Child and Adolescent Major Depressive Disorder Physician Performance Measurement Set

Transcription

1 Physician Consortium for Performance Improvement (PCPI) Child and Adolescent Major Depressive Disorder Physician Performance Measurement Set PCPI Approved September 2008 Child and Adolescent Major Depressive Disorder Work Group Richard Hellman, MD, FACP, FACE (co-chair) (methodologist; clinical endocrinology) John Oldham, MD (co-chair) (psychiatry) Boris Birmaher, MD (child/adolescent psychiatry) Mary Dobbins, MD, FAAP (pediatrics/psychiatry) Scott Endsley, MD, MSc (family medicine) William E. Golden, MD, FACP (internal medicine) Margaret L. Keeler, MD, MS, FACEP (emergency medicine) Louis J. Kraus, MD (child/adolescent psychiatry) Laurent S. Lehmann, MD (psychiatry) Karen Pierce, MD (child/adolescent psychiatry) Reed E. Pyeritz, MD, PhD, FACP, FACMG (medical genetics) Laura Richardson, MD, MPH (internal medicine/pediatrics) Sam J.W. Romeo, MD, MBA (family medicine) Carl A. Sirio, MD (critical care medicine) Sharon Sweede, MD (family medicine) Scott Williams, PsyD (The Joint Commission) American Medical Association Heidi Bossley, MSN, MBA Joseph Gave, MPH Karen Kmetik, PhD Shannon Sims, MD, PhD Samantha Tierney, MPH American Psychiatric Association Robert Plovnick, MD, MS National Committee for Quality Assurance Phil Renner, MBA Consultants Timothy Kresowik, MD Rebecca Kresowik

2 Physician Performance Measures (Measures) and related data specifications are developed by the American Medical Association (AMA) in collaboration with the Physician Consortium for Performance Improvement (PCPI). 2 These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA, (on behalf of the PCPI). Neither the AMA, the PCPI nor its members shall be responsible for any use of the Measures. THE MEASURES AND SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND American Medical Association. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, NCQA, the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other coding contained in the specifications. CPT contained in the Measures specifications is copyright 2007 American Medical Association. LOINC copyright 2004 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT ) copyright 2004 College of American Pathologists (CAP). All Rights Reserved. Use of SNOMED CT is only authorized within the United States.

3 Purpose of the Measures: These clinical performance measures, developed by the Physician Consortium for Performance Improvement (PCPI), are designed for individual quality improvement. Unless otherwise indicated, the measures are also appropriate for accountability if appropriate methodological, statistical, and implementation rules are achieved. Accountability Measures: Measure#1: Interview of Adolescent or Child Measure#2: Diagnostic Evaluation Measure#3: Suicide Risk Assessment Measure#4: Psychotherapy Measure#5: Medications Considered Measure#6: Follow-Up Care Intended Audience and Patient Population These measures are designed for use by physicians and for calculating reporting or performance measurement at the individual physician level. When existing hospital-level or plan-level measures are available for the same measurement topics, the PCPI attempts to harmonize the measures to the extent feasible. These measures are designed for any physician who manages the ongoing care of patients aged 6 through 17 years with a diagnosis of major depressive disorder (MDD). The PCPI also encourages the use of these measures by eligible health professionals, where appropriate. Measure Specifications The PCPI seeks to specify measures for implementation using multiple data sources, including paper medical record, administrative (claims) data, and particular emphasis on Electronic Health Record Systems (EHRS). Specifications to report on these measures for Child and Adolescent Major Depressive Disorder using administrative (claims) data are included in this document. We have identified codes for these measures, including ICD-9 and CPT (Evaluations & Management Codes, Category I and where Category II codes would apply). Specifications for additional data sources, including EHRS, will be fully developed at a later date. Measure Exclusions For process measures, the PCPI provides three categories of reasons for which a patient may be excluded from the denominator of an individual measure: Medical reasons Includes: -not indicated (already received/performed, other) -contraindicated (patient allergic history, potential adverse drug interaction, other) Patient reasons Includes: -patient declined -economic, social, or religious reasons -other patient reasons System reasons Includes: -resources to perform the services not available -insurance coverage/payor-related limitations -other reasons attributable to health care delivery system 2008 American Medical Association. All Rights Reserved. 3

4 These measure exclusion categories are not available uniformly across all measures; for each measure, there must be a clear rationale to permit an exclusion for a medical, patient, or system reason. The exclusion of a patient may be reported by appending the appropriate modifier to the CPT Category II code designated for the measure: Medical reasons: modifier 1P Patient reasons: modifier 2P System reasons: modifier 3P Although this methodology does not require the external reporting of more detailed exclusion data, the PCPI recommends that physicians document the specific reasons for exclusion in patients medical records for purposes of optimal patient management and audit-readiness. The PCPI also advocates the systematic review and analysis of each physician s exclusions data to identify practice patterns and opportunities for quality improvement. For example, it is possible for implementers to calculate the percentage of patients that physicians have identified as meeting the criteria for exclusion. Please refer to documentation for each individual measure for information on the acceptable exclusion categories and the codes and modifiers to be used for reporting. Measures #1-6 in the Child and Adolescent Major Depressive Disorder measurement set are process measures. For outcome measures, the PCPI specifically identifies all acceptable exclusion reasons for which a patient may be excluded from the denominator. Each specified reason is reportable with a CPT Category II code designated for that purpose. There are no outcome measures in the Child and Adolescent Major Depressive Disorder measurement set. The PCPI continues to evaluate and likely will evolve its methodology for handling exclusions as it gains experience in the use of the measures. Data Capture and Measure Calculation The PCPI intends for physicians to collect data on each patient eligible for a measure. Feedback on measures should be available to physicians by patient to facilitate patient management and in aggregate to identify opportunities for improvement across a physician's patient population. Measure calculations will differ depending on whether a rate is being calculated for performance or reporting purposes. The method of calculation for performance follows these steps: first, identify the patients who meet the eligibility criteria for the denominator (PD); second, identify which of those patients meet the numerator criteria (A); and third, for those patients who do not meet the numerator criteria, determine whether an appropriate exclusion applies and subtract those patients from the denominator (C). (see examples below) The methodology also enables implementers to calculate the rates of patient exclusions and to further analyze both low and high rates, as appropriate (see examples below). The method of calculation for reporting differs. One program which currently focuses on reporting rates is the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI). Currently, under that program design, there will be a reporting denominator determined solely from claims data (CPT and ICD-9), which in some cases result in a reporting denominator that is much larger than the eligible population for the performance denominator. Additional components of the reporting denominator are explained below American Medical Association. All Rights Reserved. 4

5 The components that make up the numerator for reporting include all patients from the eligible population for which the physician has reported, including: the number of patients who meet the numerator criteria (A), the number of patients for whom valid exclusions apply (C) and also the number of patients who do not meet the numerator criteria (D). These components, where applicable, are summed together to make up the inclusive reporting numerator. The calculation for reporting will be the reporting numerator divided by the reporting denominator. (see examples below). Examples of calculations for reporting and performance are provided for each measure. Calculation for Performance For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator, Denominator, and Denominator Exclusions. Numerator (A) Includes: Number of patients meeting numerator criteria Performance Denominator (PD) Includes: Number of patients meeting criteria for denominator inclusion Denominator Exclusions (C) Include: Number of patients with valid medical, patient or system exclusions (where applicable; will differ by measure) Performance Calculation A (# of patients meeting numerator criteria) PD (# patients in denominator) C (# patients with valid denominator exclusions) It is also possible to calculate the percentage of patients excluded overall, or excluded by medical, patient, or system reason where applicable: Overall Exclusion Calculation C (# of patients with any valid exclusion) PD (# patients in denominator) OR Exclusion Calculation by Type C1 (# patients with medical reason) PD (# patients in denominator) C2 (# patients with patient reason) PD (# patients in denominator) C3 (# patients with system reason) PD (# patients in denominator) Calculation for Reporting For reporting purposes, this measure is calculated by creating a fraction with the following components: Reporting Numerator and Reporting Denominator 2008 American Medical Association. All Rights Reserved. 5

6 Reporting Numerator includes each of the following components, where applicable. (There may be instances where there are no patients to include in A, C, D, or E). A. Number of patients meeting additional denominator criteria (for measures where true denominator cannot be determined through ICD-9 and CPT Category I coding alone) AND numerator criteria C. Number of patients with valid medical, patient or system exclusions (where applicable; will differ by measure) D. Number of patients not meeting numerator criteria and without a valid exclusion E. All other patients not meeting additional denominator criteria (for measures where true denominator cannot be determined through ICD-9 and CPT Category I coding alone) Reporting Denominator (RD) Includes: RD. Denominator criteria (identifiable through ICD-9 and CPT Category I coding) Reporting Calculation A(# of patients meeting additional denominator criteria AND numerator criteria) + C(# of patients with valid exclusions) + D(# of patients NOT meeting numerator criteria) + E(# of patients not meeting additional denominator criteria) RD (# of patients in denominator) 2008 American Medical Association. All Rights Reserved. 6

7 Child and Adolescent Major Depressive Disorder Measure #1: Interview of Adolescent or Child This measure may be used as an Accountability measure. Clinical Performance Measure Numerator: Patients who were interviewed directly by the evaluating clinician on or before the date of diagnosis Denominator: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Denominator Exclusions: None Measure: Percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder who were interviewed directly by the evaluating clinician on or before the date of diagnosis The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure: The evaluation should include direct interviews with the child and parents/caregivers and, ideally, with the adolescent alone. (AACAP 1 ) The clinical interview of the child provides the setting for the direct exploration of the child's own perceptions of the presenting problem and the assessment of the child's overall developmental and mental status the direct interview with the child provides information that may not be available from other sources, for example, the degree of the child's personal suffering, information concerning affects and mental phenomena which may not be observable (e.g., anxiety, suicidal thoughts, obsessional thoughts, hallucinations), and secrets such as antisocial activities or sexual abuse. (AACAP 2 ) If the screening indicates significant depressive symptomatology, the clinician should perform a thorough evaluation to determine the presence of depressive and other comorbid psychiatric and medical disorders [MS]. Since most children and adolescents presenting to treatment are experiencing their first episode of depression, it is difficult to differentiate whether their depression is part of unipolar major depression or the depressive phase of bipolar disorder. Certain indicators such as high family loading for bipolar disorder, psychosis, and history of pharmacologically-induced mania or hypomania may herald the development of bipolar disorder. (AACAP 1 ) Rationale for the measure: A clinical interview with the child or adolescent is recommended as an essential element to diagnose depression. Furthermore, treatment outcomes are significantly better when the informant [is] the youngster when compared with their parents. 1 Data capture and calculations: Note: The interview is intended to be performed at the time of diagnosis. However, for use in certain implementation programs, this measure would need to be reported a minimum of once per reporting period, regardless of when the interview is performed. Calculation for Performance For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator and Denominator. There are no allowable exclusions for this measure American Medical Association. All Rights Reserved. 7

8 Numerator (A) Includes: Patients who were interviewed directly by the evaluating clinician on or before the date of diagnosis Denominator (PD) Includes: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Performance Calculation A (# of patients meeting measure criteria) PD (# of patients in denominator) Components for this measure are defined as: A PD # of patients who were interviewed directly by the evaluating clinician on or before the date of diagnosis # of patients aged 6 through 17 years with a diagnosis of major depressive disorder Calculation for Reporting For reporting purposes, this measure is calculated by creating a fraction with the following components: Reporting Numerator and Reporting Denominator Reporting Numerator includes each of the following instances: A. Patients who were interviewed directly by the evaluating clinician on or before the date of diagnosis D. Patients who were not interviewed directly by the evaluating clinician on or before the date of diagnosis Reporting Denominator (RD) Includes: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Reporting Calculation A(# of patients meeting numerator criteria ) + D(# of patients NOT meeting numerator criteria) RD (# of patients in denominator) Components for this measure are defined as: A # of patients who were interviewed directly by the evaluating clinician on or before the date of diagnosis D # of patients who were not interviewed directly by the evaluating clinician on or before the date of diagnosis RD # of patients aged 6 through 17 years with a diagnosis of major depressive disorder 2008 American Medical Association. All Rights Reserved. 8

9 Measure Specifications Measure #1: Interview of Adolescent or Child Measure specifications will be provided for multiple data sources. A. Administrative claims data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. (Note: The specifications listed below are those needed for performance calculation.) Denominator (Eligible Population): All patients aged 6 through 17 years with a diagnosis of major depressive disorder ICD-9 diagnosis codes: , , , , (MDD single episode); , , , , (MDD recurrent episode) AND CPT service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90847, 90853, 90857, 90862, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, Denominator Exclusion: None Numerator: Patients who were interviewed directly by the evaluating clinician on or before the date of diagnosis Report the CPT Category II code (in development) designated for this numerator: XXXXF B. Electronic Health Record System (in development) C. Paper Medical Record (in development) 2008 American Medical Association. All Rights Reserved. 9

10 Child and Adolescent Major Depressive Disorder Measure #2: Diagnostic Evaluation This measure may be used as an Accountability measure. Clinical Performance Measure Numerator: Patients with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified Denominator: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Denominator Exclusions: None Measure: Percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified Definition: The criteria for a MDD episode includes five (or more) of nine specific symptoms: - depressed mood (Note: in children and adolescents, can be irritable mood) - marked diminished interest/pleasure; - significant weight loss or gain; (Note: in children, consider failure to make expected weight gains) - insomnia or hypersomnia; - psychomotor agitation/ retardation; - fatigue or lost of energy; - feelings of worthlessness; - diminished ability to concentrate; and - recurrent suicidal ideation which have been present during the same two-weeks period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure. Note: The essential feature of a major depressive disorder is a period of at least two weeks during which there is either depressed mood or irritability or the loss of interest or pleasure in nearly all activities. In children and adolescents, can be irritable or cranky mood. The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure: A comprehensive psychiatric diagnostic evaluation is the single most useful tool currently available to diagnose depressive disorders. (AACAP 1 ) Patients with major depressive disorder symptoms should receive a thorough diagnostic evaluation to 1) confirm the diagnosis of a major depressive disorder and 2) reveal the presence of other psychiatric or general medical conditions. (APA 3 ) The criteria for a major depressive disorder episode include five (or more) of nine specific symptoms which have been present during the same two-week period and represent a change from previous functioning; at least one of the 2008 American Medical Association. All Rights Reserved. 10

11 symptoms is either 1) depressed mood or 2) loss of interest or pleasure. In addition, these symptoms do not meet criteria for a mixed episode (e.g., criteria for both a manic episode and for major depressive order are exhibited nearly daily). The symptoms cause clinically significant distress or impairment in social, occupations, or other important areas of functioning. The symptoms are not due to the direct physiological effects of a substance or general medical condition. The symptoms are not due to bereavement and they persist longer than two months. The symptoms may be characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. (DSM-IV 4 ) In children and adolescents, an irritable or cranky mood may develop rather than a sad or dejected mood. (DSM-IV 4 ) Rationale for the measure: Depression in children and adolescents is often underdiagnosed; one-quarter to one-half of all cases of major depressive disorders are estimated to be properly recognized by primary care and non-psychiatric practitioners. 5,6,7 Thorough assessment of depressive symptoms sets the basis for accurate diagnosis and treatment of major depressive disorder. Data capture and calculations: Note: The diagnostic evaluation is intended to be performed at the time of diagnosis. However, for use in certain implementation programs, this measure would need to be reported a minimum of once per reporting period, regardless of when the diagnostic evaluation is performed. Calculation for Performance For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator, and Denominator. There are no allowable denominator exclusions for this measure. Numerator (A) Includes: Patients with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified Denominator (PD) Includes: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Performance Calculation A (# of patients meeting measure criteria) PD (# of patients in denominator) Components for this measure are defined as: A PD # of patients with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified # of patients aged 6 through 17 years with a diagnosis of major depressive disorder 2008 American Medical Association. All Rights Reserved. 11

12 Calculation for Reporting For reporting purposes, this measure is calculated by creating a fraction with the following components: Reporting Numerator and Reporting Denominator Reporting Numerator includes each of the following instances: A. Patients with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified D. Patients without documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified Reporting Denominator (RD) Includes: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Reporting Calculation A(# of patients meeting numerator criteria ) + D(# of patients NOT meeting numerator criteria) + RD (# of patients in denominator) Components for this measure are defined as: A # of patients with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified D # of patients without documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified RD # of patients aged 6 through 17 years with a diagnosis of major depressive disorder 2008 American Medical Association. All Rights Reserved. 12

13 Measure Specifications Measure #2: Diagnostic Evaluation Measure specifications will be provided for multiple data sources. A. Administrative claims data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. (Note: The specifications listed below are those needed for performance calculation.) Denominator (Eligible Population): All patients aged 6 through 17 years with a diagnosis of major depressive disorder ICD-9 diagnosis codes: , , , , (MDD single episode); , , , , (MDD recurrent episode) AND CPT service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90847, 90853, 90857, 90862, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, Denominator Exclusion: None Numerator: Patients with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified Report the CPT Category II code 1040F: Criteria for MDD documented B. Electronic Health Record System (in development) C. Paper Medical Record (in development) 2008 American Medical Association. All Rights Reserved. 13

14 Child and Adolescent Major Depressive Disorder Measure #3: Suicide Risk Assessment This measure may be used as an Accountability measure. Clinical Performance Measure Numerator: Patient visits with an assessment for suicide risk Denominator: All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder Denominator Exclusions: None Measure: Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure: The evaluation must include assessment for the presence of harm to self or others (MS). (AACAP 1 ) Suicidal behavior exists along a continuum from passive thoughts of death to a clearly developed plan and intent to carry out that plan. Because depression is closely associated with suicidal thoughts and behavior, it is imperative to evaluate these symptoms at the initial and subsequent assessments. For this purpose, low burden tools to track suicidal ideation and behavior such as the Columbia-Suicidal Severity Rating Scale can be used. Also, it is crucial to evaluate the risk (e.g., age, sex, stressors, comorbid conditions, hopelessness, impulsivity) and protective factors (e.g., religious belief, concern not to hurt family) that might influence the desire to attempt suicide. The risk for suicidal behavior increases if there is a history of suicide attempts, comorbid psychiatric disorders (e.g., disruptive disorders, substance abuse), impulsivity and aggression, availability of lethal agents (e.g., firearms), exposure to negative events (e.g., physical or sexual abuse, violence), and a family history of suicidal behavior. (AACAP 1 ) The American Psychiatric Association recommends that psychiatric management include an evaluation of the safety of the patient and others. The components of an evaluation for suicide risk should include 1) an assessment of the presence of suicidal or homicidal ideation, intent, or plans, 2) access to means for suicide and the lethality of those means, 3) presence of psychotic symptoms, command hallucinations, or severe anxiety, 4) presence of alcohol or substance use, 5) history and seriousness of previous attempts, and 6) family history or recent exposure to suicide. (APA 3 ) Rationale for the measure: Research has shown that patients with major depressive disorder are at a high risk for suicide, which makes this assessment an important aspect of care that should be assessed at each visit American Medical Association. All Rights Reserved. 14

15 Data capture and calculations: Calculation for Performance For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator and Denominator. Numerator (A) Includes: Patient visits with an assessment for suicide risk Denominator (PD) Includes: All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder Performance Calculation A (# of patient visits meeting measure criteria) PD (# of patient visits in denominator) Components for this measure are defined as: A PD # of patient visits with an assessment for suicide risk # of patient visits for those patients aged 6 through 17 years with a diagnosis major depressive disorder Calculation for Reporting For reporting purposes, this measure is calculated by creating a fraction with the following components: Reporting Numerator and Reporting Denominator Reporting Numerator includes each of the following instances: A. Patient visits with an assessment for suicide risk D. Patients visits without an assessment for suicide risk Reporting Denominator (RD) Includes: All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder Reporting Calculation A(# of patient visits meeting numerator criteria ) + D(# of patient visits NOT meeting numerator criteria) RD (# of patient visits in denominator) 2008 American Medical Association. All Rights Reserved. 15

16 Components for this measure are defined as: A # of patient visits with an assessment for suicide risk D # of patients visits without an assessment for suicide risk RD # of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder 2008 American Medical Association. All Rights Reserved. 16

17 Measure Specifications Measure #3: Suicide Risk Assessment Measure specifications will be provided for multiple data sources. A. Administrative claims data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. (Note: The specifications listed below are those needed for performance calculation.) Denominator (Eligible Population): All patients aged 6 through 17 years with a diagnosis of major depressive disorder ICD-9 diagnosis codes: , , , , (MDD single episode); , , , , (MDD recurrent episode) AND CPT service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90847, 90853, 90857, 90862, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, Numerator: Patient visits with an assessment for suicide risk Report the CPT Category II code 3085F: Suicide risk assessed Denominator Exclusion: None B. Electronic Health Record System (in development) C. Paper Medical Record (in development) 2008 American Medical Association. All Rights Reserved. 17

18 Child and Adolescent Major Depressive Disorder Measure #4: Psychotherapy This measure may be used as an Accountability measure. Clinical Performance Measure Numerator: Patients who received or were referred for psychotherapy during an episode of major depressive disorder Denominator: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Denominator Exclusions: Documentation of medical reason(s) for not providing or referring for psychotherapy Documentation of patient reason(s) for not providing or referring for psychotherapy (includes family reasons) Documentation of system reason(s) for not providing or referring for psychotherapy (eg, psychotherapy not regionally available) Measure: Percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder who received or were referred for psychotherapy during an episode of major depressive disorder The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure: Each phase of treatment should include psychoeducation, supportive management, and family and school involvement (MS) all subjects require supportive psychotherapeutic management, which may include active listening and reflection, restoration of hope, problem solving, coping skills, and strategies for maintaining participation in treatment. (AACAP 1 ) Education, support, and case management appear to be sufficient treatment for the management of depressed children and adolescents with an uncomplicated or brief depression or with mild psychosocial impairment (CG). (AACAP 1 ) For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated (CG). (AACAP 1 ) Rationale for the measure: Although psychotherapy is recommended for children and adolescents with a diagnosis of major depressive disorder, research has indicated that it is currently underutilized and declining in use. In , approximately 68% of children and adolescents being treated for major depressive disorder received psychotherapy or mental health counseling, a 15% decrease from 6 years earlier. 8 Data capture and calculations: Note: The measure is intended to be performed once during an episode of major depressive disorder. In a claims based implementation program, the measure will need to be reported once during each 12 month reporting period if there is a patient visit for MDD, regardless of when the decision to provide or refer for psychotherapy is performed. Calculation for Performance 2008 American Medical Association. All Rights Reserved. 18

19 For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator, Denominator, and Denominator Exclusions. Numerator (A) Includes: Patients who received or were referred for psychotherapy Denominator (PD) Includes: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Denominator Exclusions (C) Include: Documentation of medical reason(s) for not providing or referring for psychotherapy Documentation of patient reason(s) for not providing or referring for psychotherapy (includes family reasons) Documentation of system reason(s) for not providing or referring for psychotherapy (eg, psychotherapy not regionally available) Performance Calculation A (# of patients meeting measure criteria) PD (# of patients in denominator) C (# of patients with valid denominator exclusions) Components for this measure are defined as: A PD C # of patients who received or were referred for psychotherapy # of patients aged 6 through 17 years with a diagnosis of major depressive disorder # of patients with documented medical reason(s) for not providing or referring for psychotherapy or documented patient reason(s) for not providing or referring for psychotherapy or documented system reason(s) for not providing or referring for psychotherapy Calculation for Reporting For reporting purposes, this measure is calculated by creating a fraction with the following components: Reporting Numerator and Reporting Denominator Reporting Numerator includes each of the following instances: A. Patients who received or were referred for psychotherapy C. Patients who did not receive or were not referred for psychotherapy but for whom there is a documented medical reason, documented patient reason, or documented system for not doing so D. Patients with who did not receive or were not referred for psychotherapy and there is no documented medical, patient, or system reason for not doing so Reporting Denominator (RD) Includes: Patients aged 6 through 17 years with a diagnosis of major depressive disorder Reporting Calculation 2008 American Medical Association. All Rights Reserved. 19

20 A(# of patients meeting numerator criteria ) + C(# of patients with valid exclusions) + D(# of patients NOT meeting numerator criteria) RD (# of patients in denominator) Components for this measure are defined as: A # of patients who received or were referred for psychotherapy C # of patients who did not receive or were not referred for psychotherapy but for whom there is a documented medical reason or documented patient reason for not doing so D # of patients who did not receive or were not referred for psychotherapy and there is no documented medical reason or patient reason for not doing so RD # of patients aged 6 through 17 years with a diagnosis of major depressive disorder 2008 American Medical Association. All Rights Reserved. 20

21 Measure Specifications Measure #4: Psychotherapy Measure specifications will be provided for multiple data sources. A. Administrative claims data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. (Note: The specifications listed below are those needed for performance calculation.) Denominator (Eligible Population): All patients aged 6 through 17 years with a diagnosis of major depressive disorder ICD-9 diagnosis codes: , , , , (MDD single episode); , , , , (MDD recurrent episode) AND CPT service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90847, 90853, 90857, 90862, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, Denominator Exclusion: Documentation of medical reason(s), patient reason(s), or system reason(s) for not providing or referring for psychotherapy Report CPT Category II codes 4060F-1P, 4062F-1P (medical reason(s)): 4060F-2P, 4062F-2P (patient reason(s)): 4060F-3P, 4062F-3P (system reason(s)) Numerator: Patients who received or were referred for psychotherapy during an episode of major depressive disorder Report the CPT Category II code 4060F: Psychotherapy services provided OR 4062F: Patient referral for psychotherapy documented B. Electronic Health Record System (in development) C. Paper Medical Record (in development) 2008 American Medical Association. All Rights Reserved. 21

22 Child and Adolescent Major Depressive Disorder Measure #5: Medications Considered This measure may be used as an Accountability measure. Clinical Performance Measure Numerator: Patients for whom an antidepressant medication was considered* or prescribed during an episode of major depressive disorder * The numerator criteria will be met if an antidepressant medication was either prescribed or there is documentation that the antidepressant medication was not prescribed for documented reasons. Denominator: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Denominator Exclusions: None Measure: Percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder for whom an antidepressant medication was considered or prescribed during an episode of major depressive disorder Note: The Food and Drug Administration (FDA) has now made a black box cautionary statement for SSRIs secondary to studies which reported increased suicidal ideations in newly treated children and adolescents with major depressive order. It should be noted that no suicides by children or adolescents were reported within these studies. The TADS study 9 reported that fluoxetine with cognitive behavioral therapy led to significant improvement in 71% of adolescent patients without an increase in suicidal ideations. In addition, fluoxetine continues to have formal FDA approval for treating depression in the pediatric population. All treatments can be associated with side effects. Approximately 3% to 8% of youth, particularly children, also may show increased impulsivity, agitation, irritability, silliness, and behavioral activation. 1 A careful weighing of the risks and benefits, with appropriate follow-up to help reduce risks, is the best that can be currently recommended. 10 The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure: For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated (CG). (AACAP 1 ) It is important to evaluate carefully for the presence of subtle or short-duration hypomanic symptoms because these symptoms often are overlooked, and these children and adolescents may be more likely to become manic when treated with antidepressant medications. Those with a family history of bipolar disorder should be carefully monitored for onset of mania or mixed state. (AACAP 1 ) 2008 American Medical Association. All Rights Reserved. 22

23 Rationale for the measure: As a result of the recent FDA warnings regarding the possible suicide risk with antidepressant use in children and adolescents, prescriptions for antidepressants in children age years decreased by 10-16% in This decline in use contrasts with a 50% increase between 1998 and One recent study found that the decreased use of antidepressants was associated with an increase in suicide rates by 14% between 2003 and 2004, which is the largest year-to-year change in suicide rates in this population since the Centers for Disease Control and Prevention began systematically collecting suicide data in Given the greater number of patients who benefit from selective serotonin reuptake inhibitors (SSRI) than who experience serious adverse events, the lack of any completed suicides, and the decline in overall suicidality on rating scales, the risk benefit ratio for SSRI use in pediatric depression appears to be favorable, with careful monitoring. 1 As a result, the need for antidepressants should be considered on an individual basis with children and adolescents with major depressive disorders. Antidepressant medications are recommended for those who have a more complicated or severe depression. Data capture and calculations: Note: The measure is intended to be performed once during an episode of major depressive disorder. In a claims based implementation program, the measure will need to be reported once during each 12 month reporting period if there is a patient visit for MDD, regardless of when the consideration for antidepressant therapy is performed. Calculation for Performance For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator and Denominator. There are no allowable denominator exclusions for this measure. Numerator (A) Includes: Patients for whom an antidepressant medication was considered or prescribed Denominator (PD) Includes: All patients aged 6 through 17 years with a diagnosis of major depressive disorder Performance Calculation A (# of patients meeting measure criteria) PD (# of patients in denominator) Components for this measure are defined as: A PD # of patients for whom an antidepressant medication was considered or prescribed # of patient aged 6 through 17 years with a diagnosis of major depressive disorder Calculation for Reporting For reporting purposes, this measure is calculated by creating a fraction with the following components: Reporting Numerator and Reporting Denominator Reporting Numerator includes each of the following instances: A. Patients for whom an antidepressant medication was considered or prescribed D. Patients for whom an antidepressant medication was not considered nor prescribed Reporting Denominator (RD) Includes: Patients aged 6 through 17 years with a diagnosis of major depressive disorder 2008 American Medical Association. All Rights Reserved. 23

24 Reporting Calculation A(# of patients meeting numerator criteria ) + D(# of patients NOT meeting numerator criteria) RD (# of patients in denominator) Components for this measure are defined as: A # of patients for whom an antidepressant medication was considered or prescribed D # of patients for whom an antidepressant medication was not considered nor prescribed RD # of patients aged 6 through 17 years with a diagnosis of major depressive disorder 2008 American Medical Association. All Rights Reserved. 24

25 Measure Specifications Measure #5: Medications Considered Measure specifications will be provided for multiple data sources. A. Administrative claims data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. (Note: The specifications listed below are those needed for performance calculation.) Denominator (Eligible Population): All patients aged 6 through 17 years with a diagnosis of major depressive disorder ICD-9 diagnosis codes: , , , , (MDD single episode); , , , , (MDD recurrent episode) AND CPT service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90847, 90853, 90857, 90862, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, Denominator Exclusion: None Numerator: Patients for whom an antidepressant medication was considered or prescribed during an episode of major depressive disorder Report the CPT Category II code (in development) designated for this numerator: XXXXF B. Electronic Health Record System (in development) C. Paper Medical Record (in development) 2008 American Medical Association. All Rights Reserved. 25

26 Child and Adolescent Major Depressive Disorder Measure #6: Follow-Up Care This measure may be used as an Accountability measure. Clinical Performance Measure Numerator: Patient visits with a plan for follow-up care documented Denominator: All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder Denominator Exclusions: None Measure: Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with a plan for follow-up care documented The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure: During all treatment phases, clinicians should arrange frequent follow-up contacts that allow sufficient time to monitor the subject s clinical status, environmental conditions, and, if appropriate, medication side effects (MS). (AACAP 1 ) It is recommended that all patients receiving [antidepressants] be carefully monitored for suicidal thoughts and behavior, as well as other side effects thought to be possibly associated with increased suicidality, particularly during the first weeks of treatment. The FDA recommends that depressed youth should be seen every week for the first 4 weeks and biweekly thereafter. However, it is not always possible to schedule weekly face-to-face appointments. In this case, evaluations should be briefly carried out by phone, but it is important to emphasize that there is no data to suggest that the monitoring schedule proposed by the FDA or telephone calls have any impact on the risk of suicide. Monitoring is important for all patients, but patients at increased risk for suicide (e.g., those with current or prior suicidality, impulsivity, substance abuse, history of sexual abuse, family history of suicide) should be scrutinized particularly closely. (AACAP 1 ) The treatment of depressive disorders should always include an acute and continuation phase. Some children may also require maintenance treatment (MS). (AACAP 1 ) To consolidate the response to the acute treatment and avoid relapses, treatment should always be continued for 6 to 12 months (MS). (AACAP 1 ) Rationale for the measure: Given the high drop-out rate among children and adolescents who begin treatment, it is critical that a plan be established to continue and monitor treatment. 13 Data capture and calculations: Calculation for Performance For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator, Denominator, and Denominator Exclusions. Numerator (A) Includes: Patient visits with a plan for follow up care documented 2008 American Medical Association. All Rights Reserved. 26