Testing a Comprehensive Measure Set for
Well Child Care
Sepheen C. Byron, MHS
Director, Performance Measurement
AcademyHealth Annual Research Meeting
June 27, 2010
1
Outline
• Introduction & Background
• Methods
• Results
• Conclusions
2
Acknowledgments
Child Health Measurement Advisory Panel
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Charles Homer, MD, MPH (chair)
Jeanne Alicandro, MD
Barbara Dailey
Denise Dougherty,
Dougherty PhD
Foster Gesten, MD
Ted Ganiats, MD
Nikki Highsmith, MPA
Jeff Kamil, MD
Edison Machado,, MD,, MBA
Mary McIntyre, MD, MPH
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•
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Virginia Moyer, MD, MPH
Lee Partridge
Xavier Sevilla, MD, FAAP
g , MD
Michael Siegal,
Janet Sullivan, MD
M
Measurement
t Subpanel
S b
l
• Paula Duncan, MD
• Virginia Moyer, MD, MPH
• Xavier Sevilla, MD, FAAP
Thanks to The Commonwealth Fund and our project officer,
Edward L. Schor, MD
3
Background
• The IOM defines child health as
– “the
“th extent
t t tto which
hi h an individual
i di id l child
hild or groups off
children are able or enabled to: a) develop and
realize their potential; b) satisfy their needs; and c)
develop the capacities that allow them to interact
successfully
y with their biological,
g
physical,
p y
and social
environments.
• The p
primary
yp
purpose
p
of health care for children
is to help children grow and develop into
y adults
healthy
4
Deficits in the Quality of Child Health Care
• Children received less than half of indicated
medical care,
care with the greatest deficits in
preventive care †
– 68% of indicated care for acute medical problems
– 53% of indicated care for chronic medical conditions
– 41% of indicated preventive care
• Most parents say their concerns related to
parenting education,
parenting,
education or screening are not
addressed
• Low-income
i
ffamilies
ili att risk
i k ffor poorer care
†Mangione-Smith,
R, et al. NEJM 2007
5
Long-Term Vision
• Develop measurement strategy to increase
attention to child health outcomes
– School readiness, workforce readiness, family
productivity
• Explore opportunities for assessing return on
investment and for communicating with
stakeholders
• Identify opportunities to use new and emerging
technologies to build a new infrastructure for
monitoring child health
• Build strategic partnerships to achieve vision
and complement other efforts
6
Comprehensive Well Care Measures
• Specify measures for age-appropriate
strategy
t t
for
f comprehensive
h
i wellll child
hild
care
• Conduct a field test at the health plan
and physician levels
• Examine the impact of alternative
eligibility criteria and methods for
calculating
g performance
p
rates
7
By Age 6 Mo
By Age 2 Yr
By Age 6 Yr
By Age 13 Yr
By Age 18 Yr
Protection of Health
Newborn Hearing
S
Screening
i
Newborn Metabolic
Screening
Hip Dysplasia
Immunizations
O l Health
Oral
H lth Access
A
Iron Deficiency
Assessment &
Supplementation
Lead Screening
g
Immunizations
O l Health
Oral
H lth Access
A
Vision Screening
Blood Pressure
Screening
Immunizations
O l Health
Oral
H lth Access
A
Vision Screening
Blood Pressure
Screening
Immunizations
O l Health
Oral
H lth Access
A
Vision Screening
Blood Pressure
Screening
y
Screening
g
Chlamydia
Cervical Cancer Screening
Healthy Cognitive, Social-emotional, Behavioral, & Physical Development
Breastfeeding
Counseling
Physical Growth
Assessment
Maternal Depression
Screening
Parental Competencies
Developmental Screening
Developmental
Screening
Autism Screening
Physical Growth
Assessment
Parental Competencies
Maternal Depression Screening
Nutritional Adequacy
Mental Health
Screening
Healthy Physical
Development
Developmental Screening
Parental competencies
Risky Behavior
Screening
Depression Screening
Healthy Physical
Development
Risky Behavior
Screening
Depression Screening
Healthy Physical
Development
Mental Health Assessment (General)
Parental competencies
Mental Health Assessment
(General)
Protection of Health through a Safe Environment
Sudden Infant Death
Syndrome Counseling
Environmental
Tobacco Assessment
& Counseling
Domestic Violence
Prevention of Burn
Burn, Fall
Fall, Choking
Choking, &
Drowning
Cardiopulmonary Resuscitation
Vehicle Safety
Environmental
Tobacco Assessment
& Counseling
Environmental
Tobacco Assessment
& Counseling
Domestic Violence
Prevention of Burn, Fall, Poison, &
Drowning
Firearm Safety
Vehicle Safety
Domestic Violence
Safety: Firearm, Vehicle, Water,
Sports
Environmental Tobacco Assessment
and Counseling Home Safety
Domestic Violence
Safety: Firearm, Vehicle, Water,
Sports
Environmental Tobacco
Assessment and Counseling
Management & Follow-Up for Children with Chronic Conditions
Individualized Care Plan
Individualized Care Plan
Individualized Care
Plan
Individualized Care Plan
Individualized Care Plan
8
Field Test
• General research questions
– Performance
Performance, variation,
variation and room for
improvement
– Availability of data
– Burden of data collection
– Prevalence
P
l
and
d iimpactt off exclusions
l i
• Specific issues for child health
– Eligibility
– Continuous enrollment
– Look-back period
9
Methods
• 8-week data collection period
• Plans
– 250 medical record reviews, 50 for each age
group
• For Medicaid/CHIP plans, data stratified by
enrollment periods of 6 months and 12 months
• Physicians
– 50 medical record reviews, 10 for each age group
10
Health Plan Sites
Region
Commercial
MCO/HMO
Medicaid
MCO
Plan 1
Midwest

Plan 2
Midwest

Yes
Plan 3
South

No
Plan 4
West
Plan 5
East
EHR
Yes

Yes

No
11
Physician Sites
• 20 physicians recruited, 19 submitted data
– 16 pediatricians, 3 family physicians
WA
ME
ND
MT
VT
MN
OR
NH
WI
SD
ID
NY
MI
WY
NV
UT
CA
PA
IA
NE
MO
CO
IL
NM
OK
WV
KY
VA
DE
MD
DC
NC
TN
AR
SC
MS
TX
CT
NJ
OH
IN
KS
AZ
MA
RI
AL
GA
LA
FL
AK
HI
12
Results: By Age 2 Years
Indicators
Lead Screening
Oral Health Access
Physical Growth
Developmental Screening
Autism Screening
E i
Environmental
lT
Tobacco
b
C
Counseling
li
Patient-Centered Composite
p
% of children who met all indicators
Mean % of applicable indicators met
Health Plan
N= 305
61 3%
61.3%
73.1%
80.0%
8.9%
13.4%
60 %
60.7%
Physician
N= 180
72 8%
72.8%
74.4%
99.4%
70.6%
37.8%
77.2%
2%
0.0%
49.6%
9.0%
72.0%
13
Results: By Age 13 Years
Indicators
Oral Health Access
Vision Screening
Blood Pressure Screening
Depression Screening
BMI Assessment
Nutrition Counseling
Physical Activity Counseling
Screen Time Counseling
Risky Behavior: Sexual Activity
Risky Behavior: Substance Abuse
Ri k B
Risky
Behavior:
h i Al
Alcohol
h l Use
U
Risky Behavior: Tobacco Use
Immunizations: HPV
Patient-Centered Composite
% of children who met all indicators
Mean % of applicable indicators met
Health Plan
N= 291
67.0%
38 5%
38.5%
90.0%
7.6%
46 1%
46.1%
39.2%
61.5%
33 7%
33.7%
48.1%
55.0%
51 2%
51.2%
55.0%
3.8%
Physician
y
N= 179
80.5%
78 2%
78.2%
98.9%
52.0%
89 4%
89.4%
76.0%
77.7%
44 7%
44.7%
70.4%
71.5%
73 7%
73.7%
77.7%
10.6%
1.0%
49 4%
49.4%
17.0%
74 2%
74.2%
14
Results: All Ages
By Age
6 months
2 years
Plans
6 years
13 yyears
18 years
6 months
2 years
Physicians 6 years
13 years
18 years
% Met All Indicators
13.7%
0 0%
0.0%
1.3%
0.7%
0.4%
11.7%
9.4%
14.4%
17.3%
3.1%
Mean % of Applicable
Indicators Met
66.8%
49 6%
49.6%
47.9%
49.4%
49.5%
76.7%
72.0%
71.4%
74.2%
70.2%
15
Children with Chronic Conditions
• Ages: 6 mo and 2, 6, 13, 18 years
• An Individualized Care Plan is a separate document
that outlines important health information for children
with chronic conditions. The Individualized Care Plan
must include the following components.
components
–
–
–
–
–
–
–
–
Current list of allergies, diagnoses, and medications
Treatment plan
Goals for self-management
Other clinicians/agencies involved in the child’s health care
Instructions for when to seek urgent care
Information on the next scheduled appointment
E id
Evidence
th
thatt the
th plan
l
was di
discussed
d with
ith th
the ffamily/caregivers
il /
i
Evidence that the plan was given to the family/caregivers
16
Individualized Care Plan: Eligibility
By Age
Eligibility
6 Mo
Plans
26.7%
Physicians
17.2%
2Y
Yr
25 6%
25.6%
26 7%
26.7%
6 Yr
13 Yr
18 Yr
28.7%
34.7%
%
48.8%
32.8%
43.3%
%
37.8%
17
Individualized Care Plan: By Age 6 Yr
Component
Component Documented
Plans
Physicians
List of allergies, diagnoses, other meds
14.8%
72.9%
Treatment plan
10.2%
78.0%
Goals for self-management
9.1%
49.2%
Other clinicians involved in care
6.8%
50.8%
11 4%
11.4%
44 1%
44.1%
8.0%
62.7%
Discussed with family/caregivers
12.5%
61.0%
Given to family/caregivers
12 5%
12.5%
42 4%
42.4%
Urgent care instructions
Next appointment
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Conclusions
• Gaps in children’s health care
– Screenings documented
– Often not documented
• Results
• Follow
Follow-up
up of abnormal or indeterminate results
• Standardized tools
• Coordination of care for children with
chronic conditions could be improved
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Acknowledgments
NCQA Team
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Natalie E.P. Davis, MA
Vivian Kong, MPH
Judy Ng, PhD
Phil Renner, MBA
Sarah Hudson Scholle, MPH, DrPH
Faye Xia
Jin Zhang
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