Diagnosis of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents (NQF 0106)

eMeasure Name Diagnosis of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents eMeasure Id C845A8AE-31F4-42EA-A5A0-B6604A17BCD3
Version number 1 eMeasure Set Id 77DC6DFE-EC28-4214-B403-EB7A3A663252
Available Date No information Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward Institute for Clinical Systems Improvement
Endorsed by National Quality Forum
Description Percentage of patients newly diagnosed with ADHD whose medical record contains documentation of DSM-IV-TR or DSM-PC criteria.
Copyright
Measure scoring Proportion
Measure type Process
Stratification
None
Risk Adjustment
None
Data Aggregation
Rationale
The general consensus of the scientific and profession communities is to use DSM-IV criteria. According to the ICSI ADHD in Primary Care Guideline recommendation, "Evaluate children/adolescents suspected of having ADHD based on DSM-IV/DSM-PC diagnostic criteria using consistent and appropriate diagnostic tools."
Clinical Recommendation Statement
Attention deficit hyperactivity disorder (ADHD) may have an impact on a child's/adolescent's experience within school, family, play or work. Approximately 8.7% of children 8-15 met DSM-IV criteria for ADHD in the National Health and Nutrition Examination Survey (NHANES) (Froehlich, 2007 [D]). It is a chronic condition that may be variably expressed depending on the child's environment, as well as on the specific demands placed upon the child within that environment. The DSM-IV-TR/DSM-PC classifies ADHD into three subtypes depending on the prevalence of specific behaviors: Predominantly Inattentive, Predominantly Hyperactivity/Impulsive, and Combined Types.

The evaluation of primary symptoms should include information from multiple sources such as parents, the child and school personnel. A comprehensive interview with parents or caregivers – including current symptoms and their previous history, past medical and developmental history, school and educational history, and family and psychosocial history – is most important. There is no single evaluation tool available to make a definitive diagnosis of ADHD. The diagnosis is based on a clinical picture of early onset, significant duration and pervasiveness, and causing functional impairment within the life of the child or adolescent. This can be facilitated through the use of semistructured interview or questionnaire, with behavior rating scales completed by the parents, other caregivers and school personnel.
Improvement notation
Increase the use of DSM-IV-TR or DSM-PC criteria for diagnosing attention deficit hyperactivity disorder.
Measurement duration
12 month(s)
Reference
Institute of Clinical Systems Improvement (ICSI). Diagnosis and management of attention deficit hyperactivity disorder in primary care for school age children and adolescents, 8th ed. Bloomington MN: Institute for Clinical Systems Improvement (ISCI), March 2010; p.4
Reference
CDC National Center for Birth Defects and Developmental Disabilities. Available at: http://www.cdc.gov/ncbddd/adhd/data.html. Accessed 8/20/09.
Reference
Biederman J, Faraone SV, Lapey K. Comorbodity of diagnosis in attention deficit hyperactivity disorder. Child Adolesc Psychiatr Clin North AM 1992; 1:335-60.
Reference
Faraone SV, Biederman J, Wozniak J, et al. Is comorbidity with ADHD a marker for juvenile-onset mania? J Am Acad Child Adolesc Psychiatry 1997; 36:1046-54.
Reference
Geller B, Zimerman B, Willians M, et al. DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention deficit hyperactivity and normal controls. J of Child Adol Psychopharmacology 2002; 12:11-24.
Reference
Giedd JN. Bipolar disorder and attention deficit hyperactivity disorder in children and adolescents. J Clin Psychiatry 2000; 61:31-34.
Reference
Jensen VK, Larrieu JA, Mack KK. Differential diagnosis between attention deficit hyperactivity disorder and pervasive developmental disorder-not otherwise specified. Clin Pediatr 1997; 36:555-61.
Reference
Spitzer RL, ed. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington DC: American Psychiatric Press, 1994; 63-65.
Reference
Werry JS, Elkind GS, Reeves JC. Attention deficit, conduct, oppositional, and anxiety disorders in children: Ill. laboratory differences. J Abnorm Child Pshycol 1987; 15:409-28.
Reference
Wozniak J, Biederman J, Kiely K, et al. Mania-like symptoms suggestive of childhood-onset bipolar disorders in clinically referred children. J Am Acad Child Adolesc Psychiatry 1995;34:867-76.
Reference
Wolraich ML, Felice ME, Drotar DE, eds. In Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnosis and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Elk Grove, IL: American Academy of Pediatrics, 1996.
Definition
Newly diagnosed is defined as documented ADHD in past six months and no documentation of ADHD in the previous 6 - 12 months.

Documented is defined as any evidence in the medical record that DSM-IV-TR or DSM-PC criteria were addressed.
Definition
Initial Patient Population(s): All children and adolescents ages 5-18 newly diagnosed with attention deficit hyperactivity disorder (ADHD) with an outpatient encounter during the measurement period.
Definition
Denominator(s): All patients in the initial population.
Definition
Denominator Exclusion(s): Patients with Diagnosis of  Pervasive Developmental Disorder, Schizophrenia, Mood Disorders, Personality Disorder, Dissociative Disorder, or other Psychotic Disorders
Definition
Numerator(s): Number of patients with newly diagnosed ADHD with documentation of at least six symptoms of hyperactivity / impulsivity and at least six symptoms of inattention starting before age 7 and with symptoms continuing in at least two settings during the six months prior to the outpatient encounter. Expected symptoms are derived from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) or Diagnostic and Statistical Manual for Primary Care (DSM-PC).
Definition
Denominator Exception(s): N/A
Guidance
DSM-IV-TR or DSM-PC criteria include evaluation for: 1) symptoms, 2) onset, 3) duration, 4) pervasiveness and 5) impairment. Behavioral health professionals are expected to measure their practice performance on a monthly basis to determine the need to modify processes.  This eMeasure version addresses performance on an annual basis.

To establish the numerator criteria, existing terminology includes only the higher level concepts (inattention and hyperactivity/impulsivity). Therefore the implementation of the measure should apply these elements only if six or more of the specified symptoms are present and if they occur in at least two settings (home, school or work environments) for at least six months to a degree that is maladaptive and inconsistent with developmental level for the concepts "Inattention" or "Hyperactivity/Impulsivity," respectively.

Inattention (six of the following must be present):
1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
2. Often has difficulty sustaining attention in tasks or play activities
3. Often does not seem to listen when addressed directly
4. Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
5. Often has difficulty organizing tasks and activities
6. Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools)
8. Is easily distracted by external stimuli
9. Is often forgetful in daily activities

Hyperactivity/Impulsivity (six of the following must be present):
1. Often fidgets with hands or feet or squirms in seat
2. Often leaves seat in classroom or in other situations in which remaining seated is expected
3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults may be limited to subjective feelings of restlessness)
4. Often has difficulty playing or engaging in leisure activities quietly
5. Is often "on the go" or often acts if "driven by a motor"
6. Often talks excessively
7. Often blurts out answers before questions have been completed
8. Often has difficulty awaiting turn
9. Often interrupts or intrudes on others (e.g., butts into conversations or games)
Supplemental Data Elements
Report "Patient Characteristic: Gender" using "Gender HL7 Value Set (2.16.840.1.113883.1.11.1)"; Report "Patient Characteristic: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"; Report "Patient Characteristic: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"; Report "Patient Characteristic: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.113883.3.221.5)".

Table of Contents


Population criteria

Data criteria (QDM Data Elements)

Supplemental Data Elements




Measure set CLINICAL QUALITY MEASURE SET 2011-2012