Summary of Discussion
Quality Measures for Children's Healthcare in Medicaid and Children's Health Insurance Program
The Agency for Healthcare Research and Quality's (AHRQ) National Advisory Council (NAC) has created the Subcommittee on Quality Measures for Children's Healthcare in Medicaid and Children's Health Insurance Program (CHIP). This is a summary of the first Subcommittee meeting on July 24, 2009, convened to help identify and prioritize the core quality measurement set for use by Medicaid and CHIP programs.
NAC Members Present
Neil Powe, M.D., M.P.H., M.B.A., San Francisco General Hospital (Chair)
Jane F. Barlow, M.D., M.P.H., M.B.A., Medco Health Solutions, Inc.
Timothy J. Brei, M.D., The James Whitcomb Riley Hospital for Children
Andrew J. Fishmann, M.D., F.C.C.P., F.A.C.P., Good Samaritan Hospital
Robert S. Galvin, M.D., General Electric
Wishwa N. Kapoor, M.D., M.P.H., University of Pittsburgh
Kathleen Lohr, Ph.D., RTI International
Thomas P. Miller, J.D., American Enterprise Institute
Michael K. Raymond, M.D., Rush North Shore Medical Center
William Smith, Pharm.D., Ph.D., M.P.H., Virginia Commonwealth University
Myrl Weinberg, C.A.E., National Health Council
Anthony C. Wisniewski, J.D.
Ex Officio Member Present
Jane Sisk, Ph.D., National Center for Health Statistics, Centers for Disease Control and Prevention (CDC)
Rita Mangione-Smith, M.D., M.P.H.
Jeffrey Schiff, M.D., M.B.A.
AHRQ Members and Staff Present
Carolyn M. Clancy, M.D., Director
Denise Dougherty, Ph.D.
Kathie Kendrick, M.S., C.S., R.N., Deputy Director
Ernest Moy, M.D., M.P.H.
Deborah Queenan, NAC Coordinator
Jean Slutsky, P.A., M.S.P.H., Director, Center for Outcomes and Evidence
Scott Smith, Ph.D., M.S.P.H., Center for Outcomes and Evidence
Jeffrey Schiff, M.D., M.B.A., Medicaid Medical Director, Minnesota, and Rita Mangione-Smith, M.D., M.P.H., University of Washington and Seattle Children's Hospital Research Institute
Dr. Jeffrey Schiff and Dr. Rita Mangione-Smith, both pediatricians and co-chairs of the NAC Subcommittee on Children's Healthcare Quality Measures for Medicaid and CHIP Programs, reviewed background and progress of the subcommittee's work. Dr. Schiff cited elements of Public Law 111-3, Title IV, which was meant to strengthen the quality of care and health outcomes. The law calls on the Department of Health & Human Services (HHS) Secretary to identify and publish for general comment a core set of child health quality measures by January 1, 2010. The measures will be used to estimate the overall national quality of health care for children. The law is meant to:
- Encourage voluntary and standardized reporting.
- Ensure timeliness and accuracy of provider reporting.
- Encourage provider compliance.
- Encourage quality improvement strategies.
- Improve efficiency in data collection using health information technology (Health IT).
- Create valid, reliable, evidence-based measures.
- Allow families and health care providers to understand quality of care.
Dr. Schiff described the membership of the subcommittee, which features wide representation. NAC members Kathleen Lohr and Timothy Brei also are members. The subcommittee held its first meeting and reached a consensus on the scope of a core set of measures, definitions for evaluation criteria, and a process for developing a final core set of measures to be recommended by the subcommittee to the AHRQ NAC by September 30, 2009.
Dr. Mangione-Smith reviewed the subcommittee's consensus for the required validity of the measures. She also described the subcommittee's recommendations for feasibility and importance. The Subcommittee employed a modified Delphi process to initially assess validity and feasibility of measures that were found to be in use by State Medicaid and CHIP programs. At their July 22 meeting, the subcommittee members discussed the Delphi results for validity and feasibility. Measures that passed criterion scores for validity and feasibility were then scored for importance. Measures passing the criterion scores for all three elements were as follows:
- Frequency of ongoing prenatal care.
- Smoking cessation and prevention.
- Chlamydia screening.
- Immunizations for 2-year-olds.
- Adolescent immunization.
- Influenza vaccination.
- Well-child visit (WCV) rates—first 15 months..
- WCV rates—3-, 4-, 5-, 6-year-olds.
- Adolescent WCV rates overall.
- Hearing screening.
- Vision screening.
- Comprehensive periodic oral health exams.
- Annual dental visits.
- Upper respiratory infection (URI)—appropriate treatment..
- Pharyngitis—appropriate testing.
- Asthma—appropriate medications for people with asthma.
- Attention-Deficit/Hyperactivity Disorder (ADHD) care, initiation phase.
- ADHD care, continuation and maintenance.
- Followup after hospitalization for mental illness.
- Depression management.
- Healthcare Effectiveness Data and Information Set (HEDIS) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) for healthy children.
- HEDIS CAHPS® for children with special health care needs.
- Access to primary care practitioners (by age and total).
- Utilization of ambulatory services.
Nominations for additional measures are now being taken. These will be scored for validity, feasibility, and importance. At its next meeting to be held September 17-18, 2009, the subcommittee will discuss the above measures and new measures, leading to a recommendation to the AHRQ NAC for a parsimonious core measurement set. The recommended core set will be accompanied by discussions of the evidence bases for validity, feasibility, and importance of the measures to make the process transparent. The subcommittee came to consensus that an ideal initial core set should of no more than 10-25 measures, in light of current economic burdens on many States and in light of the unprecedented opportunities for States and others to develop new and enhance existing children's health care quality measures over the next several years. The future for children's health care quality measure development is bright.
Dr. Lohr noted that the effort could raise concerns about aspects of Medicaid funding and mandates. Dr. Powe encouraged the subcommittee to address all ages in the spectrum of children and adolescents (and the roles of parents). Andrew Fishmann, M.D., reminded the subcommittee members to be cautious in the use of unpublished data. The NAC members agreed that there will be a need for specifications and a need to determine how measures can be operationalized to transform care. Jane Sisk, Ph.D., cautioned that there could be instances where doing nothing would be preferable to doing the wrong thing (as when there is a lack of evidence). William Smith, Pharm.D., Ph.D., encouraged the subcommittee to address medication issues (measuring compliance, etc.). Dr. Galvin encouraged the subcommittee to consider risk behaviors in addition to smoking. Dr. Mangione-Smith noted that measures for obesity-body mass index (BMI) and diabetes management are still to come. Dr. Powe urged an emphasis on racial/ethnic disparities.
The NAC invited public representatives to make comments about the measures project. Michael Duenas, O.D., of the American Optometric Association, encouraged the subcommittee to address, in its vision measure, methodologies for vision screening, which vary widely. Also, screening should be required only when treatment is available. Minorities experience a significant disparity regarding vision testing.
Jayne Hart Chambers, of the Federation of American Hospitals, asked how the measures will be publicly reported. Barbara Dailey, R.N., of the Centers for Medicare & Medicaid Services (CMS), responded that the Children's Health Insurance Program Reauthorization Act (CHIPRA) requires that CMS report State quality reports publicly but does not currently require the inclusion of the core measures that are being developed. Ms. Chambers urged the creation of a national infrastructure for collecting and reporting the data.
Dr. Powe stated that the next NAC meeting will take place on November 13, 2009. He thanked the participants and adjourned the meeting.