Equity of Emergency Care Capacity and Quality HOQR

This measure's main objectives are to capture variation in equity of emergency care and measure capacity and quality of emergency care to support hospital quality improvement. The measure aims to reduce patient harm and improve outcomes for patients requiring emergency care in an emergency department (ED). Emergency care capacity is inclusive of several concepts pertaining to boarding and crowding in an ED. This measure will be designed to align with incentives to promote improved care both in EDs and the broader health system to help identify where patients do not receive equitable access to emergency care.

The measure intends to capture established outcome metrics that quantify capacity and access of care in an ED, including for patients with mental health disorders. Additional disparities in ED care are well documented for patients of older age, by race and ethnicity, primary language, and insurance status; such documented disparities include significantly longer ED wait times, higher left without being seen rates, longer boarding times, and longer total length of stay in the ED.

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These performance specifications are not clinical guidelines and do not establish a standard of medical care and have not been tested for all potential applications.

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Four cohorts of the measure will be calculated, stratified by age and mental health visits. The measure's outcome will be stratified by race and ethnicity, primary language, and insurance status to best address equity of emergency care.

A history of mental health disorders will not automatically exclude or include patients in the strata; the principal diagnosis defines inclusion in the appropriate strata. For the purposes of this measure, mental health disorders do not include substance use disorders. Stratification by age will be reported for patients less than 18 years of age and patients 18 years of age and older, for both mental health and non-mental health cohorts.

Total score and score for the following strata will be reported:

Non-Mental Health Visits
Stratification 1: all patients aged less than 18 years seen in the ED who do not have an ED encounter principal diagnosis consistent with mental health disorders. Patients who have an ED encounter principal diagnosis consistent with substance use disorders will be included in this stratification.

Stratification 2: all patients aged 18 years and older seen in the ED who do not have an ED encounter principal diagnosis consistent with mental health disorders. Patients who have an ED encounter principal diagnosis consistent with substance use disorders will be included in this stratification.

Mental Health Visits
Stratification 3: all patients aged less than 18 years seen in the ED who have an ED encounter principal diagnosis consistent with mental health disorders.

Stratification 4: all patients aged 18 years and older seen in the ED who have an ED encounter principal diagnosis consistent with mental health disorders.

The measure will utilize volume standardization to address differences in patient population between hospitals. Volume-standardization is harmonized with other existing measures and accommodates a “like to like” comparison among hospitals. Large volume EDs will always be compared to large volume EDs, while smaller volume EDs will always be compared to EDs of similar size. We will collect other demographic data to explore score variation by various social and demographic risk factors.

NA

This measure aims to reduce patient harm and improve outcomes for patients requiring emergency care in an ED by addressing the variation in equity of emergency care and measuring the capacity and quality of emergency care. There are long-standing concerns about parameters that impact the quality and timeliness of care in the ED. Currently, there are no national metrics to assess the proportion of patients impacted by the quality of timely ED care.

The goal of this Emergency Care Capacity and Quality (ECCQ) measure is to assess and improve the safety and equity of care for the 140 million ED visits that patients experience each year. Limitations in capacity and quality of emergency care have been shown to be associated with harm, such as increases in mortality, delays in care, preventable errors, poor patient experience and staff burnout. These capacity and quality limitations are also associated with increased costs of care. This proposed ECCQ measure, still in development, is intended for use in CMS’s HOQR program. The numerator is comprised of all ED visits that meet the criteria, defined in the numerator, of a quality gap in access. Challenges related to emergency care access and capacity have been increasing and have prompted public calls for action. Prior efforts to measure components of this proposed measure (for example, ED boarding, through use of the ED-2 measure) were unsuccessful, likely in part due to the construction of the measure score, which was based on median performance that obscured poor performance. Implementation of this proposed measure, which captures multiple components of quality and capacity, will minimize gaming, and help identify facilities where patients do not receive equitable access to emergency care. This measure, therefore, could positively impact millions of patients who seek treatment in the ED and help address long-standing disparities in emergency care, including for patients with mental health disorders.

Improvement noted as a decrease in measure score (decrease in proportion of eligible visits that meet the numerator criteria).

Reference Type: CITATION

Reference Text: 'American College of Emergency Physicians. 2018. Definition of Boarded Patient. Policy Statements. https://www.acep.org/patient-care/policy-statements/definition-of-boarded-patient'

Reference Type: CITATION

Reference Text: 'American Medical Association. 2022. What is Behavioral Health. https://www.ama-assn.org/delivering-care/public-health/what-behavioral-health'

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. Emergency Department Visits. https://www.cdc.gov/nchs/fastats/emergency-department.htm (2021)'

Reference Type: CITATION

Reference Text: 'ECQI Resource Center. Median Admit Decision Time to ED Departure Time for Admitted Patients.'

Mental Health: 
Behavioral health generally refers to mental health disorders, life stressors and crises, and stress-related physical symptoms. Behavioral health care refers to the prevention, diagnosis, and treatment of those conditions. For this measure, mental health cohorts will be defined separately from substance use disorders. 

Boarding:
The practice of holding patients in the emergency department after they have been admitted to the hospital because no inpatient beds are available.

ED Observation:
ED observation stays, defined as an observation encounter where the patient remains physically in an area under control of the emergency department and under the care of an emergency clinician inclusive of observation in a hospital bed. ED observation involves placing patients in observation status after their initial evaluation, allowing for continued assessment, treatment, and the determination of a safe disposition. ED observation stays are generally longer than routine ED visits and may allow time to evaluate a patient’s response to treatment.

Measure Score Calculation
The measure score is first calculated at the individual ED level as the proportion of ED visits where any one of the four outcomes occurred. Scores will be standardized z-scores by ED case volume strata (defined in ED visit volume bands of 20,000 visits). For CCN’s with more than one ED, volume-adjusted z-scores are then combined as a weighted average for that CCN. A z-score of greater than zero means worse performance and less than zero means better performance, compared to like EDs.

For the purposes of this measure, a decision to admit can be captured using any of the following: 
  - a decision to admit order to admit the patient inpatient 
  - an evaluation that results in a decision to admit
  - an order to admit to inpatient
  - an order for a bed assignment
  - start of inpatient admission

TBD

Target population includes all ED visits associated with patients of all ages, for all payers, during the measurement period. Patients can have multiple visits during a measurement period; each visit is eligible to contribute to the outcome.

Equals Initial Population

None

The numerator is comprised of any ED visit in the denominator with any quality gap in access; if the patient experiences any of the following during a visit, the visit is included in the numerator:
1. The patient waited longer than 60 minutes (1 hour) to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination, or 
2. The patient left the ED without being evaluated by a physician/advanced practice nurse/physician’s assistant, or  
3. The patient boarded (time from Decision to Admit (order) to ED departure for admitted patients) in the ED for longer than 240 minutes (4 hours), or
4. The patient had an ED length of stay (LOS) (time from ED arrival to ED physical departure as defined by the ED depart timestamp) of longer than 480 minutes (8 hours).

ED encounters with ED observation stays will be excluded from criteria #3 (boarding), and #4 (ED LOS). To clarify, patients who have a ‘decision to admit’ after an ED observation stay remain excluded from criteria #3 (boarding) calculations.

Transfers out to a facility will be excluded from criteria #4 (ED LOS).

None

For every patient in the Initial Population, also identify county, ethnicity, payer, primary language, race, sex, state and zip code.