New National “Vital Signs” to Measure Population-wide Pediatric Health

In 2017, an opinion piece in JAMA Pediatrics started this way: “We call for a national effort to develop a parsimonious set of quality and outcome measures for (all) children.” And now, for perhaps the first time in American pediatrics, that “parsimonious set: has been laid out to guide communities and health systems across the United States.

A series of publications in the National Academy of Medicine’s NAM Perspectives has put forward four “Vital Signs for Pediatric Health” that can be used to track overall well-being across the entire span of childhood in United States, the way a vital sign like blood pressure can help measure health for an individual.

The signs are elegantly simple, but they are also proxy measures pointing to the most complex issues in childhood:

• Infant Mortality
• School Readiness
• Chronic Absenteeism in Middle School
• High School Graduation

“Without these kinds of population health measures, hospitals can build wonderful facilities that have magic inside of them, but the communities at large can decay,” says Kelly Kelleher, MD, MPH, vice president for Community Health at Nationwide Children’s Hospital. Dr. Kelleher is both one of the authors of that original call in 2017 and one of the lead authors of the recent group of “Vital Signs for Pediatric Health” publications.

Nationwide Children’s has previously instituted its own set of Pediatric Vital Signs, showing the promise, and the challenge, of such a large initiative. Now other health care organizations have a national roadmap — if they choose to follow it.

Developing the Vital Signs for Pediatric Health

The original idea for the pediatric vital signs was embedded in a larger group of overall core health metrics proposed by the National Academy of Medicine in 2015. Also called “Vital Signs,” the 15 metrics names issues from individual spending burden (the amount a person must spend on health care) to overall life expectancy. those metrics focused on adults.

A series of pediatric-focused meetings followed, first through Nationwide Children’s, Children’s Hospital Association and the American Academy of Pediatrics, and then through the National Academies of Sciences, Engineering and Medicine’s Forum for Children’s Well-Being.

The discussions took a while.

“With kids, you have so much changing all the time, the mental, the emotional, the behavioral, the physical health, that we had to make the argument cogently and often that kids are different,” says Kimberly Eaton Hoagwood, PhD, Cathy and Stephen Graham Professor of Child and Adolescent Psychiatry at New York University’ Grossman School of Medicine. Dr. Hoagwood is the lead author of the recent vital sign publication about high school graduation, and she is a co-author of two of the other papers.

The child metrics were carefully selected to encompass different stages of child growth, capturing a small number of meaningful metrics which has at least some available data at state and/or local levels, says Jennifer Kaminski, PhD, lead health scientist, Policy Analysis and Engagement Office, Office of Policy, Performance, and Evaluation at the Centers for Disease Control and Prevention. Dr. Kaminski is lead author of the recent vital sign publication about school readiness, and a co-author of the other papers.

With funding from the CDC, the convening power of the NASEM and the contributions from experts across childhood health, four core metrics were proposed.

The Vital Signs

The signs are separated by age and developmental stage. For a group of metrics developed by people in pediatric health care, they can seem more focused on education than health. But that’s where much of the available data on children and adolescents are, says Dr. Kaminski. Biology, education, parent income level, geography, race, access to health care and many more elements can all play a role in child health and development.

Infant Mortality Rate

The rate of child death before 1 year of age may be the most widely used measure of overall child health in the United States, according to the authors. It’s a possible indicator of, and it is driven by, maternal health, gaps in community care systems, socioeconomic inequity and other population health-level elements.

It is, perhaps, the most obvious vital sign to use.

Infant mortality varies widely by geography and demographics; in 2020, some states had double the rates of others, and for most of the last 60 years, Black infants died at over two times the rate of White infants.

Importantly, communities that have positively affected infant mortality rates have developed collaborations across sectors, potentially promoting better coordination among and between child and maternal health systems, according to the authors. Infant mortality rate is an indicator, but its improvement can also be a spur to broader community improvement.

School Readiness

Readiness for kindergarten can serve as a lens to gauge the early development of children across a variety of domains, the authors argue. Measuring readiness, however, is not simple.

A full accounting of readiness considers physical well-being and sensory motor development; social and emotional development; approaches to learning language development; and general knowledge and cognition, such as literacy and math skills. The measures used across districts and states can vary widely.

Only 42.5% of children 3-5 years of age were considered “health and ready to learn” in 2019 according to the National Survey of Children’s Health, and significant readiness disparities exist among demographic categories. In addition, not all states and jurisdictions measure school readiness.

One of the major challenges of using school readiness and any other education-related metric is the traditional disconnect between education systems and health care. and the additional consent needed for sharing data. Still, school readiness may be the most comprehensive overall look at well-being in early childhood, the authors write.

Chronic Absenteeism in Middle School

Absenteeism as a metric can be used at any schooling age, but with proposed metrics at other developmental states, the authors suggest it made most sense to use it as a vital sign for children who are approximately 10-15 years old.

The U.S. Department of Education defines “chronic absenteeism” as missing 10% or more of enrolled school days. Approximately 14% of middle school students are chronically absent in a given year, again with large disparities by incomes, geography, race and other demographics.

Most drivers of absenteeism are “external” to education — health, economic stability, parental resources — and the metric could be especially illuminating in 2024.

“Chronic absenteeism may take on a renewed importance as a vital sign as the U.S. works to recover from the health, economic social and education impact of the prolonged COVID-19 pandemic,” the authors write.

High School Graduation

Like infant mortality, high school graduation has become a signal measure of population health over the last several decades. It is seen as not only a snapshot of the way things are, but as one predictor of adult outcomes. Nearly 80% of men in prison, for example, have not graduated from high school according to one study, and lifetime earnings are significantly less for people without a high school degree.

The authors chose the U.S. Department of Education’s Adjusted Cohort Graduation Rate as the most representative way to look at the statistic. In 2018-2019, the national rate was 86%, an improvement over the 79% rate in 2010-2011. The kinds of disparities that exist with the other proposed vital signs exist in high school graduation as well.

And as with the other signs, there are potential benefits far beyond education that may come with focusing on high school graduation rate and trying to improve it, the authors say. Precursors to dropping out of high school include issues from early chronic absenteeism to teenage pregnancy. A strategy to positively impact those precursors could also impact graduation.

Just The Start

Identifying these vital signs is just the beginning of a challenging continual process to support health systems in promoting pediatric growth and development. The experience at Nationwide Children’s may be illustrative.

Nationwide Children’s developed its own group of eight “Pediatric Vital Signs” to measure the health of children in Franklin County, Ohio in 2018; infant mortality, kindergarten readiness, high school graduation, obesity, teenage pregnancy, suicide, all-cause child mortality, and a hybrid measure called “preventative services delivery.” Dozens of members of the Nationwide Children’s staff are involved improving well-bring through those metrics, with community public health, education, health care and other partners.

Certain metrics, such as infant mortality, showed real improvement before COVID-19. Promising strategies were developed and implemented in the other metrics. Then the pandemic came.

“In many cases, we’re now trying to get back to our pre-COVID baseline,” says Dr. Kelleher.

The Nationwide Children’s Pediatric Vital Signs, however, have helped provide a specific analysis of the pandemic’s impact on child well-being. They point to particular areas of stress in social areas, and the team at Nationwide Children’s is adjusting their strategies to make a difference.

What the most recent proposed metrics provide is a place for other pediatric health systems to start, says Dr. Kaminski. Those systems may decide that other metrics make sense in their regions, or that strategies different from the ones suggested in the NAM Perspectives publications make sense.

“I have realistic optimism about the project,” she says.

“Even a great set of papers foes not alone change the world. What I think this will do, is where there is already interest or investment in moving population health forward, you can point to these and say, ‘here’s a set of metrics. Look, the NASEM and CDC and Nationwide Children’s have shown evidence for these.’ It’s a long game, but public health is a long game.”

Dr. Hoagwood feels similar optimism because of her discussions with young people and young adult peer leaders. She also thinks of these publications as a starting place, and that many of the best strategies for improving metrics like infant mortality and high school graduation rates are going to come from communities themselves.

This article appeared in the Spring/Summer 2024 issue. Download the full issue.

References:

1. Kelleher KJ, Hoagwood K, Walker DK, Kaminski JW, Gardner W, Fox EG. Vital signs for pediatric health: infant mortality. NAM Perspectives. 2023 Jun 26; 2023:10.31478/202306a.
2. Kaminski JW, Barrueco S, Kelleher KJ, Hoagwood K, Edwards A, Fox EG. Vital signs for pediatric health: school readiness. NAM Perspectives. 2023 Jun 26; 2023:10.31478/202306b.
3. Johnson SB, Edwards A, Cheng T, Kelleher KJ, Kaminski J, Fox EG. Vital signs for pediatric health: chronic absenteeism. NAM Perspectives. 2023 Jun 26; 2023:10.31478/202306c.
4. Hoagwood K, Walker DK, Edwards A, Kaminski JW, Kelleher KJ, Spandorfer J, Fox EG. Vital signs for pediatric health: high school graduation. NAM Perspectives. 2023 Jun 26; 2023:10.3147/202306d.

Image credits: iStock (header); Nationwide Children’s (Kelleher); New York University (Hoagwood)