

HS11164).

• AHRQ’s evidence-based practice

program is synthesizing scientific

evidence to improve quality of care.

Under this program, 12 5-year

contracts have been awarded to

institutions in the United States and

Canada to serve as evidence-based

practice centers (EPCs). They review

the scientific literature on assigned

topics and produce evidence reports

and assessments that can be used by

public and private organizations as

the basis for QI tools and activities.

The following topics for evidence

reports relevant to children were

assigned in 2001 and are in

development:

- Management of bronchiolitis.

Research Triangle Institute and

University of North Carolina at

Chapel Hill.

- Neonatal hyperbilirubinemia.

New England Medical Center.

- Preventing adolescent criminal

and other health-risking social

behavior. Oregon Health and

Science University.

- Treatment-resistant epilepsy.

Emergency Care Research

Institute (ECRI).

Recent Findings

• Regionalization of cardiac surgery

patients saves lives. 

A simulated regionalization of surgery

study uncovered benefits to referring

pediatric cardiac surgery patients

from low- to high-volume hospitals.

Based on 2 years of discharge data,

results show a decrease in mortality

along with an increase in travel

distance for families. Chang and

Klitzner, Pediatrics 109(2):173-181,

2002 (NRSA training grant T32

HS00028).

• CAHPS® survey results differ for

adults and children.

Researchers examined the adult and

child versions of the Consumer

22
Assessment of Health Plans Study

(CAHPS®). CAHPS® scores for

children were significantly higher

than those for adults except for

customer service (which was lower for

children) and specialist ratings.

Zhan, Sangl, and Meyer, Med Care

40(2):145-154, 2002 (AHRQ

Publication No. 02- R047)*

(Intramural).

• Factors affecting physician behavior

change are outlined.

According to a review of studies on

changing physician behavior to

improve the quality of pediatric care,

factors affecting change include:

continuing medical education that

includes interactive intervention,

practice guideline implementation,

reminders, and educational outreach.

Bauchner, Simpson, and Chessare,

Arch Dis Child 84:459-462, 2001

(AHRC Publication No. 01-R067)*

(Intramural).

• Availability of care reduces

ambulatory-care-sensitive

hospitalizations. 

Using Healthcare Cost and

Utilization Project data, researchers

analyzed 1994 hospital discharges.

They found high rates of locally

available primary care doctors and

high market penetration by health

maintenance organizations are

associated with reduced

hospitalizations for children with

ambulatory-care-sensitive conditions.

Friedman and Basu, J Managed Care

7(5):473- 481, 2001 (AHRQ

Publication No. 01-R074)*

(Intramural).

• A video and brochure are not

sufficient to teach parents about the

correct use of antibiotics.

A control group of parents (no

intervention) was paired with an

educational group who were shown a

20-minute video and given brochures

on the appropriate use of antibiotics.

After 2 months, only a modest effect

on parent knowledge, beliefs, and

self-reported behaviors was found in

the intervention group. Bauchner,

Osganian, Smith, et al., Pediatrics

108(4):845-850, 2001 (NRSA

training grant T32 HS00063).

• Parental assessments note

racial/ethnic disparities in care.

Parental evaluations of the pediatric

care provided by 33 Medicaid HMOs

in six States indicate the following:

health plans need to pay increased

attention to racial/ethnic differences

in assessments of care, and language

barriers are a significant contributor

to racial/ethnic disparities in care.

Weech-Maldonado, Morales, Spritzer,

et al., Health Serv Res 36(3):575-594,

2001 (AHRQ grant HS09204). 

• Proposed information technologies

may empower families.

At the conference “Information

Technology in Children’s Health

Care,” researchers described a variety

of information technologies to assess

their promise for improving care for

children and barriers to their use.

Technologies that can facilitate

information sharing and empower

children and families include the

electronic pediatric personal medical

record, customized health

information systems, and interactive

physician offices with e-mail and

telemedicine capabilities. Several

papers commissioned for the

conference were published.

D’Alessandro and Dosa, Arch Pediatr

Adolesc Med 155:1131-1136, 2001;

Kaushal, Barker, and Bates, Arch

Pediatr Adolesc Med 155:1002-1007,

2001; Weitzman and Shiffman, Arch

Pediatr Adolesc Med 155:990-991,

2001; Johnson, Arch Pediatr Adolesc

Med 155:1374-1379, 2001 (AHRQ

contract 290-95-2000).

• Summit suggests improvements are

needed in pediatric sedation

practices.

The proceedings from a summit on

pediatric sedation features lectures on

the challenges facing providers of

pediatric sedation and a roundtable

discussion of controversial issues.

Joseph P. Cravero, Principal

Investigator (AHRQ grant

HS10110), Dartmouth Symposium

on Pediatric Sedation (Final Report,

NTIS Accession No. PB2002-

102263).**

• Study measures parental perceptions

of primary care.

The Parent’s Perceptions of Primary

Care (P3C) is a 23-item

questionnaire that asks parents to

evaluate the elements of primary care

defined by the Institute of Medicine.

Researchers found the P3C has good

internal consistency, reliability, and

validity and can be used by

pediatricians, medical groups, and

policymakers. Seid, Varni, Bermudez,

et al., Pediatrics 108(2):264-270,

2001 (AHRQ grant HS10317).

• Medication errors are common

among hospitalized children.

Researchers analyzed data on 1,120

pediatric patients admitted to two

urban teaching hospitals in 1999.

They found errors occurred in 5.7

percent of medication orders. Also,

the rate of potential adverse drug

events was three times the rate found

in a similar study of hospitalized

adults. Kaushal, Bates, Landrigan, et

al., JAMA 285(16):2114-2120, 2001

(NRSA training grant T32

HS00063).

• Different measures are needed to

assess the quality of health care

provided to children and adults. 

Because children differ from adults in

their health care needs and in the way

they use care, researchers should use

measures of health care quality that

are appropriate to children. Future

research should address specific

methodologic challenges involved in

measuring quality of pediatric health

care. Palmer and Miller, Ambulatory

Pediatrics 1(1):39-52, 2001 (AHRQ

Publication No. 01- R037)*

(Intramural).

• Parents stress the importance of

parent-doctor and child-doctor

communication.

The Child Core Survey from the

Consumer Assessment of Health

23
Plans Study (CAHPS®) was used to

assess the interpersonal care of

children based on parental responses.

The most important factors—

according to 3,083 assessments of

overall care and of personal doctors—

are parent-doctor communication,

child-doctor communication, and

sufficient time spent with the child.

Homer, Fowler, Gallagher, et al., Jt

Comm J Qual Improv 25(7):369-377,

1999 (AHRQ grant HS09205).

• Children in staff-model Medicaid

managed care receive care equal to

that of privately insured children in

managed care.

Researchers used administrative data

and a telephone survey to obtain data

on access to, satisfaction with, and

use of services for enrollees of Kaiser

Permanente of Northern California.

They found that Medicaid-enrolled

children received care at least equal to

that of their commercially enrolled

peers. Newacheck, Lieu, Kalkbrenner,

et al., Ambulatory Pediatrics 1(1):28-

35, 2001 (AHRQ Publication No.

01-R039)* (Intramural).

• Researchers review research on QI

and examine barriers to QI

activities in children’s health care.

Researchers reviewed the published

literature (1985-1997) on QI

activities in child health and

interviewed experts. Research shows

that some QI strategies are effective.

Barriers to pediatric QI were similar

to those for adult populations and

were complicated by limited resources

and difficulties in measuring health

outcomes, among other factors.

Ferris, Dougherty, Blumenthal et al.,

Pediatrics 107:143-155, 2001

(AHRQ Publication No. 01-R020)*

(Intramural).

• Measuring quality for vulnerable

children requires a special approach.

These authors point out that

pediatric quality measurement is

distinct from that for adults because

of factors related to children’s

development and dependence,

differential epidemiology,

demographic factors, and differences

between the child and adult health

service systems. A noncategorical

approach, rather than one based on

illness status or specific condition, is

indicated. Seid, Varni, and Kurtin,

Am J Med Qual 15(4):182-188, 2000

(AHRQ grant HS10317).

• Reducing errors in treating febrile

infants may require system changes. 

A research team found that 7 percent

of infants arriving at the emergency

room with a high fever were treated

inappropriately. They either were

given antibiotics they did not need or

did not receive antibiotics they

actually did need. Glauber,

Goldmann, Homer, et al., Pediatrics

105(6):1330-1332, 2000 (NRSA

grant T32 HS00063).

• Embedding guidelines in a

computer charting system does not

improve quality of care.

Researchers embedded clinical

guidelines for managing young

children with high fevers and

examined the impact of this approach

on 830 febrile children under age 3.

There were no changes in

appropriateness of care or hospital

charges for these children. Schriger,

Baraff, Buller, et al., J Am Med Inform

Assoc 7(2):186-195, 2000 (AHRQ

grant HS06284).

• Study tracks hospital admissions

data to determine impact of

insurance status on potentially

unnecessary hospitalizations.

Researchers used hospital data for 19

States to determine baseline rates of

ambulatory-care-sensitive (ACS)

conditions and analyze trends in the

rates prior to the implementation of

the State Children’s Health Insurance

Program. The rate of ACS admissions

for self-pay and Medicaid-enrolled

children increased between 1990 and

1995, but the rate for other insured

children decreased significantly.

Friedman, Jee, Steiner, and Bierman,

Med Care Res Rev 56(4):440-455,

1999 (AHRQ Publication No. 00-

R009)* (Intramural).

• Monthly recertification of Medicaid

eligibility may undermine health

care quality.

Twelve months of continuous

Medicaid enrollment and an assigned

primary care physician (PCP)

improved the care of children with

middle ear infections, say researchers.

Children who are continuously

enrolled are far less likely to visit the

ER for middle ear infections, more

apt to receive antibiotics for the

condition, and more likely to be

referred for ear surgery than those

who are discontinuously enrolled

(due to monthly recertification) and

lack a PCP. Berman, Bondy, Lezotte,

et al., Pediatrics 104(5):1192-1197,

1999 (AHRQ grant HS07816).

• A number of variables affect

assessments of managed care for

children. 

A review of the research found that

access to, satisfaction with, and

quality of managed care depend on a

range of variables. Future research

should focus on specific features of

managed care, managed care

providers, and poor and chronically

ill children. Simpson and Fraser, Med

Care Res Rev 56(Suppl. 2), 13- 36,

1999 (AHRQ Publication No. 99-

R062)* (Intramural).

• Pediatric practice guidelines lack

input from families.

A review of the literature on pediatric

practice guidelines found that patient

and family involvement in guideline

development has been limited,

potentially affecting the likelihood

that guidelines will be successfully

implemented. Bauchner and

Simpson, Health Serv Res 33(4):1161-

1177, 1998 (AHRQ Publication No.

99-R003)* (Intramural).

• Do practice guidelines make a

difference?

Researchers argue that practice

guidelines can enhance health care

24
quality. Physician participation in

guideline development and their

perception of the philosophy behind

a guideline were identified as key

factors affecting guideline

acceptance. Simpson, Kamerow, and

Fraser, Pediatr Ann 27(4):234-240,

1998. (AHRQ Publication No. 98-

R081)* (Intramural).

• Earlier recognition of a child’s

terminal illness allows clinicians

and parents to focus on improving

the child’s quality of life and

comfort.

According to researchers, doctors

usually accept that a child is

terminally ill about 6 months before

the child’s death, compared with 3

months for the parents. Earlier recognition of this prognosis by

both doctors and parents was

associated with more comfort

treatment and greater integration of

palliative care. Wolfe, Klar, Grier, et

al., JAMA 284(19):2469-2475,

2001 (NRSA training grant T32

HS00063).

• Caregivers should pay more

attention to palliative care.

A review of medical records of

children who had died of cancer

showed that parents were more

likely than physicians to report that

their child had fatigue, poor

appetite, constipation, and diarrhea

and that these symptoms were not recognized by the medical team.

Also, pain was more likely in

children whose parents reported that

the physician was not actively

involved in end-of-life care. Wolfe, Grier, Klar, et al., N Engl J Med

342:326-333, 2000 (NRSA training

grant T32 HS00063).

• Providers give reasons for not

reporting all cases of suspected

child abuse.

Researchers surveyed 85 providers in

a regional practice-based research

network. Reasons given for not reporting suspected abuse included

uncertainty about the abuse

diagnosis, past negative experience

with Child Protective Services, and a

perception that past reporting of

abuse did not help the child. Flaherty, Sege, Binns, et al., Arch Pediatr Adolesc Med 154:489-493,

2000 (AHRQ grant HS09811).

Capacity-Building High-quality research in children’s

health care can only come from

having a pool of talented researchers

and a strong infrastructure to

support analytic projects. AHRQ is

committed to the development and

support of health services researchers, particularly minority researchers and those who are new

to the field.

Research in Progress • Conference focused on ways to

improve child health care.

The purpose of the March 2002 First Annual Forum for Improving

Children’s Health Care was to

disseminate best practices and research findings. Tracks focused on

improving care and flow in clinical

settings, teaching and education,

safety and therapy, and systems of

care. Charles Homer, Principal

Investigator (AHRQ grant

HS12070). • Child health services researchers

(CHSRs) meet.

The fourth annual CHSR meeting

featured plenary sessions on the

future of CHSR and communityfocused CHSR. Sessions addressed

health insurance, welfare reform,

patient safety, disparities, mental

health treatment, and issues

pertaining to terrorism. Go to

http://academyhealth.org/childhealt

h/agenda.htm to access slides and

presentations from the meeting. The

fifth annual meeting will be held June 26, 2003 in Nashville, TN. Wendy Valentine, Principal

Investigator (AHRQ grant

HS08201). • Scholars and data users discuss

methodology and measures.

The Pediatric Health Status and Outcome Measurement Conference

will address the current state of

25
knowledge in pediatric measures, as well as measurement validity,

appropriate ways to obtain data, and

use of measures. Lynn Olson, Principal Investigator (AHRQ grant

HS12078). • Child health services research

consortium is planned.

This project will develop the

infrastructure to generate and

support a child health services research program in the Intermountain West. The program

will emphasize children with special

health care needs. Charles J. Hoff, Principal Investigator (AHRQ grant

HS11826).

• Program focuses on improving

health in the Mississippi Delta.

Investigators will develop a

multidisciplinary research program

to improve the health care and

health outcomes of underserved, rural, predominantly minority

children in 12 impoverished

counties in the Mississippi Delta.

Linda H. Southward, Principal

Investigator (AHRQ grant

HS11849).

• Phase II of Pediatric Practice Research Group (PPRG) begins. During this phase of an ongoing

PPRG study, researchers will

develop a plan for phased trials of

computerized data collection in the

practice setting, develop strategies

for implementing studies that lead

to enhanced patient care, and

examine the challenges and diversity

of clinic flow patterns. Helen Binns, Principal Investigator (AHRQ grant

HS11248).

• Project will further develop a

pediatric research group. 

The Cincinnati Pediatric Research

Group Enhancement Project will

continue creating the infrastructure

for an established community

practice-based research network to

provide pediatric primary care. Michele Kiely, Principal Investigator

(AHRQ grant HS11201).

• Data collection methodologies will

be compared.

This study will compare the

traditional paper/pencil data

collection for the National

Ambulatory Medical Care Survey

(NAMCS) with data collection via Web-based technologies. Richard C. Wasserman, Principal Investigator

(AHRQ grant HS11192).

• Study to obtain measures to

monitor access and quality.

This Mentored Clinical Scientist

Development Award will enable the

investigator to conduct research

using interviews, focus groups, and

a pilot test to document the factors

necessary for monitoring access and

quality of primary health care for

homeless youths. B. Josephine Ensign, Principal Investigator

(AHRQ grant HS11414).

• Four projects support and facilitate

health services researchers’ career

development in children’s health.

An Independent Scientist Award to Marielana Lara is facilitating her

development as a researcher whose

work will improve health outcomes

and quality of life for Latino

children with asthma (AHRQ grant

K08 HS00008). John Feudtner’s 5- year project will develop techniques

to monitor health care use for

indicators of quality of care for

dying children and develop and test

a longitudinal needs assessment

program for children with complex

chronic conditions (AHRQ grant

K08 HS00002). Glenn Flores is

focusing on ways to increase health

coverage of Hispanic children.

(AHRQ grant K02 HS11305).

Christopher Forrest’s project will

focus on the mechanisms by which

managed care influences children’s

access to medical care, use of

specialty care, and expenditures for

health care. He will examine the

impact of alternative models of

primary-specialty care collaboration

on quality, costs, and outcomes for

children with chronic and mental

health disorders (AHRQ grant K02

HS00003). 26
• Training program builds the field of

child health services research.

This project supports and expands an

ongoing training program for

pediatric health services research

within the Children’s Hospital in

Boston. Donald Goldmann, Principal

Investigator (NRSA grant T32

HS00063).

Recent Findings

• New KID database facilitates child

health services research.

In August 2001, AHRQ unveiled the

Kids’ Inpatient Database (KID), the

Nation’s first all-children’s hospital

care research database. It was

developed for use in making national

and regional estimates of children’s

treatment, including surgery and

other procedures, and for estimating

treatment outcomes and hospital

charges. The database includes

information on the hospital care of

children from birth through age 18,

regardless of insurance status. The

KID contains information on the

inpatient stays of about 1.9 million

children at over 2,500 hospitals across

the country in 1997. KID is a

component of AHRQ’s Healthcare

Cost and Utilization Project

(HCUP). For more information, go

to the AHRQ Web site at

www.ahrq.gov and click on “HCUP.”

(Intramural)

• Methodological problems pose

special challenges for research on

pediatric health issues. 

The authors outline methodological

challenges in child health services

research, including issues involving

empirical research, policy analyses,

evidence-based guidelines, and QI.

Lohr, Dougherty, and Simpson,

Ambulatory Pediatrics 1:36-38, 2001

(AHRQ Publication No. 01-R038)*

(Intramural).

• Proceedings highlight key issues in

child health.

This report describes a 1998

conference, which provided a forum

for introducing junior investigators to

key issues in child health services

research. James Perrin, Principal

Investigator (AHRQ grant

HS09815), Ambulatory Pediatric

Association Child Health Services

Research Conference (final report,

NTIS Accession No. PB2000-

105025).** 

Other Research

Research in Progress

• Researchers examine the

epidemiology and causes of injuries.

This project will examine the

epidemiology and causes of pediatric

injuries seen in emergency and

outpatient departments. Simon J.

Hambidge, Principal Investigator

(AHRQ/HRSA joint project 240-97-

0043).

• Researchers will analyze trends in

managing splenic injury.

Study participants plan to

characterize the diffusion of

nonoperative management of splenic

injury in children within a

regionalized trauma system. Daniela

H. Davis, Principal Investigator

(AHRQ/HRSA joint project 240-97-

0043).

• Office visits will include assessments

of school readiness.

This project will analyze current

practices during pediatric office visits.

Investigators will focus on the school

readiness assessment from the

National Survey of Early Childhood

Health. Alice Kuo, Principal

Investigator (AHRQ/HRSA joint

project 240-97-0043).

• Researchers are assessing poverty,

diet, and poor growth in U.S.

children.

This project is examining how

poverty and growth are associated in

U.S. children aged 2 months to 5

years. Jennifer Kasper, Principal

Investigator (AHRQ/HRSA joint

project 240-97-0043).

• Center will focus on therapeutics for

the pediatric population. 

Improvement in child health is the

focus of this Center for Education

and Research on Therapeutics.

Potential study topics include

therapeutic drug monitoring in HIVinfected children, drug metabolism,

vitamin D-deficient rickets, asthma

care, attention-deficit/hyperactivity

disorder, and adverse drug reactions.

William Campbell, Principal

Investigator (AHRQ grant

HS10397).

• Telemedicine may enhance pediatric

care in rural, urban, and suburban

settings.

Telemedicine employs

telecommunications and computer

technology as a substitute for inperson contact between providers and

patients. Investigators are examining

whether telemedicine will improve

access and increase the efficiency of

routine pediatric care in urban and

suburban areas. Kenneth

McConnochie, Principal Investigator

(AHRQ grant HS10753).

Recent Findings

• Children can provide valid answers

to questions about their health.

Using three cross-sectional interviews

of children, investigators determined

the children’s ability to respond to

questions about their health. The

results will enable the development of

a pediatric health status questionnaire

for children aged 6 to 11. Rebok,

Riley, Forrest, et al., Qual Life Res

10:59-70, 2001 (AHRQ grant

HS07045).

• Evidence syntheses in child health

are difficult to build.

Child health researchers face a lack of

high-quality primary studies,

difficulty in finding existing studies,

variability in the usefulness of

outcome measures, and problems

with production and dissemination.

Moyer, Ambulatory Pediatrics 1(1):53-

58, 2001 (AHRQ grant HS09815). 

27
28

For More Information

AHRQ’s World Wide Web site

(www.ahrq.gov) provides information

on the Agency’s children’s health

services research agenda, including

detailed information on funding

opportunities. Also,

www.ahrq.gov/child includes a Stateby-State map of AHRQ-funded

research projects and other child

health services research information.

AHRQ also offers a child and

adolescent health LISTSERV®

(AHRQkid-L) to which users may

subscribe via e-mail (Address:

Listserv@list.ahrq.gov; in the message

box, type: subscribe AHRQkid-L

Your Full Name).

Further details on AHRQ’s programs

and priorities in child health services

research are available from:

Denise M. Dougherty, Ph.D.

Senior Advisor, Child Health

Agency for Healthcare Research 

and Quality

2101 East Jefferson Street

Rockville, MD 20852

Phone: 301-594-2051

Fax: 301-594-7194

E-mail: ddougher@ahrq.gov\

Items in this program brief that are

marked with an asterisk (*) are

available free from the AHRQ

Clearinghouse; to order, contact the

AHRQ Clearinghouse, P.O. Box

8547, Silver Spring, MD 20907;

phone 800-358-9295. Please use the

AHRQ publication number when

ordering.

Items marked with two asterisks (**)

may be purchased from the National

Technical Information Service

(NTIS). Call NTIS at 800-553-6847

for more information.

www.ahrq.gov

AHRQ Pub. No. 03-P008

November 2002

(Replaces AHRQ Pub. No. 02--P005)