Title: AHRQ National Advisory Council on Healthcare Research and Quality Subcommittee on Childrens Healthca
1AHRQ National Advisory Council on Healthcare
Research and Quality Subcommittee on Childrens
Healthcare Quality Measures for Medicaid and CHIP
Progress Report to AHRQ National Advisory
Council, July 24, 2009
- Jeffrey Schiff, MD, MBA, Co-Chair
- Rita Mangione-Smith, MD, MPH, Co-Chair
2Potential Impact of Core Measures Identification
Work 45 of Americas Children under Age 19
Sources AHRQ, based on Coverage estimates
Based on 2008 national participant and spending
data derived from CMS and U.S. Census Current
Population Survey data sources, reported by the
National Center on Children in Poverty,
http//www.nccp.org/profiles/index_32.html.
CHIP estimates are for number of children in
separate SCHIP programs. Medicaid estimates
include children in Medicaid SCHIP programs.
Coverage estimates reflect Medicaid and CHIP
enrollees whether or not they received health
care services. Total number of children under 19
interpolated from U.S. Census Bureau figures for
number of children 17 and under (73.9 million)
and children 19 and under (83 million).
3Public Law 111-3 Title IV- Strengthening Quality
of Care and Health Outcomes
- Section 401 Child Health Quality Improvement
Activities for Children Enrolled in Medicaid or
CHIP - Section 1139A Child Health Quality Measures
- By January 1, 2010, the Secretary shall identify
and publish for general comment an initial,
recommended core set of child health quality
measures for use by .
4Public Law 111-3 Title IV (continued)
- Initial core set that includes (but is not
limited to) - 1. Presence and duration of health insurance
- 2. Availability and effectiveness of
- Preventive services
- Services for acute conditions
- Services to promote healthy birth, prevent and
treat premature birth, detect the presence or
risk of conditions that could adversely affect
growth and development - Treatments to correct and ameliorate the effects
of chronic physical and mental conditions - (continued)
5Public Law 111-3 Title IV (continued)
- Initial core set (continued)
- 3. Availability of care
- Ambulatory
- Inpatient
- 4.Taken together Used to estimate the overall
national quality of health care for children - Including children with special health care needs
and comparing disparate populations
6Public Law 111-3 (continued)
- 1. Encourage voluntary and standardized reporting
- 2. Particular attention to techniques that
- Ensure the timeliness and accuracy of provider
reporting - Encourage provider compliance
- Encourage successful quality improvement
strategies, and - Improve efficiency in data collection using HIT
- 3. Valid, reliable, and evidence-based
- 4. Allow families and health care providers to
understand the quality of care
7Subcommittee on Childrens Healthcare Quality
Measures for Medicaid and CHIP Programs
- Membership includes
- Two NAC members
- CHIP director
- Title V director
- Two Medicaid Medical Directors
- Organizational members
- American Academy of Pediatrics, American Board
of Pediatrics, American Academy of Family
Physicians, March of Dimes, National Academy for
State Health Policy, National Association of
Childrens Hospitals and Related Institutions,
National Association of State Medicaid Directors,
National Association of Pediatric Nurse
Practitioners - Individuals with expertise in dental care, mental
health and chemical dependency, community health
centers, children with special health needs,
disparities, quality measurement
8Goals of the First Meeting
- Reach consensus on the scope of the core
measurement set - Reach consensus on definitions for evaluation
criteria - Validity
- Feasibility
- Importance
- Identify a preliminary core set of quality
measures that meet these criteria - Establish the group process for arriving at the
final recommended core set of quality measures by
September 30, 2009
9Conceptual Framework Guiding Determination of
the Scope for Core Measurement Set
- Grounded ? Intermediate ? Aspirational
- Measures Measures Measures
- Lean towards recommending more grounded measures
- Grounded10-25, currently feasible, many already
in place - Intermediate category number to be determined,
good specifications, some States already using
them - Aspirational needed measures to fill in the gaps
10Scope for Core Measurement Set
- 1. Must be realistic about staffing/funding needs
for pulling/analyzing/reporting available data - 2. Comprehensive effort to find good measures for
all service categories, duration of enrollment,
and other aspects of care required by the
legislation however, if no good measures
currently exist for a given aspect of care, a
measure will not be recommended for the core set - 3. Include measures not currently used by
Medicaid/CHIP - e.g. State and national measurement efforts
- 4. Choose measures that are actionable
- There should be clear steps a State can take to
improve on performance the measure should
inform what these steps need to be
11Consensus on Criteria Definitions
- Validity
- Measures must be supported by scientific evidence
or, where evidence is insufficient, by expert
consensus - Measures must support a link between
- Structure and outcomes of care
- Structure and processes of care
- Processes and outcomes of care
- The measure must represent an aspect of care that
is under the control of health care providers and
systems - The measure should truly assess what it purports
to measure - Measures supported by evidence from unpublished
data should be considered for inclusion
12Consensus on Criteria Definitions
- Feasibility
- The data necessary to score the measure must be
available to State Medicaid and CHIP programs - Administrative data, medical records data, survey
data - Detailed specifications must be available for the
measure that allow for reliable and unbiased
scoring of the measure across States and
institutions
13Consensus on Criteria Definitions
- Importance
- The measure should be actionable
- Cost of the condition to the Nation should be
substantial - Health care systems are clearly accountable for
the quality problem assessed by the measure - The extent of the quality problem should be
substantial - There should be documented variation in
performance on the measure - The measure should be representative of a class
of quality problems sentinel measure of
quality of care provided for preventive care,
mental health care, or dental care, etc.
14Consensus on Criteria Definitions
- Importance
- The measure assesses an aspect of health care
where there are known disparities - The core set should represent a balanced
portfolio of measures and be consistent with the
intent of the legislation - Improving on performance for the core set of
measures should have the potential to transform
care for our Nations children
15Consensus on Criteria Definitions
- Transparency
- For all measures recommended for inclusion in
the core set - The level of scientific evidence supporting the
measure will be reported - Example U.S. Preventive Services Task Force
grades A, B, C, or I Level I, II, III - The level of expected burden for obtaining the
data needed to score the measure will be reported - Low, moderate, high
16Pre-Work Process Completed by Sub-Committee
Members
- Delphi process to assess validity and feasibility
of measures in use by State Medicaid and CHIP
programs - Round 1 completed prior to meeting
- Measures scored on a 9-point scale
- 7-9 Measure is definitely valid and feasible
- 4-6 Measure has uncertain validity and
feasibility - 1-3 Measure is not valid or feasible
17Meeting July 22, 2009 Discussion of Delphi Round
1 Results
- Controversial measures
- Validity or feasibility ratings with substantial
disagreement among subcommittee members were
discussed - Round 2 Delphi process for these controversial
measures after meeting deliberations
18Meeting July 23, 2009 Assessing Measure
Importance
- Evaluated importance for measures with passing
validity and feasibility in Round 1 - Validity score of 7-9
- Feasibility score of 4-6
- Delphi process to assess importance
- 9-point scale
- 7-9 Measure of clear importance
- 4-6 Level of importance uncertain
- 1-3 Measure does not meet importance criteria
- Measures with an importance score of 4 or higher
on the 9-point Delphi scale were retained in the
preliminary set of core measures
19Measures Having Passing Scores for Validity,
Feasibility, and Importance
- Preventive Care Measures
- Frequency of ongoing prenatal care
- Smoking cessation and prevention
- Chlamydia screening
- Immunizations for 2-year olds
- Adolescent immunization
- Influenza vaccination
- Well child care visit (WCV) rates - first 15
months - WCV Rates- 3, 4, 5, 6-year olds
- Adolescent WCV - overall
- Hearing screening
- Vision screening
20Measures having passing scores for Validity,
Feasibility, and Importance
- Dental Care Measures
- Comprehensive periodic oral health exams
- Annual dental visit
- Acute Care Measures
- Upper respiratory infection- Appropriate
treatment - Pharyngitis- Appropriate testing
- Chronic Care Measures
- Asthma- Appropriate medications for people with
asthma
21Measures Having Passing Scores for Validity,
Feasibility, and Importance
- Mental Health Care Measures
- Attention-Deficit/Hyperactivity Disorder (ADHD)
care - Initiation phase - ADHD Care - Continuation and maintenance phase
- Followup after hospitalization for mental illness
- Depression management
- Family Experiences with Care Measures
- Healthcare Effectiveness Data and Information Set
(HEDIS), Consumer Assessment of Healthcare
Providers and Systems (CAHPS) - For healthy children
- For children with special health care needs
- Access and Utilization Measures
- Access to primary care practitioners, by age and
total - Utilization of ambulatory services
22Additional Measures in Use Proposed During Meeting
- Identify evidence supporting measure
- Identify who is currently using the measure
- Obtain specifications for the measure
- Delphi process for new measures to assess
- Validity
- Feasibility
- Importance
23Selection of Measures Recommended for Inclusion
in the Final Core Set
- September 2009 meeting
- Further discuss and rate importance for
preliminary core set and new measures identified
as valid and feasible - Arrive at the most parsimonious set of measures
that when assessed together will provide valid
estimates of the overall national quality of
health care for children insured by Medicaid and
CHIP
24 Our View of the Opportunity Presented by the
Legislation
- Long-term focus on health care quality for
children beyond CHIP - Opportunity to bring together efforts of
disparate organizations/parts of government to
create focus and move the child health quality
agenda forward - Need support from the NAC to build the bridge
toward our aspirational long-term vision of being
able to rigorously and comprehensively assess and
improve on health care quality for the Nations
children