Quality Measures for Children's Healthcare in Medicaid and Children's Health Insurance Program
Summary of Discussion
National Advisory Council Subcommittee Meeting
November 13, 2009
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 second Subcommittee meeting on November 13, 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)
Timothy J. Brei, M.D., Indiana University School of Medicine
Nancy E. Donaldson, D.N.Sc., R.N., FAAN, Center for Nursing Research and Innovation, University of California, San Francisco (by telephone)
Andrew J. Fishmann, M.D., F.C.C.P., F.A.C.P., Good Samaritan Hospital
Robert S. Galvin, M.D., General Electric (by telephone)
Arthur Garson, Jr., M.D., M.P.H., University of Virginia
Wishwa N. Kapoor, M.D., M.P.H., University of Pittsburgh
Lisa M. Latts, M.D., M.B.A., M.S.P.H., WellPoint Inc. (by telephone)
Kathleen Lohr, Ph.D., RTI International
Thomas P. Miller, J.D., American Enterprise Institute
Keith J. Mueller, Ph.D., Nebraska Center for Rural Health Research
Xavier Sevilla, M.D., FAAP, Manatee County Rural Health Services Inc. (by telephone)
David L. Shern, Ph.D., Mental Health America
Bruce Siegel, M.D., M.P.H., George Washington University
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., U.S. Chamber of Commerce
David Atkins, M.D., M.P.H., Veterans Health Administration
Sarah Lutter, J.D., Office of Science Policy, National Institutes of Health
AHRQ Staff Present
Carolyn M. Clancy, M.D., Director
Denise Dougherty, Ph.D., Child Health and Quality Improvement
Kathie Kendrick, M.S., C.S., R.N., Deputy Director
Ernest Moy, M.D., M.P.H.
Deborah Queenan, NAC Coordinator
Jeff Schiff, M.D.
Sheila P. Burke, R.N., M.P.A
Kathleen Lohr, Ph.D., RTI International, Research Triangle Park, NC, and Timothy Brei, M.D., Riley Hospital for Children, Indianapolis, IN
Dr. Lohr reported on efforts of this subcommittee, which has been developing a set of core measures for children's healthcare quality, drawing from the large number of measures that exist. Public Law 111-3, Title IV, called on the HHS Secretary to identify and publish for general comment a core set of child health quality measures by January 1, 2010. The subcommittee, chaired by Jeffrey Schiff, M.D., M.B.A., and Rita Mangione-Smith, M.D., and including Drs. Lohr and Brei, of the NAC, worked throughout the summer and fall against a tight deadline. Dr. Lohr specifically thanked the AHRQ staff, under Dr. Denise Dougherty's leadership, for the diligence and speed with which they worked to support the development of the core set of measures. Without their support the completion of the Subcommittee's task would not have been possible.
Dr. Lohr reviewed the timeline and processes of the committee, which seeks a posting of final draft measures by December 18, 2009 (an initial core set of measures). Candidate measures were assessed for validity, feasibility, and importance. They were ranked and posted for public comment during the summer months (the public also could nominate measures). The developers recognized that a scope of measures could include grounded measures (currently feasible), intermediate measures (in use in some states), and aspirational measures (needed in the future). They sought to create a set of up to 25 grounded measures. Dr. Lohr presented the final draft set of 25 measures in order of rank (immunizations for 2-year-olds was ranked #1). The measures represent a broad range of conditions and an emphasis on prevention and health promotion. Most are to be applied in the ambulatory setting.
Dr. Brei reviewed issues that were revealed during the process to develop the set of measures:
- A lack of standardization among duration of enrollment measures.
- A lack of standardization of denominators across measures.
- A need to expand the use of measures across the entire Medicaid/CHIP population.
- Inconsistent disparities reporting.
- Missing/needed measures (e.g., specialty care, inpatient care, mental health treatment, substance abuse care, medical home healthcare).
Dr. Brei expressed a hope for strategies to develop additional measures in the future. Dr. Fishmann suggested identifying measures for pediatric asthma for both inpatient and emergency cases.
Dr. Sevilla praised the work of the Subcommittee and described his experience of learning that many measures are found to be insufficient to the task. We need research to establish validity, and we need to develop more outcomes measures. Dr. Brei noted that the process will be aided by the identification of needed measures by the Joint Commission. Dr. Schiff added that the Medicaid Medical Directors will continue to push the measures process. The average level of evidence for the measures chosen by the subcommittee is about a B. It is expected that the measurement set will evolve over time.
Dr. Powe suggested that the subcommittee identify areas in the measures that can target minority groups. Dr. Smith proposed the future addition of measures related to medications. Dr. Lohr stated that the Subcommittee process represented a new model for undertaking such activities. She encouraged the NAC members to continue to forward comments to AHRQ (CHIPRAqualitymeasures@ahrq.hhs.gov).