More evidence that the U.S. health-care system is far from stellar: It seems that even white, middle-class, well-insured children get poor quality health care more often than not. A large study published in the New England Journal of Medicine found that American children receive recommended health-care procedures only 46% of the time when they see a doctor. In fact, children get even worse care than adults, who receive appropriate care about half the time, according to a similar survey published in 2003.

"Taken together, these studies show that no one, anywhere, is immune from poor quality of care [in the U.S.]," says lead researcher Rita Mangione-Smith of Seattle Children's Hospital Research Institute.

The researchers, from the Rand Corp. and University of Washington as well as Seattle Children's, reviewed the medical records of 1,536 children from 12 metropolitan areas around the country and assessed 175 measures of quality in 12 clinical areas. They found that children in the U.S. do not routinely receive regular weight and measurement checks, widely recommended screening tests, or standard care for asthma and diarrhea. "As a pediatrician, I was shocked by some of our findings," says Mangione-Smith. "I rescreened several of the charts because I couldn't believe the results we were getting."

The children in the study were predominantly from white, middle- or upper-middle-class families; 82% were covered by private insurance. Children without insurance likely fare far worse, the researchers noted.

Insurance Is No Guarantee of Proper Care

The study, published in the Oct. 11 issue of the journal, comes a week after President Bush vetoed a bill that would have expanded the State Children's Health Insurance Plan (SCHIP). Charles Homer, a pediatrics professor at Harvard Medical School, points out that the bill would also have funded federal initiatives to improve quality of care. "If SCHIP were implemented, and quality initiatives were put in place. I believe private insurers would have followed its lead," says Homer. "In general, getting more kids insured is a good thing for their quality of care. That's a no-brainer."

Mangione-Smith also recommends that pediatricians do a better job, particularly in managing chronic conditions, some of which, such as hypertension and diabetes, are on the rise among children due to the rise in obesity. "We need to get on top of these problems now, both to keep children healthy and to avoid the higher costs of treating out-of-control chronic diseases in adults," she says.

But the study revealed that having insurance is no guarantee children will receive standards of care as promoted by pediatric associations and federal and state guidelines. "I work in the field of quality, and I knew things were not what they should be, but I didn't think they were this bad." says Homer.

Startling Statistics

How bad are they? According to the researchers, the children received 41% of recommended preventive care such as routine screenings, 53% of recommended care for chronic medical conditions such as asthma and diabetes, and 68% of recommended care for acute medical problems and respiratory and gastric illnesses.

Some of the more startling discoveries:

• Sixty-nine percent of 3- to 6-year-olds did not have their height and weight measured at annual checkups, and only 15% of adolescents were weighed and measured, even though one-third of American children are overweight or obese.

• Fifty-four percent of children diagnosed with asthma did not get recommended treatment.

• Sixty-two percent of children were not screened for anemia in the first two years of life, although the test is recommended for all babies.

• Only 38% of children received the proper care for acute diarrhea, one of the main causes of hospitalizations in children under age 5.

The researchers blamed much of the care deficit on insurers, whom they said pressure doctors to spend only 10 minutes on a regular checkup, leaving them little time to run all the recommended tests. In addition, pediatricians are trained to deal with acute illnesses rather than preventive care because their residential training is all in hospitals, where they don't do regular checkups, just serious illnesses. "Until now, most people assumed that quality was not a problem for children," says Elizabeth McGlynn, associate director of Rand Health and a co-author of the study. "This new study tells us that's not true."