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  • Measure Summary
  • NQMC:010623
  • Oct 2015

Emergency department utilization: risk-adjusted ratio of observed to expected ED visits during the measurement year, for members 18 years of age and older.

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.
National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

This is the current release of the measure.

Primary Measure Domain

Related Health Care Delivery Measures: Use of Services

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the risk-adjusted ratio of observed to expected emergency department (ED) visits, for members 18 years of age and older.

Rationale

The National Committee for Quality Assurance (NCQA) investigated the appropriateness of developing this risk adjusted HEDIS measure by building on the existing, unadjusted measure: Ambulatory Care (AMB). Since 1993, the AMB measure has reported the unadjusted emergency department (ED) and outpatient services across health plan members of all ages.

The aim of applying a risk adjustment strategy to this utilization measures is to allow better comparison of inpatient use across health plans and to create an "even playing field" by removing the effect of select patient characteristics and health status differences on the reported results.

Test results reveal that risk adjustment is a desirable refinement and demonstrate that the proposed risk adjustment strategy is both accurate and reliable. NCQA's advisory panels agree that the results support the reliability of the risk adjustment model and that the measures can help identify opportunities for quality improvement.

Evidence for Rationale

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

Primary Health Components

Emergency department (ED) utilization

Denominator Description

Members age 18 years of age and older as of December 31 of the measurement year (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

All emergency department (ED) visits during the measurement year (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

All HEDIS measures undergo systematic assessment of face validity with review by measurement advisory panels, expert panels, a formal public comment process and approval by the National Committee for Quality Assurance's (NCQA's) Committee on Performance Measurement and Board of Directors. Where applicable, measures also are assessed for construct validity using the Pearson correlation test. All measures undergo formal reliability testing of the performance measure score using beta-binomial statistical analysis.

Evidence for Extent of Measure Testing

Rehm B. (Assistant Vice President, Performance Measurement, National Committee for Quality Assurance, Washington, DC). Personal communication. 2015 Mar 16.  1 p.

State of Use

Current routine use

Current Use

Accreditation

External oversight/Medicare

Monitoring and planning

Measurement Setting

Emergency Department

Hospital Outpatient

Managed Care Plans

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age 18 years and older

Target Population Gender

Either male or female

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

The measurement year

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Time window precedes index event

Denominator Inclusions/Exclusions

Inclusions
Members age 18 years of age and older as of December 31 of the measurement year

Note:

  • Members must have been continuously enrolled for the measurement year and the year prior to the measurement year.
  • Allowable Gap: No more than one gap in enrollment of up to 45 days during each year of continuous enrollment.

Exclusions
Unspecified

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS Volume 2, which includes the Value Set Directory.

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
All emergency department (ED) visits during the measurement year

  • Count each visit to an ED that does not result in an inpatient encounter once, regardless of the intensity or duration of the visit. Count multiple ED visits on the same date of service as one visit. Identify all ED visits during the measurement year using either of the following:
    • An ED Visit (ED Value set)
    • A procedure code (ED Procedure Code Value Set) with an ED place of service code (ED POS Value set)

Note:

  • Refer to the original measure documentation for risk adjustment determination, risk adjustment weighting and calculation of expected events.
  • Report:
    • Number of Members in the Eligible Population. The number of members in the eligible population for each age and gender combination.
    • Number of Observed Events. The number of observed ED visits within each age and gender group and the overall total.
    • Observed Visits per 1,000 Members. The number of observed ED visits divided by the number of members in the eligible population, multiplied by 1,000 within each age and gender group and the overall total.
    • Number of Expected Events. The number of expected ED visits within each age and gender group and the overall total.

Exclusions
Exclude encounters with any of the following:

  • A principal diagnosis of mental health or chemical dependency (Mental and Behavioral Disorders Value Set)
  • Psychiatry (Psychiatry Value Set)
  • Electroconvulsive therapy (Electroconvulsive Therapy Value Set)
  • Alcohol or drug rehabilitation or detoxification (AOD Rehab and Detox Value Set)

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS Volume 2, which includes the Value Set Directory.

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Risk Adjustment Weighting Process Diagram

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Ratio

Interpretation of Score

Does not apply to this measure (i.e., there is no pre-defined preference for the measure score)

Allowance for Patient or Population Factors

Analysis by subgroup (stratification by individual factors, geographic factors, etc.)

Risk adjustment devised specifically for this measure/condition

Description of Allowance for Patient or Population Factors

This measure requires that separate rates be reported for commercial and Medicare product lines.

Risk Adjustment Determination and Weighting. For each member in the eligible population, identify risk adjustment categories based on presence of a comorbidity, age, and gender. Calculation of risk-adjusted outcomes (counts of emergency department [ED] visits) uses predetermined risk weights generated by two separate regression models. Weights from each model are combined to predict how many visits each member may have during the measurement year, given. Refer to the original measure documentation for additional details.

Measure results are stratified by age and gender.

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Emergency department utilization (EDU).

Measure Collection Name

HEDIS 2016: Health Plan Collection

Measure Set Name

Utilization and Risk Adjusted Utilization

Measure Subset Name

Risk Adjusted Utilization

Submitter

National Committee for Quality Assurance - Health Care Accreditation Organization

Developer

National Committee for Quality Assurance - Health Care Accreditation Organization

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

National Committee for Quality Assurance's (NCQA's) Measurement Advisory Panels (MAPs) are composed of clinical and research experts with an understanding of quality performance measurement in the particular clinical content areas.

Financial Disclosures/Other Potential Conflicts of Interest

In order to fulfill National Committee for Quality Assurance's (NCQA's) mission and vision of improving health care quality through measurement, transparency and accountability, all participants in NCQA's expert panels are required to disclose potential conflicts of interest prior to their participation. The goal of this Conflict Policy is to ensure that decisions which impact development of NCQA's products and services are made as objectively as possible, without improper bias or influence.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

Source(s)

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

Measure Availability

Source available for purchase from the National Committee for Quality Measurement (NCQA) Web site External Web Site Policy.

For more information, contact NCQA at 1100 13th Street, NW, Suite 1000, Washington, DC 20005; Phone: 202-955-3500; Fax: 202-955-3599; Web site: www.ncqa.org External Web Site Policy.

Companion Documents

The following is available:

  • National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical update. Washington (DC): National Committee for Quality Assurance (NCQA); 2015 Oct 1. 12 p.

For more information, contact the National Committee for Quality Assurance (NCQA) at 1100 13th Street, NW, Suite 1000, Washington, DC 20005; Phone: 202-955-3500; Fax: 202-955-3599; Web site: www.ncqa.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 13, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

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