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Serious Gaps Exist in Health Care Quality for America’s Children
Children in the United States fail to get recommended health care more than half the time, according to a new study from the RAND Corporation, the Seattle Children’s Hospital Research Institute, and the University of Washington School of Medicine.
The study — the largest and most comprehensive examination ever of health care quality for America’s children — shows that when it comes to getting the right care at the right time, the nation’s children fare even worse than adults. Children are not receiving recommended preventive care and screening services, such as regular weight and measurement checks to ensure they are growing properly and not at risk for obesity; nor are they receiving standard care for conditions such as asthma and diarrhea.
Previous research released by RAND Health in 2003 found that U.S. adults, on average, receive only about half the recommended care for the leading causes of death and illness. That research shattered the widely held perception that health care quality is not a problem in the United States.
“Our earlier findings provided a wake-up call to improve health care quality for adults,” said senior study author Elizabeth McGlynn, associate director of RAND Health. “Up until now, most people probably assumed quality was not a problem for children. This new study tells us that’s not true. We need to get health care right for children — and we need to do it now.”
The study, which appeared in the October 11, 2007, issue of the New England Journal of Medicine, assessed 175 measures of quality covering 12 clinical areas, including preventive care. Researchers reviewed the medical records of more than 1,500 children randomly selected from 12 metropolitan areas.
Quality varied widely according to type of care: Children received 68 percent of recommended care for acute medical problems, 53 percent of recommended care for chronic medical conditions, and 41 percent of recommended preventive care. Problems were found across the continuum of care: Children received 66 percent of recommended care for treatment, but only 38 percent for screening, 47 percent for diagnosis, and 45 percent for follow-up services.
For Children, There Are Great Differences in Performance by Medical Condition |
SOURCE: “The Quality of Ambulatory Care Delivered to Children in the United States,” The New England Journal of Medicine, Vol. 357, No. 15, pp. 1515-1523, October 11, 2007, Rita Mangione-Smith, Alison H. DeCristofaro, Claude M. Setodji, Joan Keesey, David J. Klein, John L. Adams, Mark A. Schuster, Elizabeth A. McGlynn. |
The figure illustrates some of the differences in performance by medical condition, ranging from a high of 92 percent of recommended care received by children for upper respiratory infection to a low of 35 percent of recommended care received for adolescent preventive services.
McGlynn and coauthor Rita Mangione-Smith, a researcher at Seattle Children’s Hospital Research Institute and associate professor of pediatrics at the University of Washington School of Medicine, argue that ensuring the delivery of needed care will require greater investment in health information technology systems as well as increased attention to documenting and measuring quality of care for children. As Mangione-Smith put it, “We can’t close the quality gap without first addressing the information gap.” 
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Army Follows One Policy on Women in Combat, but Not Another?
Although the U.S. Army is complying with the U.S. Department of Defense policy barring the assignment of women to units whose primary mission is ground combat, concerns persist about whether the army is following the letter of its own policy about assigning women, according to a RAND study.
| Senior Defense Officials Agree on What Objectives Should Be in the Policy but Not on Whether They Are in the Current Policy | |||||||||||||||||||||||||||||||||||||||
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The defense department policy excludes women from assignments to “units below the brigade level whose primary mission is to engage in direct combat on the ground.” The army has a separate policy that excludes women from assignment to units with “a routine mission to engage in direct combat, or which collocate routinely with units assigned to a direct combat mission.” Depending on the definition of “direct combat” and the meaning of “collocate,” there are concerns about whether the letter of the army’s policy is being followed.
Researchers found no shared understanding of the meaning of many additional terms used in the army and defense department policies, including “enemy” and “forward or well-forward.” The study also finds that there is no consensus among senior defense officials about the objectives of the army and defense department policies. The table shows that although the officials mostly agree on the objectives of an ideal assignment policy, there is no consensus about the objectives of the current policy.
“Neither the letter nor the spirit of the policies is clear,” said Margaret Harrell, lead author of the study. “A large part of the problem appears to be that the policies do not anticipate the nature of combat experienced in Iraq, where there is no clearly defined battlefield.”
One issue in determining whether the army is complying with the assignment policy depends on the definition of collocation, which might refer to close proximity or might mean both close proximity and interdependence. The assessment finds that support units are clearly in close proximity with direct combat units in Iraq, but it is unclear whether they are also interdependent with one another. Collocation does not violate defense department policy, but the army may not be complying with its own policy, depending on the selected definition.
The assessment reveals that some aspects of the army assignment policy, such as its focus on a defined enemy on a linear battlefield and its restriction against repelling the enemy’s assault, are clearly inappropriate for future military operations. Meanwhile, the appropriateness of other aspects of the policy depends on the policymakers’ intent.
The study recommends that if the defense department decides to continue having an assignment policy for women, the policy should be revised to provide greater clarity and to reflect the changing nature of warfare. The study urges policymakers to consider whether a revised policy should exclude women from units and positions where they have performed successfully. The study also asks policymakers to consider how much the assignment policies in the army and other services should differ from the overall defense department policy.
For more information:
Assessing the Assignment Policy for Army Women, RAND/MG-590-1-OSD, ISBN 978-0-8330-4150-0, 2007.
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Liberia Sees Opportunity to Transform Its National Security Sector
Under former Liberian President Charles Taylor, the country’s security institutions met none of the criteria for a sound security sector — coherence, legitimacy, effectiveness, and affordability — according to a new RAND report. But under President Ellen Johnson Sirleaf, Liberia’s new government has made security sector transformation a high priority, and RAND has recommended steps to help the sector meet those four criteria.
“A ‘big picture’ is important to maximize the benefits from individual investments.” |
The study provides an integrated analysis of the security sector institutions, forces, and services needed for the new Liberia — an overall architecture in which they can fit and a unified strategy for building them. “Such a ‘big picture’ is important to maximize the benefits from individual investments and efforts and to set priorities for the use of scarce resources,” said lead author David Gompert.
A key part of the study identifies and assesses three options for an integrated Liberian force structure (see the table). The options revolve around four variables: the size of the Liberian National Police, which addresses internal threats; the size of Armed Forces of Liberia, which addresses external threats; whether there should be a quick-reaction police unit within the Liberian National Police; and whether there should be a coast guard.
| Option 3 Offers Liberia Better Security at the Best Price | |||||||||||||||||||||||||||||||||||||||||
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Option 1 (small Liberian National Police force, a small armed force, no quick-reaction police unit, and no coast guard) represents the status quo. “Option 1 is sound but may not be adequate to meet Liberia’s needs, especially for maintaining basic public safety, preventing armed internal opposition, and providing coastal security,” said Gompert.
Option 2 would double the size of the Liberian National Police force and the Armed Forces of Liberia and add a coast guard. This option would also nearly double the national security sector’s annual operating costs, and yet it could still fall short of providing adequate security against armed internal opposition without relying excessively on domestic intervention by the Armed Forces of Liberia.
Incorporating the quick-reaction police unit within the Liberian National Police (Option 3) would do a better job of meeting Liberia’s security challenges, especially armed internal opposition. “Option 3 seems like a wise investment for Liberia and its supporters,” noted Gompert. “Operating costs would be only $5 million more than Option 1, and it would cost $43 million less to build than Option 2.”
Now is an opportune moment for Liberia to transform its national security sector, said Gompert. “The presence of the UN Mission in Liberia, the commitment of the United States, and a somewhat less hostile external security environment — albeit one that may change rapidly — provide Liberia with valuable time to create security institutions and forces that are effective against dangers, are legitimate in the eyes of Liberia’s people and neighbors, fit together and work coherently, and are well worth the cost.”
The findings in this study were informed by field visits to Liberia and by exchanges with hundreds of interested parties in Liberia and elsewhere.
For more information:
Making Liberia Safe: Transformation of the National Security Sector, RAND/MG-529-OSD, ISBN 978-0-8330-4008-4, 2007.
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Alternative Farming Could Replace Crops with a Cleaner Cornucopia
Current methods of farming typically involve planting a single species of annuals — picture endless fields of wheat across the Kansas prairie. But planting multiple species of perennials — what is known as perennial polyculture farming — can help increase food production while reducing environmental damage and other undesirable effects of current farming methods, according to a new RAND study.
The Green Revolution, launched in 1943 in Mexico, was a particular boon to developing countries because it increased agricultural production; 64 years later, Green Revolution technologies are still going strong.
“But we’re discovering there was a price to pay in terms of, among other things, environmental degradation, erosion, soil degradation, water depletion and contamination, and a loss of biodiversity,” according to study author James Dewar, director of the RAND Frederick S. Pardee Center for Longer Range Global Policy and the Future Human Condition.
Perennial Polycultures Are Plausible in Areas of Rain Forest, Temperate Forest, Grassland, and Chaparral |
SOURCE: The source of this image is Windows to the Universe, of the University Corporation for Atmospheric Research. Copyright © 2004 University Corporation for Atmospheric Research. All rights reserved. Used with permission.
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One solution he proposed is to move toward perennial polyculture farming, which, in a sense, involves “reengineering the prairie” that was originally a perennial polyculture before man began farming it. The study points out that perennial polycultures are plausible in many of the world’s land areas, including rain and temperate forests, grasslands, and chaparral (see the map).
“Successful perennial polyculture farming could address many of the environmental problems connected with existing agricultural methods,” noted Dewar. “The perfect ‘reengineered prairie’ would provide year-round ground cover to minimize erosion by wind and water, diminishing the need for irrigation.”
This method would also reduce soil degradation caused by the depletion of minerals and by contamination from pesticides, herbicides, and other pollutants. Contamination of freshwater systems would likewise be curtailed by reduced use of fertilizers, pesticides, and other chemicals. Protecting freshwater systems would, in turn, help prevent such environmental problems as ocean dead zones, caused in large part by agricultural runoff. Additionally, perennial polyculture farming would help reverse biodiversity loss.
Beyond environmental benefits, the study notes, perennial polyculture farming could indirectly yield social benefits by leading to reductions in hunger and poverty, improvements in health and education, and lower energy use.
While perennial polyculture farming may appear fanciful, modern farmers already use techniques that emulate its methods, such as rotating crops to limit the needs for pesticides and fertilizers. Recent research suggests that while perennial polyculture farming could be made to work, its economic viability is difficult to gauge. Proponents believe it would make economic sense on marginal lands with highly erodible soils, a situation that exists in many areas of the world, including much of the United States.
Technological challenges exist, “but perhaps an even greater challenge is to make sure the necessary intellectual and experimental work occurs in a world dominated by large agricultural businesses,” concluded Dewar. “An opportunity to continue research exists in developing countries, where the development community is paying increasing attention to agriculture as a key to reducing poverty.”
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