eMeasure Title Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
eMeasure Identifier
(Measure Authoring Tool)
177 eMeasure Version number 3
NQF Number 1365 GUID 848d09de-7e6b-43c4-bedd-5a2957ccffe3
Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Measure Developer American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Endorsed By National Quality Forum
Description
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
Copyright
Copyright 2013 American Medical Association. All Rights Reserved.
Disclaimer
Physician Performance Measures (Measures) and related data specifications have been developed by the American Medical Association (AMA) - convened Physician Consortium for Performance Improvement(R) (PCPI[R]). These 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, eg, 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, 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. 

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, the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications. 

CPT(R) contained in the Measure specifications is copyright 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
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.  According to a study analyzing the quality of health care in the United States, only about 25.8% of patients with depression had documentation of the presence or absence of suicidal ideation during the first or second diagnostic visit.  76.11% of those patients who have suicidality were asked if they have specific plans to carry out suicide.  A 2003 study reviewed medical records to assess the degree to which providers adhered to depression guidelines in a VA primary care setting.  Providers documented exploration for suicidal ideation in 57% of the records.
Clinical Recommendation Statement
The evaluation must include assessment for the presence of harm to self or others (MS).  (AACAP)

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)

A careful and ongoing evaluation of suicide risk is necessary for all patients with major depressive disorder (Category I).  Such an assessment includes specific inquiry about suicidal thoughts, intent, plans, means, and behaviors; identification of specific psychiatric symptoms (e.g., psychosis, severe anxiety, substance use) or general medical conditions that may increase the likelihood of acting on suicidal ideas; assessment of past and, particularly, recent suicidal behavior; delineation of current stressors and potential protective factors (e.g., positive reasons for living, strong social support); and identification of any family history of suicide or mental illness (Category I). (APA)
Improvement Notation
Higher score indicates better quality
Reference
American Academy of Child and Adolescent Psychiatry (AACAP). Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J. Am. Acad. Child Adolesc. Psychiatry, 2007;
46(11):1503-1526. Available at: http://www.aacap.org/galleries/PracticeParameters/Vol%2046%20Nov%202007.pdf.
Reference
Gelenberg AJ, Freeman MP, Markowitz JC, et al; American Psychiatric Association Work Group on Major Depressive Disorder.  Practice guideline for the treatment of patients with major depressive disorder.  3rd ed.  http://www.psychiatryonline.com/pracGuide/pracGuideTopic_7.aspx.  Published October 2010.  Accessed November 24, 2010.
Reference
Zimmerman M, Galione J. Psychiatrists' and Nonpsychiatrist Physicians' Reported Use of the DSM-IV Criteria for Major Depressive Disorder.  J Clin Psychiatry. 2010;71:235-238.
Reference
Dobscha SK, Gerrity MS, Corson K, Bahr A, Cuilwik NM. Measuring adherence to depression treatment guidelines in a VA primary care clinic. Gen Hosp Psychiatry. 2003;25:230-7.
Reference
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA.  The quality of health care delivered to adults in the United States. New England Journal of Medicine.  2003;348(26):2635-2645.
Definition
Numerator Definition: The specific type and magnitude of the suicide risk assessment is intended to be at the discretion of the individual clinician and should be specific to the needs of the patient.  Suicide risk assessment can include “specific inquiry about suicidal thoughts, intent, plans, means, and behaviors; identification of specific psychiatric symptoms (eg, psychosis, severe anxiety, substance use) or general medical conditions that may increase the likelihood of acting on suicidal ideas; assessment of past and, particularly, recent suicidal behavior; delineation of current stressors and potential protective factors (eg, positive reasons for living, strong social support); and identification of any family history of suicide or mental illness.”  “Low burden tools to track suicidal ideation and behavior such as the Columbia-Suicidal Severity Rating Scale can [also] be used.”
Guidance
A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period. 

This measure is an episode-of-care measure; the level of analysis for this measure is every visit for major depressive disorder during the measurement period. A minimum of two encounters are required during the measurement period for a patient to be included in this measure to establish that the eligible professional has an existing relationship with the patient; if the patient is only seen once by the eligible professional, the patient is not included in the measure. Once it has been established that the patient has been seen at least twice by the eligible professional, every visit for major depressive disorder should be counted as a measurable episode for the measure calculation. For example, at every visit for MDD, the patient should have a suicide risk assessment.

Use of a standardized tool or instrument to assess suicide risk will meet numerator performance.  Standardized tools can be mapped to the concept “Intervention, Performed: Suicide Risk Assessment” included in the numerator logic below.
Transmission Format
TBD
Initial Patient Population
All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder
Denominator
Equals Initial Patient Population
Denominator Exclusions
None
Numerator
Patient visits with an assessment for suicide risk
Numerator Exclusions
Not Applicable
Denominator Exceptions
None
Measure Population
Not Applicable
Measure Observations
Not Applicable
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 Data Elements)

Reporting Stratification

Supplemental Data Elements




Measure Set
None