NQF

Child Workgroup Agenda Synopsis

Full Agenda

Measure Index

• NQF #0710e: Depression Remission at Twelve Months
• NQF #0711: Depression Remission at Six Months
• NQF #0712e: Depression Utilization of the PHQ-9 Tool
• NQF #1884: Depression Response at Six Months- Progress Towards Remission
• NQF #1885: Depression Response at Twelve Months- Progress Towards Remission

• NQF #0024: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents- Body Mass Index Assessment for Children/Adolescents
• NQF #2393: Pediatric All-Condition Readmission Measure

• NQF #0108: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication
• NQF #2800: Metabolic Monitoring for Children and Adolescents on Antipsychotics
• Use of Multiple Concurrent Antipsychotics in Children and Adolescents

• NQF #2548: Child HCAHPS

• NQF #2797: Transcranial Doppler Ultrasonography Screening Among Children with Sickle Cell Anemia
• NQF #3166: Antibiotic Prophylaxis Among Children with Sickle Cell Anemia

Full Measure Information

Measure Specifications

• NQF Number (if applicable): 0710
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who reach remission twelve months (+/- 60 days) after an index visit.
  
  
• Numerator: The number of patients in the denominator who reached remission, with a PHQ-9 or PHQ-9M result less than five, twelve months (+/- 60 days) after an index visit.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia and an initial (index) PHQ-9 or PHQ-9M score greater than nine.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO-PM
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: Medicare Shared Savings Program (Implemented),Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals (Implemented),Merit-Based Incentive Payment System (MIPS) Program (Finalized)
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0710e
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is a Outcome: PRO-PM measure. This measure is currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is included in CMS’s Meaningful Use program, PQRS and the Accountable Care Organization. It is also publically reported in MN HealthScores. This measure supports alignment of measurement across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure is an eMeasure. It may not be feasible for states not equipped to report eMeasures. The data sources for this measure include electronic health records and paper medical records. Multiple versions of this measure do not exist. However, this measure is paired with a process measure, Depression Utilization of the PHQ-9 or PHQ-9M Tool (NQF# 0712). The behavioral health Committee noted during the 2015 maintenance review that the measure is not simple to report but it is feasible.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age and adult patients (18 years of age or older).
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measures on the adult core set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could potentially have an impact on the quality of care for Medicaid patients with depression. “The BH Committee strongly supported measures (0710 and 0711), noting they are 2 of the only true population-based outcome measures for mental health and substance use disorders that are widely used and publicly reported.”
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 0711
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who reach remission six months (+/- 60 days) after an index visit.
  
  
• Numerator: The number of patients in the denominator who reached remission, with a PHQ-9 or PHQ-9M result less than five, six months (+/- 60 days) after an index visit.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia and an initial (index) PHQ-9 or PHQ-9M score greater than nine.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO-PM
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: Medicare Physician Quality Reporting System (Implemented),Merit-Based Incentive Payment System (MIPS) Program (Finalized),Physician Feedback/Quality Resource Use Report (Finalized),Physician Value-Based Payment Modifier (Finalized)
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0711
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is a Outcome: PRO-PM measure. This measure is currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is included in MN Bridges to Excellence and PQRS. It is also publically reported in MN HealthScores. It is used in the Minnesota Department of Health Statewide Quality Reporting and Measurement System. This measure supports alignment of measurement across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The behavioral Health Committee noted during the 2015 maintenance review that the measure is not simple to report but it is feasible. The data sources for this measure include electronic health records and paper medical records.There are not multiple version of this measure. This measure is paired with a process measure, Depression Utilization of the PHQ-9 or PHQ-9M Tool (NQF# 0712). This measure and measure #0710 differ only slightly. The measures only difference is they examine the same patient at two different points in time (6 months and 12 months), assessing for the patient-reported outcome of absence of depressive symptoms as measured by the PHQ-9 tool.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age and adult patients (18 years of age or older)
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measured on the adult core set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could potentially have an impact on the quality of care for Medicaid patients with depression. “The BH Committee strongly supported measures (0710 and 0711), noting they are 2 of the only true population-based outcome measures for mental health and substance use disorders that are widely used and publicly reported.”
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 0712
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia who have a completed PHQ-9 or PHQ-9M tool during the measurement period.
  
  
• Numerator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) included in the denominator who have at least one PHQ-9 or PHQ-9M tool administered and completed during a four month measurement period.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals (No Status),Merit-Based Incentive Payment System (MIPS) Program (Finalized)
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0712e
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is a process measure. This is an eMeasure. This measure is currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure has been publically reported in MN HealthScores and is also included in CMS Meaningful Use Program.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure is an eMeasure. It may not be feasible for states not equipped to report eMeasures. The Behavioral Health Standing Committee agreed that this measure is “highly feasible.” The data sources for this measure include electronic health records and paper medical records. Multiple versions of this measure do not exist. This measure is paired with outcome measures: Depression Remission at Twelve Months (NQF#0710); Depression Remission at Six Months (NQF#0710); Depression Response at Six Months- Progress Towards Remission (NQF# 1884) and Depression Response at Twelve Months- Progress Towards Remission (NQF# 1885).
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age and adult patients (18 years of age or older)
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measured on the adult core set. Patients with depression and dysthymia (9% of the population) are frequently untreated, undertreated, or treated inappropriately.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could potentially have an impact on the quality of care for Medicaid patients with depression.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 1884
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who demonstrated a response to treatment six months (+/- 60 days) after an index visit.
  
  
• Numerator: The number of patients in the denominator who demonstrated a response to treatment, with a PHQ-9 or PHQ-9M result that is reduced by 50% or greater from the index PHQ-9 or PHQ-9M score, six months (+/- 60 days) after an index visit.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia and an initial (index) PHQ-9 or PHQ-9M score greater than nine.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO-PM
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/1884
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is an outcome: PRO-PM measure. This measure is not currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is not currently being used in federal reporting programs. However, the measure is currently used for public reporting and pay for performance programs in Minnesota. It also has the potential to be added to the child core set as it is specified for the ages 12-17.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The BH Steering Committee agreed the measure is feasible. Although, concern was expressed about the potential burden of collecting this measure with the PHQ-9 measure and other required measures. The Committee noted the burden would be offset by the measure benefits to the patient. The data sources for this measure include electronic health records and paper medical records. Multiple versions of this measure do not exist. This measure is paired with a process measure, Depression Utilization of the PHQ-9 or PHQ-9M Tool (NQF# 0712).
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age and adult patients (18 years of age or older)
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measured on the adult core set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure may have a high impact as depression affects approximately 16% of the population over a lifetime.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 1885
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who demonstrated a response to treatment twelve months (+/- 60 days) after an index visit.
  
  
• Numerator: The number of patients in the denominator who demonstrated a response to treatment, with a PHQ-9 or PHQ-9M result that is reduced by 50% or greater from the index PHQ-9 or PHQ-9M score, twelve months (+/- 60 days) after an index visit.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia and an initial (index) PHQ-9 or PHQ-9M score greater than nine.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO-PM
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/1885
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is an outcome measure: PRO-PM. This measure is not currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is not currently being used in federal reporting programs. However, the measure is currently used for public reporting and pay for performance programs in Minnesota. It also has the potential to be added to the child core set as it is specified for the ages 12-17.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The BH Steering Committee agreed the measure is feasible. Although, concern was expressed about the potential burden of collecting this measure with the 6-month companion measure and other required measures. The Committee noted the burden would be offset by the measure benefits to the patient. The data sources for this measure include electronic health records and paper medical records. Multiple versions of this measure do not exist. This measure is paired with a process measure, Depression Utilization of the PHQ-9 or PHQ-9M Tool (NQF# 0712).
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age and adult patients (18 years of age or older)
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measured on the adult core set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure may have a high impact as depression affects approximately 16% of the population over a lifetime.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 0024
  
  
• Description: Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the measurement year:- Body mass index (BMI) percentile documentation- Counseling for nutrition - Counseling for physical activity
  
  
• Numerator: Patients who had evidence of the following during the measurement year: a body mass index (BMI) percentile documentation, counseling for nutrition, counseling for physical activity.
  
  
• Denominator: Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB-GYN during the measurement year.
  
  
• Exclusions: The measure excludes female patients who have a diagnosis of pregnancy and patients who use hospice services during the measurement year.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims, Electronic Health Records, Paper Medical Records
  
  
• Level of analysis: Health Plan, Integrated Delivery System
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: NCQA
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Measure Specifications

• NQF Number (if applicable): 2393
  
  
• Description: This measure calculates case-mix-adjusted readmission rates, defined as the percentage of admissions followed by 1 or more readmissions within 30 days, for patients less than 18 years old. The measure covers patients discharged from general acute care hospitals, including children’s hospitals.
  
  
• Numerator: The numerator consists of hospitalizations at general acute care hospitals for patients less than 18 years old that are followed by 1 or more readmissions to general acute care hospitals within 30 days. Readmissions are excluded from the numerator if the readmission was for a planned procedure or for chemotherapy. The measure outcome is a readmission rate, defined as the percentage of index admissions with 1 or more readmissions within 30 days. The readmission rate, unadjusted for case-mix, is calculated as follows:number of index admissions with 1 or more readmissions within 30 days/total number of index admissions
  
  
• Denominator: Hospitalizations at general acute care hospitals for patients less than 18 years old.
  
  
• Exclusions: EXCLUSIONS FROM THE NUMERATOR (READMISSIONS) AND DENOMINATOR (INDEX HOSPITALIZATIONS)We exclude certain hospitalizations from the measure entirely (i.e., from the numerator and denominator) based on clinical criteria or for issues of data completeness or quality that could prevent assessment of eligibility for the measure cohort or compromise the accuracy of readmission rates. Hospitalizations are excluded from the measure if they meet any of the following criteria: 1. The hospitalization was at a specialty or non-acute care hospital.Rationale: The focus of the measure is admissions to hospitals that provide general pediatric acute care. Records for admissions to specialty and non-acute care hospitals are therefore omitted from the dataset. Because hospital type cannot be determined for records with missing data in the hospital type variable, these records are also removed from the dataset.2. Records for the hospitalization contain incomplete data for variables needed to assess eligibility for the measure or calculate readmission rates, including hospital type, patient identifier, admission date, discharge date, disposition status, date of birth, primary ICD-9 or principal ICD-10 diagnosis codes, or gender.Rationale: Complete and valid information for the variables listed above is needed to define the measure cohort and calculate case-mix-adjusted readmission rates. Identifying readmissions within 30 days requires information on dates of admission and end-of-service dates and the ability to link unique patient identifiers across inpatient claims records. Hospital identifiers are needed to determine the hospital at which index admissions occurred. The disposition status is needed to determine whether a patient was discharged or experienced some other outcome (e.g., was transferred to another acute care hospital, left against medical advice, died). Establishing a patient’s eligibility for membership in the pediatric cohort and performing case-mix adjustment requires an accurate date of birth and end-of-service date. Because gender is 1 of the variables used for case-mix adjustment, episodes of care with missing or inconsistent gender cannot be evaluated in the measure.3. Records for the hospitalization contain data of questionable quality for calculating readmission rates, includinga. Inconsistent date of birth across records for a patient.b. Discharge date prior to admission date.c. Admission or discharge date prior to date of birth.d. Admission date after a disposition status of death during a prior hospitalization.Rationale: Complete and valid information for the variables listed above is needed to define the measure cohort and calculate case-mix-adjusted readmission rates. Identifying readmissions within 30 days requires information on dates of admission and end-of-service. A valid disposition status is needed to determine whether a patient was discharged or experienced some other outcome (e.g., was transferred to another acute care hospital, left against medical advice, died). Establishing a patient’s eligibility for membership in the pediatric cohort and performing case-mix adjustment requires an accurate date of birth and end-of-service date.4. Codes other than ICD-9 or ICD-10 codes are used for the primary procedure.Rationale: ICD-9 or ICD-10 procedure codes are necessary for applying clinical exclusions.5. The patient was older than 18 years, 29 days at the time of admission.Rationale: This age exclusion limits the population to pediatric patients and prevents inclusion of records that overlap with adult readmission measures. Age eligibility for inclusion in the measure is based on age at the time of discharge from the index admission. Because the focus of the measure is pediatric patients, a patient’s hospitalization is ineligible for inclusion in the measure as an index admission if the patient was 18 years old or greater at the time of discharge. Because the subsequent observation period for readmissions is 30 days, a patient's hospitalization is ineligible for inclusion in the measure as a readmission if the patient was older than 18 years, 29 days at the start of the readmission.6. The hospitalization was for obstetric care, including labor and delivery.Rationale: Hospitalizations for obstetric conditions are excluded because care related to pregnancy does not generally fall within the purview of pediatric providers.7. The primary ICD-9 or principal ICD-10 diagnosis code was for a mental health condition.Rationale: Hospitalizations for mental health conditions are excluded because patients admitted for psychiatric treatment are typically cared for in separate psychiatric centers that are not comparable to short-term acute care hospitals. We describe this analysis in detail in Section 2b.3 of the Measure Testing Submission Form.8. The hospitalization was for birth of a healthy newborn.Rationale: Hospitalizations for birth of healthy newborns are excluded because these hospitalizations, unlike all others, are not for evaluation and management of disease.EXCLUSIONS FROM THE DENOMINATOR ONLY (INDEX HOSPITALIZATIONS ONLY)We also apply further exclusions to the denominator only (i.e., these hospitalizations are excluded from index hospitalizations but could still meet criteria for readmissions). Hospitalizations are excluded from the denominator only if they meet any of the following criteria:9. The patient was 18 years old or older at the time of discharge.Rationale: Age eligibility for inclusion in the measure is based on age at the time of discharge from the index admission. Because the measure covers pediatric patients, a patient's hospitalization is ineligible for inclusion in the measure as an index admission if the patient was 18 years old or greater at the time of discharge.10. The discharge disposition was death.Rationale: A patient must be discharged alive from an index admission in order to be readmitted. Therefore, any record with a discharge disposition of death cannot serve as an index admission.11. The discharge disposition was leaving the hospital against medical advice.Rationale: A discharge disposition of leaving against medical advice indicates that a patient left care before the hospital determined that the patient was ready to leave. 12. The hospital has less than 80% of records with complete patient identifier, admission date, and discharge date or less than 80% of records with complete primary ICD-9 or principal ICD-10 diagnosis codes. (Records for these hospitals are still assessed as possible readmissions, but readmission rates are not calculated for these hospitals due to their lack of complete data.)Rationale: Readmission rates are not calculated for hospitals missing large amounts of data for the above variables because these hospitals have limited data to accurately apply measure cohort exclusions and calculate case-mix-adjusted readmission rates. Assessing eligibility for the measure cohort and performing case-mix adjustment requires information on admission dates, end-of-service dates, and diagnosis codes. Identifying readmissions requires information on admission dates and end-of-service dates and the ability to link unique patient identifiers across inpatient claims records. 13. The hospital is in a state not being analyzed.Rationale: A claims database used for readmission analysis may contain records for hospitals located in states that are not included in the database (because covered patients may sometimes be admitted to out-of-state hospitals). Records for these out-of-state hospital admissions are not excluded from the measure dataset because these records may meet criteria for being counted as readmissions as part of an in-state hospital’s readmission rate. However, readmission rates are not calculated for out-of-state hospitals due to the lack of complete data for these hospitals.14. Thirty days of follow-up data are not available for assessing readmissions.Rationale: Identifying readmissions within 30 days requires a full 30 days of follow-up data.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome
  
  
• Data Source: Claims
  
  
• Level of analysis: Facility
  
  
• Care Setting: Inpatient/Hospital
  
  
• Use in Federal Programs: N/A
  
  
• Steward: Center of Excellence for Pediatric Quality Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/2393
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the Medicaid gap area: care coordination. The 2015 Committee emphasized the potential for this measure to improve disparities in care, particularly for Black and Hispanic patients. The Committee also agreed this measure was high priority given that readmission occurs in 2 to 6 percent of hospitalizations for children, costing $2.8 billion for children with 4 or more hospitalizations, over a one year period.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This is an outcome measure and is currently not used in federal reporting programs. The data source is administrative claims.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is used by the Solutions for Patient Safety, an initiative by over 100 children’s hospitals to reduce harm but is not used in federal reporting programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure can be feasibly reported. The data source is administrative claims with level of analysis at the facility level. However, the 2015 Committee discussed that the measure faces challenges in terms of implementation. With regards to the use of Medicaid claims, the Committee expressed concerns that Medicaid claims are challenging to use as they vary from state to state. The Committee also noted the challenge that children’s health is covered by a number of insurance plans, spread among Medicaid and private insurance and that comparisons to children covered by private insurance versus Medicaid are not always analogous.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; The measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: No; The population is in-hospital patients less than 18 years old.
  
  
• Summary: What is the potential value to the program measure set?: This measure addresses a gap area identified by Task Force members during the 2017 annual meeting. This measure can be used to distinguish variations and/or disparities in care.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure can provide prevalence data on pediatric readmissions and possibly distinguish variations or disparities in care.
  
  
• Lead Discussant: Richard Antonelli
  
  

Measure Specifications

• NQF Number (if applicable): 0108
  
  
• Description: Percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which is within 30 days of when the first ADHD medication was dispensed. An Initiation Phase Rate and Continuation and Maintenance Phase Rate are reported.
  
  
• Numerator: Among children newly prescribed ADHD medication, those who had timely and continuous follow-up visits.
  
  
• Denominator: Children 6-12 years of age newly prescribed ADHD medication.
  
  
• Exclusions: Children who had an acute inpatient encounter for mental health or chemical dependency following the Index Prescription Start DateChildren with a diagnosis of narcolepsy: Many of the medications used to identify patients for the denominator of this measure are also used to treat narcolepsy. Children with narcolepsy who are pulled into the denominator are then removed by the narcolepsy exclusion. Children using hospice services during the measurement year. Children in hospice may not be able to receive the necessary follow-up care.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims, Electronic Health Data
  
  
• Level of analysis: Health Plan, Integrated Delivery System
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: NCQA
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Measure Specifications

• NQF Number (if applicable): 2800
  
  
• Description: The percentage of children and adolescents 1–17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.
  
  
• Numerator: Children and adolescents who received glucose and cholesterol tests during the measurement year.
  
  
• Denominator: Children and adolescents who had ongoing use of antipsychotic medication (at least two prescriptions).
  
  
• Exclusions: No exclusions
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of analysis: Health Plan, Integrated Delivery System, Population : Regional and State
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: National Committee for Quality Assurance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/2800
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure address the Medicaid gap area: behavioral health. In addition, the Pediatric Committee agreed this is an important measure to monitor the serious side effects of prescribing antipsychotic medications to children and adolescents (e.g., diabetes, rapid weight gain).
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is a process measure. The data source is administrative claims. This measure is not currently used in a federal reporting program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; The measure is intended for children enrolled in commercial health plans and/or Medicaid and have been used for HEDIS reporting beginning in 2015.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The measure can be feasibly reported. The data source is administrative claims with a level of analysis at the health plan and state/regional level.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed
  
  
• Both Medicaid Adult and Child sensitive?: No; The measure population is only for children 1-17 years of age.
  
  
• Summary: What is the potential value to the program measure set?: This measure addresses a Medicaid gap: behavioral health. This measure addresses the potential risks for children who are on multiple antipsychotics.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: Antipsychotic medications offer the potential for effective treatment of psychiatric disorders in children; however, they can also increase a child’s risk for developing serious health concerns, including metabolic health complications. This data provides information on the approach to encourage monitoring the prescribing and judicious use of antipsychotic medications.
  
  
• Lead Discussant: Lindsay Cogan
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: Percentage of children and adolescents ages 1 to 17 who were treated with antipsychotic medications and who were on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year.Note: A lower rate indicates better performance.
  
  
• Numerator: Beneficiaries on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year. Do not include denied claims.
  
  
• Denominator: The eligible population.
  
  
• Exclusions:
  
  
• Endorsement Status: Not Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type:
  
  
• Data Source: Administrative
  
  
• Level of analysis:
  
  
• Care Setting:
  
  
• Use in Federal Programs: N/A
  
  
• Steward: NCQA
  
  
• NQF Medicaid Staff Notes: Technical specifications: https://www.medicaid.gov/medicaid/quality-of-care/downloads/medicaid-and-chip-child-core-set-manual.pdf
  
  

Measure Specifications

• NQF Number (if applicable): 2548
  
  
• Description: The Consumer Assessment of Healthcare Providers and Systems Hospital Survey – Child Version (Child HCAHPS) is a standardized survey instrument that asks parents and guardians (henceforth referred to as parents) of children under 18 years old to report on their and their child’s experiences with inpatient hospital care. The performance measures of the Child HCAHPS survey consist of 39 items organized by overarching groups into the following 18 composite and single-item measures:Communication with Parent 1. Communication between you and your child’s nurses (3 items) 2. Communication between you and your child’s doctors (3 items) 3. Communication about your child’s medicines (4 items) 4. Keeping you informed about your child’s care (2 items) 5. Privacy when talking with doctors, nurses, and other providers (1 item) 6. Preparing you and your child to leave the hospital (5 items) 7. Keeping you informed about your child’s care in the Emergency Room (1 item)Communication with Child 8. How well nurses communicate with your child (3 items) 9. How well doctors communicate with your child (3 items) 10.Involving teens in their care (3 items)Attention to Safety and Comfort 11.Preventing mistakes and helping you report concerns (2 items) 12.Responsiveness to the call button (1 item) 13.Helping your child feel comfortable (3 items) 14.Paying attention to your child’s pain (1 item)Hospital Environment 15.Cleanliness of hospital room (1 item) 16.Quietness of hospital room (1 item)Global Rating 17.Overall rating (1 item) 18.Recommend hospital (1 item)We recommend that the scores for the Child HCAHPS composite and single-item measures be calculated using a top-box scoring method. The top box score refers to the percentage of respondents who answered survey items using the best possible response option. The measure time frame is 12 months. A more detailed description of the Child HCAHPS measure can be found in the Detailed Measure Specifications (Appendix A).
  
  
• Numerator: Using the top-box scoring method, the numerator of the top-box score for a measure consists of the number of respondents with a completed survey who gave the best possible answer for the item(s) in a measure.For example, the top-box numerator for the communication between you and your child’s nurses composite is the number of respondents who answered “Always” to questions about how well nurses communicated well with them.
  
  
• Denominator: The denominator for each single-item measure is the number of respondents with a completed survey who responded to the item. The denominator for each composite measure is the number of respondents with a completed survey who responded to at least one of the items within the measure. The target population for the survey is parents of children under 18 years old who have been discharged from the hospital during the target 12-month time frame.
  
  
• Exclusions: SURVEY AND MEASURES 1-18Exclude parents of certain patients from the measure (numerator and denominator) based on clinical and non-clinical criteria: 1. “No-publicity” patients 2. Court/law enforcement patients 3. Patients with a foreign home addresses 4. Patients discharged to hospice care (hospice-home or hospice-medical facility) 5. Patients who are excluded because of state regulations 6. Patients who are wards of the state 7. Healthy newborns 8. Maternity-stay patients 9. Patients admitted for observation 10.Patients discharged to skilled nursing facilities 11: Patients who are emancipated minors MEASURES 1-18Exclude respondents from the numerator and denominator of a measure if they have completed survey items in the measure using multiple marks (i.e., they gave multiple answers to an individual question). MEASURES 8-9Exclude the following respondents from the numerator and denominator: 1. All those who answered “No” to screener question 6 (Is your child able to talk with nurses and doctors about his or her health care?) 2. All those whose child was under 3 years old at discharge as determined using administrative dataMEASURE 10Exclude the following respondents from the numerator and denominator: 1. All those who answered “No” in screener question 43 (During this hospital stay, was your child 13 years old or older?) 2. All those whose child was under 13 years old at discharge as determined using administrative data 3. All those who answered “No” in screener question 6 (Is your child able to talk with nurses and doctors about his or her health care?)MEASURE 12Exclude the following respondents from the numerator and denominator: 1. All those who answered “No” in screener question 25 (During this hospital stay, did you or your child ever press the call button?)MEASURE 14Exclude the following respondents from the numerator and denominator: 1. All those who answered “No” in screener question 30 (During this hospital stay, did your child have pain that needed medicine or other treatment?)
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO-PM
  
  
• Data Source: Information not provided
  
  
• Level of analysis: Facility
  
  
• Care Setting: Inpatient/Hospital
  
  
• Use in Federal Programs: N/A
  
  
• Steward: Agency for Healthcare Research and Quality
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/2548
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the Medicaid gap area: patient-reported outcome measures.Information provided by the developer included identifying specific provider actions that can influence the patient experience being measured. Performance scores in the 18 individual measures indicate considerable variation and opportunity for improvement. The 2015 Committee overwhelmingly voted this measure to be a high priority.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This is an outcome, instrument-based measure and is not used in federal reporting programs. The data source is patient-reported data. The survey consists of 39 items organized by overarching groups into 18 composite and single-item measures.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is used by hospitals across the country but is not publicly reported or used in federal reporting programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure can be feasibly reported but the 2015 Committee commented that the survey could be considered burdensome due to its length. The data source is patient-reported data with level of analysis at the facility level.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; The measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: No; The population is children less than 18 years old who were previously hospitalized.
  
  
• Summary: What is the potential value to the program measure set?: This measure addresses a gap area identified by Task Force members during the 2017 annual meeting. This measure could provide insight into the experiences of all pediatric patients during their hospital stay. The pediatric patient voice is an important but often forgotten component of the entire hospital experience.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could provide insight into the experiences of all pediatric patients during their hospital stay. This measure does not specifically address quality of care among Medicaid pediatric patients, but rather, of all pediatric patients.
  
  
• Lead Discussant: Richard Antonelli
  
  

Measure Specifications

• NQF Number (if applicable): 2797
  
  
• Description: The percentage of children ages 2 through 15 years old with sickle cell anemia (Hemoglobin SS) who received at least one transcranial Doppler (TCD) screening within a year.
  
  
• Numerator: The numerator is the number of children ages 2 through 15 years old with sickle cell anemia who received at least one TCD screening within the measurement year.
  
  
• Denominator: The denominator is the number of children ages 2 through 15 years with sickle cell anemia within the measurement year.
  
  
• Exclusions: None
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Administrative Claims
  
  
• Level of analysis: Health Plan
  
  
• Care Setting: Other
  
  
• Use in Federal Programs: N/A
  
  
• Steward: QMETRIC - University of Michigan
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/2797
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the Medicaid gap area: sickle cell disease. The Pediatric Committee agreed the clinical evidence provided by the measure developer demonstrated that a lack of annual screening is strongly associated with poor outcome. They highlighted performance gaps between different types of health plans (e.g., Medicaid versus commercial). Based on data presented from different states, Committee members concurred that a gap in care exists, and there is an opportunity for improvement. They also noted disparities based on socioeconomic status are unlikely, since the majority of the children with sickle cell disease are covered by Medicaid.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This is a process measure and is currently not used in federal reporting programs. The data source is administrative claims.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is currently in use by New York Medicaid but is not used in federal reporting programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure can be feasibly reported. The data source is administrative claims with level of analysis at the health plan level.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; The measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: No; The population is children ages 2-15 years with sickle cell anemia.
  
  
• Summary: What is the potential value to the program measure set?: This measure addresses a gap area identified by Task Force members during the 2017 annual meeting. This measure can provide data on a large subpopulation of children covered by Medicaid.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure provides data on the care received by children with sickle cell anemia (a relatively small percentage of children) but with significant health outcomes and high mortality rates. The majority of these children are covered by Medicaid.
  
  
• Lead Discussant: Gary Freed
  
  

Measure Specifications

• NQF Number (if applicable): 3166
  
  
• Description: The percentage of children ages 3 months to 5 years old with sickle cell anemia (SCA, hemoglobin [Hb] SS) who were dispensed appropriate antibiotic prophylaxis for at least 300 days within the measurement year.
  
  
• Numerator: The numerator is the number of children ages 3 months to 5 years old with SCA (Hb SS) who were dispensed appropriate antibiotic prophylaxis for at least 300 days within the measurement year.
  
  
• Denominator: The denominator is the number of children ages 3 months to 5 years with SCA (Hb SS) within the measurement year.
  
  
• Exclusions: None
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Administrative Claims
  
  
• Level of analysis: Health Plan
  
  
• Care Setting: Other
  
  
• Use in Federal Programs: N/A
  
  
• Steward: QMETRIC - University of Michigan
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/3166
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the Medicaid gap area: sickle cell disease.The Pediatric Committee acknowledged that the measure addresses a medical condition affecting a relatively small population, children with sickle cell anemia (SCA), but recognized that its focus has significant impact on their health outcomes, including high mortality rates. The Committee also found that there was significant variation in performance among states (the developer reports a range of 5.7-36%) and noted there has not been an increase in antibiotic prophylaxis over time, which the developer and Committee agreed reflected a lack of work to improve this area. The Committee agreed there is significant room for improvement.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This is a process measure and is currently not used in federal reporting programs. The data source is administrative claims.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is currently in use among health plans as well as New York Medicaid but is not used in federal reporting programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure can be feasibly reported. The data source is administrative claims with level of analysis at the health plan level. The Pediatric Committee also agreed this measure was highly feasible, since the data elements required for the measure are routinely generated and used during care delivery, and all data elements used in the measure have defined fields in electronic claims.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; The measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: No; The population is children ages 2-15 years with sickle cell anemia.
  
  
• Summary: What is the potential value to the program measure set?: This measure addresses a gap area identified by Task Force members during the 2017 annual meeting. This measure can provide data on a large subpopulation of children covered by Medicaid.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure provides data on the care received by children with sickle cell anemia (a relatively small percentage of children) but with significant health outcomes and high mortality rates. The majority of these children are covered by Medicaid.
  
  
• Lead Discussant: Gary Freed
  
  

Gap Area Index

• Asthma* 
  
  
• Behavioral health and integration with primary care 
  
  
• Care coordination 
  
  
• Cost measures* 
  
  
• Dental care access for children with disabilities* 
  
  
• Durable medical equipment (DME)* 
  
  
• Duration of children's health insurance coverage over a 12-month period* 
  
  
• Exposure to Adverse Childhood Experiences (ACEs)* 
  
  
• Injuries and Trauma* 
  
  
• Maternal and Reproductive Health* 
  
  
• Mental health  
  
  
• Overuse/medically unnecessary care* 
  
  
• Patient-reported outcome measures 
  
  
• Screening for abuse and neglect* 
  
  
• Sickle cell disease 
  
  
• Substance abuse* 
  
  

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