Adjusting for social risk factors in pediatric quality measures: Adding to the evidence base

Background: Outcome and utilization quality measures are adjusted for patient case-mix including demographic characteristics and comorbid conditions to allow for comparisons between hospitals and health plans. However, controversy exists around whether and how to adjust for social risk factors. OBJECTIVE: To assess an approach to incorporating social risk variables into a pediatric measure of utilization from the Pediatric Quality Measures Program (PQMP). Methods: We used data from California Medicaid claims (2015-16) and Massachusetts All Payer Claims Database (2014-2015) to calculate health plan performance using measure specifications from the Pediatric Asthma Emergency Department Use measure. Health plan performance categories were assessed using mixed effect negative binomial models with and without adjustment for social risk factors, with both models adjusting for age, gender and chronic condition category. Mixed effects linear models were then used to compare patient social risk for health plans that changed performance categories to patient social risk for health plans that did not. Results: Of 133 health plans, serving 404,649 pediatric patients with asthma, 7% to 13% changed performance categories after social risk adjustment. Health plans that moved to higher performance categories cared for lower socioeconomic status (SES) patients whereas those that moved to lower performance categories cared for higher SES patients. Conclusions: Adjustment for social risk factors changed performance rankings on the PQMP Pediatric Asthma Emergency Department Use measure for a substantial number of health plans. Some health plans caring for higher risk patients performed more poorly when social risk factors were not included in risk adjustment models. In light of this, social risk factors are incorporated into the National Quality Forum-endorsed measure; whether to incorporate social risk factors into pediatric quality measures will differ depending on the use case.