Tens of thousands of children in northern New England do not receive essential lead screening tests, while thousands of others undergo unnecessary CT scans for stomachaches, according to a Dartmouth Atlas report on children’s health care in northern New England. In the study, released on Dec. 11, researchers found striking variations in pediatric medicine across Maine, New Hampshire and Vermont, suggesting that local hospitals may need to reexamine their health care delivery systems.
The research demonstrates that in some cases, children do not receive adequate care or are prescribed unnecessary and harmful treatment — variations that can be attributed more to local medical culture than individual medical conditions, Atlas co-principal investigator and Geisel School of Medicine professor David Goodman said.
The report by the Dartmouth Atlas, a project that uses Medicare data to analyze national, regional and local health care markets, examined approximately 691,000 infants and children under 18 years old based on records from 2007 to 2010 of all insurance claims paid in Vermont, New Hampshire and Maine.
Among children insured by Medicaid in Northern New England, the rate of lead screening between 2008 and 2010 varied from 8 percent in Dover-Foxcroft, Maine, to 86 percent in Berlin, N.H.
To improve health care delivery, hospitals must develop systems of monitoring effective care and use that information to identify gaps in quality, Goodman said. Physicians should also reexamine discretionary procedures such as tonsillectomies, CT scans and ear tube placements, which offer limited benefits at high risks, and they should more thoroughly discuss possible side effects with families before they deciding on a course of action, he said. There was an average of 8.8 chest or abdominal CT scans per 1,000 children in Northern New England from 2007-2010.
Associate professor of The Dartmouth Institute Nancy Morden, a study author, said the decisions physicians make for children are complex and often uncertain.
“What we need to do is be honest, open and transparent to the parents about the benefits and risks,” she said.
Parents have a special role in the decision-making process as well, Goodman said.
“Parents need to be asking more questions – does my child really need a head CT for a headache or abdominal x-rays for constipation?” he said. “They need to ask about alternatives to tonsillectomies and tubes placed in their children’s ears, not so that they won’t have these procedures, but so they can make a high-quality decision.”
Goodman said the pediatric community has responded positively to the report’s findings. The Dartmouth Atlas will speak with hospital stakeholders in northern New England to discuss future strategies.
Keith Loud, interim chair of pediatrics at Dartmouth-Hitchcock Medical Center, said he was pleased that the study brought variations in pediatric care to the public’s attention.
“We are proud to be where this important, ground-breaking research is taking place,” Loud said.
Many pediatricians at DHMC are excited about the opportunity to communicate with physicians in the region about issues raised by the study, Loud said.
“We’ve always been committed to learning from our colleagues and this gives us a robust tool,” he said. “It is part of our constant, never-ending quest to improve patient care and outcomes.”
The Dartmouth Atlas’s next project is a national study of children’s health care using Medicaid data that includes about half of the pediatric population of the United States, allowing researchers to examine children of diverse racial, socioeconomic and geographic backgrounds, Morden said.
Based on past national studies of regional variations in health care for other age groups, Goodman said variation in pediatric care likely exists outside of New England as well.
The two-year project received a $500,000 grant from the Charles H. Hood Foundation, which supports pediatric research in New England.
