A Practice-Based Intervention to Enhance Quality of Care in the First Three Years of Life: Results from the Healthy Steps for Young Children Program Donna Strobino, PhD Cynthia S Minkovitz, MD, MPP Women’s & Children’s Health Policy Center Johns Hopkins University

Developmental and Behavioral Services D eficiencies in quality of care (McLearn 1996, Bethell 2001, Halfon 2002) P ractice barriers to delivering services (Minkovitz 1998) R enewed emphasis and collaboration with child health professionals in The Future of Pediatric Education II report (2000)

Healthy Steps for Young Children Program Enhanced Well Child Care Home Visits Telephone Line Child Development & Family Check-Ups Written Materials Parent Groups Linkages to Resources 2 HS Specialists/site (1 per 100 families) A Physician-Developmental Specialist Partnership

Program Goals P romote the knowledge, skills and confidence of mothers and fathers in their childrearing abilities P romote the healthy development of young children P romote the clinical capacity and effectiveness of pediatric primary care to meet the needs of families with young children

Approach E xpand Pediatric Services by Adding Developmentally-Oriented Services In home In office U niversal Intervention

National Evaluation: Design 6 randomization & 9 quasi-experimental sites Allentown, PABoston, MA Kansas City, KS Amarillo, TXChapel Hill, NC New York, NY Florence, SCChicago, IL Richmond, TX Iowa City, IADetroit, MI Pittsburgh, PAGrand Junction, CO San Diego, CAKansas City, MO S ites selected for high quality

Objective T o determine whether Healthy Steps enhances quality of care and parenting practices

Sample 5565 children 2963 intervention, 2602 control September, 1996 to November, 1998 < 4 weeks of age At hospital or office F ollowed birth to age 3

Data Sources N ewborn registration forms (5565) P arent telephone interviews: 2-4 months of age (4896) months of age (3737) 5-51/2 years (3165) M edical record reviews (4737)

Healthy Steps Families Reflect the Diversity of All U.S. Families Guyer et al. Pediatrics

Outcomes: Quality of Care (IOM, 2001) E ffectiveness F amily-centeredness T imeliness E fficiency E quity

Parent Outcomes   Parenting practices that promote child development   Parenting practices related to safety   Parent’s perceptions of child’s health, behavior, and social development

I ntention to treat L ogistic regression adjusted for baseline characteristics and sites R esults reported as odds ratiosAnalysis

“Crossing the Quality Chasm” (IOM 2001) Better Quality of Care  Effective  Patient-Centered  Timely  Efficient  Equitable  Safe Better Parent and Child Outcomes

“Crossing the Quality Chasm” (IOM 2001) Better Quality of Care Effective  Patient-Centered  Timely  Efficient  Equitable  Safe Better Parent and Child Outcomes

Developmental Services (30-33 months) % 19.79* (16.24, 24.13) 15.97* (13.27, 19.22) 10.36* (8.51, 12.60) * p <.05

Developmental Services (30-33 months) % 8.00* (6.69, 9.56) 29.07* (23.52, 35.94) 4.23* (3.56, 5.02) * p <.05

Better Quality of Care  Effective Patient-Centered  Timely  Efficient  Equitable  Safe Better Parent and Child Outcomes “Crossing the Quality Chasm” (IOM 2001)

% * p < * (1.80, 2.43) Satisfied with Care (30-33 months) “ Someone Went Out of the Way to Help”

Better Quality of Care  Effective  Patient-Centered Timely  Efficient  Equitable  Safe Better Parent and Child Outcomes “Crossing the Quality Chasm” (IOM 2001)

Age-Appropriate Well Child Visits * p< * (1.30, 3.00) 1.97* (1.55, 2.51) 1.53* (1.25, 1.89) 1.71* (1.41, 2.08) 2.06* (1.65, 2.56) 1.68* (1.35, 2.09)

On-Time Vaccinations * p< * (1.17,1.71) 1.60* (1.32, 1.93) 1.49* (1.29, 1.71) 1.40* (1.17, 1.69)

Better Quality of Care  Effective  Personalized  Timely Efficient  Equitable  Safe Better Parent and Child Outcomes “Crossing the Quality Chasm” (IOM 2001)

Last Office Visit After 20 Months 1.82* (1.57, 2.12) % * p <.05

Better Quality of Care  Effective  Personalized  Timely  Efficient Equitable  Safe Better Parent and Child Outcomes “Crossing the Quality Chasm” (IOM 2001)

No Variation by Subgroups P arity (first-time, second-time or greater parent) I ncome ( $50k) M aternal age ( 30 years)

Enhanced Quality of Care Effective   More received 4+ Healthy Steps services   More discussed 6+ developmental topics   More had home visit since 6 months Patient-Centered   Someone in practice went out of their way Timely   More age-appropriate well child visits   More age-appropriate vaccinations and up to date Efficient   Greater practice retention at 2 years Equitable   Consistent findings across subgroups that variation by parity, income, maternal age

Infants

Sleep Position 1.3* (1.10, 1.56) % * p <.05

Book Sharing and Playing 1.22* (1.07, 1.40) 1.24* (1.00, 1.54) * p <.05 %

Infants Toddlers

Discipline Strategies Discipline Strategies  Majority of mothers used multiple strategies, primarily non-physical  ~ Half spanked with hand (57%) or slapped on hand (52%)  5 % or less used severe physical discipline: spanked with object (5%); slapped in face (2%)

Discipline Strategies 0.73* (0.55, 0.97) 0.78* (0.62, 0.99) threaten, yell, slap on hand, spank with hand slapped face or spanked child with object * p <.05

Problem Behaviors   Mean scores   Similar to norms for non-referred children   Substantially lower than clinical cutoffs   More HS mothers report aggressive behaviors, sleep problems

Problem Behaviors InterventionControl Mean (SD) Aggressive Behavior*8.6 (5.1)8.3 (4.9) Anxious/Depressed4.7 (2.9)4.6 (2.9) Problems Sleeping*2.9 (2.4)2.8 (2.4) *p<0.05

Acknowledgements Healthy Steps Families and Practices The National Healthy Steps Evaluation Team The Commonwealth Fund & Local Funders Agency for Healthcare Research & Quality

Discipline Strategies “When (child) misbehaves, how often did you [ ] in an average week?” Explain rules and consequences; Show more acceptable activity; Give timeout; Withdraw privileges; Ignore misbehavior Threaten; Yell in anger; Slap on the hand; Spank with hand Slap face; Spank with object