This report presents findings from Periodic Survey #37, on pediatricians’ opinions and experiences with clinical practice parameters (or guidelines) for specific conditions, as well as other quality improvement approaches in their practices. The survey was initiated by the Subcommittee on Implementation of the AAP Committee on Quality Improvement. These data were collected to help evaluate current dissemination and implementation strategies and plan for future initiatives. The survey was conducted from July to November 1997; after five mailings a total of 1,165 completed questionnaires were received for a response rate of 63.7%. These analyses are based on responses from the 932 post-residency pediatricians who provide direct patient care (DPC) (93.3% of all post-residency respondents).

Use of Clinical Practice Parameters (among post-residency pediatricians in DPC who have treated patients for the condition and are familiar with the parameter)

Most pediatricians who have treated children with these conditions during the prior year are familiar with the AAP practice parameter:

• 89% who treat children with asthma are familiar with this parameter;
• 83% who treat children with hyperbilirubinemia are familiar with this parameter;
• 71% who treat children with gastroenteritis are familiar with this parameter;
• 86% who treat children with otitis media with effusion are familiar with this parameter;
• 77% who treat children with simple febrile seizures are familiar with this parameter.

Pediatricians who are familiar with a parameter and who have treated children with that condition were asked if the parameter affected the way they care for patients with that condition. Most pediatricians have made changes in the way they care for patients with asthma as a result of the recommendations in the parameter: 41% have made “some” changes and 15% “many” to “extensive” changes. About half of pediatricians have made changes as a result of the parameters on hyperbilirubinemia (36% some; 15% many/extensive), gastroenteritis (37% some, 12% many/extensive), and otitis (39% some, 11% many/extensive). Fewer pediatricians report changes based on the febrile seizure parameter: 31% say they have made some changes and 10% many changes.

Overall, these pediatricians agree with the practice parameters and think the parameters are consistent with their community’s standards of care:

• An overwhelming majority agree with the parameter recommendation: asthma, 97%; hyperbilirubinemia, 96%; gastroenteritis, 90%, otitis, 90%; febrile seizures, 97%.

• For most, the parameter recommendations on asthma, hyperbilirubinemia and febrile seizures appear to be consistent with their community’s standard of care (81%, 90%, 90% agree); fewer pediatricians think this is so for the gastroenteritis (63% agree; 27% unsure) and otitis (72% agree; 22% unsure) recommendations.

Overall, the majority of these pediatricians say use of practice parameters has not changed the time needed for the patient encounter, the cost burden for parents, or the cost to their practice for providing care. However, a notable proportion have indicated changes in these areas, particularly as a result of the asthma parameter:

• About one-fourth of pediatricians say the cost burden for parents has decreased with the use of the parameters on hyperbilirubinemia (29%), gastroenteritis (24%), otitis (29%) and febrile seizures (28%); less than 10% report an increased cost burden in any of these areas. Slightly fewer (19%) say the cost to parents has decreased since using the asthma parameter, while 20% report an increase.

• One-fifth of pediatricians report the cost to their practice of providing care for hyperbilirubinemia and febrile seizures has decreased by using the parameters (23%, 21%); 16% and 15% report decreased costs when using the gastroenteritis parameter and the otitis parameter, respectively. Reported increases are minimal. However, for the asthma parameter, 16% report a decrease in these costs and 26% report an increase.

• An increase in time needed for patient encounters was reported by 11% of pediatricians as a result of the hyperbilirubinemia parameter, 26% for gastroenteritis, 28% for otitis and 14% for febrile seizures; decreases in time were reported by fewer than 10%. Thirty-six percent report an increase in time for patient encounters as a result of the asthma parameter; 14% reports a decrease.

Quality Improvement Approaches in Pediatric Practices (reported by all post-residency pediatricians in DPC)

Experiences with Quality Approaches:

• Overall, three-fourths of pediatricians (77%) receive information on patients’ satisfaction with their practice:
• 66% receive letters or phone calls from individual patients,
• 50% receive surveys conducted by their practice,
• 43% receive surveys conducted by a managed care plan.

• Sixteen percent of pediatricians say insurers with whom their practice is affiliated offer financial incentives for achieving specified levels of patient satisfaction; 34% do not know.

• Most pediatricians do not measure patient outcomes, other than immunization rates, in their practice:
• 55% measure immunization rates,
• 45% measure mortality or other adverse outcomes,
• 40% measure hospitalization rates,
• 36% measure emergency room visits rates,
• 28% measure functional status of patients.

• Six out of 10 pediatricians report their practice has a person specifically responsible for quality improvement, most likely a pediatrician (60% so report). Most pediatricians (82%) report their practice staff has met during the past year to discuss measuring or improving quality.

• About half of pediatricians (49%) indicate they participated in CME during the past year that covered approaches to quality improvement.

Criteria for Judging Quality

Pediatricians were asked to rate how well a list of commonly used criteria reflects the quality of a pediatric practice. More than half rated all items as “fair” to “good”; with two exceptions, very few pediatricians rated any criteria as “poor”.

The proportion of pediatricians who rated each criterion as an “excellent” indicator of quality varies:

46% - achievement of preventive care goals
46% - board certification
45% - satisfied patients
45% - ongoing process review and improvement
38% - low rate of adverse outcomes in care
35% - participation in CME
21% - academic affiliation
17% - AAP membership
16% - use of clinical practice parameters
13% - absence of malpractice suits (14% think this is a poor measurement of quality)
3% - contracts with managed care plans (31% say this is a poor indicator of quality)

Means of Improving Quality

Pediatricians were asked to rate the effectiveness of several components of quality improvement.

• About three-fourths of pediatricians think measurement of patient outcomes (79%), checklists in records (75%), and clinical practice parameters (72%) are effective means of improving quality of care.

• About two-thirds of pediatricians think measurement of patient satisfaction (68%), total quality improvement methods (65%), and formal peer review processes (62%) are effective means of improving quality of care. About one-half (51%) think comparing outcomes or processes with other practices is effective.

A large majority of pediatricians think it is important that the AAP promote quality improvement in pediatrics by focusing its QI efforts in these areas:

• Develop tools to measure pediatric outcomes (53% somewhat important; 24% very important)
• Provide materials to help practices use parameters (52% somewhat important; 26% very important)
• Establish standards of pediatric care (47% somewhat important; 29% very important)
• Write practice parameters (49% somewhat important; 23% very important)
• Provide CME programs on quality improvement methods (53% somewhat important; 20% very important).