Developing Quality Measures for Medicaid Beneficiaries with Schizophrenia: Final Report. 1. Measure Concepts Considered, Specified, and Tested, and Submitted for Endorsement

01/30/2012

The project team sought to develop measures in three domains, pharmacology, psychosocial care, and physical health, as well as cross-cutting measures that span several of these domains. Tables III.1-III.4 list the proposed measure concepts, the measures that were specified and tested in focus groups, the measures that were tested in the MAX data, and the measures submitted for NQF endorsement. The final ten measures submitted to NQF for endorsement consideration are listed in the last column. Appendix F consists of the proposed measures' numerator, denominator, and exclusions.

TABLE III.1. Pharmacological Concepts Considered, Specified, Tested, and Submitted
  Proposed Measure Concepts   Measures Specified &
  Tested in Focus Groups  
  Measures Tested  
in MAX Files
Measures Submitted
  for NQF Endorsement  
  1. Use of antipsychotic medications for treatment of schizophrenia.
  2. Antipsychotic medication possession ratio.
  3. Use of clozapine in treatment-resistant patients.
  4. Polypharmacy treatment.
  1. Use of antipsychotic medications for treatment of schizophrenia.
  2. Antipsychotic medication possession ratio.
  1. Use of antipsychotic medications.
  2. Antipsychotic medication possession ratio.
  1. Use of antipsychotic medications.
  2. Antipsychotic medication possession ratio.

Use of clozapine in treatment-resistant patients was dropped due to difficulty with identifying treatment-resistant patients from claims data and concerns about small denominator size. The polypharmacy treatment measure concept was dropped because there is insufficient evidence to define a polypharmacy threshold (e.g., two versus three antipsychotics) and lack of evidence regarding the impact of polypharmacy on quality of care. The TAG also was uncertain whether to broaden the concept to encompass other psychiatric medications (e.g., antidepressants).

TABLE III.2. Psychosocial Concepts Considered, Specified, Tested, and Submitted
  Proposed Measure Concepts   Measures Specified &
  Tested in Focus Groups  
  Measures Tested  
in MAX Files
Measures Submitted
  for NQF Endorsement  
  1. Use of Assertive Community Treatment (ACT) post-hospitalization.
  2. Use of case management.
  3. Use of family therapy.
  4. Use of supported employment.
  5. Use of cognitive behavioral therapy.
  6. Use of social education.
  7. Use of any psychosocial treatment.
  8. Availability of psychosocial treatment.
  9. Presence or duration of waiting list for psychosocial treatment.
  1. Use of any psychosocial treatment.
(None) (None)

Use of ACT post-hospitalization, case management, family therapy, supported employment, cognitive behavioral therapy, and social education were dropped as a result of the inconsistent availability of these services across state Medicaid programs and, where those services are available, unreliable coding and uncertain fidelity to the evidence-based models. Use of any psychosocial treatment was specified and tested in focus groups, but was dropped because of the fidelity and reliability concerns. Availability of and the presence or duration of a waitlist for psychosocial treatment are structural measures not suited to claims data measurement.

TABLE III.3. Physical Health Concepts Considered, Specified, Tested, and Submitted
  Proposed Measure Concepts   Measures Specified &
  Tested in Focus Groups  
  Measures Tested  
in MAX Files
Measures Submitted
  for NQF Endorsement  
  1. Monitoring of metabolic conditions among patients taking antipsychotic medications.
  2. Weight assessment and counseling among patients who are taking antipsychotics.
  3. Appropriate health maintenance and prevention.
  4. Appropriate infectious disease screenings.
  5. Screening and counseling of substance use disorders.
  6. Tobacco counseling.
  1. Cervical cancer screening for women.
  2. HIV screening.
  3. Diabetes screening (schizophrenia or bipolar disorder).
  4. Cardiovascular health screening (schizophrenia or bipolar disorder).
  5. Diabetes monitoring.
  6. Cardiovascular health monitoring.
  1. Cervical cancer screening for women.
  2. Diabetes screening (schizophrenia or bipolar disorder).
  3. Cardiovascular health screening (schizophrenia or bipolar disorder).
  4. Diabetes monitoring.
  5. Cardiovascular health monitoring.
  1. Cervical cancer screening for women.
  2. Cardiovascular health screening (schizophrenia or bipolar disorder).
  3. Diabetes screening (schizophrenia or bipolar disorder).
  4. Diabetes monitoring.
  5. Cardiovascular health monitoring.

Weight assessment and counseling among patients on antipsychotics was deemed identifiable only from chart data, which were out of scope for this project. Concerns about reliable documentation of tobacco and substance use screening and counseling in claims data resulted in removing these concepts from further consideration. HIV screening was dropped because of the lack of strong evidence suggesting a gap in care for people with schizophrenia.

TABLE III.4. Cross-Cutting Concepts Considered, Specified, Tested, and Submitted
  Proposed Measure Concepts   Measures Specified &
  Tested in Focus Groups  
  Measures Tested  
in MAX Files
Measures Submitted
  for NQF Endorsement  
  1. Use of combination antipsychotic medication and psychosocial treatment.
  2. Outpatient follow-up visit after hospitalization.
  3. ED use.
  4. Continuous Medicaid enrollment.
  1. 7-day follow-up visit after mental health hospital discharge.
  2. 30-day follow-up after mental health hospital discharge.
  3. Any mental health ED use.
  4. Any ED use.
  1. 7-day follow-up visit after mental health hospital discharge.
  2. 30-day follow-up after mental health hospital discharge.
  3. Any mental health ED use.
  1. 7-day and 30-day follow-up visit after mental health hospital discharge.
  2. Any mental health ED use.

The use of combination antipsychotic medication and psychosocial treatment measure concept was dropped due to the inability to capture psychosocial treatments reliably through claims data.

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