Background Report on 2013 Retirement of Measures from the Child Core Set
Discussion or Rationale Related to Each Measure
1. Timeliness of Prenatal Care
SNAC members regarded this measure as important, especially as a proxy for access to care and in combination with the measure of frequency of prenatal care. Although they also expressed interest in an improved measure including the content of the prenatal visit, they did not think this measure should be retired until an improved measure was available. One noted that the measure has room for improvement when compared to commercial rates. As with other HEDIS measures, this measure has high reliability scores, but little information on measure validity was provided. Many States reported on the measure, and overall the percentage of States able to report is increasing, so SNAC members rated this measure high on feasibility. Several SNAC members noted that although the evidence for improvability was lacking, they also credited the measure for driving improvement in managed care organizations.
2. Frequency of Ongoing Prenatal Care
SNAC members noted that although the measure is not well tied to outcomes, it affects a large proportion of Medicaid patients, and there is room for improvement. Similar to measure 1 (timeliness), this measure demonstrates high reliability, even if information on validity is lacking. Overall, although SNAC members would prefer an improved measure, the measure represents an important topic area and is important to retain in conjunction with measure 1.
3. Live Births Weighing Less Than 2,500 Grams
SNAC members enthusiastically endorsed the importance of this measure because it was one of the few measures of outcomes. With regard to scientific acceptability, there was some concern that the measure was not risk adjusted, but otherwise validity was rated as high. Because the measure can rely on links between Medicaid and vital statistics, there are some concerns regarding data collection difficulties; however, at least one SNAC member thought it was important to encourage those links. Another SNAC member noted that, with regard to improvability, even small improvements in this measure could have an important impact.
4. Cesarean Rate for Nulliparous Singleton Vertex
SNAC members acknowledged that this measure represents a high-cost issue that is aligned with Federal concerns, but they noted that there seems to be disagreement on reliability and validity. Some SNAC members have feasibility concerns relative to data collection because of the use of vital statistics, whereas others felt diagnosis coding would make this measure highly feasible. Other SNAC member concerns were what an appropriate C-section rate is, and the measure’s failure to consider reasons for a C-section. The measure would be improved with risk adjustment. Some SNAC members believed that managed care contracts or payment reform could improve this measure or that it might be more applicable to obstetrics than pediatrics.
5. Childhood Immunization Status
SNAC members noted that this measure affects a large portion of the Medicaid population, has a large public health impact, can help address disparities, and still has room for improvement. Reliability is high, and some data suggest that validity is good as well. The measure specifications are well understood by Medicaid agencies, but concerns remain over coding and administrative burden. One member noted the measure’s importance in monitoring public health access and creating feedback to drive improvement.
6. Immunization Status for Adolescents
SNAC members noted that this measure affects a large portion of the Medicaid population, has a large public health impact, can help address disparities, and still has room for improvement. Reliability is high and some data suggest that validity is good as well. The measure specifications are well understood by Medicaid agencies, but concerns remain over coding and administrative burden.
7. Weight Assessment Counseling for Nutrition and Physical Activity for Children and Adolescents: Body Mass Index Assessment for Children/Adolescents
SNAC members acknowledged that obesity has a high prevalence in the population covered by Medicaid and CHIP, it results in increased costs and chronic health conditions over time, there is room for improvement, and the measure addresses health care disparities. Some members noted that data collection may be burdensome unless an electronic health record is adopted, but they also noted that because this is a HEDIS measure, the specification should be well understood. Although this measure aligns with other federal initiatives, it does not address treatment of obesity or followup care related to the body mass index assessment. Some SNAC members suggested that coupling it with an intervention measure would be important, whereas others noted that the measure as it is as is key for intervention assessment and outcome-driven research.
8. Developmental Screening in the First Three Years of Life
SNAC members noted that many children in this age group are insured by Medicaid, there is room for improvement, and disparities are present. However, no reliability or validity data were available, and members expressed concern that the measure does not address several components of quality, such as the validity of screenings used or the use of followup based on screening results. Other concerns about feasibility centered on the inability to capture screening done in different venues, as well as the newness of this measure. SNAC members believe that the importance and potential for improvement is strong, but an improved measure should be considered.
9. Chlamydia Screening in Women
SNAC members expressed mixed sentiments about this measure. On one hand, some noted that many in this age group are insured by Medicaid or CHIP, and there may be room for improvement. The measure also received enthusiastic review by some SNAC members because it represents evidence-based care and is the only measure for gynecological care for this population. With regard to feasibility, SNAC members noted that as a HEDIS measure, its specifications are familiar to Medicaid programs, and administrative data can be collected easily. However, others questioned the measure’s validity because of the difficulty in identifying sexually active teens. Additionally, one SNAC member questioned whether this could be a proxy for the quality of adolescent care, and others were uncertain as to the measure’s improvability.
10. Well-Child Visits in the First 15 Months of Life
SNAC members agreed that this is an important measure of a key part of pediatric care: prevention. Well-child visits affect many insured by Medicaid, and the measure shows room for improvement, particularly when compared to the commercial population. SNAC members also noted that the measure has high reliability, but that little information on validity data was provided—yet, looking across all the well-care visit measures, one SNAC member stated that the link between these visits and child outcomes was the greatest. As a HEDIS measure, SNAC members believed that the specifications are familiar to Medicaid programs, and high levels of reporting indicate that the measure is feasible. Overall, SNAC members agreed that this measure is important for measuring access and monitoring and addressing disparities in care, but there is some concern that the content of such visits is not addressed in the measure.
11. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life
SNAC members agreed that this is an important measure of a key part of pediatric care: prevention. One SNAC member suggested that all three well-care visit measures should be considered as linked and either kept in the set together or retired from the set together. Similar to the other well-child visit measures, this measure shows room for improvement, particularly when compared to the commercial population. SNAC members also noted that the measure has high reliability, but that little information on validity data was provided. With regard to validity, one SNAC member’s perspective was that this measure may be less tightly linked to outcomes for first 15 months of life. With regard to feasibility, SNAC members also noted that this is a HEDIS measure and has high levels of reporting by States. Although this measure was considered to be important for measuring access and monitoring and addressing disparities in care, one common concern was that the measure does not address the content of such visits.
12. Adolescent Well-Care Visits
SNAC members agreed that this is an important measure, focused on prevention, that affects many insured by Medicaid and shows room for improvement, particularly when compared to the commercial population. SNAC members also noted that the measure has high reliability. However, several SNAC members questioned this measure’s validity more than the validity of the other well-care visit measures, either because this population may get free or low-cost care from different sources, or because the evidence linking these visits to health outcomes was weak or not available. With regard to feasibility, SNAC members also noted that this is a HEDIS measure and that high levels of reporting indicate that the measure is feasible. Although this measure was considered to be important for measuring access and monitoring and addressing disparities in care, one common concern was that the measure does not address the content of such visits.
13. Children and Adolescent Access to Primary Care Practitioners
SNAC members varied in their assessment of the importance of this measure. Although the SNAC members noted this as an important concept, and access to care is an issue that affects a large number of children, common concerns cited by the SNAC members were that the performance is already high, and that measures of preventive visits are a better measure of access. It was noted several times that this is a measure of utilization, not quality. Although SNAC members noted the high reliability and feasibility of this measure, they questioned the measure’s validity. In general, SNAC members seemed to agree that it is unclear whether this measure adds value beyond the other well-child-visit measures under consideration.
14. Appropriate Testing for Children with Pharyngitis
T he members that attended the second SNAC meeting seemed to universally agree that this measure should be retired, and the comments on this measure supported that perspective. As one SNAC member put it, “Discussion suggests evidence for the clinical importance of this measure is obsolete.” For example, the measure does not target inappropriate antibiotic use and may increase unnecessary testing. While at least one SNAC member supported retaining this measure because it was the only measure of appropriateness of care, and other SNAC members noted that many States report this measure and it scores high on reliability, there were general concerns about its usefulness, as well as the true potential to improve on this measure. One SNAC member suggested that a better measure for reducing antibiotic use for viral infections is needed.
15. Ambulatory Care – Emergency Department [ED] Visits
SNAC members generally supported the importance of this measure because the cost of ED visits is high, but they also acknowledged that the measure may be difficult to interpret without the context of primary care measures. At least one SNAC member called for replacing this measure with an improved measure, if possible. Although ED use is an important topic, this measure does not differentiate appropriate and inappropriate ED use, and it is not risk adjusted. Relatively few States report on this measure, causing some SNAC members to question the feasibility of the measure as well. Several SNAC members noted that it is unclear whether there is room for improvement, and results may not be timely enough to be actionable.
16. Pediatric Central Line–Associated Blood Stream Infections
SNAC members gave mixed support for this measure. They generally acknowledged this measure’s importance because, although the number of affected individuals is small, these infections can be a huge cost for Medicaid, the event is an outcome that is completely avoidable. Also, at this time there is low performance on the basis of statewide Centers for Disease Control and Prevention data, which are currently used as a proxy for Medicaid/CHIP performance rather than data specific to Medicaid- or CHIP-covered children in the neonatal intensive care unit. However, SNAC members differed as to their assessment of the appropriateness of this measure in the Child Core Set. Some stated that, although this is an important measure of quality, as a hospital-level measure it may not be appropriate to report at the State Medicaid level. Others indicated that there would be potential for Medicaid/CHIP programs and hospitals to partner to address this quality issue.
17. Annual Percentage of Asthma Patients with One or More Asthma-Related Emergency Room [ER] Visits
SNAC members noted that many Medicaid and CHIP enrollees have asthma, and many asthma-related ER visits are costly and likely treatable in the primary care setting instead of the ER. Despite these indicators of the measure’s importance, SNAC members were concerned about the validity of the measure (the measure is not risk adjusted) and the feasibility of the measure because its steward has decided not to continue maintenance of the measure. Although some preference was expressed for this measure over the other ER measure (measure 15) because of its focus on a specific prevalent condition with demonstrated disparities in care, several SNAC members indicated that there may be better measures related to asthma care.
18. Followup Care for Children Prescribed Attention Deficit/Hyperactivity Disorder (ADHD) Medication
SNAC members noted that a large percentage of Medicaid-insured children have a diagnosis of ADHD, and there appears to be room for improvement, arguing for this measure’s importance. However, several SNAC members noted weaknesses in the measure’s validity—namely, that the measure does not address coordination of care between different types of providers who are likely involved (e.g., the primary care physician, behavioral care specialist, prescriber), and that because followup visits by telephone are not being counted, this measure could have the unintended consequence of encouraging unnecessary office visits. SNAC members seemed to conclude that although an improved measure is preferred, the measure represents an important area of focus.
19. Annual Pediatric Hemoglobin (HbA1c) Testing
SNAC members generally expressed support for retiring this measure. They noted that this measure affects a small of number of Medicaid-enrolled children, has a poor evidence grade, and may be approaching an improvement ceiling. Among other concerns with validity, at least one SNAC member noted that the measure does not distinguish between Type I and Type II diabetes, and it is unclear whether it is a good measure of care in pediatric patients. With regard to feasibility, SNAC members noted that few States report this measure.
20. Followup After Hospitalization for Mental Illness
SNAC members supported retention of this measure because it addresses the clinically important topic of behavioral health and demonstrates an opportunity for improvement. SNAC members noted that no reliability or validity data were provided. With regard to feasibility, SNAC members noted that an increasing number of States are reporting the measure. With regard to usability, other SNAC members noted that there seems to be some improvement in this measure over time. Although several SNAC members expressed preference for an improved measure, such as a measure of coordination between a primary care physician and behavioral health providers, there was general agreement that the measure represents an important area of focus.
Note: ADHD = attention deficit/hyperactivity disorder; CHIP = Children’s Health Insurance Program; C-section = cesarean section; ED = emergency department; ER = emergency room; HEDIS = Healthcare Effectiveness Data and Information Set; SNAC = Agency for Healthcare Quality and Research Subcommittee to the National Advisory Council on Children's Health Quality Measures.