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Article| Volume 14, ISSUE 5, SUPPLEMENT , S19-S26, September 01, 2014

Advancing Children's Health Care and Outcomes Through the Pediatric Quality Measures Program

  • Kamila B. Mistry
    Correspondence
    Address correspondence to Kamila B. Mistry, PhD, MPH, Office of Extramural Research, Education, and Priority Populations, Agency for Healthcare Research and Quality, 540 Gaither Rd, Rockville, MD 20850.
    Affiliations
    Children's Health Insurance Program Reauthorization Act Pediatric Quality Measures Program, Office of Extramural Research, Education, and Priority Populations, Agency for Healthcare Research and Quality, Rockville, MD
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  • Francis Chesley
    Affiliations
    Children's Health Insurance Program Reauthorization Act Pediatric Quality Measures Program, Office of Extramural Research, Education, and Priority Populations, Agency for Healthcare Research and Quality, Rockville, MD
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  • Karen LLanos
    Affiliations
    Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services, Baltimore, Md
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  • Denise Dougherty
    Affiliations
    Children's Health Insurance Program Reauthorization Act Pediatric Quality Measures Program, Office of Extramural Research, Education, and Priority Populations, Agency for Healthcare Research and Quality, Rockville, MD
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DOI:https://doi.org/10.1016/j.acap.2014.06.025
Advancing Children's Health Care and Outcomes Through the Pediatric Quality Measures Program
Previous ArticleAn AHRQ and CMS Perspective on the Pediatric Quality Measures Program
Next ArticleDeveloping Measures for Pediatric Quality: Methods and Experiences of the CHIPRA Pediatric Quality Measures Program Grantees

      Abstract

      In 2009 Congress passed the Children's Health Insurance Program Reauthorization Act (CHIPRA), which presented an unprecedented opportunity to measure and improve health care quality and outcomes for children. The Agency for Healthcare Research and Quality, in partnership with the Centers for Medicare & Medicaid Services, has worked to fulfill a number of quality measurement provisions under CHIPRA, including establishing the Pediatric Quality Measures Program (PQMP). The PQMP was charged with establishing a publicly available portfolio of new and enhanced evidence-based pediatric quality measures for use by Medicaid/Children's Health Insurance Program and other public and private programs and to also provide opportunities to improve and strengthen the Child Core Set of quality measures. This article focuses on the PQMP and provides an overview of the program's goals and related activities, lessons learned, and future opportunities.

      Keywords

      In this article, we provide an overview of the Pediatric Quality Measures Program (PQMP), its goals and related activities, lessons learned, and future opportunities.

      History and Background

       The Children's Health Insurance Program Reauthorization Act: Focus on Health Care Quality

      The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 provided a unique opportunity to direct resources and national attention to pediatric quality measurement and standardized reporting as important steps toward improving care and health outcomes for children.

      Children's Health Insurance Program Reauthorization Act of 2009. Public Law 111–113. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW-111publ3.pdf. Accessed December 12, 2013.

      Until passage of CHIPRA, measurement of the quality of health care for children had lagged substantially with most health care quality and payment reform efforts focused on adults, in particular the elderly and Medicare.
      • Dougherty D.
      • Schiff J.
      • Mangione-Smith R.
      The Children's Health Insurance Program Reauthorization Act quality measures initiatives: moving forward to improve measurement, care, and child and adolescent outcomes.
      Acad Pediatr. 2011; 11: S1-S10
      , 
      • Partridge L.
      Review of Access and Quality of Care in SCHIP Using Standardized National Performance Measures.
      National Health Policy Forum, Washington, DC2007
      , 
      • Institute of Medicine
      Medicare: A Strategy for Quality Assurance.
      National Academy Press, Washington, DC1990
      , 

      US Congress, Office of Technology Assessment. Quality of Medical Care: Information for Consumers. Washington, DC: US Government Printing Office. Available at: https://www.princeton.edu/∼ota/disk2/1988/8832/8832.PDF. Accessed April 3, 2014.

      Currently more than 1 of 3 children in the US are enrolled in the country's major public programs, Medicaid/Children's Health Insurance Program (CHIP), and approximately $120 billion was spent on health care for children, in 2011.

      US Department of Health and Human Services, Centers for Medicare & Medicaid Services. 2013 Annual Report on the Quality of Care for Children in Medicaid and CHIP. Available at: http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2013-Ann-Sec-Rept.pdf. Accessed March 31, 2014.

      , 

      Mirel LB, Carper, K. Trends in health care expenditures for children under age 18: 2001, 2006, and 2011. Statistical Brief #428. January 2014. Agency for Healthcare Research and Quality, Rockville, Md. Available at: http://www.meps.ahrq.gov/mepsweb/data_files/publications/st428/stat428.pdf. Accessed April 4, 2014.

      Therefore, ensuring a high-quality system of care for children has garnered national attention and aligns with The National Quality Strategy, which is the first overarching national policy aimed at providing better, more affordable care for individuals and their communities.

      US Department of Health and Human Services, Agency for Healthcare Research and Quality. National quality strategy (NQS). Available at: http://www.ahrq.gov/workingforquality/. Accessed December 12, 2013.

      Title IV of CHIPRA focused on “strengthening quality of care and health outcomes” for children with a number of provisions relating specifically to the development and use of quality measures.

      Children's Health Insurance Program Reauthorization Act of 2009. Public Law 111–113. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW-111publ3.pdf. Accessed December 12, 2013.

      These included an Institute of Medicine report on child health and health care measurement, demonstration programs consisting of awards to states to improve health care quality and delivery systems for children in Medicaid/CHIP, development of an Electronic Health Record format for children's health care, the identification of an Initial Child Core Set of quality measures for voluntary use by state Medicaid/CHIP programs with required annual updates, and the establishment of the PQMP by January 2011.

      Children's Health Insurance Program Reauthorization Act of 2009. Public Law 111–113. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW-111publ3.pdf. Accessed December 12, 2013.

      , 
      • Institute of Medicine
      Child and Adolescent Health and Health Care Quality–Measuring What Matters.
      National Academy Press, Washington2011
      , 

      US Department of Health and Human Services, Agency for Healthcare Research and Quality. Children’s electronic health record format. Available at: http://healthit.ahrq.gov/health-it-tools-and-resources/childrens-electronic-health-record-ehr-format. Accessed December 19, 2013.

      PQMP

      As outlined in the Title IV legislation, the broad goals of the PQMP are 1) to establish a publicly available portfolio of new and enhanced evidence-based pediatric quality measures for use by Medicaid/CHIP and other public and private programs, and 2) to provide opportunities to improve and strengthen the Child Core Set.

      Children's Health Insurance Program Reauthorization Act of 2009. Public Law 111–113. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW-111publ3.pdf. Accessed December 12, 2013.

      Since 2011, the Agency for Healthcare Research and Quality (AHRQ), in partnership with Centers for Medicare & Medicaid Services (CMS) has worked to fulfill the PQMP provisions (Figure).
      Figure thumbnail gr1
      FigureTimeline and overview of key activities. PQMP indicates Pediatric Quality Measures Program; CHIPRA, Children's Health Insurance Program Reauthorization Act; COE, Centers of Excellence; and CCS, Child Core Set.

      PQMP Goals and Related Activities

       Establish a Publicly Available Portfolio of New and Enhanced Evidence-Based Pediatric Quality Measures

      In February 2011, 7 PQMP Centers of Excellence (Centers) were established to develop new pediatric quality measures and methods. Six of the 7 PQMP Centers are located in academic medical centers and one in a not-for-profit organization (Table 1). In accordance with the Title IV CHIPRA provisions, each of the Centers operates as a consortium involving multiple stakeholders, including state-level Medicaid/CHIP program officials, health care providers, patient and family advocates, and clinical experts.

      Children's Health Insurance Program Reauthorization Act of 2009. Public Law 111–113. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW-111publ3.pdf. Accessed December 12, 2013.

      Table 1CHIPRA PQMP Pediatric Quality Measure Topics and Completed Measures and Methods, According to COE
      AHRQ-CMS PQMP COE
      Current as of June 20, 2014.
      and Institutional Affiliation      		Prevention and Health Promotion Quality MeasuresTreatment and Management Quality Measures
      Some measures might apply to children with chronic conditions, acute conditions, or both.
      		Other
      Perinatal/PrenatalChild Clinical Preventive ServicesManagement of Acute ConditionsManagement of Chronic Conditions
      CAPQUAM: Collaboration for Advancing Pediatric Quality Measures

      Icahn School of Medicine at Mount Sinai
      • •
        Availability of HROB care
      • •
        Timely temperature for LBW newborns
      • •
        Temperature on admission of LBW neonate to Level ≥2 nurseries
      • •
        Medication reconciliation
      • •
        Follow-up after mental hospitalization
      • •
        Asthma-related ED use
      CEPQM: Children's Hospital Boston COE for Pediatric Quality Measurement

      Children's Hospital Boston
      • •
        Pediatric (nonneonatal) hospital readmissions (all causes, lower respiratory infection)
      • •
        Global pediatric inpatient safety tool
      • •
        Identification of children with disabilities
      • •
        Transition from child- to adult-focused care
      • •
        Child HCAHCPS (Web version to come)
      CHOP: COE at the Children's Hospital of Philadelphia (CHOP)/University of Pennsylvania

      Children's Hospital of Philadelphia
      • •
        Neonatal readmissions
      • •
        Neonatal cost-quality interaction
        Concept/method; not a measure.
      • •
        Oral health PRO
      • •
        Avoidance of antimicrobial use for otitis media
      • •
        Duration of enrollment and coverage measures
        Two of the 3 measures were recommended by the 2012 SNAC for the Child Core Set, but not adopted.
      • •
        Risk adjustment
      • •
        Pediatric global health measure (PRO)
        For a literature review, see the article by Woods et al,11 in this issue.
      • •
        Cost-to-quality
        For preliminary work, see the article by Silber and Forrest,12 in this issue.
      COE4CCN: COE on Quality of Care Measures for Children with Complex Needs

      Seattle Children's Research Institute
      • •
        Pediatric medical complexity algorithm
      • •
        Care coordination
      • •
        Mental health ED and hospital
      • •
        Quality of transitions (eg, inpatient setting to home; within hospital)
      NCINQ: National Collaborative for Innovation in Quality Measurement

      National Committee for Quality Assurance
      • •
        Sexual activity status documentation
        Recommended by the 2012 SNAC for uses other than the Child Core Set.
      • •
        Tobacco use identification and help with quitting
        Recommended by the 2012 SNAC for uses other than the Child Core Set.
      • •
        Antipsychotic use measures (depression management and follow-up)
      • •
        Alcohol/drug screening of depressed adolescents
      • •
        Foster care measures
      PMCoE: Pediatric Measurement COE

      Children's Hospital and Health System of Wisconsin
      • •
        Prenatal behavioral health risk assessment
        Added to the Child Core Set in January 2013.
      • •
        Other perinatal measures
        For a literature review, see the article by Woods et al,11 in this issue.
        :
        • -
          Spontaneous labor and birth
        • -
          Elective delivery before 39 weeks
        • -
          Prenatal care screening
      • •
        Follow-up to developmental screening
      • •
        PICU quality
      • •
        Dental treatment
      • •
        Continuum of care measures
      • •
        ADHD follow-up: accurate ADHD diagnosis in preschoolers; behavioral therapy as first-line treatment
      • •
        ADHD follow-up and symptom management process measure
      • •
        ADHD follow-up and symptom management outcome measure
        For a literature review, see the article by Woods et al,11 in this issue.
      Q-METRIC: Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium

      University of Michigan, Ann Arbor
      • •
        Follow-up to child BMI assessment
      • •
        Sepsis
      • •
        Imaging for headaches and seizures
      • •
        Respiratory bundle
      • •
        Sickle cell disease treatment measures
      • •
        Availability of non-HROB specialty services (physical health specialty services; mental health specialty services; dental services)
      CHIPRA indicates Children's Health Insurance Program Reauthorization Act; PQMP, Pediatric Quality Measures Program; COE, Center of Excellence; HROB, high-risk obstetric; LBW, low birth weight; ED, Emergency Department; HCAHCPS, Hospital Consumer Assessment of Health Care Providers and Systems; PRO, patient-reported outcome measure; SNAC, Subcommittee of the Agency for Healthcare Research and Quality National Advisory Council; PICU, Pediatric Intensive Care Unit; ADHD, attention-deficit hyperactivity disorder; and BMI, body mass index.
      Assigned measure topics are in normal text and completed measures are in bold text.
      ∗ Current as of June 20, 2014.
      † Some measures might apply to children with chronic conditions, acute conditions, or both.
      ‡ Concept/method; not a measure.
      § Two of the 3 measures were recommended by the 2012 SNAC for the Child Core Set, but not adopted.
      || For a literature review, see the article by Woods et al,
      • Woods D.
      • Wolraich M.
      • Pierce K.
      • et al.
      Considerations and Evidence for an ADHD Outcome Measure.
      Acad Pediatr. 2014; 14: S54-S60
      in this issue.
      For preliminary work, see the article by Silber and Forrest,
      • Forrest C.B.
      • Silber J.H.
      Concept and Measurement of Pediatric Value.
      Acad Pediatr. 2014; 14: S33-S38
      in this issue.
      # Recommended by the 2012 SNAC for uses other than the Child Core Set.
      ∗∗ Added to the Child Core Set in January 2013.
      Funding for each Center was provided through a cooperative agreement grant that allowed for greater flexibility than a contract and therefore greater recipient autonomy. However, it also permitted federal program staff to be more actively involved in advising Centers on measure development approaches, particularly with regard to providing insights on the quality measurement needs of both state and federal programs.
      In meeting the PQMP goal of establishing a publicly available portfolio of pediatric quality measures, measure topics were selected, measure assessment criteria were identified, and new and enhanced measures and methods were developed.

       Selection and Assignment of Measure Topics

      To identify high-priority measure topics for the Centers, AHRQ and CMS started with the domains included in the CHIPRA Title IV legislation and then sought additional guidance from a panel of experts who provided recommendations for the Initial Child Core Set, the public, and the Centers themselves.

      Children's Health Insurance Program Reauthorization Act of 2009. Public Law 111–113. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW-111publ3.pdf. Accessed December 12, 2013.

      , 
      • Medicaid and CHIP Programs
      Initial Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs.
      Federal Register. 2009; 74: 68846-68849
      Because of the dearth of children's measures, more than 40 topics were assigned across the 7 Centers. Most topics were initially broad (eg, content of prenatal care, sickle cell treatment); therefore, the Centers worked to refine the topics into specific measure or method concepts based on evidence reviews and stakeholder input. Some concepts were identified by Centers or AHRQ as overlapping and a few measures did not hold up through the entire development process.
      • Byron S.C.
      • Gardner W.
      • Kleinman L.C.
      • et al.
      Developing Measures for Pediatric Quality: Methods and Experiences of the CHIPRA Pediatric Quality Measures Program Grantees.
      Acad Pediatr. 2014; 14: S27-S32
      Table 1 lists the topic assignments and completed measures and methods, according to Center.

       Identification of Criteria for Measure Assessment

      A set of criteria (termed “desirable measure attributes”) for assessing measures (Supplementary Appendix A) were identified by a panel consisting of subject matter experts, Medicaid/CHIP officials, the Centers, and AHRQ.

      Children's Health Insurance Program Reauthorization Act of 2009. Public Law 111–113. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW-111publ3.pdf. Accessed December 12, 2013.

      In large part, the PQMP desirable measure attributes were modeled on requirements set by leading measure development entities, including the National Quality Measures Clearinghouse, National Quality Forum, and National Committee for Quality Assurance, for assessing nominated measures. However, specific criteria corresponding to requirements outlined in the CHIPRA Title IV legislation for PQMP-developed measures were also included as desirable measure attributes: relevance to Medicaid/CHIP, attributes specifically related to children, ability of measures to assess disparities, be risk-adjusted (where appropriate), and be reportable at different levels of care (eg, state, health system, health plan, and provider).

      Children's Health Insurance Program Reauthorization Act of 2009. Public Law 111–113. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW-111publ3.pdf. Accessed December 12, 2013.

      Additionally, to encourage innovation, the Centers were given an opportunity to explain why a submitted measure was suitable for measuring children's health care quality, even if all criteria were not met. The desirable measure attributes were codified in the CHIPRA PQMP Candidate Measure Submission Form which is used by the Centers to submit new measures for review.

      US Department of Health and Human Services, Agency for Healthcare Research and Quality. Candidate Measure Submission Form. CHIPRA Pediatric Quality Measures Program (PQMP). Available at: http://www.ahrq.gov/policymakers/chipra/cpcf-form.html. Accessed December 9, 2013.

       Development of PQMP Measures

      The Centers have begun to produce a broad range of child quality health measures and methods that fill previous gaps in child health care quality measurement (Table 1). Measures have been completed for the following topics: behavioral risk assessment during prenatal care, screening and treating tobacco smoking, assessing the quality of treatment for sickle cell disease, asthma emergency department use, duration of insurance enrollment and coverage, medical complexity, neonatal care, availability of high-risk obstetric services, hospital readmissions, and measures related to antipsychotic medication use in children. Supplementary Appendix B, C, and D provide descriptions of selected completed measures focused on key PQMP measurement domains—perinatal/prenatal health, patient-reported outcomes, and management of chronic conditions. Completed measures may be considered for future updates of the Child Core Set and for other public and private uses. As work by the Centers is ongoing through 2015, updated information on the PQMP measures and methods including technical specifications can be accessed at http://www.ahrq.gov/pqmp.

       Improve and Strengthen the Child Core Set of Quality Measures

      In December 2009, an Initial Child Core Set of 24 children's health quality measures for voluntary use by the Medicaid/CHIP programs was released for public comment by CMS (Supplementary Appendix E).

      US Department of Health and Human Services. Centers for Medicare & Medicaid Services. CHIPRA Initial Core Set of Children's Health Care Quality Measures. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/CHIPRA-Initial-Core-Set-of-Childrens-Health-Care-Quality-Measures.html. Accessed December 9, 2013.

      The Initial Child Core Set served as an important starting point for establishing a national system for standardized reporting by States' Medicaid/CHIP programs; however, it did not address all critical gaps in child quality measurement.
      • Mangione-Smith R.
      • Schiff J.
      • Dougherty D.
      Identifying children's health care quality measures for Medicaid and CHIP: an evidence-informed, publicly transparent expert process.
      Acad Pediatr. 2011; 11: S11-S21
      The CHIPRA legislation required that CMS issue annual updates to the Child Core Set, beginning in January 2013 (Supplementary Appendix E). Periodic assessment and update of measures that comprise the Child Core Set allows for the identification of new measures and methods that reflect the latest evidence and approaches to health care delivery. In addition, it also allows for the integration of feedback from States regarding implementation and use of measures.

      US Department of Health and Human Services. Centers for Medicare & Medicaid Services. State Health Official Letter #13–001. January 2013. Available at: http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf. Accessed December 12, 2013.

      As detailed herein, the 2013 update focused on the addition of new measures to fill gap areas in the Initial Child Core Set whereas the 2014 update aimed to identify which, if any, of the 2013 Child Core Set measures should be considered for retirement.

       Identification of Additional Measures

      The 2013 update focused on filling gap areas in the Initial Child Core Set by identifying additional measures for possible inclusion. AHRQ, in partnership with CMS conducted a public call for nominations of measures to be considered for the Child Core Set.
      Request for Nominations of Children's Healthcare Quality Measures for Potential Inclusion in the CHIPRA 2013 Improved Core Set of Health Care Quality Measures for Medicaid/CHIP.
      Federal Register. 2012; 77: 11119-11120
      A total of 77 reviewable measures—64 through the public call and 13 from the Centers—were submitted, covering a range of pediatric topic areas.

      US Department of Health and Human Services, Agency for Healthcare Research and Quality. Recommendations to Improve Children’s Health Care Quality Measures- Background Report on the 2012 Process. Available at: http://www.ahrq.gov/policymakers/chipra/pubs/background-2012/backgrnd2012.pdf. Accessed December 19, 2013.

      From June to October 2012, AHRQ convened an expert panel (referred to as the Subcommittee of the AHRQ National Advisory Council on Healthcare Research and Quality (SNAC)

      US Department of Health and Human Services, Agency for Healthcare Research and Quality. National Advisory Council for Healthcare Research and Quality. Available at: http://www.ahrq.gov/cpi/about/organization/nac/index.html. Accessed June 20, 2014.

      —to review the submitted measures, based on the desirable measure attributes (discussed previously). The SNAC expert panel provided recommendations regarding which measures would serve to strengthen the Initial Child Core Set (ie, be suitable for Medicaid/CHIP), and which would be appropriate for programs other than Medicaid/CHIP. Of the 77 measures, the SNAC expert panel reviewed 63 that had sufficient information (eg, numerator/denominator specifications) to conduct an assessment and recommended a total of 7 measures.

      US Department of Health and Human Services, Agency for Healthcare Research and Quality. Recommendations to Improve Children’s Health Care Quality Measures- Background Report on the 2012 Process. Available at: http://www.ahrq.gov/policymakers/chipra/pubs/background-2012/backgrnd2012.pdf. Accessed December 19, 2013.

      Five of these were recommended to CMS as improvements to the Initial Child Core Set: coverage in Medicaid/CHIP, duration of a newborn's first enrollment, human papillomavirus vaccine in female adolescents, recording of computerized tomography exposure in children, and medication management and adherence for children with asthma. Two were recommended for other public or private uses: maternity care–behavioral health risk assessment, and tobacco use and help with quitting among adolescents. From the 7 recommended by the SNAC expert panel, CMS selected 3 (human papillomavirus vaccine for female adolescents, medication management and adherence for children with asthma and maternity care–behavioral health risk assessment) as additions; these were reflected in the 2013 Child Core Set.

      US Department of Health and Human Services. Centers for Medicare & Medicaid Services. State Health Official Letter #13–001. January 2013. Available at: http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf. Accessed December 12, 2013.

      , 

      US Department of Health and Human Services. Centers for Medicare and Medicaid Services. Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set): Technical Specifications and Resource Manual for Federal Fiscal Year 2013 Reporting. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-and-CHIP-Child-Core-Set-Manual.pdf. Accessed April 3, 2014.

      In addition, CMS retired 1 measure (otitis media with effusion) because of challenges in collecting and reporting by states (Supplementary Appendix E).

      US Department of Health and Human Services. Centers for Medicare & Medicaid Services. State Health Official Letter #13–001. January 2013. Available at: http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf. Accessed December 12, 2013.

      Additional information on the process can be found at: http://www.ahrq.gov/policymakers/chipra/pubs/background-2012/index.html.

       Identification of Measures for Retirement

      For the 2014 update, AHRQ and CMS, in collaboration with a new SNAC expert panel reviewed a subset of CMS-selected measures from the 2013 Child Core Set to identify which, if any, should be considered for retirement.
      • Dougherty D.
      • Mistry K.
      • Lindly O.
      • et al.
      A Systematic Evidence-Based Quality Measurement Lifecycle Approach To Measure Retirement In CHIPRA.
      Acad Pediatr. 2014; 14: S97-S104
      Six of the 2013 Child Core Set measures were not included in this review because they were recently added or they were required by a legislative mandate. The remaining 20 measures were assessed based on importance (including evidence for the focus of the measure), scientific acceptability of the measures (measure reliability and validity), feasibility, and usability (including evidence on the effectiveness of quality improvement strategies related to the measure topics). The SNAC expert panel recommended 3 measures for retirement: appropriate testing for children with pharyngitis (2–18 years), annual pediatric hemoglobin A1C testing (5–17 years), and child and adolescent access to primary care practitioners. Of the 3 measures recommended by the SNAC expert panel, CMS selected 2 for retirement (pharyngitis testing and hemoglobin A1C testing) and also recommended retiring annual percentage of asthma patients who are 2–20 years old with 1 or more asthma-related Emergency Department visits.

      US Department of Health and Human Services, Centers for Medicare & Medicaid Services. CMCS Informational Bulletin. 2014 Updates to the Child and Adult Core Health Care Quality Measurement Sets. Available at: http://medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-12-19-13.pdf. Accessed April 3, 2014.

      The asthma measure was retired because the measure had lost formal stewardship. These changes are reflected in the 2014 Child Core Set Update (Table 2 and Supplementary Appendix E).

      US Department of Health and Human Services, Centers for Medicare & Medicaid Services. CMCS Informational Bulletin. 2014 Updates to the Child and Adult Core Health Care Quality Measurement Sets. Available at: http://medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-12-19-13.pdf. Accessed April 3, 2014.

      Dougherty et al,

      US Department of Health and Human Services. Centers for Medicare and Medicaid Services. Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set): Technical Specifications and Resource Manual for Federal Fiscal Year 2013 Reporting. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-and-CHIP-Child-Core-Set-Manual.pdf. Accessed April 3, 2014.

      in this issue, provide additional information on the process for identifying measures for retirement.
      Table 2Core Set of Child Health Care Quality Measures for Medicaid and CHIP in 2014
      Reproduced from: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-and-CHIP-Child-Core-Set-Manual.pdf.
      AbbreviationNQF No.Measure StewardMeasure Name
      ADD0108NCQAFollow-Up Care for Children Prescribed Attention Deficit Hyperactivity Disorder (ADHD) Medication
      AMBNANCQAAmbulatory Care–Emergency Department (ED) Visits
      AWCNANCQAAdolescent Well-Care Visit
      BHRANAAMA-PCPIBehavioral Health Risk Assessment (for Pregnant Women)
      CAPNANCQAChild and Adolescents' Access to Primary Care Practitioners
      CHL0033NCQAChlamydia Screening in Women
      CIS0038NCQAChildhood Immunization Status
      CLABSI0139CDCPediatric Central Line–Associated Bloodstream Infections—Neonatal Intensive Care Unit and Pediatric Intensive Care Unit
      CPCNANCQAConsumer Assessment of Healthcare Providers and Systems CAHPS 5.0H (Child Version Including Medicaid and Children with Chronic Conditions Supplemental Items)
      PC020471TJCCesarean Section for Nulliparous Singleton Vertex
      DEV1448OHSUDevelopmental Screening in the First Three Years of Life
      FPC1391NCQAFrequency of Ongoing Prenatal Care
      FUH0576NCQAFollow-up After Hospitalization for Mental Illness
      HPV1959NCQAHuman Papillomavirus (HPV) Vaccine for Female Adolescents
      IMA1407NCQAImmunization Status for Adolescents
      LBW1382CDCLive Births Weighing Less than 2,500 Grams
      MMA1799NCQAMedication Management for People with Asthma
      PDENTNACMSPercentage of Eligibles That Received Preventive Dental Services
      PPC1517NCQATimeliness of Prenatal Care
      TDENTNACMSPercentage of Eligibles That Received Dental Treatment Services
      WCC0024NCQAWeight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Body Mass Index Assessment for Children/Adolescents
      W151392NCQAWell-Child Visits in the First 15 Months of Life
      W341516NCQAWell-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life
      NQF indicates National Quality Forum; CHIP, Children's Health Insurance Program; NCQA, National Committee for Quality Assurance; AMA-PCPI, American Medical Association-Physician Consortium for Performance Improvement; CDC, Centers for Disease Control and Prevention; TJC, The Joint Commission; OHSU, Oregon Health and Science University; CMS, Centers for Medicare & Medicaid Services; and NA, measure is not NQF-endorsed.

      Key Challenges and Lessons Learned to Date

      The allocation of significant resources for the PQMP provides an unprecedented opportunity to invest in the science of measure development and to address gaps in children's quality measurement. However, a number of challenges emerged during the development of new measures and methods, including difficulty with testing using existing data infrastructures and balancing stakeholder priorities; these challenges are detailed elsewhere in this issue.
      • Byron S.C.
      • Gardner W.
      • Kleinman L.C.
      • et al.
      Developing Measures for Pediatric Quality: Methods and Experiences of the CHIPRA Pediatric Quality Measures Program Grantees.
      Acad Pediatr. 2014; 14: S27-S32
      Here we focus on 3 key cross-cutting lessons related to the CHIPRA stipulation that measures be evidence-based, tension between measure importance and feasibility, and the need for addressing measure dissemination and stewardship.
      The generation of evidence-based pediatric measures continues to be stymied by the paucity of relevant evidence in the biomedical literature. The absence of evidence on clinical preventive services for children provides just one glaring example of scarcity.
      • Stille C.
      • Turchi R.M.
      • Antonelli R.
      • et al.
      Academic Pediatric Association Task Force on the Family-Centered Medical Home
      The family centered medical home: specific considerations for child health research and policy.
      Acad Pediatr. 2010; 10: 211-217
      Thus, the PQMP goal of producing evidence-based measures is grounded in the reality that there might not be demonstrated linkages between structures and processes of care and child health outcomes. Absent these relationships, the validity and value of the measures could be questioned. After undertaking evidence reviews as a first step in measure development, Centers often had to face the reality of a paucity of relevant and rigorous studies.
      • Byron S.C.
      • Gardner W.
      • Kleinman L.C.
      • et al.
      Developing Measures for Pediatric Quality: Methods and Experiences of the CHIPRA Pediatric Quality Measures Program Grantees.
      Acad Pediatr. 2014; 14: S27-S32
      , 
      • Kealey E.
      • Scholle S.H.
      • Byron S.C.
      • et al.
      Quality concerns in antipsychotic prescribing for youth: A review of treatment guidelines.
      Acad Pediatr. 2014; 14: S68-S75
      This lack of evidence prompted some Centers to halt the production of measures on important topics, such as the provision of mental health care and the content of child and adolescent well care. Growing federal investments in comparative effectiveness research and patient-centered outcomes research should help to strengthen the evidence base.
      • Lauer M.S.
      • Collins F.
      Using science to improve the nation’s health system: NIH’s commitment to comparative effectiveness research.
      JAMA. 2010; 303: 2182-2183
      , 
      • Clancy C.
      • Collins F.S.
      Patient-Centered Outcomes Research Institute: the intersection of science and health care.
      Sci Transl Med. 2010; 2: 37cm18
      , 
      • Selby J.V.
      • Beal A.C.
      • Frank L.
      The Patient-Centered Outcomes Research Institute (PCORI) national priorities for research and initial research agenda.
      JAMA. 2012; 307: 1583-1584
      However, ensuring that these investments and other resources are applied to high-priority topics for children and youth in Medicaid/CHIP will be essential for advancing pediatric quality measurement.
      Another practical challenge is the tension that results from balancing measure importance and feasibility. During the 2012 and 2013 update process, the SNAC expert panels charged with recommending measures for voluntary use by Medicaid/CHIP programs were torn between selecting important but difficult to collect measures and measures that were more feasible for states.

      US Department of Health and Human Services, Agency for Healthcare Research and Quality. Recommendations to Improve Children’s Health Care Quality Measures- Background Report on the 2012 Process. Available at: http://www.ahrq.gov/policymakers/chipra/pubs/background-2012/backgrnd2012.pdf. Accessed December 19, 2013.

      , 
      • Dougherty D.
      • Mistry K.
      • Lindly O.
      • et al.
      A Systematic Evidence-Based Quality Measurement Lifecycle Approach To Measure Retirement In CHIPRA.
      Acad Pediatr. 2014; 14: S97-S104
      States and other public and private health care entities face limited resources and competing measurement priorities.

      US Department of Health and Human Services. Centers for Medicare and Medicaid Services. EHR Incentives Program- Recommended Measures. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed January 7, 2014.

      Thus, data collection and reporting burdens remain a paramount concern. SNAC expert panel members highlighted the need for measures on key topics for which there are measurement gaps but also emphasized the importance of considering feasibility. Trade-offs related to importance and ease and expense of data collection were debated. The Centers are developing numerous measures on assigned topics reflecting needs and gaps identified by AHRQ, CMS, and public comment (Table 1). A number of the new measures are collected through medical records and surveys and do not rely on administrative data, which is relatively easy to collect. Recognizing the practical challenges, only a limited number of new measures might initially be incorporated into the Child Core Set annually. However, improvements in states' analytic and reporting functions and the increased use of electronic health records might help redefine what is “feasible” over time and facilitate use of new, more clinically relevant quality measures.
      • Bailey C.
      • Tinoco A.
      • Mistry K.B.
      • et al.
      Addressing Electronic Clinical Information in the Construction of Quality Measures.
      Acad Pediatr. 2014; 14: S82-S89
      Additionally, as important gains continue to be made by the PQMP with regard to the development of new measures, focus needs to shift to greater dissemination, adoption, and use of measures. One PQMP measure was added to the 2013 Child Core Set for voluntary reporting by Medicaid/CHIP programs and several of the more recently developed measures and methods are being used by hospitals, such as the Child Hospital Consumer Assessment of Health Care Providers and Systems and the Pediatric Medical Complexity Algorithm, suggesting a broad audience for newly created quality measures. Ultimately, it is the widespread use and reporting on these measures that will be critical to meeting CHIPRA's vision of high-quality care for children. Reporting on the new measures might allow for broader comparative analysis and quality improvement efforts across an array of important topic areas. All measures and methods developed by the PQMP, including technical specifications, will be publicly available on the AHRQ Web site for dissemination and use. However, the time-limited grant mechanism used to fund the PQMP Centers ends in 2015; therefore, future measure stewardship remains an important consideration because measures require periodic updating with regard to technical specifications and also review of evidence underlying measures.

      Conclusion

      It is often said that children are the future and critical for the nation's continued economic health.
      National Research Council
      Children's Health, the Nation's Wealth: Assessing and Improving Child Health.
      National Academies Press, Washington, DC2004
      Children are also the present, comprising 25% of the US population, an estimated 74 million, at the beginning of 2014.

      US Census Bureau. 2012 National Population Projections. Available at: http://www.census.gov/population/projections/data/national/2012.html. Accessed February 9, 2014.

      More than a third of the nation's children receive health care through Medicaid/CHIP.

      US Department of Health and Human Services, Agency for Healthcare Research and Quality. Children’s electronic health record format. Available at: http://healthit.ahrq.gov/health-it-tools-and-resources/childrens-electronic-health-record-ehr-format. Accessed December 19, 2013.

      The life-course perspective, increasingly adopted by policymakers and researchers, highlights how quality of care deficits early in life can have long-lasting and serious consequences for children when they become adults.
      • Halfon N.
      • Larson K.
      • Lu M.C.
      • et al.
      Life course health development: past, present, and future.
      Matern Child Health J. 2014; 18: 344-365
      The PQMP has provided a foundation for advancing measurement activities aimed at maximizing quality of care and health outcomes for children. Sustained investment and focus on strengthening measurement and improvement activities along with supporting states' data collection and reporting infrastructure will play a role in achieving a high-quality health care system for all children. Health care quality programs simply cannot improve without reliable, valid, and practical quality measurement. Greater realization of CHIPRA's vision is contingent on the continual evaluation and refinement of children's health care quality measures. However, it is the adoption and use of evidence-based measures that will ultimately drive improvements in child health.

      Supplementary Data

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      Article Info

      Publication History

      Accepted: June 25, 2014
      Received: April 4, 2014

      Footnotes

      The authors have no conflicts of interest to disclose.

      Publication of this article was supported by the US Department of Health and Human Services and the Agency for Healthcare Research and Quality.

      The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Health and Human Services, the Agency of Healthcare Research and Quality, or the Center for Medicare and Medicaid Services.

      Financial disclosure: The PQMP is funded by CMS .

      Identification

      DOI: https://doi.org/10.1016/j.acap.2014.06.025

      Copyright

      Published by Elsevier Inc.

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