Background Report on request for public comment on initial, recommended core set of Children's Healthcare Quality Measures for voluntary use by Medicaid and CHIP Programs

Table 1. Initial, recommended set of children's health care quality measures

Note: Summaries of the measures can be accessed as PDF files. Select the link under each Measure Number.

Measure Number	LEGISLATIVE MEASURE TOPIC/Subtopic/ Current Measure label	Current Numeratori	Current Denominator and Enrollment Criteria	Rank by SNAC Score	Current Measure Steward	Current Data Source	Evidence Grade	Est. Number of Medicaid and CHIP Enrollees At Risk of Poor Healthcare Quality
PREVENTION AND HEALTH PROMOTION
Prenatal/Perinatal
1 PDF File (55 KB)	Frequency of ongoing prenatal care	Women in the denominator sample who had an unduplicated count of less than 21%, 21-40%, 41-60%, 61-80%, or more than 81% of expected visits, adjusted for the month of pregnancy at enrollment and gestational age	Medicaid-enrolled women who delivered a live birth on/between Nov 6 of the yr prior to measurement yr & Nov 5 of the measurement yr Continuous enrollment 43 days prior to delivery through 56 days after delivery Data can be reported separately for adolescent women	2	NCQA	H	B&D	2.1 million births/year; 123,000 adolescents <17 gave birth1
2 PDF File (60 KB)	Timeliness of prenatal care—the percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization	Number of women in the denominator sample who had a prenatal visit in the first trimester or within 42 days of enrollment	All deliveries during the measurement year Continuous enrollment 43 days prior to delivery through 56 days after delivery Data can be reported separately for adolescent women	9	NCQA	H	B&D	2.1 million births/year; 123,000 adolescents <17 gave birth1
3 PDF File (57 KB)	Percent of live births weighing less than 2,500 grams	Number of resident live births less than 2500 grams	Number of resident live births in the State reporting period Data can be reported separately for adolescents	10	NVSS	Oii	B	2.1 million births/year at risk for LBW1
4 PDF File (57 KB)	Cesarean rate for nulliparous singleton vertex	The number of women in the denominator who had a cesarean section	First live singleton births >37 weeks gestation with vertex presentation (no breech/transverse fetal positions)	16	CMQC	Oiii or Aiv	B	2.1 million total births/year at risk for C-section1
Immunizations
5 PDF File (55 KB)	Childhood immunization status	Children who received 4 DTaP vaccinations, 3 IPV, 1 MMR, 2 Hib, 3 Hepatitis B, 1 VZV, and 4 pneumococcal conjugate vaccines on or before their second birthday (Composite 3; other composites are available)	Enrolled children who turn 2 yrs of age during the measurement year Continuous enrollment for 12 months prior to child's second birthday	1	NCQA	H	B	4.9 million children ages 0-22
6 PDF File (95 KB)	Immunizations for adolescents	Number of people in the denominator who had one dose of meningococcal vaccine (MCV4) and one tetanus, diphtheria toxoid, and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoid vaccine (Td) by their 13th birthday. The measure calculates a rate for each vaccine and one combination rate.	Adolescents who turn 13 yrs of age during the measurement year Continuous enrollment for 12 months prior to the member's 13th birthday	7	NCQA	H	B	10.1 million adolescents ages 13-182
Screening
7 PDF File (55 KB)	Weight assessment for children/adolescents	Children in the denominator population who had evidence of Body Mass Index (BMI) documentation during the measurement year	Children 3-17 yrs of age who had an outpatient visit with a PCP or OB-GYN during the measurement yr Continuous enrollment—the measurement year Optional exclusion: pregnant women	4	NCQA	H	D; Iv	31.9 million children ages 2-12
8 PDF File (55 KB)	Screening using standardized screening tools for potential delays in social and emotional development	Number of children screened for social and emotional development with a standardized, documented tool or set of tools as part of a well child or other visit to primary care provider—3 rates (one for each age range in the denominator)	Children ages 0-12 months, 12-24 months, or 24-36 months who had a WCV/other primary care visit during the measurement yr who were enrollees in Medicaid/CHIP	11	Nonevi	H	B	9.5 million ages 0-32 14 million ages 0-52
9 PDF File (40 KB)	Chlamydia screening for women	At least one Chlamydia test during the measurement year	Women 16-20 yrs of age as of Dec 31st of the measurement year who were identified as sexually active. Continuous enrollment—The measurement year	14	NCQA	A	B	4.2 million females ages 16-182
Well-child Care Visits (WCV)
10 PDF File (60 KB)	WCVs in the first 15 months of life	The number of children who received 0, 1, 2, 3, 4, 5, 6 or more well child visits with a PCP during their first 15 months of life	Children who turn 15 months during the measurement yr. Continuous enrollment 31 days-15 months of age, with no more than one gap in enrollment of up to 45 days during the continuous enrollment period.	5	NCQA	H	B	2.6 million children ages 0-12
11 PDF File (55 KB)	WCVs in the third, fourth, fifth and sixth years of life	Well-child visit at 3-6 years: At least one well-child visit with a PCP during the measurement year	Children aged 3-6 yrs as of Dec 31st of the measurement yr Continuous enrollment—the measurement year		NCQA	H	B	8.7 million children ages 3, 4, 5, and 62
12 PDF File (40 KB)	WCV for 12-21 yrs of age—with PCP or OB-GYN	Adolescent Well Care: Adolescents with at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.	Adolescents 12-21 yrs of age as of Dec 31st of the measurement yr Continuous enrollment—the measurement yr		NCQA	H	B	11.9 million adolescents ages 12-18; 16,979,724 adolescents ages 12-212
Dental
13 PDF File (65 KB)	Total eligibles receiving preventive dental services (EPSDT measure Line 12B)	The total unduplicated number of children receiving dental treatment services defined by HCPC codes D1000-D1999 (ADA codes D1000-D1999)	The total no. of children shown on line 12b of the CMS-416 Form which represents the total unduplicated number of all individuals under age 21 determined to be eligible for EPSDT services. Unduplicated means each child is counted only once for the purposes of this line if multiple services were received.	6	States/CMS	Ovii	NA	31,930,562 EPSDT-eligibles. In future: all CHIP enrollees2
MANAGEMENT OF ACUTE CONDITIONS
Upper Respiratory—Appropriate Use of Antibiotics
14 PDF File (43 KB)	Pharyngitis—appropriate testing related to antibiotic dispensing	A strep test was administered in the 7-day period from 3 days prior through 3 days after the first eligible episode date	Children age 2-18 yrs who had an outpatient visit with a diagnosis of pharyngitis and were dispensed an antibiotic Continuous enrollment—30 days prior to the episode date through 3 days after the episode date (inclusive)	18	NCQA	A	A	37.2 million children ages 0-182
15 PDF File (40 KB)	Otitis Media with Effusion—avoidance of inappropriate use of systemic antimicrobials—ages 2-12	Number of patients who were not prescribed systemic antimicrobials	All patients ages 2 mos-12 yrs with a diagnosis of Otitis Media with Effusion	18	AMA PCPI	A	A	21.8 million children ages 2-122
Dental
16	Total EPSDT eligibles who received dental treatment services (EPSDT CMS Form 416, Line 12C)	The total unduplicated number of children receiving dental treatment services defined by HCPC codes D2000-D9999 (ADA/CDT codes 02000-09999)	The total no. of children shown on line 12c of the CMS-416 Form which represents the total unduplicated number of all individuals under age 21 determined to be eligible for EPSDT services. Unduplicated means that each child is counted only once for purposes of this line if multiple services were received.	17	States/CMS	Oviii	D	31.9 million EPSDT eligibles in 2008.2 In future: all CHIP enrollees
Emergency Department
17 PDF File (38 KB)	Emergency Department (ED) Utilization—Average number of ED visits per member per reporting period	Number of visits per member per year	All child and adolescent members enrolled and eligible during the measurement year	2	S/ME	A	B	37.2 million children ages 0-182
Inpatient Safety
18 PDF File (60 KB)	Pediatric catheter-associated blood stream infection rates (PICU and NICU)	Number of catheter-associated blood stream infections identified during the month selected for surveillance	Number of central line days during the month selected for surveillance	17	Hospitals/CDC	MR	B	Unknown. 400,000-600,000 PICU discharges3;108,000 children had procedures related to durable equipmentix
MANAGEMENT OF CHRONIC CONDITIONS
Asthma
19 PDF File (72 KB)	Annual number of asthma patients (>1 year old) with >1 asthma related ER visit (S/AL Medicaid Program)	Number of children >1 year old in the denominator sample who had >1 ER visit(s) during the measurement year (March 1 through February 28th) where the primary diagnosis assigned on the claim was asthma	All children >1 yr old diagnosed with asthma or are on at least two short-acting beta adrenergic agents during the measurement year	3	S/AL	A	C	2.7 million Medicaid-enrolled children ages 0-17 with asthma4
ADHD
20 PDF File (55 KB)	Follow-up care for children prescribed attention-deficit/hyperactivity disorder (ADHD) medication (Continuation and Maintenance Phase)	Children ages 6-12 as of the index prescription start date, who in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended	Children ages 6-12 as of the index prescription start date, with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days Continuous enrollment—120 days prior to the Index Prescription Start Date (IPSD) and 300 days after the IPSD	12	NCQA	A	D	6.5% of children with public coverage take medication for ADHD,5 equal to approximately 2,419,909 children ages 0-18 in 20082
Mental Health
21 PDF File (85 KB)	Follow up after hospitalization for mental illness	People in the denominator without an outpatient visit, intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 or 30 days after discharge (two rates)	Members 6 yrs of age or older who were hospitalized for treatment of selected mental health disorders and discharged Continuous enrollment date of discharge through 30 days after discharge	14	NCQA	A	B	22.8 million ages 6-182
Diabetes
22 PDF File (42 KB)	Annual hemoglobin A1C testing (all children and adolescents diagnosed with diabetes)	The number of patients in the denominator sample who have documentation of date and result for the most recent HbA1c test during the 12-month reporting period	A systematic sample of patients, ages 5-17, with a diagnosis of diabetes and/or notation of prescribed insulin/oral hypoglycemics/antihyperglycemics for at least 12 months. This is defined by documentation of a face-to-face visit for diabetes care between the physician and patient that predates the most recent visit by at least 12 months.	13	S/AL	H	D	NA for Medicaid/CHIP—low prevalence in general population
FAMILY EXPERIENCES OF CARE
23 PDF File (62 KB)	HEDIS CAHPS® 4.0 instruments including supplements for children with chronic conditions and Medicaid plans	Survey items	Currently denominator population varies—SNAC recommends collecting all survey data on all children enrolled in Medicaid and CHIP	8	NCQA	S	B	37.2 million children ages 0-182
AVAILABILITY
24 PDF File (55 KB)	Children and adolescents' access to primary care practitioners (PCP), by age and total	Number of members in each age stratification who had at least a visit with a PCP	Children who fall into the following age groups: 12-24 months, 25 months-6 yrs, 7-11 yrs, 12-19 yrs as of December 31 of the measurement year Continuous enrollment—for 12-24 months, 25 months-6 yrs, the measurement year; for 7-11 yrs, 12-19 yrs, the measurement year and the year prior to the measurement year	16	NCQA	A	NA	37.2 million children ages 0-18 2

SNAC Calculation of Priority Scores: After deliberations and voting on day 1 of the September meeting, 31 measures remained under consideration. On day 2, there were three rounds of voting where SNAC members could vote for their top 20 measures out of the 31 that remained. In round one, SNAC members voted for their top 10 measures; in round two their next 5 measures; and in round three their last 5 measures respectively. Measures voted for in the 1st round received 3 points per vote, measures voted for in the second round received 2 points per vote, and measures voted for in the 3rd round received 1 point per vote. The Priority Score represents the total points assigned to that measure by SNAC members after three rounds of voting.

Evidence Grades: Based primarily on the Oxford Centre for Evidence-based Medicine (CEBM) levels of evidence criteria.⁵
Grade A = Consistent Level 1 studies
Grade B =Consistent Level 2 or 3 studies or extrapolations from Level 1 studies
Grade C = Level 4 studies or extrapolations from Level 2 or 3 studies
Grade D = Level 5 evidence or troublingly inconsistent or inconclusive studies of any level

Note: The types and rigor of studies at various levels of evidence depend on the study purposes (e.g., therapy/prevention, prognosis, diagnosis, differential diagnosis/symptom prevalence; economic and decision analyses). Most of the studies submitted or identified as documentation of underlying scientific soundness for the measures were therapy or prevention studies. For those studies, Level 1 studies are systematic reviews of randomized controlled trials (RCTs). Level 2 studies include systematic reviews of cohort studies, individual cohort studies, including low-quality RCTs), and "outcomes" research. Level 3 studies are systematic reviews with homogeneity of case-control studies or an individual case-control study. Level 4 studies are case-series and poor quality cohort and case-control studies. Level 5 evidence is defined as expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles."

Go to footnote v for explanation of "I" grade.

Legend:

1. Agency for Healthcare Research and Quality HCUPNet. 2007 National statistics: Outcomes by patient and hospital characteristics for Major Diagnostic Category 14 Pregnancy, Childbirth & the Puerperium. Rockville, MD: AHRQ; 2007.
2. Centers for Medicare & Medicaid Services. Medicaid and CHIP enrollees by age group, 2008. SEDS FY 2008 Master File—January 22, 2009. Baltimore, MD: Author; 2009:1.
3. Centers for Disease Control and Prevention. Summary of Health Statistics U.S. Children 2007 National Health Interview Survey. National Health Interview Survey [Jan. 2009; http://www.cdc.gov/nchs/data/series/sr_10/sr10_239.pdf [ PDF file, 2 MB]. Accessed Oct. 14, 2009.
4. Bethell C. A profile of leading health problems and health care quality for children using the 2007 National Survey of Children's Health: Draft for use by AHRQ and the SNAC. Portland, OR: The Child and Adolescent Health Measurement Initiative (CAHMI); July 2009.
5. Oxford Centre for Evidence-based Medicine. Levels of Evidence. In: Howick J, Phillips B, Ball C, et al., eds. Oxford: Author; 2009:2.

Footnotes:

ⁱ  Note that the SNAC recommended that revisions might be needed to the current numerators and denominators to be suitable for a broader range of Medicaid and CHIP programs and populations.
ⁱⁱ  Birth certificate information plus enrollment data.
ⁱⁱⁱ  Birth certificate information plus enrollment data.
^iv  Hospital discharge data.
^v  The "I" grade comes from the U.S. Preventive Services Task Force (USPSTF) and means that the evidence was insufficient for the USPSTF to make a recommendation regarding the preventive service.
^vi  Developed with support of The Commonwealth Fund, which is also supporting implementation and testing in State Medicaid programs and elsewhere. States have differing data collection strategies.
^vii  EPSDT submissions using CMS Form 416.
^viii  EPSDT submissions using CMS Form 416.
^ix  The following procedures (using the Healthcare Cost and Utilization Project [HCUP] CCS classification) were included in the analysis of HCUP Kids Inpatient Database (KID) 2006 data, using HCUPNet. The numbers of procedures with Medicaid as expected payer follow the procedure labels. Children are inpatients ages 0-18 in non-federal hospitals.
5 Insertion of catheter or spinal stimulator and injection into spinal canal.
47 Diagnostic cardiac catheterization, coronary arteriography.
54 Other vascular catheterization, not heart.
55 Peripheral vascular bypass.
56 Other vascular bypass and shunt, not heart.
62 Other diagnostic cardiovascular procedures.
63 Other non-OR therapeutic cardiovascular procedures.
108 Indwelling catheter.
204 Swan-Ganz catheterization for monitoring.
102 Ureteral catheterization.

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