The Children's Health Insurance Program Reauthorization Act (CHIPRA) legislation required a core set of recommended health care quality measures to be identified for voluntary use by State Medicaid and the Children's Health Insurance Programs (CHIP), which together cover almost 40 million American children and adolescents. In a special Supplement to Academic Pediatrics, the official journal of the American Pediatric Association, noted authorities present critical insights into the issues surrounding the initial core set and key concepts for improving children's health care.

Peter Szilagyi, MD, MPH, University of Rochester School of Medicine, and Editor-in-Chief of Academic Pediatrics observed, "A well-known and insightful phrase in health care is – 'what gets measured, gets done.' Although this is not always the case, without metrics we cannot tell if our health care system is performing well. These CHIPRA quality measures will provide an excellent set of metrics to judge the quality of care for our nation's children, and to use as a blueprint for improvement."

The set of articles in this supplement includes a detailed description of how the identification of a balanced and grounded set of children's health care quality measures was accomplished by means of an open, public process combined with an evidence-informed evaluation methodology.

In the introductory article, "The Children's Health Insurance Program Reauthorization Act Quality Measures Initiatives: Moving Forward to Improve Measurement, Care, and Child and Adolescent Outcomes," Denise Dougherty, PhD, Senior Advisor, Child Health and Quality Improvement, Agency for Healthcare Research and Quality, Rockville, MD, and co-authors describe the current environment in children's health care, noting that children make up 26% of the nation's population and account for 1 in 6 health care dollars, yet only receive 47% of the recommended clinical care. They comment that, "We and others contributing to this supplement consider the identification of the initial core set to be a significant initial accomplishment under CHIPRA. With sufficient attention to making the measures feasible for use across Medicaid and CHIP programs, and with technical assistance, voluntary use should be facilitated. However, the initial core set is but one step on the road toward improved quality for children. The identification of future challenges and opportunities for measure enhancement will be helpful in setting and implementing a future pediatric quality research agenda."

KEY POINTS:

Identifying Children's Health Care Quality Measures for Medicaid and CHIP: An Evidence- Informed, Publicly Transparent Expert Process
Rita Mangione-Smith, Jeffrey Schiff, Denise Dougherty

The authors describe how an open national public process combined with an evidence-informed evaluation methodology resulted in identification of a balanced, grounded, and parsimonious core set of measures that should become feasible to implement on a widespread scale over time.

A National and State Profile of Leading Health Problems and Health Care Quality for US Children: Key Insurance Disparities and Across-State Variations
Christina D. Bethell et al.

An analysis of data from the 2007 National Survey of Child Health on the prevalence and incidence of childhood chronic conditions, and certain aspects of health care quality, finds that an estimated 43% of US children currently have at least 1 of 20 chronic conditions, not including overweight or obesity.

Monitoring Duration of Coverage in Medicaid and CHIP to Assess Program Performance and Quality
Genevieve M. Kenney, Jennifer E. Pelletier

This article addresses measures of duration of enrollment and coverage in Medicaid and CHIP and confirms that having such measures is critical to understanding health care quality within the programs. Currently, over 25% of children are excluded from quality measurement in Medicaid and CHIP because of differing exclusions based on duration of enrollment.

Measures of Availability of Health Care Services for Children
Karen A. Kuhlthau

CHIPRA also identified measures of availability of services as a high priority for the core set of recommendations. Availability of services for children enrolled in Medicaid has been of concern since the program's inception. This contribution identifies several measures of availability that can be built upon in the future (eg, geographic accessibility, provider willingness to accept insurance type).

Measuring Patient and Family Experiences of Health Care for Children
John Patrick T. Co, Scot B. Sternberg, Charles J. Homer

An accepted measure of quality is the experiences of both patients and family members. Co and colleagues point out that work is still needed on measurement of inpatient experiences for children, experiences of mental and behavioral health services, and experiences of care at the clinician-group level.

Medicaid and CHIP Children's Healthcare Quality Measures: What States Use and What They Want
Sarah E. deLone, Catherine A. Hess

This analysis of recent survey data provides a compelling case that CHIPRA's quality provisions come at an opportune time for State Medicaid and CHIP programs. These programs report that health care quality improvement is relatively high on their list of priorities and that officials desire better quality measures.

Review of Quality Measures of the Most Integrated Health Care Settings for Children and the Need for Improved Measures: Recommendations for Initial Core Measurement Set for CHIPRA
Scot B. Sternberg, John Patrick T. Co, Charles J. Homer

This article focuses on the medical home as an exemplar of integration and examines the validity and feasibility of measures of "medical homeness." Sternberg and colleagues focus on recommendations for several promising approaches to measuring this concept using existing surveys

Measuring and Reporting Quality of Health Care for Children: CHIPRA and Beyond
Gerry Fairbrother, Lisa A. Simpson

Fairbrother and Simpson present a set of recommendations related to States' needs for infrastructure and technical assistance and to the federal government in the context of new quality and coverage initiatives across the entire US population.

Families Are Key in Improving Quality
Nora Wells, Lee Partridge

This contribution identifies a need to educate both patients and providers about the CHIPRA core set and for the Department of Health and Human Services to work harder to engage these key stakeholders in both using and improving the measure sets. As Wells and Partridge point out, families and child patients have to be ready to use the data from the core sets to demand better care.

Children's Health Care Providers and Health Care Quality Measurement
Judith S. Palfrey, Timothy J. Brei

The authors reinforce the need for education of patients and providers and note the potential for an evidence-based core set to improve pay-for-performance approaches to pediatric quality improvement.

State Medicaid and Children's Health Insurance Program's Perspective on CHIPRA Core Measures

Mary Greene-McIntyre, Cathy Caldwell The authors caution that federal collaboration is needed to avoid introducing multiple measure sets from different agencies.

Transforming Children's Health Care Quality and Outcomes – A Not-So-Random Non-linear Walk Across the Translational Continuum
Denise Dougherty, Carolyn Clancy

Dougherty and Clancy note the contribution of CHIPRA'S focus on measurement and improvement to the potential for transforming children's health care and health, but also suggest that more work under other umbrellas may be needed to enhance the evidence base for measurement and improvement.

A New Era for State Medicaid and Children's Health Insurance Programs
Cindy Mann

CHIPRA provides a compelling architecture for improving children's health care quality and outcomes. This article discusses the implementation and evaluation of a variety of health care quality improvement strategies by States in response to the Federal efforts.

"Commentaries in this supplement provide additional detail on how critical it is to go beyond measurement to continuous quality improvement," commented Dr Dougherty. "We are fortunate as a nation that cares for its children that CHIPRA provides a road map for linking future pediatric quality measurement and improvement efforts."