2021 MBHR Measure: Symptom Improvement in adults with ADHD

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Title Symptom Improvement in adults with ADHD
NQS Domain Effective Clinical Care
Measure ID MBHR10
NQF ID N/A
Measure Type Patient Reported Outcome (PRO)
High Priority? Yes
Description The percentage of adult patients (18 years of age or older) with a diagnosis of ADHD who show a reduction in symptoms of 25% on the Adult ADHD Self-Report Scale (ASRS-v1.1)- 18 item self-report scale of ADHD symptoms within 2 to 10 months after initially reporting significant symptoms.

There are two aspects to this measure. The first is the assessment of the use of the ASRS v.1. during the denominator identification period (Criteria 1 also referred to as Time 1) and the second is the assessment of improvement in the ASRS v.1.1 from the first administration to the second administration of the ASRS v.1.1 (Criteria 2 also referred to as Time 2). To see additional details, please view the workflow diagram for this measure: View diagram

Denominator Denominator (Submission Criteria 1):    All patients aged 18 years or older receiving a psychiatric or behavioral intake visit and a diagnosis of ADHD during the measurement period.

Denominator Criteria (Eligible cases):
Patients aged 18 years  and older

AND

Diagnosis for ADHD (ICD-10-CM):
· F90 Attention-deficit hyperactivity disorders
· F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type
· F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type
· F90.2 Attention-deficit hyperactivity disorder, combined type
· F90.8 Attention-deficit hyperactivity disorder, other type
· F90.9 Attention-deficit hyperactivity disorder, unspecified type

AND

Patient encounter during the performance period (CPT): 0362T, 0373T, 90785, 90791, 90792, 90832,90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90875, 90876, 96110, 96112, 96113, 96116, 96121, 96127, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96159, 96164, 96165, 96167, 96170, 96171, 96178, 97129, 97130, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 98966, 98967, 98968, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215,99354, 99355, 99406, 99407, 99408, 99409, 99446, 99447, 99448, 99449, 99484, 99492, 99493, 99494, G2011, G2061, G2062, G2063, G0396, G0397, G0402, G0438, G0439

Denominator (Submission Criteria 2):
All patients aged 18 years of age or older receiving a psychiatric or behavioral intake visit with a clinically significant baseline ASRS v1.1 score of 18 or above for ADHD Inattentive (INN) or a score of 18 or above for ADHD Hyperactive (HYP) during the measurement period. If either of these scores are 18 or above the total score will also be reported.

Denominator Criteria (Eligible cases):
Patients aged 18 years or older

AND

Diagnosis for ADHD (ICD-10-CM):
· F90 Attention-deficit hyperactivity disorders
· F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type
· F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type
· F90.2 Attention-deficit hyperactivity disorder, combined type
· F90.8 Attention-deficit hyperactivity disorder, other type
· F90.9 Attention-deficit hyperactivity disorder, unspecified type

AND

Patient encounter during the performance period (CPT): 0362T, 0373T, 90785, 90791, 90792, 90832,90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90875, 90876, 96110, 96112, 96113, 96116, 96121, 96127, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96159, 96164, 96165, 96167, 96170, 96171, 96178, 97129, 97130, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 98966, 98967, 98968, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215,99354, 99355, 99406, 99407, 99408, 99409, 99446, 99447, 99448, 99449, 99484, 99492, 99493, 99494, G2011, G2061, G2062, G2063, G0396, G0397, G0402, G0438, G0439

AND

ASRS score of 18 or above for ADHD INN or ADHD HYP or a total ADHD score of 36 or above

INCLUDES TELEHEALTH? YES

Denominator Exclusion • Patients who die OR
• Are enrolled in hospice in the measurement year OR
• Are unable to complete the measure at follow-up due to cognitive deficit, visual deficit, motor deficit, language barrier, or low reading level, AND a suitable recorder (e.g., advocate) is not available
Denominator Exception • Patient refused to complete the measure at follow-up OR
• Ongoing care not indicated (e.g., referred to another provider or facility, consultation only) OR
• Patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown) OR
• Medical reasons (e.g., scheduled for surgery or hospitalized)
Numerator Numerator (Submission Criteria 2)
Patient administered a psychiatric or behavioral health intake visit with a clinically significant ASRS v1.1 score of 18 or above for ADHD INN or ADHD HYP or ADHD total symptoms of 36 who demonstrated an improvement (reduction) of 25% in symptoms on the ASRS assessment taken 2 to 10 months later on ADHD INN or ADHD HYP or ADHD TOTAL
Data Source Claims, EHR, Paper Medical Record, Registry
Meaningful Measure Area Prevention, Treatment, and Management of Mental Health
Meaningful Measure Rationale Screening for ADHD in adults will promote interventions and best practices that are effective at reducing symptoms and improve functional status and quality of life by identifying and addressing appropriate treatment needs. This provides a standardized way to communicate status which will improve both quality of treatment and efficient use of resources
Inverse Measure? No
Proportional Measure? Yes
Continuous Variable Measure? No
Ratio Measure No
Number of Performance Rates 2
Risk Adjusted No
Preferred Specialty Mental/Behavioral Health
Applicable Specialties Family Practice, Internal Medicine, Geriatric Medicine, Psychiatry, Behavioral Health
Care Settings Ambulatory Care: Hospital; Inpatient; Rehabilitation Facility; Nursing Home; Outpatient Services; Long Term Care

Measure Justification

Impact. As with ADHD in children and adolescents there is a robust and extensive literature on the prevalence and impact of ADHD in adults. ADHD is conceptualized as a neurodevelopment disorder in the DSM 5 (APA, 2013) with prevalence estimated to be between 5 and 10% (e.g. Rowland, Skipper, & Umbach, 2015; Thomas, Sanders, Doust, Beller, & Glousiou, 2015). Current estimates are that between 4 and 5% of adults have ADHD (Kessler, et. al 2006) in the United States. ADHD in adults is also related to difficulties in school, occupational functioning, relationships, health, and various adaptive and psychological problems (see Barkley, 2015 as an example). Once thought to be a disorder of childhood, ADHD is now understood to be a disorder that continues well into adulthood including older adulthood.

Assessment and Treatment. Given the now well understood importance of ADHD in adults there are has been significant advancement in identifying how to assess and treat ADHD. The literature is voluminous. As with impact there are now a significant number of reviews of how to screen and diagnosis ADHD in adulthood (see Goodman, 2009; Ramsay, 2017; Ramsay & Rostain, 2016 in addition to the general reviews cited above as well as the CADDRA and NICE Guidelines). Given that attentional issues saturate multiple clinical presentations it is important that clinicians complete a thorough assessment using multiple methods to arrive at a proper diagnosis of ADHD. There are effective medications for ADHD as well as effective psychosocial treatments for this disorder. The issues in the current literature focus on relative efficacy and effectiveness of individual and combined treatments (see Ramsay & Rostain, 2016 as an example).

Underlying Mechanisms and Measuring Outcomes. Even though the word attention is prominent in the very diagnostic label (ADHD), the problems reflected in this diagnosis actually reflect deficits in more central cognitive processes, especially executive functioning (EF or on the deficit side, ED referring to executive dysfunction). Effective EF is needed for success in most tasks of adulthood in this society – planning, organization, execution, prioritizing, social skill, delay of gratification, and impulse control. Individuals with ADHD as defined in the DSM have difficulty with these tasks, and the issue in much of the literature has focused on whether ED is a correlate of ADHD or a criterial feature of ADHD much like the other symptoms in the DSM. There is uniform agreement that individuals with ADHD have difficulty with EF when it is assessed in addition to assessing the diagnostic symptoms of ADHD. Executive Dysfunction (ED) is the mechanism that translates the diagnosis of ADHD in the life difficulties experienced by adults who have this disorder. Therefore, any assessment or formal tracking of treatment outcomes must also address ED.

Specific Rationale for the Proposed Measurement Process. For the purpose of the proposed measure in this document the work of Adler and his colleagues provides the rationale and justification for the selection of the ASRS as the outcome assessment tool. The ASRS developed by the WHO Workgroup on Adult ADHD, is a patient report rating scale based on DSM ADHD symptoms that has been extensively used in clinical work and in research. (Adler, Kessler & Spencer, 2003; Kessler, et. al., 2005). The ASRS is publicly available and is easy to use in clinical settings. Given that ED central to addressing the impact of treatment it needs to be part of the assessment of outcome. In a series of important papers on this topic Adler and his associates have investigated the relation between ADHD/ED relationship and have demonstrated that independent measures of ED are highly correlated with ADHD symptoms in multiple samples (Adler, Faraone, Spencer, Berglund, Alperine, & Kessler, 2017; Silverstein, Faraone, Alperin, Biederman, Spencer, & Adler, 2018; Silverstein, Faraone, Leon, Biederman, Spencer, & Adler, 2018). In Adler et al. (2017), the intercorrelations between symptoms and ED are so substantial that the argument is made that ED is a core feature of ADHD and not simply a correlate of it. For the purpose of the measure proposed in the current document this work means that using the ASRS serves not only as a symptom measure but also serves as a proxy for the measurement of ED. Therefore, there is substantial empirical support for using only a symptom measure to track outcomes of care because this assessment also measures the mechanism that underlies the surface symptoms that are both reported by patients and observed by researchers.

The use of the ASRS in the current project is iterative step in developing a robust set of metrics and measures for assessing and monitoring the process and outcomes of care for adult ADHD. Also related to ADHD in adults are other emotional issues and quality of life difficulties (Agarwal, Goldenberg, Perry, & Ishak, 2012; Barkley, 2015).While these topics are important, and can be addressed either in metric refinement or new measures, they are excluded from this initial measure in this important area. The identification and development of this measure is consistent with the measure development model developed by the American Psychological Association (APA, see Wright, Goodheart, Bard, Bobbitt, Butt, Lysell, McKay, & Stephens, 2019 for overview of the APA project). Also excluded from this metric is proscription about the type of treatment that patients receive. It is expected that clinicians from different professional backgrounds will draw upon the above referenced Guidelines and also on the extant published literature on clinical best practices.

Both the National Institute for Health and Care Excellence (NICE, 2018) and the Canadian ADHD Guidelines (CADDRA, 2011) identify the importance of effective identification of ADHD in adults and the need to provide effective treatment for this disorder. The NICE (2018) Guidelines in particular provide specific recommendations on psychopharmacological treatment including the monitoring of side effects of prescribed medications. Both also recognize the importance of psychosocial treatments in treating adults with ADHD. As with all treatment guidelines, the focus is on the treatment of individual patients and not the construction of quality metrics – thus, there is not much detail that does translate directly into population based metrics. However, a theme in both of these guidelines is the ongoing monitoring of care which is consistent with the use of standardized measures that can be used to assess the outcomes of care.

In addition to these two formal guidelines, Faraone and colleagues (see Faraone, Silverstein, Antshel, Biederman, Goodman, Mason, …. & Adler, 2019 for an initial report) are in the process of systematically developing a set of quality measures (using standard population quality metrics – a percentage ratio that uses a defined denominator and numerator) that can be used to track the process and outcome of care in populations of individuals with ADHD. Faraone et al. (2019) identify the importance of developing quality measures for screening, diagnosis, treatment and clinical follow-up for adults with ADHD. This effort included a thorough literature review based on formal criteria, solicited feedback from subject matter experts (SMEs), and a document review of existing practice guidelines followed by an SME panel review. The initial literature review found no measures for screening, some for diagnosis, one for treatment initiation and several for treatment follow-up. One of the SME measures was percent of patients screened using a validated method for diagnosis, the percent of patients who had a validated self-report of symptoms used to augment a diagnostic evaluation. For the current purpose, the search for guidelines is most important. Faraone et al. did not limit their search to formal guidelines such as the NICE or CADDRA guidelines. Rather they searched the literature and identified a large number of specific guidelines (e.g. gave patients information about care at every stage in the treatment). These were also cross walked in a panel session, where SMEs rated all 46 potential QMs and ranked the top 10.

One of the surviving measures in this analysis is the use of a validated measure of symptom change used to assess the impact of treatment. It is important that this metric is similar to the one being proposed in the present document. The review of both the comprehensive guidelines (CADDRA and NICE) as well as the carefully done work by Faraone et. al. (2019) provides a solid basis for implementing the outcome of care metric proposed in the current document.