Embed Size (px)
Citation preview
TRANSLATIONS
Gaps in Quality Measures for Child Mental HealthCare: An Opportunity for a Collaborative Agenda
Bonnie T. Zima, M.D., M.P.H., Rita Mangione-Smith, M.D., M.P.H.
mc
twpQtfPmetsmegae
T he past 2 years has been an exciting time forthose who believe that health care for chil-dren in the United States can be improved
through better quality measurement and publicreporting of performance. Tracking adherence toquality indicators and making these data avail-able to purchasers of health insurance is a well-established approach for improving health carequality.1 Two recent child health quality initia-tives, one legislatively mandated and one led bya nonprofit organization, systematically ratedlarge pools of quality measurements and recom-mended a limited number to monitor the qualityof care received by U.S. children. In accordancewith Section 401(a) of the Children’s HealthInsurance Program Reauthorization Act of 2009,an initial core set of pediatric quality measure-ments for voluntary use by Medicaid and theChildren’s Health Insurance Program was rec-ommended by the U.S. Secretary of Health andHuman Services on January 1, 2010.2 This pre-liminary phase informed the framework for thePediatric Quality Measures Program, which ismandated by the same legislation to improve andstrengthen the initial core set of measurements,enhance existing pediatric quality measure-ments, and advance the development of newmeasurements by January 1, 2013.2 To align withthis legislation’s mission, the National QualityForum enlarged their portfolio of endorsed childhealth measurements that could be used by pub-licly insured child health programs.3 As an intro-duction to the debate on how to define andmeasure the quality of child mental health care,this column briefly summarizes the decision pro-cesses and the quality measurements recom-
An interview with the author is available by podcast at
www.jaacap.org.JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 50 NUMBER 8 AUGUST 2011
ended that directly pertain to child psychiatricare.
In the legislatively mandated project, the iden-ification of an initial core set of measurements
as informed by the work of the multidisci-linary Agency for Healthcare Research anduality National Advisory Council Subcommit-
ee on Children’s Healthcare Quality Measuresor Medicaid and Children’s Health Insurancerograms (hereafter referred to as the “Subcom-ittee”). The Subcommittee was charged with
stablishing quality measurement evaluation cri-eria, identifying a strategy for gathering mea-ures, and applying the evaluation criteria to theeasurements.4 It comprised multiple stakehold-
rs, including officials from publicly insured pro-rams, national professional organizations, childnd family advocacy organizations, and nationalxperts in health care quality measurement.5
Over a 4-month period, the Subcommittee heldtwo public meetings, undertook substantial workoutside these meetings and regularly integratedpublic comments. At both public meetings, theSubcommittee rated the measurements using anadapted version of the RAND/University of Cal-ifornia Los Angeles modified Delphi method.4,5
The basic components of this method are reviewof evidence-based tables followed by two roundsof ratings (i.e., before the face-to-face meetingand after the discussion) for each measurement.From a pool of 119 measurements, of which 12were specific to child mental health, the Subcom-mittee rated the level of scientific evidence sup-porting the measurement’s validity, feasibility,and importance.4,5 When considering impor-tance, priority was given to measurements thatwere deemed actionable (i.e., the extent to whicha publicly insured program has the ability toimprove their performance) and likely to sub-stantially decrease health care costs.5 Details of
the methods and administrative review path-735www.jaacap.org
npsfmscfticymcmau
CooT1ChsIrcwts
ZIMA AND MANGIONE-SMITH
ways before final submission of the initial coreset of measurements are described elsewhere.4,5
From this process, the initial core set of 25measurements yielded only two measurementsdirectly related to child mental health care andboth assessed follow-up care. The target popula-tions were children diagnosed with attention-deficit/hyperactivity disorder and children hos-pitalized for selected mental illnesses. Theattention-deficit/hyperactivity disorder mea-surement assesses the proportion of children 6 to12 years old who, in addition to having at leastone visit within the first 30 days of startingmedication (i.e., initiation phase), had at leasttwo visits within 270 days after the initiationphase. Although used as a national benchmarkfor attention-deficit/hyperactivity disorder caresince 2006,1 this quality measurement is sup-ported by only grade D evidence, correspondingto expert consensus opinion or inconsistent/in-conclusive studies.4 The second quality measure-ment examines the proportion of children (�6years old) and adults hospitalized for treatmentof selected mental health disorders who had anoutpatient visit, intensive outpatient encounter,or partial hospitalization with a mental healthpractitioner within 7 or 30 days after discharge.This measurement has been used to track healthplan performance since 20011 and is supportedby grade B evidence, corresponding to cohort orcase-control studies or extrapolations from ran-domized controlled trials.4
During this process, the Subcommittee waswell aware of the its work’s limitations andadopted a philosophy of “leaving an emptychair” to symbolize the major child health areaslacking valid, feasible, and important qualitymeasurements.4 Remarkably, four of the nineareas were directly related to the care of childpsychiatric disorders, namely availability of care,specialty care, mental health treatment, and carefor substance abuse.4,5 The other areas also hadimplications for child mental health care. Thesewere integrated health care systems (medicalhome, integration with entities outside thetraditional health care system), duration ofcoverage, inpatient care, health outcomes, anduniform reliable methods to measure and iden-tify disparities.4,5
Complementing this work, the National Qual-ity Forum spearheaded a transparent, standard-ized process to evaluate and endorse standards
for child outcomes and health quality measure-JOURN
736 www.jaacap.org
ments.3 For both projects, the process involvedine steps that occurred during a 12- to 18-montheriod, beginning with a public call for candidatetandards and ending with board ratificationollowed by a 30-day appeals period. After sub-
ission of the candidate standards, a multi-takeholder steering committee was convened toonduct a detailed review in person and/or by con-erence call. After the discussion, the steering commit-ee rated the extent a standard meets four criteria:mportance to measure and report, scientific ac-eptability, usability, and feasibility. The finales/no vote for recommendation for endorse-ent challenged the rater to weigh the four
riteria, making it possible for some measure-ents without well-established scientific accept-
bility but of high public health significance,sability, and feasibility to be recommended.
Of the 26 measurements considered for thehild Outcomes Measures Project, 15 were rec-mmended for endorsement; and of these, onlyne was related to child mental health outcomes.his measurement assesses whether patients 4 to6 years old who had the Pediatric Symptomhecklist given during a mental health encounterad a decrease of at least one point in their totalcore within 6 months of the baseline screening.t received a time-limited endorsement (i.e., to beeconsidered after additional field testing) be-ause this measurement raised the question ofhether a screening instrument designed to de-
ect a need for further mental health evaluationhould be used as an outcome measurement.3 In
addition, it raised the question of whether clini-cians should be held accountable for clinicaloutcomes. If a child receives recommended carebut the rating scale score does not change orincreases over time, can one conclude that theclinician provided poor care? In response, theorganization staff worked with the measurementdeveloper to restrict this measurement to thepopulation level.
Likewise, a similar proportion of candidatestandards was recommended during the ChildHealth Quality Measures Project. Of the 75 stan-dards reviewed, 41 were recommended for en-dorsement; and of these, four were specific tochild or adolescent depression care. Two stan-dards assess the percentage of adolescents whoturned 13 or 18 years of age during the measure-ment year and who had documentation of de-pression screening using a standardized tool.
These standards raised the question of whetherAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 50 NUMBER 8 AUGUST 2011
TRANSLATIONS
better detection leads to greater access to care.Another standard was restricted to children 6through 17 years of age with major depressionand assesses the percentage of visits with asuicide risk assessment. The final standard re-ceived a time-limited endorsement. It assesseswhether there was documentation of DSM-IVcriteria in children 6 to 17 years old with adiagnosis of major depression. This standardraised questions about whether more completedocumentation is associated with improved di-agnostic accuracy, access to specialty mentalhealth care, or receipt of guideline-concordantcare.
Together, these initiatives identified few qual-ity measurements pertaining to child mentalhealth care and determined that even fewer metcriteria for recommended use in publicly fundedchild health programs. Nevertheless, the nationalfocus on child health care quality is an unprece-dented opportunity to establish new and ongo-ing collaborations among primary care provid-ers, child mental health professionals, qualitymeasurement developers, and other dedicatedkey stakeholder groups. So how should the gaps
in quality measurements for child mental healthcessed March 10, 2011.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 50 NUMBER 8 AUGUST 2011
care be filled? How should priorities be set? Howinvolved should child and adolescent psychia-trists be? And if involved, which values shouldguide how quality of child mental health care isdefined and measured? &
Accepted May 2, 2011.
Dr. Zima is with the University of California at Los Angeles and theUniversity of California at Los Angeles Center for Health Services andSociety. Dr. Mangione-Smith is with the University of Washington andthe Seattle Children’s Research Institute Center for Child Health,Behavior and Development.
This article was supported by the National Institute of Mental Health(P30MH082760).
Disclosure: Dr. Zima was a member of the Steering Committees for theNational Quality Forum’s National Voluntary Consensus Standards forPatient Outcomes: Child Health (Phase III) and for Child Health QualityMeasures Projects. Dr. Rita Mangione-Smith was co-chair of theAgency for Healthcare Research and Quality National AdvisoryCouncil Subcommittee on Children’s Healthcare Quality Measures forMedicaid and Children’s Health Insurance Program and is principalinvestigator for the Center of Excellence on Quality of Care Measuresfor Children with Complex Needs funded by the Agency for Health-care Research and Quality.
Correspondence to Bonnie T. Zima, M.D., M.P.H., Professor-in-Residence, Child and Adolescent Psychiatry, Department ofPsychiatry and Biobehavioral Sciences, University of California atLos Angeles, Associate Director, UCLA Center for Health Servicesand Society, 10920 Wilshire Blvd., #300, Los Angeles, CA
90024; e-mail: [email protected]REFERENCES1. National Committee for Quality Assurance. The state of health care
quality: reform, the quality agenda and resource use; 2010. http://www.ncqa.org. Accessed February 25, 2011.
2. Children’s Health Insurance Program Reauthorization Act of 2009, PL111-3; February 4, 2009. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname�111_cong_public_laws&docid�f:publ003.111%20%C2%A0%C2%A0. Accessed February 25, 2011.
3. National Quality Forum. Measuring performance. http://www.quality-forum.org/Measuring_Performance/Measuring_Performance.aspx. Ac-
4. Mangione-Smith R. Lessons learned from the process used to identifyan initial core quality measures set for children’s health care inMedicaid and CHIP. http://www.ahrq.gov/chipra/lessons.htm. Ac-cessed February 25, 2011.
5. Federal Register Notice 2472-NC-CMS: request for public com-ment on initial, recommended core set of children’s healthcarequality measures for voluntary use by Medicaid and CHIP pro-grams. http://www.ahrq.gov/chip/corebackgrnd.htm. Accessed
March 16, 2011.737www.jaacap.org
