ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication

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.

Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). 

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Attention-deficit/hyperactivity disorder (ADHD) is one of the more common chronic conditions of childhood. 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). Given the high prevalence of ADHD among school-aged children (4 to 12 percent), primary care clinicians will encounter children with ADHD in their practices regularly and should have a strategy for diagnosis and long-term management of this condition (American Academy of Pediatrics 2001).

The American Academy of Pediatrics (AAP) clinical practice guidelines provide evidence-based recommendations for the treatment of children diagnosed with ADHD. Two treatment approaches are recognized for efficacy: stimulant medication therapy or behavior therapy. Despite data showing that stimulant medications are safe, there are widespread misunderstandings about the safety and use of these drugs. Those used to treat ADHD have known side effects and, like all medications, need to be closely monitored (American Academy of Pediatrics 2001).

Systematic monitoring of dosage and side-effects for children on stimulants is recommended in order to target any adverse effects (American Academy of Pediatrics 2001). Alternatively, a child may respond poorly to stimulant medication because of an undiagnosed co-morbid condition, the emergence of psychosocial stressors or noncompliance (Smucker and Hedayat 2001). The AAP clinical guideline recommends that clinicians evaluate the original diagnosis when a child does not meet target outcomes, in addition to treatment adherence. Assessment of target outcomes is based upon a systematic follow-up for the child with ADHD (American Academy of Pediatrics 2000).

American Academy of Pediatrics (2001)

Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition (strength of evidence: good; strength of recommendation: strong). 

The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management (strength of evidence: good; strength of recommendation: strong). 

The clinician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong). 

When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions (strength of evidence: weak; strength of recommendation: strong).

The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child (strength of evidence: fair; strength of recommendation: strong).

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.

American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement. 2001. “Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder.” Pediatrics 108(4):1033-43.

Smucker, W., and M. Hedayat. 2001. “Evaluation and Treatment of ADHD.” Am Fam Physician 64(5):817-830.

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.

Initial Patient 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 Patient 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 Patient Population

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. 

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.

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.

For every patient evaluated by this measure also identify payer, race, ethnicity and sex.

------ Population Criteria 1 ------

Initial Patient Population 1 =
- AND: FIRST:
  - OR: "Occurrence A of Medication, Dispensed: ADHD Medications" <= 60 day(s) starts after start of "Measurement Period"
  - OR: "Occurrence A of Medication, Dispensed: ADHD Medications" <= 90 day(s) starts before start of "Measurement Period"
- AND: "Patient Characteristic Birthdate: birth date" >= 6 year(s) starts before start of "Measurement Period"
- AND: "Patient Characteristic Birthdate: birth date" < 12 year(s) starts before start of "Measurement Period"
- AND:
  - OR: "Encounter, Performed: Office Visit"
  - OR: "Encounter, Performed: Face-to-Face Interaction"
  - OR: "Encounter, Performed: Home Healthcare Services"
  - OR: "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17"
  - OR: "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17"
  - during "Measurement Period"
Denominator 1 =
- AND: "Initial Patient Population 1"
Denominator Exclusions 1 =
- AND:
  - OR: "Diagnosis, Active: Narcolepsy" starts before or during "Measurement Period"
  - OR: "Medication, Active: ADHD Medications" <= 120 day(s) starts before start of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Inpatient Encounter" <= 30 day(s) starts after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND:
      - OR:
        
        AND NOT: "Occurrence A of Diagnosis, Active: Mental Health Diagnoses" ends before start of "Occurrence A of Encounter, Performed: Inpatient Encounter"
        
        AND: "Occurrence A of Diagnosis, Active: Mental Health Diagnoses (ordinality: 'principal')" starts before or during "Occurrence A of Encounter, Performed: Inpatient Encounter"
      - OR:
        
        AND NOT: "Occurrence A of Diagnosis, Active: Substance Abuse" ends before start of "Occurrence A of Encounter, Performed: Inpatient Encounter"
        
        AND: "Occurrence A of Diagnosis, Active: Substance Abuse (ordinality: 'principal')" starts before or during "Occurrence A of Encounter, Performed: Inpatient Encounter"
Numerator 1 =
- AND:
  - OR: "Encounter, Performed: Office Visit"
  - OR: "Encounter, Performed: Hospital Observation Care - Initial"
  - OR: "Encounter, Performed: Home Healthcare Services"
  - OR: "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17"
  - OR: "Encounter, Performed: Psych Visit - Psychotherapy"
  - OR: "Encounter, Performed: Psych Visit - Diagnostic Evaluation"
  - OR: "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17"
  - OR: "Encounter, Performed: Preventive Care Services - Group Counseling"
  - OR: "Encounter, Performed: Preventive Care Services-Individual Counseling"
  - OR: "Encounter, Performed: Behavioral Health Follow-up Visit"
  - OR: "Encounter, Performed: Face-to-Face Interaction"
  - OR: "Encounter, Performed: Psychotherapy and Pharmacologic Management (facility location: 'Ambulatory')"
  - OR: "Encounter, Performed: Discharge Services- Observation Care"
  - OR: "Encounter, Performed: Outpatient Consultation"
  - <= 30 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
Denominator Exceptions 1=
- None

------ Population Criteria 2 ------

Initial Patient Population 2 =
- AND: FIRST:
  - OR: "Occurrence A of Medication, Dispensed: ADHD Medications" <= 60 day(s) starts after start of "Measurement Period"
  - OR: "Occurrence A of Medication, Dispensed: ADHD Medications" <= 90 day(s) starts before start of "Measurement Period"
- AND NOT: "Occurrence A of Medication, Active: ADHD Medications" ends before start of "Measurement Period"
- AND: "Patient Characteristic Birthdate: birth date" >= 6 year(s) starts before start of "Measurement Period"
- AND: "Patient Characteristic Birthdate: birth date" < 12 year(s) starts before start of "Measurement Period"
- AND: "Occurrence A of Medication, Active: ADHD Medications (cumulative medication duration >= 210 day(s))" starts before or during "Measurement Period"
- AND:
  - OR: "Encounter, Performed: Office Visit"
  - OR: "Encounter, Performed: Face-to-Face Interaction"
  - OR: "Encounter, Performed: Home Healthcare Services"
  - OR: "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17"
  - OR: "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17"
  - during "Measurement Period"
Denominator 2 =
- AND: "Initial Patient Population 2"
Denominator Exclusions 2 =
- AND:
  - OR: "Diagnosis, Active: Narcolepsy" starts before or during "Measurement Period"
  - OR: "Medication, Active: ADHD Medications" <= 120 day(s) starts before start of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Inpatient Encounter" <= 300 day(s) starts after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND:
      - OR:
        
        AND NOT: "Occurrence A of Diagnosis, Active: Mental Health Diagnoses" ends before start of "Occurrence A of Encounter, Performed: Inpatient Encounter"
        
        AND: "Occurrence A of Diagnosis, Active: Mental Health Diagnoses (ordinality: 'principal')" starts before or during "Occurrence A of Encounter, Performed: Inpatient Encounter"
      - OR:
        
        AND NOT: "Occurrence A of Diagnosis, Active: Substance Abuse" ends before start of "Occurrence A of Encounter, Performed: Inpatient Encounter"
        
        AND: "Occurrence A of Diagnosis, Active: Substance Abuse (ordinality: 'principal')" starts before or during "Occurrence A of Encounter, Performed: Inpatient Encounter"
Numerator 2 =
- AND:
  - OR: "Encounter, Performed: Office Visit"
  - OR: "Encounter, Performed: Hospital Observation Care - Initial"
  - OR: "Encounter, Performed: Home Healthcare Services"
  - OR: "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17"
  - OR: "Encounter, Performed: Psych Visit - Psychotherapy"
  - OR: "Encounter, Performed: Psych Visit - Diagnostic Evaluation"
  - OR: "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17"
  - OR: "Encounter, Performed: Preventive Care Services - Group Counseling"
  - OR: "Encounter, Performed: Preventive Care Services-Individual Counseling"
  - OR: "Encounter, Performed: Behavioral Health Follow-up Visit"
  - OR: "Encounter, Performed: Face-to-Face Interaction"
  - OR: "Encounter, Performed: Psychotherapy and Pharmacologic Management (facility location: 'Ambulatory')"
  - OR: "Encounter, Performed: Discharge Services- Observation Care"
  - OR: "Encounter, Performed: Outpatient Consultation"
  - <= 30 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
- AND:
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Office Visit" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Office Visit" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Hospital Observation Care - Initial" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Hospital Observation Care - Initial" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Preventive Care Services - Group Counseling" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Preventive Care Services - Group Counseling" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Behavioral Health Follow-up Visit" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Behavioral Health Follow-up Visit" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Preventive Care Services-Individual Counseling" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Preventive Care Services-Individual Counseling" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Psychotherapy and Pharmacologic Management" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Psychotherapy and Pharmacologic Management" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Face-to-Face Interaction" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Face-to-Face Interaction" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Discharge Services- Observation Care" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Discharge Services- Observation Care" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Outpatient Consultation" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Outpatient Consultation" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Home Healthcare Services" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Home Healthcare Services" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Psych Visit - Diagnostic Evaluation" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Psych Visit - Diagnostic Evaluation" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Psych Visit - Psychotherapy" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Psych Visit - Psychotherapy" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
- AND:
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Office Visit" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Office Visit" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Hospital Observation Care - Initial" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Hospital Observation Care - Initial" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Outpatient Consultation" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Outpatient Consultation" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Home Healthcare Services" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Home Healthcare Services" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Psych Visit - Diagnostic Evaluation" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Psych Visit - Diagnostic Evaluation" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Psych Visit - Psychotherapy" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Psych Visit - Psychotherapy" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Preventive Care Services - Group Counseling" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Preventive Care Services - Group Counseling" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Behavioral Health Follow-up Visit" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Behavioral Health Follow-up Visit" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Preventive Care Services-Individual Counseling" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Preventive Care Services-Individual Counseling" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Psychotherapy and Pharmacologic Management" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Psychotherapy and Pharmacologic Management" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Telehealth Services" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Telehealth Services" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Telephone Management" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence A of Encounter, Performed: Telephone Management" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Face-to-Face Interaction" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Face-to-Face Interaction" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
  - OR:
    - AND: "Occurrence B of Encounter, Performed: Discharge Services- Observation Care" >= 31 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
    - AND: "Occurrence B of Encounter, Performed: Discharge Services- Observation Care" <= 300 day(s) ends after end of "Occurrence A of Medication, Dispensed: ADHD Medications"
Denominator Exceptions 2=
- None

"Diagnosis, Active: Mental Health Diagnoses" using "Mental Health Diagnoses Grouping Value Set (2.16.840.1.113883.3.464.1003.105.12.1004)"
"Diagnosis, Active: Narcolepsy" using "Narcolepsy Grouping Value Set (2.16.840.1.113883.3.464.1003.114.12.1011)"
"Diagnosis, Active: Substance Abuse" using "Substance Abuse Grouping Value Set (2.16.840.1.113883.3.464.1003.106.12.1004)"
"Encounter, Performed: Behavioral Health Follow-up Visit" using "Behavioral Health Follow-up Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1054)"
"Encounter, Performed: Discharge Services- Observation Care" using "Discharge Services- Observation Care Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1039)"
"Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"
"Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"
"Encounter, Performed: Hospital Observation Care - Initial" using "Hospital Observation Care - Initial Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1002)"
"Encounter, Performed: Inpatient Encounter" using "Inpatient Encounter Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1060)"
"Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"
"Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1008)"
"Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" using "Preventive Care - Established Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1024)"
"Encounter, Performed: Preventive Care Services - Group Counseling" using "Preventive Care Services - Group Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1027)"
"Encounter, Performed: Preventive Care Services-Individual Counseling" using "Preventive Care Services-Individual Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1026)"
"Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" using "Preventive Care- Initial Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1022)"
"Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit - Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"
"Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"
"Encounter, Performed: Psychotherapy and Pharmacologic Management" using "Psychotherapy and Pharmacologic Management Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1055)"
"Encounter, Performed: Telehealth Services" using "Telehealth Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1031)"
"Encounter, Performed: Telephone Management" using "Telephone Management Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1053)"
"Medication, Active: ADHD Medications" using "ADHD Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1171)"
"Medication, Dispensed: ADHD Medications" using "ADHD Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1171)"
"Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set (2.16.840.1.113883.3.560.100.4)"
Attribute: "Facility location: Ambulatory" using "Ambulatory Grouping Value Set (2.16.840.1.113883.3.464.1003.122.12.1003)"
Attribute: "Ordinality: Principal" using "Principal Grouping Value Set (2.16.840.1.113883.3.67.1.101.11.724)"

"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex Administrative Sex Value Set (2.16.840.1.113762.1.4.1)"

eMeasure Title	ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication
eMeasure Identifier (Measure Authoring Tool)	136	eMeasure Version number	3
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
Description	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.
Copyright	Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, 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 use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures. (c) 2008-2013 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2012 American Medical Association. LOINC(R) copyright 2004-2012 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2012 International Health Terminology Standards Development Organisation. ICD-10 copyright 2012 World Health Organization. All Rights Reserved.
Disclaimer	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 AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. 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	Attention-deficit/hyperactivity disorder (ADHD) is one of the more common chronic conditions of childhood. 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). Given the high prevalence of ADHD among school-aged children (4 to 12 percent), primary care clinicians will encounter children with ADHD in their practices regularly and should have a strategy for diagnosis and long-term management of this condition (American Academy of Pediatrics 2001). The American Academy of Pediatrics (AAP) clinical practice guidelines provide evidence-based recommendations for the treatment of children diagnosed with ADHD. Two treatment approaches are recognized for efficacy: stimulant medication therapy or behavior therapy. Despite data showing that stimulant medications are safe, there are widespread misunderstandings about the safety and use of these drugs. Those used to treat ADHD have known side effects and, like all medications, need to be closely monitored (American Academy of Pediatrics 2001). Systematic monitoring of dosage and side-effects for children on stimulants is recommended in order to target any adverse effects (American Academy of Pediatrics 2001). Alternatively, a child may respond poorly to stimulant medication because of an undiagnosed co-morbid condition, the emergence of psychosocial stressors or noncompliance (Smucker and Hedayat 2001). The AAP clinical guideline recommends that clinicians evaluate the original diagnosis when a child does not meet target outcomes, in addition to treatment adherence. Assessment of target outcomes is based upon a systematic follow-up for the child with ADHD (American Academy of Pediatrics 2000).
Clinical Recommendation Statement	American Academy of Pediatrics (2001) Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition (strength of evidence: good; strength of recommendation: strong). The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management (strength of evidence: good; strength of recommendation: strong). The clinician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong). When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions (strength of evidence: weak; strength of recommendation: strong). The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child (strength of evidence: fair; strength of recommendation: strong).
Improvement Notation	Higher score indicates better quality.
Reference	American Academy of Pediatrics. 2000. “Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder.” Pediatrics 105(5):1158-70.
Reference	American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement. 2001. “Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder.” Pediatrics 108(4):1033-43.
Reference	Smucker, W., and M. Hedayat. 2001. “Evaluation and Treatment of ADHD.” Am Fam Physician 64(5):817-830.
Definition	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.
Guidance	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	TBD
Initial Patient Population	Initial Patient 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 Patient 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.
Denominator	Equals Initial Patient 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. 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.
Numerator	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	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