CHIPRA Quality Measures: NAC Subcommittee Discussion

CHIPRA Quality Measures:CHIPRA Quality Measures:NAC Subcommittee DiscussionNAC Subcommittee Discussion

November 13, 2009November 13, 2009National Advisory Committee MeetingNational Advisory Committee Meeting

Kathleen Lohr, PhDKathleen Lohr, PhDTimothy Brei, MDTimothy Brei, MD

CHIPRA – Title IV CHIPRA – Title IV

CMS, AHRQ, NAC, and CMS, AHRQ, NAC, and Subcommittee RolesSubcommittee Roles

Director, AHRQ

Secretary, HHS

AHRQ National Advisory CouncilAHRQ National Advisory Council

on Healthcare Research and Qualityon Healthcare Research and Quality

Subcommittee on Children’sSubcommittee on Children’s Healthcare Quality Measures forHealthcare Quality Measures for

Medicaid and CHIP ProgramsMedicaid and CHIP Programs

Centers for Medicare and

Medicaid Services

Key Players for SNAC WorkKey Players for SNAC Work

SNAC Co-Chairs:SNAC Co-Chairs: Jeffrey Schiff, MD, MBA Minnesota Department of Human Jeffrey Schiff, MD, MBA Minnesota Department of Human

ServicesServices Rita Mangione-Smith, MD, MPH, University of WashingtonRita Mangione-Smith, MD, MPH, University of WashingtonAHRQ Staff:AHRQ Staff: Denise Dougherty, PhD, Senior Advisor, Child Health and Denise Dougherty, PhD, Senior Advisor, Child Health and

Quality Improvement Quality Improvement

NAC Members:NAC Members: Timothy Brei, MD, FAAPTimothy Brei, MD, FAAP Kathleen Lohr, PhDKathleen Lohr, PhD

Members:Members: Another ~ 20 experts from clinical, Medicaid, CHIP, quality Another ~ 20 experts from clinical, Medicaid, CHIP, quality

measurement, research, and policy fieldsmeasurement, research, and policy fields

Subcommittee ChargeSubcommittee Charge

Identify initial Identify initial core health care quality measurement setcore health care quality measurement set

for Medicaid and CHIP programs for Medicaid and CHIP programs and in doing thisand in doing this

Provide guidance on criteria for identification Provide guidance on criteria for identification of initial core setof initial core set

Provide guidance on a strategy for identifying Provide guidance on a strategy for identifying additional measures in use for considerationadditional measures in use for consideration

Review and apply criteria to compilation of Review and apply criteria to compilation of measures currently in use by Medicaid/CHIPmeasures currently in use by Medicaid/CHIP

Timeline to January 1 Posting Timeline to January 1 Posting for Public Commentfor Public Comment

20092009

Law passed, Law passed, CMS-AHRQ CMS-AHRQ partnership partnership establishedestablished

JanuaryJanuary AprilApril JulyJuly

Subcommittee Subcommittee Meeting #2 Meeting #2

(September)(September)

Subcommittee Subcommittee Meeting #1Meeting #1

OctoberOctober

Revised Revised draft to draft to

Secretary Secretary (November)(November)

First full First full draft of draft of

initial core initial core set for set for

Federal Federal reviewreview

20102010

Final for Final for posting posting (Dec. 18)(Dec. 18)

Revisions Revisions if needed if needed

(December)(December)

Key Points about Process (I)Key Points about Process (I)

Three major criteria for selection of measuresThree major criteria for selection of measures– Validity Validity – FeasibilityFeasibility– Importance Importance 

Philosophically, preferred to leave an "empty Philosophically, preferred to leave an "empty chair" than to recommend quality measures chair" than to recommend quality measures that simply were too weak;that simply were too weak;

Sought breadth where possible Sought breadth where possible Sought familiarity with or use of measures on Sought familiarity with or use of measures on

part of Medicaid programs and/or SCHIP part of Medicaid programs and/or SCHIP programsprograms

Recognized nothing was going to be perfect   Recognized nothing was going to be perfect  

Key Points about Process (II)Key Points about Process (II)

Short amount of time AHRQ had to do this Short amount of time AHRQ had to do this Immense effort AHRQ staff and the SNAC Immense effort AHRQ staff and the SNAC

Co-Chairs over the summer  Co-Chairs over the summer  Intense involvement, interest, contributions of Intense involvement, interest, contributions of

the people on the subcommittee  the people on the subcommittee  Notable collaboration and collegiality with a Notable collaboration and collegiality with a

sister agency (namely CMS)  sister agency (namely CMS) 

SNAC Nomination and SNAC Nomination and Scoring ProcessScoring Process

Initial measure identificationInitial measure identification Delphi I – Validity and FeasibilityDelphi I – Validity and Feasibility SNAC definitions of SNAC definitions of

– ValidityValidity– Feasibility (with reliability)Feasibility (with reliability)– ImportanceImportance

Understanding of a “core, grounded, and parsimonious” Understanding of a “core, grounded, and parsimonious” setset

Broad measure nominationBroad measure nomination Delphi II – VFIDelphi II – VFI Ranking processRanking process Final voteFinal vote SNAC key issuesSNAC key issues

Key Features of the SNACKey Features of the SNACPublic ProcessPublic Process

TransparentTransparent Multiple stakeholders Multiple stakeholders

per CHIPRA per CHIPRA Public comment Public comment

including public including public nominations of nominations of measures measures

Focused on measures Focused on measures in use per CHIPRA in use per CHIPRA

Evidence-informed (per Evidence-informed (per CHIPRA) SNAC Delphi CHIPRA) SNAC Delphi processes June and processes June and August August

Conceptual Framework for Scope Conceptual Framework for Scope of Core Measurement Setof Core Measurement Set

GroundedGrounded → → IntermediateIntermediate →→ AspirationalAspirational

MeasuresMeasures Measures Measures Measures Measures

Consensus of the subcommittee to focus on Consensus of the subcommittee to focus on choosing grounded measureschoosing grounded measures GroundedGrounded: N : N ≈≈ 10-25, currently feasible, many already in 10-25, currently feasible, many already in

placeplace Intermediate categoryIntermediate category: N = ?, good specifications, some : N = ?, good specifications, some

states already using themstates already using them AspirationalAspirational: needed measures to fill in the gaps: needed measures to fill in the gaps

Consensus on Criteria Consensus on Criteria DefinitionsDefinitions

ValidityValidity– Measures must be Measures must be supported by scientific evidencesupported by scientific evidence or, where or, where

evidence is insufficient, by evidence is insufficient, by expert consensusexpert consensus

– Measures must support a link from Measures must support a link from structure to process to outcomesstructure to process to outcomes

– The measure must represent an aspect of care that is The measure must represent an aspect of care that is under the under the controlcontrol of health care providers and systems of health care providers and systems

– The measure should truly The measure should truly assess what it purports to measureassess what it purports to measure

– Measures supported by evidence from Measures supported by evidence from unpublished dataunpublished data should be should be considered for inclusionconsidered for inclusion

Consensus on Criteria Consensus on Criteria DefinitionsDefinitions

FeasibilityFeasibility– The data necessary to score the measure must be The data necessary to score the measure must be

available to state Medicaid and CHIP programsavailable to state Medicaid and CHIP programs Administrative data, medical records data, survey dataAdministrative data, medical records data, survey data

– Detailed specifications must be available for the measure Detailed specifications must be available for the measure that allow for reliable and unbiased scoring of the that allow for reliable and unbiased scoring of the measure across states and institutionsmeasure across states and institutions

Consensus on Criteria Consensus on Criteria DefinitionsDefinitions

ImportanceImportance– The measure should be The measure should be actionableactionable

– CostCost of the condition to the nation should be high of the condition to the nation should be high

– Health care systems are clearly Health care systems are clearly accountableaccountable for the quality for the quality problem assessed by the measureproblem assessed by the measure

– The extent of the quality The extent of the quality problemproblem should be substantial should be substantial

– There should be documented There should be documented variationvariation in performance on in performance on the measurethe measure

– The measure should be The measure should be representativerepresentative of a class of quality of a class of quality problems: “sentinel measure” of QOC provided for problems: “sentinel measure” of QOC provided for preventive care, mental health care, or dental care, etc.preventive care, mental health care, or dental care, etc.

Consensus on Criteria Consensus on Criteria DefinitionsDefinitions

ImportanceImportance– The measure assesses an aspect of health care where The measure assesses an aspect of health care where

there are known there are known disparitiesdisparities

– The core set should represent a The core set should represent a balancedbalanced portfolio of portfolio of measures and be consistent with the intent of the legislationmeasures and be consistent with the intent of the legislation

– Improving on performance for the core set of measures Improving on performance for the core set of measures should have the potential to should have the potential to transformtransform care for our nation’s care for our nation’s childrenchildren

SNAC Recommended Quality SNAC Recommended Quality MeasuresMeasures

by Ranking based on SNAC Priority Scores,

Legislative Topic, Condition, Age Group, Setting, Source of Data

Recommended Topics by Rank Recommended Topics by Rank (per SNAC priority score) (I)(per SNAC priority score) (I)

1 Immunizations for 2 year-olds (NCQA measure)1 Immunizations for 2 year-olds (NCQA measure)2 Frequency of ongoing prenatal care (NCQA measure)2 Frequency of ongoing prenatal care (NCQA measure)2 Emergency Department Utilization - Average number of 2 Emergency Department Utilization - Average number of

emergency room visits per member per reporting periodemergency room visits per member per reporting period3 Annual number of asthma patients (> 1 year-old) with > 1 3 Annual number of asthma patients (> 1 year-old) with > 1

asthma-related ER visit (S/AL Medicaid Program)asthma-related ER visit (S/AL Medicaid Program)4 Body Mass Index documentation 2-18 year olds (NCQA 4 Body Mass Index documentation 2-18 year olds (NCQA

measure)measure)5 Well-Child Visits (three NCQA measures): (1) first 15 months of 5 Well-Child Visits (three NCQA measures): (1) first 15 months of

life; (2) third, fourth, fifth and sixth years of life; (3) Adolescent life; (2) third, fourth, fifth and sixth years of life; (3) Adolescent 6 Total eligibles receiving preventive dental services (EPSDT 6 Total eligibles receiving preventive dental services (EPSDT

measure)measure)7 Adolescent immunization (NCQA revised for 2010)7 Adolescent immunization (NCQA revised for 2010)8 HEDIS CAHPS 4.0 including supplements for children with 8 HEDIS CAHPS 4.0 including supplements for children with

chronic conditions and Medicaid Planschronic conditions and Medicaid Plans9 Timeliness of prenatal care (NCQA measure)9 Timeliness of prenatal care (NCQA measure)

Recommended Topics by Rank Recommended Topics by Rank (per SNAC priority score) (II)(per SNAC priority score) (II)

1010 % of live births weighing less than 2,500 grams % of live births weighing less than 2,500 grams 1111 Rates of screening using standardized screening tools for Rates of screening using standardized screening tools for

potential delays in social and emotional development potential delays in social and emotional development 12 12 Follow-up care for children prescribed Follow-up care for children prescribed

attention-deficit/hyperactivity disorder (ADHD) (Medication attention-deficit/hyperactivity disorder (ADHD) (Medication Continuation and Maintenance Phase – NCQA measure)Continuation and Maintenance Phase – NCQA measure)

1313 Annual dental visit (NCQA measure)Annual dental visit (NCQA measure)1313 Child and adolescent Major Depressive Disorder (MDD) - Child and adolescent Major Depressive Disorder (MDD) -

suicide risk assessment suicide risk assessment 1313 Annual hemoglobin A1C testing (all children and adolescents Annual hemoglobin A1C testing (all children and adolescents

diagnosed with diabetes)diagnosed with diabetes)

Recommended Topics by Rank Recommended Topics by Rank (per SNAC priority score) (III)(per SNAC priority score) (III)

14 Chlamydia screening 16-20 year-old females (NCQA measure) 14 Followup after hospitalization for mental illness (NCQA measure)16 Cesarean rate for low-risk first birth women 16 Access to primary care practitioners, by age and total 16 Use of clinician & group primary care CAHPS survey for

practitioners participating in Medicaid and CHIP (CAHPS family of measures)

17 Total EPSDT eligibles who received dental treatment services (EPSDT)

17 Pediatric catheter-associated blood stream infection rates (PICU/NICU)

18 Pharyngitis: appropriate testing (NCQA measure)18 Otitis media with effusion: avoidance of inappropriate use of

systemic antimicrobials

Multiple Conditions Multiple Conditions Represented Represented

ConditionCondition NumberNumber

Multiple conditions (e.g., vaccine-preventable)Multiple conditions (e.g., vaccine-preventable) 55

Pregnancy and childbirthPregnancy and childbirth 44

Social, emotional, mental health conditionsSocial, emotional, mental health conditions 44

DentalDental 33

Upper respiratory infection Upper respiratory infection 22

Vaccine-preventable diseases (multiple)Vaccine-preventable diseases (multiple) 22

OverweightOverweight 11

AsthmaAsthma 11

Diabetes Diabetes 11

Sexually transmitted infections Sexually transmitted infections 11

Preventable infection (e.g., vaccine-preventable)Preventable infection (e.g., vaccine-preventable) 1 1

Measure Areas by CHIPRA Measure Areas by CHIPRA Legislative TopicLegislative Topic

Prevention/health promotionPrevention/health promotion 1111

Management of acute conditionsManagement of acute conditions 55

Management of chronic conditionsManagement of chronic conditions 55

Family experiences of care Family experiences of care 22

Availability/accessAvailability/access 22

Duration of enrollment/coverageDuration of enrollment/coverage 00

Most integrated health care settingMost integrated health care setting 00

Most Measures Focus on Most Measures Focus on Prevention/Health Promotion Prevention/Health Promotion

0

2

4

6

8

10

12

Prev/HP Acute Chronic FEC Avail

Most Measures Cross All or Most Measures Cross All or Most Age GroupsMost Age Groups

Peri 0-2

0-3

6-Adol

All

0

1

2

3

4

5

6

7

8

9

10

Note: SNAC voted to include all well-child visits (ages 15 mos-13 y) as one measure. Perinatal measures are for babies; they are not counted separately here asadolescent measures.

All but One Measure is for All but One Measure is for Ambulatory Settings Ambulatory Settings

0

5

10

15

20

25

AMB Inpatient

Note: Ambulatory includes Emergency department; dental care; specialty care

Topics by Data Source Topics by Data Source

0123456789

10

Admin Hybrid Survey Birth + Other

Note: Admin = Admin only; Hybrid = admin + chart; Birth + = Medicaid enrollment plus birth certificate data. Other refers to 2 dental EPSDT measures.

Major Issues IdentifiedMajor Issues Identifiedby the SNAC (I)by the SNAC (I)

Standardization of duration of enrollment Standardization of duration of enrollment measuresmeasures

Standardization of the denominator across Standardization of the denominator across measuresmeasures

Expansion of use of measures for the whole Expansion of use of measures for the whole Medicaid/ CHIP populationMedicaid/ CHIP population

Improved disparities reportingImproved disparities reporting

(Continued)(Continued)

Major Issues Identified Major Issues Identified by the SNAC (II)by the SNAC (II)

““Empty chairs”Empty chairs”1.1. Most integrated health care system (medical Most integrated health care system (medical

home)home)2.2. Specialty careSpecialty care3.3. Inpatient careInpatient care4.4. Care for substance abuseCare for substance abuse5.5. Mental health treatmentMental health treatment6.6. Measures of integration of care with services Measures of integration of care with services

outside of the health care systemoutside of the health care system7.7. Health outcomesHealth outcomes

Other Factors of Interest (I)Other Factors of Interest (I)

Quality assessment and improvement for federalQuality assessment and improvement for federal(insurance) programs is (insurance) programs is hard, complicatedhard, complicated

Issues are very broadIssues are very broad: e.g., including dental,: e.g., including dental, mental health, prevention, populations, settings, etc ..., mental health, prevention, populations, settings, etc ...,

Medicaid and CHIP programs differ markedlyMedicaid and CHIP programs differ markedly in what they in what they already do and likely can do at the momentalready do and likely can do at the moment

Wide range of Wide range of – probable funding from their states probable funding from their states – access to data now and/or what is now reported to them  access to data now and/or what is now reported to them  – types of health care systems that deliver care (managed types of health care systems that deliver care (managed

care plans v mostly private practice or whatever)care plans v mostly private practice or whatever)– centralized v. decentralized ways the programs are centralized v. decentralized ways the programs are

administered in different states administered in different states 

Other Factors of Interest (II)Other Factors of Interest (II)

The CHIPRA quality measurement activity The CHIPRA quality measurement activity is voluntary at the momentis voluntary at the moment

butbut Skepticism that things will stay that way Skepticism that things will stay that way

and not become mandatoryand not become mandatory soso SNAC wanted to be careful about numbers SNAC wanted to be careful about numbers

of measures, complexity, and other factorsof measures, complexity, and other factors

Discussion Questions Discussion Questions

Comments on the recommended core Comments on the recommended core set or the SNAC process?set or the SNAC process?

A model for the Subcommittees of the A model for the Subcommittees of the future?future?

NAC interest in next phases of AHRQ NAC interest in next phases of AHRQ CHIPRA work?CHIPRA work?

Other?Other?