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David Pating, MDChief, Addiction MedicineKaiser San FranciscoAssociate Clinical Professor UCSFMember, NQF Behavioral Health Standing Committee
April 27, 2017
National Consensus Standards for Behavioral Health Conditions
…an unofficial introduction
The National Quality Forum: A Unique Role
Unauthorized presentation for demonstration purposes only. 3
Established in 1999, NQF is a non-profit, non-partisan, membership-based organization that brings together public and private sector stakeholders to reach consensus on healthcare performance measurement. The goal is to make healthcare in the U.S. better, safer, and more affordable.
Mission: To lead national collaboration to improve health and healthcare quality through measurement
▪ An Essential Forum▪ Gold Standard for Quality Measurement▪ Leadership in Quality
NQF Activities in Multiple Measurement Areas
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▪ Performance Measure Endorsement▫ 600+ NQF-endorsed measures across multiple clinical areas▫ 19 empaneled standing committees
▪ Measure Applications Partnership (MAP) ▫ Advises HHS on selecting measures for 20+ federal programs, Medicaid,
and health exchanges
▪ National Quality Partners▫ Convenes stakeholders around critical health and healthcare topics▫ Spurs action on patient safety, early elective deliveries, and other issues
▪ Measurement Science▫ Convenes private and public sector leaders to reach consensus on
complex issues in healthcare performance measurement such as attribution, alignment, sociodemographic status (SDS) adjustment
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NQF endorsement evaluation
MAP pre-rulemaking
recommendations
NQF evaluation summary provided
to MAP
MUC that has never been through NQF
MUC given conditional support
pending NQF endorsement
MAP feedback on endorsed measures:• Entered into NQF database• Shared with Committee during
maintenance• Ad hoc review if MAP raises any
major issues addressing criteria for endorsement
• NQF outreach to MUC developers in February and during Call for Measures
• Funding proposals include MAP topics
• MAP feedback to Committee
CDP-MAP INTEGRATION – INFORMATION FLOW
Types of Performance Measures
▪ Quality▪ Resource use/cost ▪ Efficiency (combination of quality and resource use)▪ Composite (two or more measures in a single score)
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NQF endorsement reflects rigorous scientific and evidence-based review for Standardized performance measures are used for comparisons.
Characteristics of Measures
▪ Measures are different from concepts or ideas» Quality of care is an abstract construct» A quality measure is a numeric quantification of healthcare quality
▪ Measures have detailed specifications» What to count (including codes, definitions)» Who is included and/or excluded» When to count» Where to find data» How to compute score
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Numerators = XDenominators Y
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Person-Centered Measures
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▪ 0008: Experience of Care and Health Outcomes (ECHO) Survey (behavioral health, managed care versions) (CMS)*
▪ 0027: Medical Assistance With Smoking and Tobacco Use Cessation (NCQA)*
▪ 0028: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (PCPI Foundation)*
▪ 3185: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (eMeasure) (PCPI Foundation)
▪ 0108: Follow-Up Care for Children Prescribed ADHD Medication (NCQA)*
▪ 0576: Follow-Up After Hospitalization for Mental Illness (NCQA)*
Behavioral Health Portfolio of MUC measures: 4*Measures for maintenance evaluation
▪ 3132: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (eMeasure) (CMS)
▪ 3148: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (CMS)*
▪ 3172: Continuity of Pharmacotherapy for Alcohol Use Disorder (RAND Corporation)
▪ 3175: Continuity of Pharmacotherapy for Opioid Use Disorder (RAND Corporation)
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NQF currently has more than 50 endorsed measures within the area of behavioral health. Endorsed measures undergo periodic evaluation to maintain endorsement – “maintenance”.
Measure Evaluation Criteria Overview
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NQF Consensus Development Criteria
▪ Criteria #1: Importance to Measure and Report*
▪ Criteria #2: Scientific Acceptability of Measure Properties*
▪ Criteria #3: Feasibility
▪ Criteria #4: Usability and Use *=(must-pass)
▪ Criteria #5: Comparison to Related or Competing Measures
Final Recommendation for Endorsement/Harmonization
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Criterion #1: Importance to Measure & Report
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1. Importance to measure and report - Extent to which the specific measure focus is evidence-based and important to making significant gains in healthcare quality where there is variation in or overall less-than-optimal performance.
1a. Evidence: the measure focus is evidence-based
1b. Opportunity for Improvement: demonstration of quality problems and opportunity for improvement, i.e., data demonstrating considerable variation, or overall less-than-optimal performance, in the quality of care across providers; and/ordisparities in care across population groups
1c. Quality construct and rationale (composite measures only)
Subcriterion 1a: Evidence for Measure Focus
▪ Hierarchical preference for▫ Outcomes linked to evidence-based processes/structures▫ Outcomes of substantial importance with plausible
process/structure relationships▫ Intermediate outcomes▫ Processes/structures
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Most closely linked to outcomes
Criterion #2: Reliability and Validity– Scientific Acceptability of Measure Properties
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2a. Reliability (must-pass)2a1. Precise specifications including exclusions 2a2. Reliability testing—data elements or measure score
2b. Validity (must-pass)2b1. Specifications consistent with evidence 2b2. Validity testing—data elements or measure score2b3. Justification of exclusions—relates to evidence2b4. Risk adjustment—typically for outcome/cost/resource use2b5. Identification of differences in performance 2b6. Comparability of data sources/methods2b7. Missing data
Extent to which the measure, as specified, produces consistent (reliable) and credible (valid) results about the quality of health care delivery
Reliability and Validity
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Assume the center of the target is the true score…
Consistent,
but wrong
Consistent &
correct
Inconsistent &
wrong
Criterion #3: Feasibility
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Extent to which the required data are readily available, retrievable without undue burden, and can be implemented for performance measurement.
3a: Clinical data generated during care process
3b: Electronic sources
3c: Data collection strategy can be implemented
Criterion #4: Usability and Use
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Extent to which potential audiences are using or could use performance results for both accountability and performanceimprovement to achieve the goal of high-quality, efficient healthcare for individuals or populations.
4a: Accountability and Transparency
4b: Improvement
4c: Benefits outweigh the harms
4d: Vetting by those being measured and others
Criterion #1: Importance to measure and report Criteria emphasis is different for new vs. maintenance measures
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New measures Maintenance measures
• Evidence – Quantity, quality,
consistency (QQC)
• Established link for process
measures with outcomes
DECREASED EMPHASIS: Require measure
developer to attest evidence is
unchanged evidence from last evaluation;
Standing Committee to affirm no change
in evidence
IF changes in evidence, the Committee
will evaluate as for new measures
• Gap – opportunity for
improvement, variation, quality
of care across providers
INCREASED EMPHASIS: data on current
performance, gap in care and variation
Criterion #2: Scientific Acceptability
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New measures Maintenance measures
• Measure specifications are
precise with all information
needed to implement the
measure
NO DIFFERENCE: Require updated
specifications
• Reliability
• Validity (including risk-
adjustment)
DECREASED EMPHASIS: If prior testing
adequate, no need for additional testing at
maintenance with certain exceptions (e.g.,
change in data source, level of analysis, or
setting)
Must address the questions for SDS Trial
Period
Criteria #3-4: Feasibility and Usability and Use
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New measures Maintenance measures
Feasibility
• Measure feasible, including
eMeasure feasibility assessment
NO DIFFERENCE: Implementation
issues may be more prominent
Usability and Use
• Use: used in accountability
applications and public reporting
INCREASED EMPHASIS: Much
greater focus on measure use and
usefulness, including both impact
and unintended consequences• Usability: impact and unintended
consequences
Recommendation for Endorsement or Endorsement +
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▪ The Committee votes on whether to recommend a measure for NQF Endorsement
▪ Or “Endorsement +” designation, indicating that the measure exceeds NQF criteria if
▫ Meets evidence criteria without exception▫ Good results on reliability testing of the measure score▫ Good results on empirical validity testing of the measure score
(not just face validity)▫ Well-vetted in real world settings by those being measured and
others in key areas.
▪ Harmonization of related or competing measures
www.qualityforum.org
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The Business of Making Measures
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Busy Clinic - The App!
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▪ Peter Briss, MD, MPH, (Co-Chair)
▪ Harold Pincus, MD (Co-Chair)
▪ Robert Atkins, MD, MPH
▪ Mady Chalk, PhD, MSW
▪ Shane Coleman, MD, MPH*
▪ David Einzig, MD
▪ Julie Goldstein Grumet, PhD
▪ Charles Gross, PhD*
▪ Constance Horgan, ScD
▪ Lisa Jensen, DNP, APRN
▪ Dolores (Dodi) Kelleher, MS, DMH
▪ Kraig Knudsen, PhD
▪ Michael R. Lardieri, LCSW
▪ Tami Mark, PhD, MBA
Behavioral Health Standing Committee
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▪ Raquel Mazon Jeffers, MPH, MIA
▪ Bernadette Melnk, PhD, RN, CPNP/FAANP, FNAP, FAAN
▪ Laurence Miller, MD
▪ Brooke Parish, MD*
▪ David Pating, MD
▪ Vanita Pindolia, PharmD
▪ Rhonda Robinson Beale, MD
▪ Lisa Shea, MD, DFAPA
▪ Andrew Sperling, JD*
▪ Jeffery Susman, MD
▪ Michael Trangle, MD
▪ Bonnie Zima, MD, MPH
▪ Leslie S. Zun, MD, MBA
*indicates new committee member
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Evidence: Gap
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Evidence Validity
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Feasibility
Useability
Review of HEDIS: AOD_IET Measure
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence* (first visit in calendar year) who received the following:
•Inpatient
•Intensive Outpatient
•Partial Hospitalization
•Outpatient
•Detoxification
•ED Encounter
•Inpatient
•Intensive Outpatient
•Partial Hospitalization
•Outpatient
Index Episode
Start Date
(IESD)
14 days
inclusive Initiation Visit30 days
Two
Engagement
Visits
Primary Focus •Inpatient
•Intensive Outpatient
•Partial Hospitalization
•Outpatient
HEDIS “dependence” definition is very broad and contains almost all alcohol and substance related codes (see appendix)
Unhealthy Drinking In KPNC Primary Care
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Abstainers
Low-Risk Drinkers
Unhealthy Drinkers
w/out dependence
6.8%
Alcohol Dependent
Institute of Medicine. 1990, and World Health Organization, 2001
Need Specialty
Treatment
Brief Intervention
7.5%
0.8%
20 Most Frequent Dx in Med-FMS 2013
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Contact: Sue Paulsen QOS 8-428-3264
Diagnoses 2013 # Index Visits % Initiated
1 ALCOHOL ABUSE 2527 12%
2 ALCOHOL DEPENDENCE 2484 9%
3 ALCOHOL USE, EXCESSIVE, NON-DEPENDENT 1454 6%
4 OPIOID DEPENDENCE 905 12%
5 CANNABIS DEPENDENCE 455 6%
6 CANNABIS ABUSE 428 7%
7 SUBSTANCE ABUSE 344 20%
8 ALCOHOL DEPENDENCE, CONTINUOUS 184 9%
9 DRUG DEPENDENCE 165 16%
10 DRUG ABUSE 140 26%
11 ALCOHOLISM 133 19%
12 OPIOID WITHDRAWAL 131 27%
13 DRUG SEEKING BEHAVIOR 125 12%
14 CAFFEINE USE 119 2%
15 ALCOHOL ABUSE, EPISODIC 96 16%
16 OPIOID DEPENDENCE, CONTINUOUS 94 12%
17 CAFFEINE DEPENDENCE 81 5%
18 METHAMPHETAMINE DEPENDENCE 81 11%
19 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE 79 11%
20 POLYSUBSTANCE ABUSE 71 11%
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HEDIS IET AOD
Approved for CMS: January 1 2014
AUDIT Screening Tool
▪ Alcohol Use Disorders Identification TestDomain Question
Hazardous Alcohol Use (1-3)Dependence Syndromes (4-6)Harmful Alcohol Use (7-10)
AUDIT Score WHO Kaiser<8 (Alc Education) No Action8-15 (Simple Advice) RN Advice>16 (Brief Counsel) LCSW&MD inbasket>20 (Specialist Tx) ------
Rx: Medication Recommendation
1. Naltrexone – Injectable Extended Release (Vivitrol) 380mg IMa. Hold if LFT > 3x normal or recent opioid use. b. If decides against IM, consider oral Naltrexone 50mg daily. (#30)
2. Topiramate – (second choice)a. Start 50mg hs x 1 week, then increase 100mg hs. (#50) b. Reduce dose ½ in renal disease. Caution: sedation.
Bryson WC1, McConnell J, Korthuis PT, McCarty D.“Extended-release naltrexone for alcohol dependence: persistence and healthcare costs and utilization.”, Am J Manag Care. 2011 Jun;17 Suppl 8:S222-34.
Aetna, 2011: XR-NTX (n=211) Disulfiram (1043),Oral NTX (1408), Acamprosate (2479)
“Compared with other medications for alcohol use disorders, XR-NTX is associated with increased days on medication and lower utilization and cost of inpatient and emergency care.”
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JC SUB 1
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JC SUB 2
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JC SUB 3
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Curative Factors in Addiction Treatment
Identity & Self-Efficacy
CognitiveSkills Training
Sober Social Networks
A BehavioralProgram of Recovery
Mind/BodyStress Mgt
Anti-Craving Medications
4/27/2017
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Resilience-based Addiction Treatment
GeneralizedResilienceResources
Cognitive skills(Mastery)
Social Support(Belonging)
Self-Concept(Acceptance)
EmotionalRegulation(Serenity)
Alcoholism
AA/SpiritualityRelationshipsHobby/Passion
Values (Life of Meaning & Purpose)
Anti-Craving Medications
A BehavioralProgram of Recovery
MotivationalInterviewing
QOLAssessment
4/27/2017
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TEA
BAM
Measuring Progress: TEMT-KP
4/27/2017
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Questions?