Research Highlights
Research activity in the Health Policy and Clinical Effectiveness Program at Children's Hospital Medical Center of Cincinnati reflects the expertise of our faculty. It focuses on five broad areas:
- Research in Pursuit of Perfect Care
- Neonatal studies
- Cost-effectiveness studies
- Liver transplant
- Health services research studies
- Community-based effectiveness studies
Research in Pursuit of Perfect Care
As one of seven institutions nationwide – and the only pediatric facility – to be awarded a Robert Wood Johnson Foundation grant in 2002 in the "Pursuing Perfection: Raising the Bar for Health Care Performance" initiative, Cincinnati Children's already is producing compelling examples of how health care organizations can improve significantly.
Led by Uma Kotagal, MBBS, MSc, of the Health Policy and Clinical Effectiveness Program, two pilot programs have been developed as model systems for delivering care to patients with acute and chronic conditions. The goal is to apply the benefits from these pilots to five subsequent projects, and then to all patient populations.
As the acute care pilot, the bronchiolitis project's goal was to establish a family-centered and evidence-based system. Key results of the bronchiolitis project include:
- Medical records are easily accessible in patient rooms, and parents can chart their child's progress
- Use of evidence-based order sheets increased to 100 percent
- Parents participated in designing the new acute care system
- After meeting discharge criteria, time to patient discharge decreased from 35 to 10 hours
- Admissions were significantly reduced and are below the national average
In the chronic care pilot, led by Maria Britto, MD, MPH, patients with cystic fibrosis and their parents were full participants in designing and implementing a comprehensive delivery system for children and adolescents. Key results the cystic fibrosis pilot include:
- The proportion of patients receiving flu shots increased from 36 percent last year to 86 percent this year
- A form to solicit parent and patient goals for routine outpatient visits was implemented, resulting in more satisfying and productive visits
Essential to the Pursuing Perfection effort is research – to bring better focus on measurement and analysis, better understanding of new knowledge, and better application of evidence. Since 1995, Cincinnati Children's has become a pediatric leader in integrating improvements at the bedside. Now, using research techniques, the organization is exploring the question, "Does redesigning the health care system improve outcomes?" The hypothesis is that by matching care more closely to patient needs, outcomes will indeed improve.
Additional acute and chronic care efforts are underway. For juvenile rheumatoid arthritis and diabetes, teams of providers and families are collecting data on clinical, functional and satisfaction outcomes. They are measuring baselines, beginning to design new chronic care delivery systems, and starting to measure new outcomes. By the end of 2003, all redesign efforts will be in place.
Neonatal Studies
Research activities have continued to focus on understanding and documenting the effects of early discharge practices regionally and nationally.
Funding from the Ohio Board of Regents has been used to analyze the impact of early discharge on the Medicaid population and to develop predictive models for non-urgent emergency department use in early infancy.
Early state-wide data show significant regional variation in length of stay and its impact. Perinatal quality of care measures for the Medicaid population have been developed and are being validated. Studies have been completed on the health system predictors of breast-feeding failure in the early post-discharge period.
A prospective randomized study of the effort of linking high risk newborns to early primary care is underway. The primary outcome of this study will be non-urgent emergency department use in Medicaid patients in the first three months of life.
Additional studies are being conducted to assess maternal knowledge of newborn health care needs, and the effectiveness of hospital services to educate indigent populations on the appropriate use of health care services. Funding for these latter studies is through a grant from the Health Foundation of Greater Cincinnati.
Prevention of prematurity is an area of research targeted for the next several years. A community-wide collaborative effort is underway through the medical outcomes task force of the Health Improvement Collaborative of Greater Cincinnati. Preliminary funding has been obtained from a variety of sources.
Cost-Effectiveness Studies
The use of decision analysis strategies to determine optimal approaches to care will increasingly become an important area of focus. Modeling of various treatment and diagnostic strategies will allow us to determine the most cost-effective approaches to care. Initial work in this area has focused on cost-minimization strategies for screening for sore throat in the office setting.
Funding through a faculty development grant from the University of Cincinnati allowed Uma Kotagal MBBS, MSc, to pursue additional training at the Division of Clinical Decision Making, New England Medical Center, and at the Harvard Center for Risk Analysis.
A grant from the American Society of Echocardiography (Tom Kimball, MD, principle investigator) has supported a cost-effectiveness analysis of optimal evaluation of heart murmurs in children. Additionally, a cost-effectiveness analysis on the optimal approach to management of the asymptomatic newborn for Group B streptococcal disease has been completed.
Liver Transplant
In the United States, approximately 4,000 patients undergo liver transplant each year; 15 percent of these patients are under 18 years of age. As survival rates following liver transplantation have increased, health care providers have begun to assess the factors which predict overall health status of liver transplant recipients, while managed care providers have tried to encourage control of resource utilization.
We have three ongoing projects related to liver transplantation:
- Reperfusion injury results in enhanced expression of adhesion molecules and histocompatibility antigens on donor endothelial cells and may increase the risk of the graft for rejection following liver transplantation.
We are testing the hypothesis that treatment of children who undergo a liver transplant with N-acetylcysteine and prostaglandin E1 will attenuate reperfusion injury, decrease the frequency and severity of graft rejection, and decrease the length of stay during primary hospitalization.
- We are also investigating the use the age-appropriate version of the Child Health Questionnaire to measure functional health status prospectively to define a model which predicts the return to functional health in children who receive a liver transplant.
- The prevalence of non-adherence to medical regimen ranges from 5-50 percent and may result in graft rejection, graft loss, and adverse reactions to medications.
In collaboration with the Division of Psychology, we will test the hypothesis that family coping skills predict adherence to medical regimen, clinical outcome, and resource utilization in the first year after a child undergoes liver transplantation.
Health Services Research Studies in Collaboration with Cincinnati Children's Divisions
Collaborative research efforts are underway in the area of clinical effectiveness with Departments / Divisions of Surgery, Radiology, Adolescent Medicine, Neurology and Hematology / Oncology, as well as through the clinical effectiveness teams established in Bone Marrow Transplant, Liver Transplant, Pediatric Asthma, Cystic Fibrosis, Diabetes, and Cardiac Surgery. Studies currently underway in those teams include:
- An evaluation of effectiveness of two methods of chest physiotherapy in cystic fibrosis patients hospitalized for exacerbation of disease / infections and a study of the relationship between health status and physiologic health measures in cystic fibrosis.
- Studies on the effectiveness of evidence-based guidelines on care of patients with bronchiolitis, appendicitis and gastroenteritis have been completed.
- Additional studies are ongoing on the effectiveness of evidence-based guidelines in fever of unknown source in infants less than 60 days of age, and on community rates of hospitalization, resource use and outcomes.
Studies are also planned in the area of prematurity prevention and on the effectiveness of various preventive strategies in the multi-fetal pregnancy.
Community-Based Effectiveness Studies
In collaboration with the Division of Community Pediatrics (Thomas DeWitt, MD, co-principal investigator) funding was obtained from the Health Foundation of Greater Cincinnati to establish a Center for the Promotion of Lifelong Health focused initially on school health.
The first project of this Center is to evaluate the impact of three different models of school-linked health services. A Child Health Data Center focused on developing areas of focus and analytic support for community interventions aimed at improving child health regionally will be established as part of the Center.
Contact Us
For more information about the Health Policy and Clinical Effectiveness program at Children's Hospital Medical Center of Cincinnati, please call 513-636-0178.
