Agency for Healthcare Research and Quality seeks data defining quality children's healthcare

For the first time, the Agency for Healthcare Research and Quality (AHRQ) is moving to designate data to be collected to establish a core set of quality indicators of children's healthcare under Medicaid and the Children's Health Insurance Program (CHIP). Several of the proposed measures relate to ob/gyn care.

Comments on the initial set of 24 indicators mandated by the Children's Health Insurance Program Reauthorization Act of 2009 were due from physicians and the public on March 1. These measurements were chosen over several months through an intense process carried out by a panel of pediatricians, provider groups, experts in quality measurement, state Medicaid officials, and other stakeholders. No obstetricians were on the selection subcommittee, and no public comments were received from obstetricians during the process.

All of the indicators are currently in use: 14 are from the Healthcare Effectiveness Data and Information Set (HEDIS) measures and are used to evaluate the quality of care by Medicaid-managed care plans in some states. Indicators include the number of women who have had a prenatal visit in the first trimester, frequency of ongoing prenatal care, percentage of live births weighing less than 2,500 grams, the rate of cesarean delivery among low-risk women giving birth to their first child, chlamydia screening among females between the ages of 16 and 20 years, and weight assessments among children who have visited a primary care provider or ob/gyn.

Although adoption of these measures by each state is currently voluntary, the goal of the initiative is to yield a set of measurements that will eventually be agreed on nationally by all states, allowing state-to-state comparisons.

Nevertheless, the question of when individual states might begin collecting data is unanswered. Some states have experience in using quality-of-care measurements; others do not. In addition, states' budget crises may delay efforts to implement such a resource-intense data collection. Some of the information will come from administrative data, but some will come from chart reviews, according to panel members.

Rita Mangione-Smith, MD, MPH, who cochaired the AHRQ advisory board subcommittee that selected the measures, said many child advocates pushed for the initiative, in particular because "so much more attention has been given" to knowing what quality of care is being provided to adults compared to that for children.

As associate professor of pediatrics at the University of Washington School of Public Health, Seattle, Mangione-Smith led a 2007 study of 1,536 children from 12 major metropolitan areas that found that children received about 46.5% of indicated ambulatory care services: 67.6% of indicated care for acute medical problems, 53.4% of care for chronic medical conditions, and 40.7% of preventive care.

A "warning call" to action

Mangione-Smith hopes the measures will influence physicians by uncovering places in which care isn't what it should be, although, she said: "I don't think it will impact them in a punitive way. I hope it will be an eye-opener."

She characterized physicians' response to her 2007 paper as: "This is a warning call that we are not doing some of the really basic stuff that we should be doing." However, Mangione-Smith suggested that if scores within a state are not good, that state's government might do something to push for quality improvement at the patient level. She added that although she can't imagine Medicaid establishing pay-for-performance measures such as those included in some health plans, "you never know."

The process of building and refining the initial set of measurements will continue. Information about the project was published in the December 29, 2009, Federal Register and at http://www.ahrq.gov/chip/chipraact.htm. For additional information and comments, contact Denise Dougherty, PhD, at 301-427-1868; denise.dougherty@ahrq.hhs.gov
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Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357(15)1515-1523.

US Department of Health and Human Services. Office of the Secretary. Medicaid and CHIP programs; initial core set of children's healthcare quality measures for voluntary use by Medicaid and CHIP programs. Federal Register. December 29, 2009. http://www.insurekidsnow.gov/professionals/CHIPRA/federalregisternotice.pdf. Accessed February 8, 2010.