In certain cases, risk adjustment of the measure is also a component of the specification process, specifically for outcome measures and cost and resource use measures. 

Risk adjustment is the modeling of health outcomes or costs as a function of various risk factors. Risk adjustment is important because health outcomes and costs are often a result of the interplay of demographic, clinical, functional, and social factors. In the context of quality measurement, the purpose of risk adjustment is to enhance meaningful comparison across measured entities. It facilitates a fairer comparison of measured entities with different patient populations and aims at leveling the playing field (Iezzoni, 2013).

The measure developer should risk adjust quality measures to facilitate fair and accurate comparisons of outcomes across measured entities. Risk factors existing outside health care encounters may affect outcomes regardless of the quality of care received. Adjusting for these risk factors can avoid misleading comparisons. However, risk adjustment models for publicly reported quality measures should not obscure disparities in care associated with race, gender, socioeconomic status, or other demographics and social factors.

The measure developer should fully disclose all measure specifications, including the risk adjustment methodology, to ensure transparency and accountability. The measure developer must update and recalibrate the risk adjustment model as needed to adjust for changes in cohort/population change, coding changes (e.g., measured entity coding practice, change from International Classification of Diseases (ICD)-9 to ICD-10 coding, new codes added), newly added clinically relevant data elements (e.g., National Institutes of Health Stroke Scale for stroke measures), or social risk factors (e.g., patient dual status).