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AHRQ National Advisory Council on Healthcare Research and Quality Subcommittee on Children


AHRQ National Advisory Council on Healthcare Research and Quality Subcommittee on Children s Healthcare Quality Measures for Medicaid and CHIP Progress Report to ... – PowerPoint PPT presentation

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Title: AHRQ National Advisory Council on Healthcare Research and Quality Subcommittee on Children

AHRQ 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

Potential 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,
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).
Public 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
  • 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 .

Public 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)

Public 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

Public Law 111-3 (continued)
  • 1. Encourage voluntary and standardized reporting
  • 2. Particular attention to techniques that
  • Ensure the timeliness and accuracy of provider
  • 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

Subcommittee 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
  • Individuals with expertise in dental care, mental
    health and chemical dependency, community health
    centers, children with special health needs,
    disparities, quality measurement

Goals of the First Meeting
  • Reach consensus on the scope of the core
    measurement set
  • Reach consensus on definitions for evaluation
  • 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

Conceptual 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
  • Aspirational needed measures to fill in the gaps

Scope 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
  • 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

Consensus on Criteria Definitions
  • Validity
  • Measures must be supported by scientific evidence
    or, where evidence is insufficient, by expert
  • 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
  • The measure should truly assess what it purports
    to measure
  • Measures supported by evidence from unpublished
    data should be considered for inclusion

Consensus 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
  • Detailed specifications must be available for the
    measure that allow for reliable and unbiased
    scoring of the measure across States and

Consensus on Criteria Definitions
  • Importance
  • The measure should be actionable
  • Cost of the condition to the Nation should be
  • Health care systems are clearly accountable for
    the quality problem assessed by the measure
  • The extent of the quality problem should be
  • 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.

Consensus 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

Consensus 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

Pre-Work Process Completed by Sub-Committee
  • Delphi process to assess validity and feasibility
    of measures in use by State Medicaid and CHIP
  • 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
  • 1-3 Measure is not valid or feasible

Meeting July 22, 2009 Discussion of Delphi Round
1 Results
  • Controversial measures
  • Validity or feasibility ratings with substantial
    disagreement among subcommittee members were
  • Round 2 Delphi process for these controversial
    measures after meeting deliberations

Meeting July 23, 2009 Assessing Measure
  • 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

Measures 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
  • WCV Rates- 3, 4, 5, 6-year olds
  • Adolescent WCV - overall
  • Hearing screening
  • Vision screening

Measures 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
  • Pharyngitis- Appropriate testing
  • Chronic Care Measures
  • Asthma- Appropriate medications for people with

Measures 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
  • Utilization of ambulatory services

Additional 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

Selection 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

Our View of the Opportunity Presented by the
  • 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
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