Correspondence

Children and the Quality of Ambulatory Care

N Engl J Med 2008; 358:532-533January 31, 2008

Article

To the Editor:

Mangione-Smith et al. (Oct. 11 issue)1 report that children receive only 46.5% of recommended health care. Is our goal 100% adherence to these recommendations? What are barriers to improvement?

Hayward commented, regarding performance-measure adherence for adults, “It sounds terrible . . . that 50% of recommended care is not received, but . . . mandating adherence to these recommendations is not necessarily in the best interest of patients or society. . . . At the heart of this problem is our wish to keep efforts at quality improvement and cost containment separate.”2 Benefits from guidelines are not necessarily additive,3,4 since there are usually costs and sometimes unintended consequences.5

Although many believe that children, with their developmental needs and relative dependence, deserve unlimited health care resources, such resources do not appear to be available currently. Choices are necessary. For example, should we give priority to hospitalizing young febrile infants,1 or instead provide immunizations, health insurance, pharmaceuticals, or developmental or mental health services or both? Ignoring cost-effectiveness often results in illogical rationing of care.

I hope that this important study will catalyze discussion regarding our society's priorities for children, our most precious national resource.

Sharon B. Meropol, M.D., M.S.C.E.
University of Pennsylvania School of Medicine, Philadelphia, PA 19104
meropols@mail.med.upenn.edu

5 References

1. 1

   Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med 2007;357:1515-1523
   Full Text | Web of Science | Medline

2. 2

   Hayward RA. Performance measurement in search of a path. N Engl J Med 2007;356:951-953
   Full Text | Web of Science | Medline

3. 3

   Barkin SL, Scheindlin B, Brown C, Ip E, Finch S, Wasserman RC. Anticipatory guidance topics: are more better? Ambul Pediatr 2005;5:372-376
   CrossRef | Web of Science | Medline

4. 4

   McMahon LF Jr, Hayward R, Saint S, Chernew ME, Fendrick AM. Univariate solutions in a multivariate world: can we afford to practice as in the “good old days”? Am J Manag Care 2005;11:473-476
   Web of Science | Medline

5. 5

   Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med 2007;357:608-613
   Full Text | Web of Science | Medline