Children's hospitals are making strides in developing new and innovative quality measures to support high-quality, cost-effective care across a wide breadth of services.
By Ellen Schwalenstocker, MBA, Ph.D.
After observing variation in surgical outcomes of soldiers in the Crimean War, Florence Nightingale voiced the need for comparative information to “show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was doing mischief rather than good.” More than 150 years ago, Nightingale presaged the notion of value-based purchasing, a term common in our vocabulary today. With implementation of the Affordable Care Act (ACA), including the formation of health insurance exchanges, the need to be able to demonstrate value is increasingly important for children’s hospitals.
Value-based purchasing is one tool to promote achievement of the National Quality Strategy “triple aim”—better care, healthier people and communities, and affordable care. Children’s hospitals need measures to determine where they are with these aims and to under-gird quality improvement efforts to achieve them. Yet, given the historic role of Medicare in driving quality measurement and reporting, most of the nationally endorsed quality measures are adult-focused. The pediatric measures that are available are limited in scope and don’t reflect the needs of all of the sub populations of patients children’s hospitals care for, particularly children with medical complexity.
The Children’s Health Insurance Program Reauthorization Act (CHIPRA) made an important step forward toward closing the gap in quality measures for children. CHIPRA contained several provisions related to quality, including requirements to develop a core set of children’s measures for states to voluntarily use to report on the quality of care provided to Medicaid and CHIP beneficiaries. The intent, as stated in the legislation, is to include measures that “taken together, can be used to estimate the overall national quality of health care for children, including children with special needs.”
Recognizing existing measures were insufficient to achieve this goal, CHIPRA called for the establishment of the Pediatric Quality Measures Program (PQMP) to not only improve and strengthen the initial set of measures—over half were related to prevention and health promotion—but to “increase the portfolio of evidence-based, pediatric quality measures available to public and private purchasers of children’s health care services, providers and consumers.” Given this charge, the government awarded funding to seven PQMP Centers of Excellence (COEs) in March 2011.
The legislation and criteria for awarding the COEs stressed the importance of partnership with a range of stakeholder groups, including children’s hospitals. Members of the Children’s Hospital Association lead five COEs, and children’s hospitals play a role in all seven. We checked in with some of them as they enter their fourth and final year of funding. The strides they are making in developing new and innovative measures will advance the kinds of measures children’s hospitals need to support high-quality and cost-effective care across a wide breadth of services and range of needs. Here are just a few examples.
Improving care coordination
Currently, there are only a few nationally endorsed measures to address the needs of special populations that children’s hospitals serve, such as children and youth with special health care needs and children with medical complexity. Promoting effective communication and coordination of care is one of the six priorities outlined in the National Quality Strategy and is essential in assuring high-quality care and outcomes for these groups. The COE on Quality of Care Measures for Children with Complex Needs, based at Seattle Children’s Hospital, is hard at work developing measures focused on care coordination in the context of the medical home.
These measures are derived from medical records and administrative data, as well as caregiver survey measures, which have undergone field testing with 1,200 families in Minnesota and Washington. Seattle Children’s will seek National Quality Forum’s (NQF) endorsement in 2014. As part of its second phase of work, this center will focus on transitions between settings of care for children with and without special health care needs and identification of children with complex social needs who may need additional care coordination.
The center also developed the Pediatric Medical Complexity Algorithm to identify children with complex needs, including mental health problems, as the eligible population for these measures. “It’s critical to be able to accurately identify children with medical complexity in this era of health care reform,” says Principal Investigator Rita Mangione-Smith, M.D., MPH. “This will allow health care organizations to appropriately delegate limited resources and funds to children who will benefit most from care coordination.”
Effective care coordination and transitions between care settings are essential for preventing unplanned hospital readmissions, which is a topic of increasing importance on the policy and payment front. There is some controversy around the appropriate level of accountability (hospital vs. delivery system) for readmissions and the effect of factors outside the health care system on readmissions. But it’s clear readmissions are an important lever in reducing health care costs, and variation in readmissions suggests hospitals can play a role in avoiding them. The ACA established the Hospital Readmissions Reduction Program requiring CMS to reduce payments to hospitals subject to the Inpatient Prospective Payment System for excess readmissions. In addition, reduction of readmissions is a focus of the Partnership for Patients’ effort.
The Readmissions Reduction Program utilizes measures endorsed by the NQF; however, other payers, including some states, have followed suit with non-endorsed measures that were not developed specifically for use in pediatrics and are not transparent to the hospitals being measured and potentially penalized. The PQMP gave high priority to readmission measures and assigned the COEs at Boston Children’s Hospital and The Children’s Hospital of Philadelphia (CHOP)/ University of Pennsylvania (U-Penn) this topic.
The Boston Children’s group initially undertook efforts to understand the prevalence and degree of variability in pediatric readmissions. This COE has since developed a 30-day pediatric readmission measure that identifies pediatric-specific codes, planned procedures and appropriate casemix variables, which will be made public and transparent. The group at CHOP/U-Penn is developing measures of readmission rates at seven, 14, 30 and 90 days after discharge for infants admitted to neonatal intensive care units. These measures will be riskadjusted for factors present at birth, complications and outpatient care. Given the historic propensity to retrofit measures developed in adult settings for pediatrics, the work of these COEs is timely and vital.
Capturing the voice of the child and family
Prioritizing measurement of outcomes of care has been a theme in discussions of measures that matter. A recent report on health policy issues underscored the importance of measuring patient and family experience with care and patient-reported outcomes as important ends in themselves. Again, the PQMP is responding to this call. The development of patient-reported outcomes measures is one of many areas of focus at CHOP and U-Penn. This group has developed a Pediatric Global Health measure (PGH-7) that is part of the patient-reported outcome measurement information system housed at the National Institutes of Health. The PGH-7 is a seven-item measure that assesses general, physical, mental and social health.
Compared to single-item general health measures, where patients report on their overall health using a poor-to-excellent range, PGH-7 has demonstrated a greater range, meaning it can better identify changes in health status, including changes resulting from health care interventions. At the same time, the brevity of PGH-7 makes its use feasible and, because it provides the patient’s view of health status regardless of the disease or condition, the tool is universally applicable. The team has demonstrated PGH-7 has excellent reliability and validity, and it is ready for use in clinical research, practice and quality improvement applications.
Public reporting of adult hospital patient experience of care using the Hospital Consumer Assessment of Healthcare Providers and Services Hospital Survey (HCAHPS) has been in place since 2008. The group at Boston Children’s was given the task of developing a child version of the HCAHPS survey, which 70 hospitals in 33 states have tested. “It looks like a lot of hospitals have been eager to have a family experience survey developed for children,” says Mark A. Schuster, M.D., Ph.D., principal investigator of the Boston Children’s COE. “Hospitals seemed excited to participate in the national field test, and others that didn’t know about the test have reached out to us to ask about implementing the survey.”
Improving mental health care
A 2013 report by the Centers for Disease Control and Prevention pointed to the prevalence and impact of mental disorders among children. The report noted that between 13 percent and 20 percent of children in the United States experience a mental disorder in a given year and highlighted a significant increase in the use of services for mental illness among children. Yet a recent paper in Pediatrics noted that only nine measures related to children’s mental health care were included in NQF-endorsed measures or the core set of children’s measures. And only a few of these measures had a high level of supporting evidence.
Mental health is an example of how the COEs are engaged in complementary work to address the gap in availability of evidence-based measures for children. The PQMP assigned three center’s topics related to mental health in the first round of assignments, and at least one center was added in the second round.
The Pediatric Measurement Center of Excellence, based at the American Academy of Pediatrics and the Medical College of Wisconsin, is leading efforts to develop and refine measures related to attention deficit hyperactivity disorder (ADHD), one of the most common reasons children are referred for mental health services. The National Collaborative for Innovation in Quality Measurement housed at the National Committee on Quality Assurance is working on adolescent depression, and has produced a logic model aimed at optimizing care from screening to treatment and monitoring.
In its second phase of work, the Seattle Children’s COE has developed surveyand medical-record based measures related to the quality of emergency department and inpatient care for children with psychosis, substance abuse and suicidality/potential danger to self, including process measures aimed at preventing future avoidable ED and inpatient care for all mental health diagnoses. More recently, the Mount Sinai Collaboration for Advancing Quality Measures has begun work on medication reconciliation in mental health as well as improving measures related to follow up after hospitalizations for mental illness.
A value framework
The breadth of pediatric quality measures developed through the PQMP enables multiple applications, including value-based purchasing. In pediatric care, the concept of value is not well conceptualized, nor are there established and accepted frameworks supporting this concept. As part of its charge to advance the conceptualization and measurement of pediatric value, CHOP/U-Penn has developed a primary care-specific framework that builds upon the work of Michael Porter, Ph.D., professor and director, Institute for Strategy and Competitiveness at the Harvard Business School. Porter argues that value is defined by the relationship between patient-centered outcomes (the outputs of health care services) and costs of providing those services.
In short, the focus of value assessment should be on outcomes that matter most to patients. “Outcomes for children as well as for parents and families are essential to understanding the whole picture,” says Chris Forrest, M.D. Ph.D., co-principal investigator at the CHOP/U-Penn COE. Specifically, this group is using clinical and empirical methods to identify naturally occurring categories of patients that have comparable types of health care needs. “Once these groups of patients are identified, the real challenge lies in determining how to assess costs, quality and outcomes, and using this information to enable primary care to become more efficient and effective,” he says.
These are just a few examples of the considerable work underway through the PQMP. Other efforts relevant to children’s hospitals include work by the Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-Metric) at the University of Michigan to develop measures around specific conditions, such as sickle cell disease, septicemia, asthma and bronchitis; efforts by the CHOP/U-Penn and Mt. Sinai COEs to measure NICU quality and outcomes; a focus on PICU at the American Academy of Pediatrics COE; and the work of Boston Children’s related to preparation for transition to adult-focused care for adolescents with chronic conditions.
As these measures become available, the Agency for Healthcare and Research will share the specifications on its website. The work of the PQMP centers is invaluable, not only in building the science of quality measurement, but also in providing expertise to quality and policy bodies. These groups have contributed to myriad NQF efforts on behalf of children’s hospitals, including expert panels on linking cost and quality; risk adjustment and socioeconomic status; evaluation criteria for episode groupers, care coordination, and person-centered care and outcomes.
Through their expertise and dedication, these centers are raising the visibility and understanding of the needs of children, and ensuring that these needs are considered at the outset of quality measurement activities.
Next steps: maintaining the gains
The PQMP has made critical gains in quality measurement, and on March 31, Congress passed legislation extending funding for the pediatric quality centers of excellence through September 2015. Enactment of this extension bill prevents any lapse in funding while a multi-year reauthorization initiative is underway. To ensure the investment in PQMP is fully realized and the work to close gaps in meaningful quality measures for children continues beyond 2015, the Children’s Hospital Association is working closely with allied organizations to advance legislation that would extend and expand on the CHIPRA quality provisions and reauthorize CHIP through 2019. Find out more about CHIP policy efforts.
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