Development of a Quality Measure for Adults with Post-Traumatic Stress Disorder. D. Selection of Measure Concept

05/01/2019

To further refine the list of potential measure concepts for consideration, the TAG completed a measure prioritization exercise in mid-March where each member was independently asked to rate each concept on a 1-9 rating scale, with 1-3 classified as low priority, 4-6 as moderate priority, and 7-9 as high priority for each of the four NQF criteria (importance, scientific acceptability, usability, and feasibility; see Section IV).[3] The TAG was asked to consider the availability of data, data collection burden, strength of the evidence supporting the concept, and saliency of the concept in prioritizing the concepts.

The TAG rated eight concepts as being of high importance; these included measures of psychotherapy, pharmacotherapy, screening for risk of suicide, and patient outcomes (Table II.2). Of these eight concepts, six were rated moderate feasibility and two ("receive at least eight sessions of CBT" and "receive CBT that includes specific components") were rated low feasibility. None of the concepts was rated high feasibility. As noted in Table II.2, the TAG rated the other concepts to be of moderate importance.

TABLE II.2. Summary of PTSD TAG Members' Prioritization of Measure Concepts
Priority* Ranking Concept Importance Mean (range) Scientific Acceptability Mean (range) Usability Mean (range) Feasibility Mean (range)
High priority
1 Screened for risk of suicide 7.75 (6-9) 6.86 (4-8) 8.00 (7-9) 6.00 (5-8)
2 In psychotherapy and receive at least 8 sessions of CBT 7.50 (7-9) 5.00 (1-8) 8.14 (7-9) 3.71 (1-7)
3 In psychotherapy and receive CBT that includes specific components 7.38 (4-9) 5.57 (1-8) 7.29 (7-9) 2.57 (1-5)
4 Symptoms improve over a period of time 7.29 (4-9) 7.00 (4-9) 8.14 (4-9) 5.71 (4-8)
5 Receive CBT or SSRIs 7.25 (5-9) 5.29 (3-8) 8.00 (6-9) 5.29 (3-8)
6 Symptoms are assessed at routine intervals 7.13 (5-9) 7.29 (6-8) 7.43 (7-9) 5.57 (4-8)
7 On medication and receive SSRIs 7.00 (5-9) 6.71 (2-9) 7.29 (5-9) 7.29 (5-9)
8 On medication who receive a 4-month dosage of SSRIs 7.00 (4-9) 6.14 (2-9) 7.57 (6-9) 6.71 (4-9)
Moderate Priority
9 In psychotherapy who receive CBT 6.88 (6-9) 4.00 (1-6) 7.29 (4-9) 3.57 (1-6)
10 Screened for depression 6.63 (4-9) 7.29 (6-8) 7.43 (5-9) 6.00 (4-7)
11 Functioning improves over a period of time 6.63 (4-9) 6.00 (2-8) 7.29 (5-9) 5.29 (3-7)
12 PTSD screened for substance abuse 6.50 (3-9) 6.86 (4-8) 7.86 (7-9) 5.00 (2-7)
13 Quality of life improves over a period of time 6.50 (4-9) 5.71 (2-8) 6.86 (5-9) 5.14 (3-7)
14 No improvement or a worsening of symptoms, and have a documented change in treatment approach 6.38 (2-9) 6.57 (3-8) 7.14 (4-9) 4.86 (4-7)
15 Assessed for sleep problems 6.38 (3-9) 6.86 (6-8) 7.57 (6-9) 5.00 (2-7)
16 Quality of life and functioning are assessed at routine intervals 6.38 (2-9) 5.71 (2-7) 7.14 (6-9) 4.71 (2-7)
17 Treatment options such as psychotherapy, medications, or a combination discussed 6.25 (3-9) 5.71 (3-7) 6.86 (5-9) 4.14 (2-7)
18 On medication and assessed regularly for medication side effects 6.13 (4-9) 6.57 (5-8) 7.14 (5-9) 3.71 (2-6)
19 Adults with documented comorbidities who have a documented care management/ coordination plan 6.00 (4-9) 5.29 (4-7) 6.57 (3-9) 4.29 (2-7)
20 Treatment preferences were considered 5.88 (3-9) 5.00 (3-7) 6.86 (5-9) 4.00 (2-6)
21 Needs for support services have been assessed 5.88 (2-9) 5.29 (2-7) 6.71 (4-9) 4.00 (2-7)
22 On medication who have a documented assessment of medication possession ratio (or other measure of medication adherence) 5.75 (1-9) 5.50 (3-7) 7.17 (6-9) 5.67 (2-8)
23 On multiple medications who have documentation of an assessment for potential drug interactions 5.63 (3-9) 6.57 (5-9) 6.57 (5-9) 4.14 (2-7)
24 Receive a referral and have documentation that the referral was followed up 5.63 (2-9) 5.57 (3-8) 6.71 (4-9) 4.43 (1-7)
25 Screened for pain 5.63 (3-9) 6.00 (2-7) 6.14 (2-9) 5.14 (2-7)
26 Receive care from more than 1 provider--that has been communicated to all providers 5.50 (2-9) 5.71 (2-7) 6.43 (3-9) 4.00 (1-7)
27 Assessed to determine if care management/care coordination is needed 5.50 (2-9) 5.50 (4-7) 6.33 (3-9) 4.00 (2-7)
28 Screened for glucose levels, lipids, high blood pressure 5.25 (3-7) 6.17 (2-9) 5.67 (2-8) 6.67 (5-8)
29 Receive antipsychotic medication 3.75 (2-8) 5.86 (2-8) 5.29 (3-8) 6.86 (4-8)
* Based upon the NQF "importance" criteria.

The TAG's identification of the eight priority measure concepts provided valuable information to inform a discussion between Mathematica, ASPE, and NIMH regarding the subsequent direction and focus of the project. Together, we selected the "delivery of evidence-based psychotherapy" concept for development and specification. This decision was influenced by the strength of the evidence regarding CBTs as the recommended first line of treatment for adults with PTSD, as well as the limited national data on the quality of psychotherapy treatment. This gap provides ASPE and NIMH the opportunity to not only advance the state of knowledge regarding the quality of psychotherapy delivered to individuals with PTSD, but also inform the broader mental health and quality improvement fields in approaches to measuring quality of psychotherapy for other mental disorders.