U.S. children who regularly see doctors get the right care less than half the time.
The findings, from the first comprehensive look at children's health care quality in the United States, are particularly troubling because nearly all the 1,536 children in the nationwide study had insurance.
Eight-two percent were covered by private insurance. Three-quarters were white, and all lived in or near large or midsized cities.
Two experts called the findings "shocking." Others said minority children, those with more-restrictive government insurance, and the millions with no insurance at all certainly fare even worse.
They said the results highlight the importance of the debate over the proposed expansion of a health insurance program for children from families who are too wealthy to receive government benefits for the poor but who cannot afford private insurance, which Congress approved and President George W. Bush vetoed. A vote to override the veto is set for next week.
The United States is one of the few western countries without universal health care.
The study, by the Seattle Children's Hospital Research Institute and the nonprofit Rand Corp. research group, concludes that overall, doctors gave children the appropriate outpatient medical care only 47 percent of the time.
"It's sad, but I think it reflects some unpleasant realities about our current health care system or, I might say, non-system," said Dr. Joseph F. Hagan, who co-edited the American Academy of Pediatrics' latest update to its children's health guidelines, due out later this month.
The compliance rate was even worse than that found in a study of adults: They got only 55 percent of recommended care.
The new research found children's doctors did best in providing the recommended care for acute medical problems - 68 percent. They scored just 53 percent for treating chronic conditions and 41 percent for preventive care.
"I was really taken aback by the results for preventive care," said Dr. Rita Mangione-Smith, lead investigator at the Seattle institute and an associate professor at the University of Washington. "It was really kind of distressing to me that there was some really basic stuff that we should be doing that's just not happening."
The study, based on a review of two years of medical records of children in 12 metropolitan areas, was reported in Thursday's edition of the New England Journal of Medicine.
The data were collected from late 1998-2000. Experts said it is unlikely children's health care has improved since then.
The researchers found a huge variance in the rates at which doctors provided care recommended for the most common illnesses and for promoting health.
Kids got the right care 92 percent of the time for upper respiratory infections and 85 percent of the time for hay fever. But they got it only 48 percent of the time for urinary tract infections, 46 percent for asthma and 35 percent for adolescent preventive care.
For instance, only 15 percent of adolescents seen by a doctor got weighed annually. Yet about one-third of American children are overweight and many are developing high blood pressure and diabetes, setting themselves up for long-term health problems.
"There can be dire consequences for the children, for their families and for society as a whole," including death, when these easily managed conditions are not controlled, said Julia Paradise of the Kaiser Family Foundation.
The researchers noted they had incomplete medical records for some children, no children from rural areas were included, and more than half the families asked to participate did not respond.
Mangione-Smith and the other experts said they hope the new findings will lead to action to address the shortcomings. Hagan said doctors can do more to keep up with the latest care guidelines. But he said they can't solve all the problems, such as insurance plans that don't cover crucial screenings and the inadequate time pediatricians have to spend with each child.
Another big challenge, Mangione-Smith said, is to change pediatrician training, which now focuses on treating acute illnesses in a hospital.
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