1. We assume this measure is intended for use by pediatricians, and not mental health specialty care providers. Granted this will seemingly improve access to care, and more children will be prescribed stimulants, which is a good thing from the perspective of more mental health problems being treated at an early age. However, a negative unintended consequence of this measure is the likelihood of the patient receiving the correct diagnosis of ADHD.
2. We question the measure's exclusion criteria, particularly in light of concerns that the correct diagnosis of ADHD is made. Considering the conditions included in the exclusion criteria share similar symptoms with ADHD, are the appropriate patients being included in this quality measure, and therefore illustrating accurate clinician performance as it relates to this patient population? Further, who is specified to make the diagnoses outlined in the measure exclusions. While there is guidance by the AAP for pediatricians to follow for the diagnosis and treatment of patients with ADHD, the diagnostic accuracy of measure excluded conditions, like Bipolar Disorder, are reduced.
3. This measure omits the action responsible for achieving symptom reduction. What is the benefit of this measure in an accountability program or internal quality improvement program? What would an outcome measure that does not explicitly examine the outcomes resulting from a specific treatment illustrate about the quality of care provided? Also, how can a physician’s office use the findings to enact quality improvement, if they don’t know what to improve?
4. The 12-month maximum range in time between the initial patient diagnostic visit and the follow-up visit presents a wide range of variability. Given that this measure evaluates screenings completed by classroom teachers, much could be said about the possibility for diminished validity and reliability of the information reported because educational quality (e.g., unique teacher traits like patience and experience; class size; classroom set up; available student accommodations; etc.) can alter from one school year to the next. It might be feasible to measure this directly in relation to the school year since it is about academic performance, and academic demands will vary more between years than within years. Measurement periods could occur and be informed by prior year visits, like June 30 of the following year if diagnosed between July and December, or by December 30, if diagnosed between January and June.
5.The specified desire for a 25% reduction in symptoms will be difficult to interpret based on known variation of pediatricians diagnoses of ADHD. Further, there is no scientific evidence that a 25% reduction in symptoms equates to falling below diagnostic threshold.

Thank you for considering our feedback.