Initial Core Set of Children's Healthcare Quality Measures

Summary Report

List of measures presented at the National Advisory Council Subcommittee on Quality Measures for Children's Healthcare in Medicaid and CHIP.

Identification of Initial Core Set of Measures for Voluntary Use by Medicaid and Children's Health Insurance Program (CHIP) Programs

Core set recommended by the AHRQ National Advisory Council Subcommittee on Children's Healthcare Quality Measures for Medicaid and CHIP Programs, September 18, 2009

This summary presents a brief overview of the processes used to recommend an initial core set of children's health care quality measures to the Agency for Healthcare Research and Quality (AHRQ) National Advisory Council on Healthcare Research and Quality, the measures recommended, and next steps to be taken by AHRQ and the Centers for Medicare & Medicaid Services (CMS).

Background | SNAC and the Public Process | Recommendations | Important Considerations | Next Steps | Tables


Background

Title IV of the Children's Health Insurance Program Reauthorization Act (CHIPRA; Public Law 111-3; February 3, 2009) called for the Secretary of the U.S. Department of Health and Human Services (HHS) to identify an initial core set of children's health care quality measures to be posted for general comment by January 1, 2010 (Section 401(a)). In April 2009, the AHRQ and CMS signed a Memorandum of Understanding giving AHRQ leadership responsibilities for identifying the initial core set, working in very close partnership with CMS which has the authority for implementation of all CHIPRA provisions.

As part of their effort to use a transparent and evidence-based process for identifying an initial core set of pediatric quality measures for voluntary use by Medicaid and CHIP Programs to be posted for general comment by January 1, 2010: CMS and AHRQ asked the AHRQ National Advisory Council on Healthcare Research and Quality (NAC) to establish a time-limited Subcommittee on Children's Healthcare Quality Measures for Use by Medicaid and CHIP programs (SNAC). The SNAC was asked to hold public meetings and was charged with developing criteria for identifying core measures, applying those criteria to measures in use or otherwise nominated for consideration, and making recommendations to the NAC. The NAC in turn provides advice to the Director, AHRQ, and to the Secretary, HHS. For more information on the public SNAC meetings and overall process for identification of the initial core measure set, other CHIPRA quality activities, a link to CMS CHIPRA activities, and a link to Public Law 111-3, visit http://www.ahrq.gov/chipra.

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SNAC and the Public Process

The SNAC met for the first time in July 2009 to discuss and further refine a SNAC-developed modified Delphi process to score measures known to be in use by Medicaid and CHIP programs on validity, feasibility, and importance. The SNAC also agreed to try to recommend a core measure set no greater than 25 measures. The SNAC report to the NAC in July 2009 is available at .

By mid-October 2009, the SNAC had 121 measures to consider during a second modified Delphi process. These 121 measures included measures that:

  1. Had passed criteria for validity, feasibility, and importance at the July SNAC meeting.
  2. Were deemed to be in need of additional information at the July SNAC meeting.
  3. Had been nominated by SNAC members, members of the public, or members of the CHIPRA Federal Quality Workgroup or identified through continuing environmental scans.

Public nominators included members of the Medicaid Medical Directors Learning Network, the Medical Association's Physician Consortium for Performance Improvement (PCPI), the National Partnership for Women and Families, and additional nominations obtained through E-mail to an AHRQ address. CHIPRA Federal Quality Workgroup nominations came from CMS and the Health Resources and Services Administration (HRSA). Papers by CHIPRA contractors also recommended measures for consideration.

Using a second modified Delphi scoring process in early September, SNAC members selected 65 of the 121 measures as meeting criteria for validity, feasibility, and importance. At the September 17-18, 2009 SNAC meeting, several measures that did not strictly pass the second Delphi round (e.g., validity scores of 6 or 6.5 rather than the cutoff of 7) were added to the list of measures to be discussed and voted on during the meeting. An example was adolescent well-care visits.

In addition, during the September 17-18, 2009, SNAC meeting, the SNAC voted to combine some measures and consider them to be single measures for purposes of further SNAC voting. For example, three well-child care visits were combined into one measure for voting purposes (shown as PHP-9 on the SNAC recommendation table); and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys for children with and without special health care needs were combined into the voting category FEC-1/FEC-5.

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Recommendations

Through a series of discussions followed by a series of votes over the day and a half meeting, the SNAC agreed to recommend to the NAC 25 measures for the initial core measure set. (Table 1).

The SNAC-recommended set of measures will next be discussed by the Children's Health Insurance Program Reauthorization Act (CHIPRA) Federal Quality Workgroup and reviewed by Medicaid and CHIP officials. Subsequently, a CMS-AHRQ-recommended initial core set will be forwarded to the Secretary, HHS, for her consideration and then to the Office of Management and Budget (OMB) for its review, before a final recommended set of measures is posted for general comment, by January 1, 2010.

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Important Considerations

It is important to note that the SNAC did not recommend that the measures on the list be implemented "as is." Rather, the measure denominators should be respecified so that they are feasible for use across all Medicaid and CHIP programs and by providers, consumers, and intermediaries (e.g., health plans contracting with State Medicaid programs). For example, HEDIS CAHPS® (FEC 1 and 5) (Healthcare Effectiveness Data and Information Set/Consumer Assessment of Health Plans and Providers) as currently specified are currently used primarily by Medicaid managed care health plans that report to the National Committee for Quality Assurance (NCQA). The SNAC recommended that in the future, the CAHPS® instruments be used by all Medicaid and CHIP programs so that family experiences of care across a broader spectrum of covered children can be understood, compared, and when needed, acted upon. Similarly, few of the measures are used to report data that distinguish care quality by race, ethnicity, socioeconomic status, or special health care need status among children. In the future, consistent with the CHIPRA legislation, data should be collected so that meaningful comparisons can be made between children with and without special health care needs and among children of varying racial and ethnic identities.

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Next Steps

The SNAC-recommended set of measures will next be discussed by the CHIPRA Federal Quality Workgroup on September 23, 2009, and reviewed by Medicaid and CHIP officials in a CMS listening session on September 29, 2009, and at other venues. Subsequently, a CMS-AHRQ-recommended initial core set of measures will be forwarded to the Secretary, HHS, for her consideration, and then to the White House Office of Management and Budget for its review, before posting a final recommended set for general comment, by January 1, 2010.

Public comments on the process of identifying the initial core measure set for voluntary use by Medicaid and CHIP programs are continuously invited via the E-mail address at .

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Table 1. SNAC-recommended initial core set of children's healthcare quality measures, in priority order by number of SNAC votes, September 17-18, 2009

Control NumberMeasure LabelSNAC Voting ResultsValidity, Feasibility, Importance Scores*
1st Place Votes2nd Place Votes3rd Place VotesSum of VotesMedian VIQRNMedian FIQRNMedian IIQRN
PHP-5Immunizations for 2-year-olds19306387-91987-91988-919
PHP-2Frequency of ongoing prenatal care (NCQA measure)13635476-71965-71966-819
AC-10ER utilization—Average number of emergency room visits per member per reporting period13555476-81976-81976-819
CC-19Annual number of asthma patients (>1 year-old) with >1 asthma-related ER visit11765376-71965-71966-819
PHP-19ABMI 2—18 years old (NCQA and nominated by CMS)11755276-71776-71775-717
PHP-9Well-child visits—SNAC voted to combine three NCQA measures: 1) WCVs in the first 15 months of life; 2) WCVs in the third, fourth, fifth and sixth years of life; 3) Adolescent Well Care Visits16105075-81964-71965-719
PHP-43Total eligibles receiving preventive dental services (EPSDT measure Line 12B)12614975.5-81286.5-81276-813
PHP-6Adolescent immunization10634587-91987-91988-919
FEC-5 & 1(SNAC voted to include children with and without chronic health conditions) HEDIS CAHPS 4.0 a. Patient Experiences with Prescription Medicine Composite b. Parent's Experiences with Getting Specialized Services c. Family Centered Care Composite d. Parent Experiences with Coordination of their Child's Care Composite11354477-81976-81987-919
PHP-1Timeliness of prenatal care (NCQA measure)10454376-81976-81976-819
PHP-26AHRSA MCH Health Status Indicator #01A—% of live births weighing < 2,500 grams8834376-81987-81886-919
PHP-33Rates of screening using standardized screening tools for potential delays in social and emotional development (ABCD)10454375-71987-81975-819
CC-2Follow-up care for children prescribed attention-deficit/hyperactivity disorder (ADHD) medication (continuation and maintenance phase)9363975-81976-71976-719
PHP-22Annual dental visit (NCQA measure)7633676-81987-81977-919
CC-29Child and adolescent Major Depressive Disorder (MDD)—suicide risk assessment5853677-81976-81987-819
CC-13Annual hemoglobin A1C testing (all children and adolescents diagnosed with diabetes)7553677-81976-81977-819
CC-5Follow up after hospitalization for mental illness7523376-81975-71977-819
PHP-12Chlamydia screening 16-20 females (NCQA)5553075-71975-71985-919
PHP-38Cesarean Rate for Low-risk First Birth Women5452875-81964-71965-719
FEC-6Use of Clinician & Group primary care CAHPS survey for practitioners participating in Medicaid and CHIP6342876-71964-71976-819
AS-1Access to primary care practitioners, by age and total.8042864-71976-81974-819
AC-3Total EPSDT eligibles who received dental treatment services (EPSDT CMS Form 416)3572676-81987-81977-919
AC-4Pediatric catheter associated blood stream infection rates (ICU and high risk nursery patients)6242675.5-81286.5-81276-813
AC-2Pharyngitis—appropriate testing (NCQA measure)2542087-81977-81975-719
AC-17OME—systemic antimicrobials—avoidance of inappropriate use4242076-81976-71975-819

SNAC Voting: 1st place votes receive 3 points; 2nd place votes receive 2 points; 3rd place votes receive 1 point. Sum of votes = sum of points awarded. Rank ordered here by total number of points awarded. Thus, 25 measures were recommended by the SNAC.

*Key: V=Validity F=Feasibility I=Importance IQR=Inter-Quartile Range N=Number of Subcommittee members rating measure.

 

Table 2. Measures that Passed Delphi II but Were Not Chosen as Recommended Measures by SNAC Voting, September 18, 2009

Control NumberProposed Core Measure Label
Prevention and Health Promotion
Prenatal/Perinatal
PHP-3Smoking Cessation and Prevention: Pregnant women
PHP-26BHRSA MCH Health Status Indicator #01B—% of live singleton births weighing less than 2,500 gms
PHP-26CHRSA MCH Health Status #02A—% of live births weighing less than1500 gms
PHP-26DHRSA MCH Health status #02B—% of live singleton births weighing less than 1500 gms
PHP-31MCHB National performance measure #8—the rate of birth (per 1,000) for teenagers aged 15-17 years
PHP-32Proportion of infants 22-29 weeks gestation treated with surfactant who are treated within 2 hours of birth
PHP-34Health systems capacity indicator #04-% of women 15-44 with a live birth during the year whose observed to expected prenatal visits are greater than or equal to 80% on the Kotelchuck Index
PHP-36ARate of elective delivery prior to 39 completed weeks gestation
Immunizations
PHP-5BTwo-year-old Immunization Measure—Assessing immunizations by timeliness and the ACIP/AAP/CDC schedule versus HEDIS dose counting (OR)
Social/Behavioral Health Screening
PHP-33AAdministration of SDBS (Standardized screening tools social and emotional (CMWF/CAHMI))
Dental/Oral Health
PHP-42Total eligibles receiving any dental services (EPSDT measure Line 12A)
PHP-43AHRSA Oral Health Measures WG Measure—% of children age 12-72 mos with 1 or more fluoride varnish apps documented
General Screening
PHP-17Newborn Hearing Screening
PHP-18Vision screening—use MEPS description and performance data
Management of Acute Conditions
Acute Upper Respiratory Tract Illness
AC-1Upper respiratory infection—appropriate treatment
Acute Otitis Externa
AC-11Acute Otitis Externa—Topical therapy
AC-13Acute Otitis Externa—Systemic antimicrobial therapy-avoidance of inappropriate use
Otitis Media with Effusion
AC-14OME Diagnostic evaluation—assessment of tympanic membrane mobility
AC-18OME—systemic corticosteroids—avoidance of inappropriate use
Inpatient Care
AC-26AHRQ Pediatric Quality Indicator Composite Measure (Patient Safety Composite)
AC-5Foreign body left after procedure (PDI 3)
AC-6Iatrogenic pneumothorax in non-neonates (PDI)
AC-20Care transitions—transition record with specified elements received by discharged patients—Inpatient
AC-23Central line associated bloodstream infection (PDI 12)
AC-24Accidental puncture and laceration
AC-25Decubitus ulcer
ED Care
AC-21Care transition—transition record with specified elements revieved by discharged patients—ED
Management of Chronic Conditions
Mental and Behavioral Health/Substance Use
ADHD Care
CC-1Followup care for children prescribed attention-deficit/hyperactivity disorder (ADHD) medication (Initiation Phase; NCQA measure)
HIV
CC-8AHIV/AIDS Bureau quality performance measure—percentage of clients with AIDS who are prescribed HAART
CC-23HIV AIDS Bureau Measure—% of clients with HIV infection who had two or more CD4 T-cell counts performed in the measurement year
CC-24HRSA HIV/AIDS QPR % of clients with HIV who had two or more medical visits in an HIV setting in the measurement year
Asthma
CC-10Asthma — appropriate medications
CC-10BUse of Appropriate Medications for People 5-20 years of age with Asthma – Average number of member controller months
CC-18Annual influenza vaccination (all children and adolescents diagnosed with asthma)
CC-20Annual number of asthma patients (>1 year old) with >1 asthma-related hospitalization
Diabetes
CC-14Annual lipid profile (adolescents with diabetes >16 years old)
CC-16Annual eye examination (adolescents with diabetes >16 years old)
CC-17Annual influenza vaccination (all children and adolescents diagnosed with diabetes)
End-Stage Renal Disease
CC-33Pediatric end-stage renal disease—Plan of care for inadequate hemodialysis
CC-34Pediatric end-stage renal disease—influenza immunization
Duration of Enrollment
D-2Retrospective duration measure

 

Table 3. Measures That Did Not Meet Thresholds for Delphi II Scoring on Validity, Feasibility, and Importance

Control NumberMeasure LabelMedian VIQRNMedian FIQRNMedian IIQRN
Prevention and Health Promotion
Prenatal/Perinatal
PHP-1AHRSA MCH MPR #18—% of infants born to pregnant women receiving prenatal care beginning in the first trimester (data source — nvss—differs from NCQA; Medicaid/CHIP specific not available from NVSS.55-71755-71765-817
PHP-26Percentage of low birth weight (PDI —hospital discharge data)6.55-71876-81876-718
PHP-27Postpartum care visit NCQA measure65-71875-71865-718
PHP-30MCHB National performance measure #17—percent of VLBW infants delivered at facilities for high-risk deliveries and neonates64.5-71665-71555-715
PHP-30AUnder 1500g infant Not Delivered at Appropriate Level of Care53-51853-51855-718
PHP-36Elective delivery prior to 39 weeks gestation64-71465-71454-714
PHP-40HRSA MCH NPR MEASURE #11—% of mothers who breastfeed their infants at 6 mos of age65-61854-61866-718
PHP-41HRSA MCH NPR #15—% of women who smoke in the last 3 mos of pregnancy65-71654-61665-716
Immunizations
PHP-8Immunization reporting (provider registry)54.5-61653.5-71653.5-716
Well Child Care (ages birth-6 years)
   No Measures
Adolescent Preventive Services
PHP-15Adolescent receipt of the following seven components of care during the measurement year: BMI percentile, assessment/counseling/education on nutrition, physical activity, risk behaviors associated with sexual health/activity/preventive actions, depression screening55-71753-61776-717
PHP-16Smoking Cessation and Prevention: adolescent tobacco users55-71854-51865-818
General Screening
PHP-19Weight Assessment and Counseling for Nutrition and Physical Activity for children and adolescents65-71365-71377-813
PHP-19BNutrition counseling—NCQA (fix label)65-71954-71975-719
PHP 19CPhysical Activity Counseling (NQCA)65-71455-71465-714
PHP-29Lead screening rate (NCQA—1st year measure—see confidential data); note USPSTF rec65-71765-71764-717
PHP-29ALead screening 2d year—% of members who turned 2 during the reporting period and received a lead test (data from MaineCare claims and the Maine CDC)54.5-61654.5-71654-6.516
PHP-29BLead screening 1st year—% of members who turned 1 during the reporting period and received a lead test (data from MaineCare Claims and Maine CDC)54.5-61654.5-71654-6.516
PHP-29CHRSA Lead screening in children by 2 years of age (data source differs from NCQA)64-71564-71564-715
PHP-39EPSDT—Percentage of members 0-20 years old who had one or more EPSDT procedure(s) during the reporting period43-61753-71753-717
Social/Behavioral Health Screening
PHP-37Percent of members under age 21 with a WCC visit by any provider during the measurement period who had a BH screen.64-71953-61966-719
Dental/Oral Health
PHP-22AHRSA oral health measure—the percentage of patients who had at least one dental visit during the measurement year (differs from NCQA—data source is CHCs; broader age range)6.56-71876-81877-818
PHP-35HRSA oral health measure—percentage of all dental patients with a comprehensive or periodic recall oral exam within a 12 month period6.56-71876-81876-818
Management of Acute Conditions
Acute Upper Respiratory Tract Illness
   No Measures
Acute Otitis Externa
AC-12Acute Otitis Externa—Pain Assessment65-71955-61953-519
Otitis Media with Effusion
AC-15OME Hearing testing66-71965-71965-719
Dental
AC-8HRSA oral health measure—percentage of all dental patients for whom the Phase I treatment plan is completed within a 12 month period54-61853-61865-618
AC-9HRSA oral health performance measure—percentage of all dental patients with a comprehensive or periodic recall oral exam, for whom the Phase I treatment plan is documented54-61942-61954-719
Inpatient Care
AC-7PICU pain assessment on admission43-61943-61953-719
AC-19Care transitions—reconciled medication list received by discharged patients65-71943-51976-819
AC-22Care transitions—timely transmission of transition record (from inpatient)64-71854-61865-718
ED Care
AC-21Care transition—transition record with specified elements reviewed by discharged patients-ED54-71953-61976-719
Management of Chronic Conditions
Mental and Behavioral Health/Substance Use
ADHD Care
CC-6Diagnosis of ADHD in primary care for school age children and adolescents (using DSM)65-71854-61865-718
Depression Care
CC-27Child and adolescent Major Depressive Disorder (MDD)—interview of adolescent or child65-71754-61766-817
CC-28Child and adolescent Major Depressive Disorder (MDD)—diagnostic evaluation65-71864-71875-718
CC-30Child and adolescent Major Depressive Disorder (MDD)—psychotherapy65-71864-71876-718
CC-32Child and adolescent Major Depressive Disorder (MDD)—followup care64-71853-71876-718
Other Mental Health/Behavioral Care
CC-4Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (ages 3-17 and 18+)66-71965-71976-719
CC-35Medication adherence as measured by maximal gaps in days during a calendar year for ADHD and antipsychotic medication in children65-71764-71764-717
Children with Special Health Care Needs
CC-37CSHCN number of missed school days due to illness or injury43-61732-61764-717
HIV
CC-8Highly active antiretroviral treatment6.56-81854-61865-818
Asthma
CC-25Percentage of patients for whom there is documentation that a written asthma management plan was provided either to the patient or the patient's caregiver OR, at minimum, specific written instructions on under what conditions the patient's doctor should be contacted or the patient should go to the emergency room.65-71754-61765-717
Chronic Disease Identified through Newborn Screening
CC-12Timely followup of positive newborn screens65-71854-61877-818
Diabetes
CC-15Annual urine protein screening (adolescents with diabetes >16 years old)65-71976-71966-719
CC-21Hemoglobin A1c test for pediatric patients63-71374-81364-815
End-Stage Renal Disease
   No Measures
Family Experiences With Care
HEDIS CAHPS for Children Without Chronic Conditions
   No Measures
HEDIS CAHPS for Children with Chronic Conditions
   No Measures
Other Family/Patient Experiences of Care Measures
FEC-2Helpfulness of counseling (adolescent-reported)53-61953-61954-719
FEC-3Communication and experience of care (adolescent-reported)54-61953-61954-719
FEC-4Dental CAHPS (overall ratings of dentist, dental plan, dental care, office staff)64-71954-71965-719
Most Integrated Healthcare Systems
MIH-2Medical home measure using subset of HEDIS CAHPS MEDICAID 4.0 survey items54-71654-6.51675-8.516
Availability of Services
AV-1Unduplicated members served per provider42-51842-71852-618
Uses of Services
US-1Utilization of ambulatory services4.53-6.51676-7.51663-716
US-2Outpatient drug utilization—per member per year average number of prescriptions42-51576-71553-715
US-3Utilization of inpatient care42.5-6.51676-81663-616
Health Status
HS-2PROMIS Pediatric item Banks: physical function, emotional distress, social role relationship, fatigue, pain and asthma63-71853-61865-618
Duration of Enrollment
D-1Prospective duration measure6.55-81865-81865-718

Key:
V = Validity
F = Feasibility
I = Importance
IQR = Inter-Quartile Range
N = Number of Subcommittee members rating measure

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Page last reviewed January 2011
Internet Citation: Initial Core Set of Children's Healthcare Quality Measures: Summary Report. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/policymakers/chipra/listtable.html