eMeasure Title

Follow-Up Care for Children Prescribed ADHD Medication (ADD)

eMeasure Identifier (Measure Authoring Tool) 136 eMeasure Version number 7.1.000
NQF Number 0108 GUID 703cc49b-b653-4885-80e8-245a057f5ae9
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward National Committee for Quality Assurance
Measure Developer National Committee for Quality Assurance
Endorsed By National Quality Forum
Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care.  Two rates are reported.  
a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.
b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
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Measure Scoring Proportion
Measure Type Process
Risk Adjustment
Rate Aggregation
Attention-deficit hyperactivity disorder (ADHD) is one of the most prevalent behavioral health diseases in children. A National Survey of Children's Health study found that, in 2007, about 9.5% of children 4 to 17 years of age, or about 5.4 million, had a history of ADHD (CDC 2010). Of those 5.4 million children with a history of ADHD, 78% had a current diagnosis of ADHD at the time of the survey (CDC 2010) and 66.3% of those children were taking medication for the disorder (CDC 2010). A similar survey conducted in 2013 found that about 10% of American children age 3-17 have been diagnosed with ADHD (Bloom et al., 2013). ADHD also incurs substantial financial costs due to medical care and work loss costs for patients and families. The annual average direct cost per ADHD patient is $1,574 dollars compared to $541 dollars among similar individuals without ADHD (Swensen et al. 2003). Additionally, children with ADHD add a higher cost to the education system - on average $5,000 each year for each student with ADHD (Robb et al., 2011). 

There are many symptoms associated with ADHD. Children with ADHD may experience significant functional problems, such as school difficulties, academic underachievement, troublesome relationships with family members and peers and behavioral problems (American Academy of Pediatrics 2000). For instance, recent studies have found that parents whose children have a history of ADHD report significantly more peer problems and a higher rate of non-fatal injuries compared to parents whose children do not have a history of ADHD (Strine et al. 2006; Xiang et al. 2005). Additional studies suggest that there is an increased risk for drug use disorders in adolescents with untreated ADHD (National Institute on Drug Abuse, 2010). One of the national objectives of the Department of Health and Human Services Healthy People 2020 initiative is to increase the proportion of children with mental health problems who receive treatment.

Medication treatment has been found to be effective for managing ADHD, but treatment requires careful monitoring by physicians. Studies have shown that psychostimulants are highly effective for 75-90% of children with ADHD by reducing symptoms of hyperactivity, impulsivity and inattention; improving classroom performance and behavior; and promoting increased interaction with teachers, parents and peers (U.S. Department of Health and Human Services 1999). Some reported adverse effects of stimulant ADHD medications including appetite loss, abdominal pain, headaches, sleep disturbance, decreasing growth velocity, and less commonly, hallucinations and other psychotic symptoms (Wolraich et al. 2011). Therefore, it is important to assess the presence or absence of potential adverse effects before and after a stimulant drug is initiated (Smucker & Hedayat 2001). Monitoring adverse effects from ADHD medication allows physicians to suggest an optimal, alternative treatment. Studies have also shown that treating children with effective medication management can lead to substantially greater improvements in social skills and peer relations compared to children who are not effectively managed (Jensen et al. 2001). Finally, treatments for children with ADHD are frequently not sustained despite the fact that they are at greater risk of significant problems if they discontinue treatment (Wolraich et al. 2011). Effective management mitigates the risk of discontinuing treatment.
Clinical Recommendation Statement
American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment and Treatment of Children and Adolescents with ADHD

- Overall Guideline
The key to effective long-term management of the patient with ADHD is continuity of care with a clinician experienced in the treatment of ADHD. The frequency and duration of follow-up sessions should be individualized for each family and patient, depending on the severity of ADHD symptoms; the degree of comorbidity of other psychiatric illness; the response to treatment; and the degree of impairment in home, school, work, or peer-related activities. The clinician should establish an effective mechanism for receiving feedback from the family and other important informants in the patient's environment to be sure symptoms are well controlled and side effects are minimal. Although this parameter does not seek to set a formula for the method of follow-up, significant contact with the clinician should typically occur two to four times per year in cases of uncomplicated ADHD and up to weekly sessions at times of severe dysfunction or complications of treatment.

- Recommendation 6: A Well-Thought-Out and Comprehensive Treatment Plan Should Be Developed for the Patient With ADHD. The treatment plan should be reviewed regularly and modified if the patient's symptoms do not respond. Minimal Standard [MS]

- Recommendation 9. During a Psychopharmacological Intervention for ADHD, the Patient Should Be Monitored for Treatment-Emergent Side Effects. Minimal Standard [MS]

- Recommendation 12. Patients Should Be Assessed Periodically to Determine Whether There Is Continued Need for Treatment or If Symptoms Have Remitted. Treatment of ADHD Should Continue as Long as Symptoms Remain Present and Cause Impairment. Minimal Standard [MS]

American Academy of Pediatrics Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of ADHD in Children and Adolescents

- Action Statement 4: The primary care clinician should recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Management of children and youth with special health care needs should follow the principles of the chronic care model and the medical home. Grade B: Strong Recommendation
Improvement Notation
Higher score indicates better quality
American Academy of Pediatrics. 2000. "Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder." Pediatrics 105(5): 1158-70.
Bloom B, Jones LI, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2012. Vital Health Statistics 10: 1-81. U.S. Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, 2013. http://www.ncbi.nlm.nih.gov/pubmed/24784481 (December 2013)
Centers for Disease Control and Prevention. 2010. "Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children --- United States, 2003 and 2007." Morbidity and Mortality Weekly 59(44):1439-1443.
Jensen P, S.P. Hinshaw, J.M. Swanson et al. 2001. "Findings from the NIMH multimodal treatment study of ADHD (MTA): implications and applications for primary care providers." Journal of Developmental and Behavioral Pediatrics 22(1):60-73.
National Institute on Drug Abuse. 2010. Comorbidity: Addiction and Other Mental Illnesses. http://www.drugabuse.gov/publications/research-reports/comorbidity-addiction-other-mental-illnesses/how-common-are-comorbid-drug-use-other-mental-diso (September 2010)
Pliszka S, AACAP Work Group on Quality Issues. 2007. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry 46(7):894-921.
Robb, J.A., M.H. Sibley, W.E. Pelham, Jr., M.E. Foster, B.S.G. Molina, E.M. Gnagy, A.B. Kuriyan. 2011. The Estimated Annual Cost of ADHD to the US Education System. School Mental Health 3.3: 169-77. http://link.springer.com/article/10.1007/s12310-011-9057-6# (September 2011)
Smucker,W.D. & M. Hedayat et al. 2001. "Evaluation and Treatment of ADHD." American Family Physician 817-830.
Strine T.W., C.A. Lesesne, C.A. Okoro, L.C. McGuire, D. P. Chapman, L.S. Balluz, A.H. Mokdad. 2006. "Emotional and behavioral difficulties and impairments in everyday functioning among children with a history of attention-deficit/hyperactivity disorder." Preventing Chronic Disease 3(2):A52.
Swensen A.R., H.G. Birnbaum, K. Secnik, M. Marynchenko, P. Greenberg, A. Claxton. 2003. "Attention-deficit/hyperactivity disorder: increased costs for patients and their families." Journal of the American Academy of Child Adolescent Psychiatry 42(12):1415-23.
U.S. Department of Health and Human Services. 1999. "Mental Health: A Report of the Surgeon General." Last modified April 9, 2002. http://profiles.nlm.nih.gov/ps/retrieve/ResourceMetadata/NNBBHS
Wolraich M., L. Brown, R.T. Brown, G. DuPaul, M. Earls, H.M. Feldman, T.G. Ganiats, B. Kaplanek, B. Meyer, J. Perrin, K. Pierce, M. Reiff, M.T. Stein, S. Visser. 2011. "ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attentiondeficit/hyperactivity disorder in children and adolescents." Pediatrics 128(5):1007-22.
Xiang H., L. Stallones, G. Chen, S.G. Hostetler,K. Kelleher. 2005. "Nonfatal injuries among US children with disabling conditions. Opportunity for Improvement." American Journal of Public Health. 95(11):1970-5.
Intake Period: The five-month period starting 90 days prior to the start of the measurement period and ending 60 days after the start of the measurement period. 

Index Prescription Start Date (IPSD): The earliest prescription dispensing date for an ADHD medication where the date is in the Intake Period and an ADHD medication was not dispensed during the 120 days prior. 

Initiation Phase: The 30 days following the IPSD. 

Continuation and Maintenance Phase: The 31-300 days following the IPSD.
CUMULATIVE MEDICATION DURATION is an individual's total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed. 

To determine the cumulative medication duration, determine first the number of the medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.

For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was prescribed again for 60 days with 1 refill for 60 days. The cumulative medication duration is (30 x 3) + (60 x 2) = 210 days over the 10 month period.
Transmission Format
Initial Population
Initial Population 1: Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who had a visit during the measurement period.

Initial Population 2: Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who remained on the medication for at least 210 days out of the 300 days following the IPSD, and who had a visit during the measurement period.
Equals Initial Population
Denominator Exclusions
Denominator Exclusion 1: Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period.

Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 30 days after the IPSD. 

Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date. 

Exclude patients who were in hospice care during the measurement year.

Denominator Exclusion 2: Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period.

Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 300 days after the IPSD.

Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date.

Exclude patients who were in hospice care during the measurement year.
Numerator 1: Patients who had at least one face-to-face visit with a practitioner with prescribing authority within 30 days after the IPSD.
Numerator 2: Patients who had at least one face-to-face visit with a practitioner with prescribing authority during the Initiation Phase, and at least two follow-up visits during the Continuation and Maintenance Phase. One of the two visits during the Continuation and Maintenance Phase may be a telephone visit with a practitioner.
Numerator Exclusions
Not Applicable
Denominator Exceptions
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents

Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables

Measure Set