Quality measurement in the emergency department: past and future.

At the Intersection of Health, Health Care and Policy

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Cite this article as: Jeremiah D. Schuur, Renee Y. Hsia, Helen Burstin, Michael J. Schull and Jesse M. Pines Quality Measurement In The Emergency Department: Past And Future Health Affairs 32, no.12 (2013):2129-2138 doi: 10.1377/hlthaff.2013.0730

Quality By Jeremiah D. Schuur, Renee Y. Hsia, Helen Burstin, Michael J. Schull, and Jesse M. Pines 10.1377/hlthaff.2013.0730 HEALTH AFFAIRS 32, NO. 12 (2013): 2129–2138 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.

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Quality Measurement In The Emergency Department: Past And Future

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he care delivered in hospital-based emergency departments (EDs) is an important element of the US struggle to improve access to and quality of health care.1 EDs are the critical staging area for severely ill patients, the site of one in eleven ambulatory care visits.2 EDs play a key role in half of hospital admissions. And EDs are an important part of America’s safety net, because they are required by law to evaluate all patients, regardless of ability to pay.3 In 2010 there were 130 million ED visits in the United States, and yearly increases in ED visits have consistently outpaced population growth.4 Providers, payers, and the general public have differing views of the quality of ED care. For example, payers often classify the ED as overused and costly, while emergency medicine specialty societies consider ED care to be efficient

Renee Y. Hsia is an associate professor in the Department of Emergency Medicine at the University of California, San Francisco. Helen Burstin is senior vice president for performance measures at the National Quality Forum, in Washington, D.C.

and safe. And the increasing use of the ED by the public can be interpreted as indicating that many people see the ED as a source of highquality care. Part of the difficulty in knowing which view of ED care is correct is that ED quality measurement today is incomplete. Care for certain conditions, such as acute myocardial infarction (heart attack), is closely monitored, performance is publicly reported, and high-quality care is rewarded—all of which creates a strong incentive to improve. But the majority of care delivered in EDs goes largely unmeasured, with the exception of metrics for length-of-stay and waiting times. Rigorous quality measurement in health care is still a relatively new field. The focus to date has been on developing measures for specific conditions, such as congestive heart failure, instead of December 2 013

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Michael J. Schull is the president and CEO of the Institute for Clinical Evaluative Sciences in Toronto, Ontario, and a professor in the Division of Emergency Medicine, Department of Medicine, at the University of Toronto. Jesse M. Pines is director of the Office for Clinical Practice Innovation, School of Medicine and Health Sciences, and a professor of emergency medicine and health policy at the George Washington University, in Washington, D.C.

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Jeremiah D. Schuur is an attending physician; chief of the Division of Health Policy Translation; and director of quality, patient safety, and performance improvement, all in the Department of Emergency Medicine, Brigham and Women’s Hospital, in Boston, Massachusetts. He is also an assistant professor of emergency medicine at Harvard Medical School.

As the United States seeks to improve the value of health care, there is an urgent need to develop quality measurement for emergency departments (EDs). EDs provide 130 million patient visits per year and are involved in half of all hospital admissions. Efforts to measure ED quality are in their infancy, focusing on a small set of conditions and timeliness measures, such as waiting times and length-of-stay. We review the history of ED quality measurement, identify policy levers for implementing performance measures, and propose a measurement agenda. Initial priorities include measures of effective care for serious conditions that are commonly seen in EDs, such as trauma; measures of efficient use of resources, such as high-cost imaging and hospital admission; and measures of diagnostic accuracy. More research is needed to support the development of measures of care coordination and regionalization and the episode cost of ED care. Policy makers can advance quality improvement in ED care by asking ED researchers and organizations to accelerate the development of quality measures of ED care and incorporating the measures into programs that publicly report on quality of care and incentive-based payment systems. ABSTRACT

Quality

The History Of ED Quality Measures The current framework of ED quality measures evolved from several different policy and aca2130

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demic initiatives, which led to the fragmented state of ED care measurement today. Quality measurement in US health care began with health plans, later spread to hospitals, and finally expanded to physician specialty societies. The first quality measures of ED care emerged in the early 2000s from the Hospital Quality Alliance’s work to measure hospital care for common conditions such as acute myocardial infarction, pneumonia, congestive heart failure, and stroke.8 Several of these hospital-based measures apply in part to the ED, but the majority focus on other areas of hospital care. An example of an ED measure is the percentage of patients with acute myocardial infarction and specific findings on the electrocardiogram (ST-segment elevation or left bundle branch block) who receive primary angioplasty within ninety minutes of arriving at the hospital. In 2004 the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) collected performance data on these measures and publicly reported the results on their websites. These were the first comparative data on ED performance that were widely available to the public and payers.8 In 2006, in preparation for CMS’s adoption of physician-level metrics, the American Medical Association’s Physician Consortium for Performance Improvement developed a set of emergency medicine physician metrics.9 Six of these measures—all related to chest pain, syncope (fainting as a result of low blood pressure), or community-acquired pneumonia—were adopted into the Physician Quality Reporting System,10 CMS’s program to measure, report, and reward physician quality. Similarly, the American College of Emergency Physicians developed a set of ten measurements. Four—those addressing abdominal pain, ectopic pregnancy, pulmonary embolus, and the use of central lines—have been incorporated into the Physician Quality Reporting System. In addition, over the past fifteen years there have been a number of independent efforts to develop quality measures for emergency medicine. Most of these efforts have been led by academic groups and have focused on specific clinical conditions or populations. The measures assess timeliness,11 geriatric care,12 pediatric care,13,14 and general ED care.15 We are not aware of any measures of ED cost and value to date, although the American College of Emergency Physicians has recently initiated a project to develop such measures. None of these independent ED-specific efforts was directly linked to a payer, government, or provider group; as a result, they have not been widely adopted. In the period 2007–09 the Na-


on developing a measurement strategy in a care location like the ED to assess the quality of its myriad functions, such as timely access, diagnosis, prognosis, treatment, and disposition. To enable the measurement and improvement of ED quality, the care delivered in EDs should first be viewed in the context of the quality priorities for the US health care system. In 2001 the Institute of Medicine divided health care quality into the following six domains: patient safety, timeliness, effectiveness, efficiency (of resource use), equity, and patient centeredness.5 The framework was useful for measuring the quality of care, but it did not prioritize specific areas of quality improvement. The National Strategy for Quality Improvement in Health Care, released in 2011, prioritizes areas for quality improvement according to the following three aims: better care, healthy people and communities, and affordable care.6 Six specific priorities accompany those aims: making care safer, engaging people in their care, promoting the coordination of care, promoting the use of best practices to address leading causes of mortality, working with communities to implement those practices, and making highquality care more affordable (for the full text of the six priorities, see the online Appendix).7 Although the national strategy does not specifically address the delivery of emergency care, these priorities should guide the vision for highquality ED care and for measuring that care. The strategy’s focus on population health serves as a reminder that high-quality ED care should be aligned with the needs of the community. Issues such as access to timely care, emergency preparedness, and cost should be measured and improved, both in individual EDs and across communities. In this article we review the history of quality measurement of ED care and lay out a vision for the future of that measurement. We discuss how measurement can drive meaningful improvement in the quality of ED care, and we describe lessons learned from successful and failed ED quality measures, using historical and international examples. Next, we identify policy levers for implementing new measurement schemes for ED care. Finally, we propose an agenda for ED performance measurement research and policy, aiming to capture EDs’ essential function of time-critical care, and we identify the areas with the greatest room for improvement. Examples include coordinating care and controlling costs.

Lessons From Early ED Quality Efforts Quality measurement is intended to drive improvement by focusing on clinically important areas where there is a gap between care that is delivered and care that is supported by clinical evidence. An example of this in ED care is acute myocardial infarction. Timely care—rapidly transferring patients with a certain type of acute myocardial infarction (ST-segment elevation or left bundle branch block) to a cardiac catheterization laboratory for intervention—is a primary goal. Patients who receive early reperfusion therapy (that is, a blocked artery is opened) have lower mortality rates and fewer complications than patients who do not receive this therapy.16 A hospital measure of the time it takes the patient to get from arrival at the ED to the catheterization laboratory (known as “door-to-balloon time”) was developed to quantify this process. It was publicly reported in 2004 and later used by CMS to determine a proportion of Medicare’s hospital payment. In response, hospitals and EDs have focused a tremendous amount of resources on the early identification of patients with acute myocardial infarction by screening patients at triage with electrocardiograms. They also have focused on ensuring that teams of ED physicians and cardiologists are immediately available to recognize this condition and deploy a complex intervention in a very short period of time (less than ninety minutes). The measurement has resulted in dramatic improvements in the quality of care for acute myocardial infarction. Secondarily, it has been an impetus for hospitals to create multidisciplinary quality improvement committees.17 Not all ED quality measurement efforts have been as effective. Some have failed because they were not based on strong evidence. Other efforts that were focused on improving the care for patients with a given condition had unintended effects that worsened the care for other patients. The initial Core Measure Set for pneumonia im-

plemented by the Joint Commission and CMS in 2002 and reported in 2004 included two measures—the timing of the administration of antibiotics and obtaining blood cultures before administering antibiotics—that serve as cautionary tales. The first measure was the percentage of patients admitted to a hospital with pneumonia who received antibiotics within four hours of arriving at the hospital (either the ED or the admitting office). In response to the measure, EDs worked to speed the diagnosis and treatment for pneumonia patients. Some EDs also responded by prescribing antibiotics any time they identified a patient with respiratory symptoms, because it is difficult to rapidly determine which patients have pneumonia. Although performance on the measure improved, patient outcomes did not. In addition, the resulting antibiotic overuse for uncomplicated upper respiratory infections promoted antibiotic resistance. The implementation of the pneumonia measures illustrates that widespread adoption of well-intended quality measures can have unintended consequences. The evidence for the early use of antibiotics in pneumonia was not as strong as that for the measure of acute myocardial infarction care, and the initial four-hour target was arbitrary.18,19 Recent studies have failed to show a link between mortality and antibiotic timing in pneumonia.20 Similarly, the measure of obtaining blood cultures before administering antibiotics to admitted patients with pneumonia was not based on published evidence. The presence of this measure led to the widespread use of blood cultures, which are seldom clinically useful in communityacquired pneumonia and which have a significant rate of false positive results. The false positives, in turn, lead to unnecessary tests, treatments, and costs.21,22 A pernicious effect of quality measurement is to focus time, resources, and attention on areas that are measured, to the detriment of other important areas. Pneumonia and acute myocardial infarction are only a small fraction of the conditions treated in EDs. But because the results from quality measures are published on the Internet and affect reimbursement, hospital and ED leaders spend a great deal of time and resources on data collection and analysis, and on making changes to maintain or improve performance for the measured conditions. There is no direct incentive to focus similarly on many other frequent, dangerous, and costly conditions or problems. For example, diagnostic errors are the leading source of errors in the ED,23 yet there are no nationally endorsed or implemented measures addressing diagnostic D e c em b e r 2 0 1 3

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tional Quality Forum convened two projects to evaluate and endorse measures of emergency care, including prehospital care and hospitalbased ED care. Ultimately the organization endorsed twenty-two standards for emergency care.9 Some of these standards have been incorporated into measurement programs, such as those of CMS or private payers, but most have not. Thus, ED care is covered by a patchwork of measures that neither align with national quality priorities nor reflect the full scope of ED care.

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Quality accuracy in the ED. Thus, when one is considering an agenda for ED quality measurement, it is important to give priority to measures that address common serious disease processes and all six domains of high-quality care.1

Challenges To ED Quality Measurement

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National ED Quality Measurement Programs ED care in the United States is subject to external quality measurement by the following four large groups or organizations: CMS and other government payers, the Joint Commission and other hospital accrediting bodies, private payers, and state regulators. Voluntary groups also assess care, including organizations such as HealthGrades25 and Press Ganey26 that give awards and ratings to measure EDs. EDs are required to report a significant number of measures to multiple agencies, each of which may have its own list of measures using different specifications; this creates a large measurement burden. CMS has eleven quality measurement programs, including three that have ED-specific measures: the Hospital Inpatient Quality Reporting Program, Hospital Outpatient Quality Reporting Program, and Physician Quality Reporting System. The online Appendix shows the measures from these programs that affect EDs, grouped by clinical condition.7 Hospitals that fail to report measures in these programs are penalized by a 1 percent reduction in their annual payment update (an incentive called “pay for reporting”); the reduction increases to 2 percent in 2014. Additionally, a percentage of a hospital’s Medicare payments is at risk based on the facility’s performance on patient experience surveys and a subset of the inpatient quality measures, including several ED


There are several challenges to accurately measuring ED quality. First, the majority of ED care is based on diagnosing and treating a patient’s symptoms, instead of on the longitudinal treatment of a specific disease. It is more difficult to measure the care of patients with chest pain than that of patients with acute myocardial infarction. This is because there is no standardized classification system in wide use for patients’ complaints and symptoms such as chest pain, as the International Classification of Diseases (ICD) system is for diagnoses such as acute myocardial infarction. There are few measures based on the most common complaints of patients in the ED, and there has been little research into the accuracy of current measures that are based on common complaints. This is a major hurdle to measuring diagnostic accuracy and the efficiency of diagnostic testing—two of the most important and costly areas in ED care. Second, quality measures would ideally reflect changes in patient outcomes such as mortality, instead of process measures such as whether or not a medicine was administered. However, data on outcome measures are difficult to obtain because the US health care system is not integrated, and data on ED treatment and subsequent outcomes cannot easily be linked in existing data sets. Third, because ED care is team based and involves numerous providers, from the prehospital emergency medical services (EMS) team to inhospital providers, it is difficult to determine the appropriate unit of attribution. In other words, should measurement attempt to capture the performance of the individual physician or that of the ED as a whole? Attribution is even more challenging when patient outcomes, such as mortality, are involved, because ED care plays a small role in the overall outcome. In general, the most reasonable unit of attribution for emergency care is the ED: Using that would encourage systematic improvement in the entire ED, which would have a greater impact than individual physician improvement. Fourth is the challenge of using a measure to assess how well the entire system is functioning to improve population health, instead of to assess a certain process in one ED. The patient with

acute myocardial infarction is a good example again. EMS systems are being regionalized so that the patient can receive the right care at the right place at the right time.24 Thus, the ideal quality measure would show how one coordinated system compares to another, instead of how one patient fared after treatment. But such measures are not feasible in most of the United States because acute care systems are fragmented. In addition, when cost or resource use is being measured, the attribution of both outpatient and inpatient care (for example, the total cost of medical care for an ED visit and during the following month) to an accountable care organization would lead to a more coordinated effort to deliver high-value care. Measures of cost that include the costs of only the ED physician and the facility risk encouraging patterns of care that are of low cost in the ED, but also of low value to the patient and the health care system overall. For example, performing fewer detailed ED evaluations that would lead to outpatient care but would result in higher rates of admission to the hospital could appear to be less expensive if the subsequent costs were not included.

Lessons From ED Quality Measures Abroad Looking outside the United States for examples of innovation in ED quality measurement reveals a mixed picture. On the one hand, policy makers in jurisdictions including England,28 Australia,29 and several Canadian provinces28 have enacted benchmarks and targets for ED length-of-stay (sometimes called “waiting time”) to address overcrowding. EDs have been held accountable for waiting time to varying degrees through public reporting of their performance and through hospital performance incentives, penalties, or both.28–30 Although success at reducing crowding varies across jurisdictions,27,28 the implementation of these benchmarks and targets has resulted in

an unprecedented focus on the problem of overcrowding by hospital and regional decision makers.30 This focus has led some US observers to advocate that either the Joint Commission or CMS should impose similar strict timing targets. On the other hand, there has been less focus abroad at the system level on implementing other measures of ED quality of care. When the government of Ontario, Canada, announced ED length-of-stay benchmarks in 2007, it committed to implementing other ED quality measures—yet no other provincewide ED quality measures are being publicly reported.31 Many hospitals measure and report on (sometimes publicly) a variety of self-selected measures of quality of care. However, these are voluntary, variable, and based on potentially noncomparable definitions, data sources, or both. England’s experience with implementing and strictly enforcing waiting time measures holds an important lesson for policy makers. In 2005 England’s National Health Service originated the four-hour rule, requiring that the maximum length-of-stay for 98 percent of patients in any ED be four hours. The country’s EDs achieved that performance target a few years later.28 Although this led to many improvements in flow and timeliness, the strict and arbitrary nature of the rule also led to gaming, with a large number of patients being admitted to another unit just before the four-hour deadline arrived.32 In 2010 the new UK government relaxed the target slightly, to 95 percent of patients from 98 percent, and promised a broader focus on the quality of care.33 Since then, seven other measures of ED quality of care have been introduced. Several of them focus on waiting times and timeliness, such as time to triage, time before being seen by a physician, and percentage of patients who left without being seen. Additional measures address other aspects of ED care, including patient experience and rates of unplanned return ED visits within seven days of discharge, admission for deep venous thrombosis or cellulitis, and emergency medicine consultant physician sign-off for defined high-risk cases.34 These National Health Service measures are relatively basic metrics of ED quality. Nonetheless, they are an impressive exercise in measuring quality across a jurisdiction. A recent high-profile report identified low-quality care provided to patients admitted to the hospital from the ED as a risk factor for higher mortality, but it did not propose specific measures to address this problem.35 Based on international examples, it does not appear that public financing and accountability of a health system are, in themselves, a guarantee of broad ED quality measurement. Dece mber 2013

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measures (“pay for performance”). Physicians who participate in the Physician Quality Reporting System are now eligible for an incentive payment. However, beginning in 2015 this incentive will transition to a combination of a penalty for nonparticipation and bonuses for low-cost, high-quality care. The Joint Commission implements quality measures through its Core Measure Sets and accreditation standards. The Core Measures are a set of hospital quality measures that are in general alignment with CMS’s measure set for acute myocardial infarction, pneumonia, and ED crowding. However, the Joint Commission has an additional set of stroke measures that affect ED care. The Joint Commission’s accreditation standards are based on measures of structure and process. A hospital can be cited for not meeting the standards and might lose accreditation as a result. Although top performers on some Joint Commission standards are publicized, comparative data on all institutions are not publicized, nor is payment tied to performance. For example, Patient Flow Standard LD.04.03.11 specifies that all hospitals must use data and metrics to manage patient flow throughout the hospital; ensure safe care during ED boarding—that is, the hours or days when admitted patients wait in EDs or ED hallways before reaching an inpatient room; and mitigate the risks experienced by psychiatric boarders. One part of the standard, which goes into effect in 2014, requires hospitals to measure and set goals for boarding, and it recommends “that boarding time frames not exceed 4 hours in the interest of patient safety and quality of care.”27 Yet the Joint Commission does not collect data on boarding or publicize hospitals’ performance on the standard.

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Quality Policy Levers For Influencing ED Quality Measurement

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The Future Of ED Care Measurement Quality measures that reflect the National Strategy for Quality Improvement6 should be developed for ED care. Initial measurement efforts should address effective care for common lifethreatening conditions for which there are not currently measures, as well as patient safety, diagnostic error, costs of care, and resource use. Exhibit 1 shows key measure domains, sample measures, and their strengths and weaknesses. The first priority for developing ED measures should be to address variations in the use of effective care for a wider range of conditions and populations than is currently measured. There are no nationally implemented ED quality measures for certain high-priority conditions that affect many patients and have a substantial burden of disease, such as sepsis, trauma, chronic obstructive pulmonary disease, and asthma. In addition, special populations—including pediatric and geriatric patients—have unique care con-


US policy makers have several tools that they could use to influence quality in EDs. First, additional measures could be added to CMS’s quality measurement programs that affect ED care. These could include new measures of ED care in the hospital inpatient and outpatient payment program and individual provider metrics in the Physician Quality Reporting System. Adding a measure to one of these programs results in public reporting of performance on the measure on the Hospital Compare website,36 which in turn leads hospitals and physicians to focus on improving performance. In addition, hospitals have a small percentage (1 percent in 2013, rising to 2 percent in 2017) of their CMS reimbursement tied to their performance on a subset of the hospital measures, which increases the measures’ importance. Furthermore, the Affordable Care Act includes a new Value-Based Payment Modifier that for the first time in Medicare’s history incorporates the value of care into a provider’s reimbursement. The modifier is a payment adjustment that will be based on measures of quality, efficiency, and cost (dollars billed to CMS), as illustrated in the Appendix.7 Providers will be rewarded in a zerosum fashion within a specialty. In other words, high-value providers will get a bonus, while lowvalue ones will be penalized. CMS is statutorily required to implement the value-based modifier for all providers for 2017 payments. CMS is designing the modifier for primary care providers based on the average total cost per Medicare beneficiary. It is not clear how the modifier will be calculated for emergency medicine providers. Although no validated cost or utilization metrics for ED care are available, CMS will need such metrics by 2015 (for 2017 payment). This need presents an opportunity for emergency medicine researchers and organizations to propose a method of comparing quality and costs. The modifier should become an important lever for reorganizing ED care to reward high-value providers. Second, policy makers could use direct regulation to address ED quality. For example, to highlight the problem of boarding in the ED, CMS could change the inpatient hospital regulations so that the start time of an inpatient admission would not begin until a patient is placed in a regular hospital bed, instead of beginning while the patient is waiting in the ED. Third, policy makers could encourage voluntary nongovernmental organizations, such as the Leapfrog Group, to adopt ED quality standards. Because it would be prestigious for hospi-

tals to meet such standards, many EDs would work on improving their performance in the areas related to the standards. Of note, there is some debate about the effectiveness of pay-for-performance programs on improving care. Although a detailed review of pay-for-performance is beyond the scope of this article, several themes should shape the use of quality measures in ED payment systems. First, providers respond to financial incentives: There is evidence that ED providers respond to the current fee-for-service system by increasing utilization and upcoding—that is, billing an increasing proportion of visits as high intensity over time—on the five-level coding system used to value ED visits.37 Second, although there is little evidence that Medicare’s pay-for-performance programs improve quality, they affect less than 5 percent of Medicare payments. That is just a fraction of the average physician’s or hospital’s revenue stream. It is possible that performance incentives that account for a larger fraction of revenue would be more effective. Third, rewarding performance on poorly designed measures risks unintended consequences, such as those described above that resulted from the ED pneumonia measure. Physicians and hospitals will continue to be paid in some manner, and EDs are likely to be paid by fee-forservice for the immediate future. Thus, we believe that a pay-for-performance program with a broad array of measures covering different aspects of ED care would be useful for reorienting the priorities of ED care and improving performance on measured areas.

Exhibit 1 High-Priority Areas For The Development Of Emergency Department (ED) Performance Measures Area

Strengths

Weaknesses

Rate of missed acute myocardial infarction after ED visit (O), hospital rate of catheter associated urinary tract infection (O)

Diagnostic errors are a leading gap in ED quality, and EDs play an important and underrealized role in health care–associated infections

The population at risk for a missed condition is large and challenging to define, it is often not possible to link ED visits and follow-up care in current data, and measuring diagnostic errors will create pressure to increase use of testing

ED patients frequently do not understand what was done during the visit, providers’ conclusions at the end of the visit, or what steps to take after the visit, leading to poor compliance and increased costs

Traditional patient surveys have small sample sizes and low response rates and thus are not reliable; focusing on patient experience may lead to overuse, as use of tests is associated with higher survey scores

Transitions after ED care are often poorly coordinated, leading to errors that affect patient safety and increase utilization; handoff communication is a welldocumented gap in ED care

Measuring the structure or process of handoffs does not guarantee the quality of the handoff or following up on transition actions; outcome measures, such as return ED visits, are influenced by patient comorbidities and sociodemographic characteristics

Sepsis measures: initiation of critical elements of early goal-directed therapy within timelines for ED patients with sepsis (P), 30-day mortality among patients with sepsis (O) Working with communities to implement best practices

Sepsis measures would focus ED improvement on leading causes of morbidity and mortality

There are not clear gaps in quality of ED care for all of the leading causes of hospital mortality, and process measures can promote interventions that may not actually improve patient outcomes

Preventive public health interventions

As part of the safety net, the ED is often the only point of contact with high-risk patients and the only opportunity to deliver preventive care

Nonacute services must be shown to be effective before they become a quality standard in the ED, which is challenged to deliver multiple services in crowded conditions

Overuse of costly tests, treatments, and hospital admission is well documented and leads to patient harm and substantial costs

Measuring utilization or costs must account for patient severity, and unintended consequences of underuse will need to be monitored; in current delivery models, ED providers have little control over post-ED utilization and costs

Ensuring person- and family-centered care Improving patient experience, engaging patients in decision making

ED Consumer Assessment of Healthcare Providers and Systems (O)a

Promoting the coordination of care Improving handoffs from the ED to inpatient and outpatient settings

Percentage of patients discharged from the ED who have a return visit within a defined time, such as 7 days (O)

Preventing and treating the leading causes of mortality Sepsis, congestive heart failure, chronic obstructive pulmonary disease, atrial fibrillation

Performance of brief motivational interventions for substance abuse (for example, for intoxicated patients with injuries) (P), presence of a trauma violence prevention program (S)

Making high-quality care more affordable Appropriate use of CT for minor head Efficient use of diagnostic injury, hospitalization rate for tests such as computed conditions that can be managed in tomography (CT) and the outpatient setting (such as hospital admission, cost of deep venous thrombosis) (P), ED episode of care median cost of care for ED patients (including ED and post-ED services) (O)

SOURCE Authors’ analysis. NOTES Sample measures are labeled according to Donabedian A. The quality of care. How can it be assessed? 1988. Arch Pathol Lab Med. 1997;121(11):1145–50. S is structural measure; P is process measure; O is outcome measure. aBeing developed by the RAND Corporation.

cerns that merit specific measures. To avoid replicating the unintended consequences of prior efforts, measures must be evidence-based and show that time-critical approaches are associated with improved outcomes. Efficient resource use should also be an initial

focus of quality measurement in the ED, because finding a balance between overtesting and diagnostic error represents the major challenge to and potential value of ED care in the United States. ED care accounts for 5–10 percent of national health expenditures, and tests and treatDece mber 2013

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Sample measures

Making care safer Reducing diagnostic errors, preventing health care– associated infections

Quality

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vendors, which limit reliability.44 In addition, current patient experience surveys focus on patient satisfaction, which is often heavily influenced by wait times and the use of advanced technology. Future surveys should ensure higher response rates and larger sample sizes so that the conclusions drawn will be reliable. Further research is needed to measure patients’ engagement in their care, including shared decision making and how well they understand their medical care and discharge instructions. EDs face challenges to care coordination, including the fact that many EDs and the physicians who work in them are not affiliated with larger health systems. As a result, there is little direct incentive to spend time coordinating care.45 ED quality measurement should focus on the quality of care coordination. However, most current measures focus on care delivered in a single ED visit and rarely assess how that care is integrated with a patient’s prior health care (for example, do patients with benign headache have repeated CT scans?) or their subsequent health care (for example, do patients follow up with primary care providers, specialists, or both after an ED visit for a chronic condition?). The latter seems particularly relevant given recent evidence that the timeliness of follow-up after ED discharge for congestive heart failure,46 chest pain,47 and atrial fibrillation48 is associated with mortality. Developing meaningful measures of care coordination is challenging and requires further research. This is because measures of the process of conducting coordination activities (for example, contacting a patient’s personal physician, arranging follow-up appointments, and providing comprehensive discharge instructions) do not clearly predict the quality of the coordination or outcomes. Developing measures of quality that reflect health system integration is particularly relevant now that new structures meant to promote integration—including accountable care organizations—are in various stages of implementation.49

Conclusion A relatively large number of quality metrics are in use in the United States. However, only certain aspects of ED care as practiced are measured in formal quality improvement programs. ED leaders should make it a high priority to develop evidence-based quality measures that can assess the extent to which the goal of high-value integrated care is being achieved. Initial priorities for ED quality measurement should be aligned


ments make up a large component of that cost.38 Whether to order advanced imaging, such as computed tomography (CT) or magnetic resonance imaging, or to hospitalize a patient are common decisions with major cost implications for EDs, and there is wide variation in decision making at both the physician and ED levels.39,40 Furthermore, the overuse of medications (for example, controlled substances and antibiotics) and other treatments is a reasonable target for utilization measures. Such measures should form the initial value-based modifier for emergency medicine. Research is needed to develop measures of episode costs for ED visits, such as the average cost for a patient with chest pain.41 Episode costs of ED care will become important as new payment models, including accountable care organizations and bundled payments, make hospitals and provider groups more responsible for highcost decisions. However, efficiency measures have limitations, such as risk adjustment. This is particularly true in the case of claims data, which do not capture the underlying reasons— such as exam findings or physiology—for resource use. The safety and validity of efficiency measures will also need to be tested, since rewarding reduced use may have the unintended consequence of increasing diagnostic errors. The rapid implementation of untested utilization measures can lead to provider pushback, as was illustrated in CMS’s proposed imaging efficiency measure for head CT in ED patients with headache.42 Utilization measures should be carefully balanced by measures of “misses”—that is, patients discharged home who return later with a serious diagnosis related to the initial complaint, such as a headache patient who returns with atraumatic subarachnoid hemorrhage. The Agency for Healthcare Research and Quality is developing ED patient safety indicators that may be useful in capturing diagnostic errors in the ED.43 Patient experience will play an increasing role in the future of ED quality measurement. Although multiple patient experience surveys for EDs exist, to standardize measurement, CMS has contracted the RAND Corporation to develop an ED Consumer Assessment of Healthcare Providers and Systems survey. The survey will be integrated into the value-based purchasing program for all hospitals participating in Medicare. Thus, it is likely to become the dominant method for measuring patient experience. Of note, measuring patient experience in the ED has been criticized because of the small sample sizes and historically low response rates (in the 10 percent range) achieved by current survey

for patients’ symptoms and chief complaints and data registries that link ED data with more complete claims data and electronic health record data. Such registries would make it possible to measure patients’ outcomes and costs after they leave the ED. Policy makers have several tools at their disposal to incorporate additional ED quality measures into public reporting and payment systems, the most important of which is Medicare’s new Value-Based Payment Modifier. If well planned, quality measurement can play an important role in improving the quality and value of ED care. ▪


with the National Strategy for Quality Improvement in Health Care.6 They should include new measures of effective care for a broad group of high-priority conditions; of efficient resource use, including high-cost imaging and hospital admissions; and of diagnostic accuracy and errors. Important topics that require further research before new quality measures can be implemented include care coordination, regionalization, and the episode cost of ED care. To overcome the challenges of developing outcome and efficiency measures for ED care, emergency medicine organizations and health systems should work together to create reliable coding systems Jeremiah Schuur serves on the Primary Care and Emergency Medicine Scientific Advisory Board of UnitedHealthcare. The authors acknowledge Stacie Jones for assistance with the figure in the online Appendix.

NOTES 1 Burstin H. “Crossing the Quality Chasm” in emergency medicine. Acad Emerg Med. 2002;9(11): 1074–7. 2 Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care: increasingly, it’s not at their doctor’s office. Health Aff (Millwood). 2010;29(9):1620–9. 3 Morganti KG, Bauhoff S, Blanchard JC, Abir M, Iyer N, Smith AC, et al. The evolving role of emergency departments in the United States [Internet]. Santa Monica (CA): RAND Corporation; 2013 [cited 2013 Oct 28]. (Research Report No. RR280-ACEP). Available from: http:// www.rand.org/content/dam/rand/ pubs/research_reports/RR200/ RR280/RAND_RR280.pdf 4 National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables [Internet]. Hyattsville (MD): NCHS; [cited 2013 Oct 28]. Available from: http:// www.cdc.gov/nchs/data/ahcd/ nhamcs_emergency/2010_ed_ web_tables.pdf 5 Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press; 2001. 6 Department of Health and Human Services. 2011 report to Congress: National Strategy for Quality Improvement in Health Care [Internet]. Washington (DC): HHS; 2011 Mar [cited 2013 Nov 7]. Available from: http://www.ahrq.gov/workingfor quality/nqs/nqs2011annlrpt.htm 7 To access the Appendix, click on the

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Appendix link in the box to the right of the article online. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals—the Hospital Quality Alliance program. N Engl J Med. 2005;353(3):265–74. National Quality Forum. National voluntary consensus standards for emergency care: a consensus report [Internet]. Washington (DC): NQF; 2009 [cited 2013 Nov 7]. Available from: http://www.qualityforum.org/ WorkArea/linkit.aspx?Link Identifier=id&ItemID=22009 CMS.gov. Physician Quality Reporting System [home page on the Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [last modified 2013 Oct 31; cited 2013 Nov 7]. Available from: http:// www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/PQRS/index.html? redirect=/PQRI/ Hwang U, McCarthy ML, Aronsky D, Asplin B, Crane PW, Craven CK, et al. Measures of crowding in the emergency department: a systematic review. Acad Emerg Med. 2011;18(5): 527–38. Terrell KM, Hustey FM, Hwang U, Gerson LW, Wenger NS, Miller DK, et al. Quality indicators for geriatric emergency care. Acad Emerg Med. 2009;16(5):441–9. Guttmann A, Razzaq A, Lindsay P, Zagorski B, Anderson GM. Development of measures of the quality of emergency department care for children using a structured panel process. Pediatrics. 2006;118(1): 114–23. Emergency Medical Services for

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Children National Resource Center. Emergency department pediatric performance measures [Internet]. Silver Spring (MD); EMSC; [cited 2013 Nov 7]. Available from: http:// www.childrensnational.org/emsc/ pubres/oldtoolboxpages/hospitalbased_performance_measures .aspx#resources Schull MJ, Guttmann A, Leaver CA, Vermeulen M, Hatcher CM, Rowe BH, et al. Prioritizing performance measurement for emergency department care: consensus on evidence-based quality of care indicators. CJEM. 2011;13(5):300–9, E28–43. American College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions, O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., et al. 2013 ACCF/ AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4): 485–510. Krumholz HM, Herrin J, Miller LE, Drye EE, Ling SM, Han LF, et al. Improvements in door-to-balloon time in the United States, 2005 to 2010. Circulation. 2011;124(9): 1038–45. Walls RM, Resnick J. The Joint Commission on Accreditation of Healthcare Organizations and Center for Medicare and Medicaid Services community-acquired pneumonia initiative: what went wrong? Ann Emerg Med. 2005;46(5):409–11.

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national-affairs/emergency-waittimes-tumble-as-four-hour-targetdoes-the-trick/story-fn59niix1226129326986 Ovens H. ED overcrowding: the Ontario approach. Acad Emerg Med. 2011;18(12):1242–5. Ontario Ministry of Health and Long-Term Care. Ontario wait times: Ontario’s emergency room wait time strategy [Internet]. Toronto (ON): The Ministry; [last modified 2011 Jan 13; cited 2013 Nov 7]. Available from: http://www.health.gov.on.ca/ en/pro/programs/waittimes/edrs/ strategy.aspx Mason S, Weber EJ, Coster J, Freeman J, Locker T. Time patients spend in the emergency department: England’s 4-hour rule—a case of hitting the target but missing the point? Ann Emerg Med. 2012; 59(5):341–9. Topping A, Campbell D. Waiting targets for accident and emergency to be scrapped. Guardian [serial on the Internet]. 2010 Jun 9 [cited 2013 Nov 7]. Available from: http:// www.guardian.co.uk/politics/2010/ jun/10/accident-and-emergencywaiting-time-nhs UK Department of Health. A&E clinical quality indicators: data definitions [Internet]. London; 2010 Dec 17 [cited 2013 Nov 7]. Available from: http://webarchive.national archives.gov.uk/20130107105354/ http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digital assets/@dh/@en/@ps/documents/ digitalasset/dh_122892.pdf Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report [Internet]. London: National Health Service; 2013 Jul 16[cited 2013 Nov 7]. Available from: http:// www.nhs.uk/NHSEngland/brucekeogh-review/Documents/ outcomes/keogh-review-finalreport.pdf Medicare.gov. Hospital Compare [home page on the Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [cited 2013 Nov 7]. Available from: http:// www.medicare.gov/hospital compare/search.html Abelson R, Creswell J, Palmer G. Medicare bills rise as records turn electronic. New York Times. 2012 Sep 12. Lee MH, Schuur JD, Zink BJ. Owning the cost of emergency medicine: beyond 2%. Ann Emerg Med. 2013;62(5):498–505. Abualenain J, Frohna WJ, Shesser R, Ding R, Smith M, Pines JM. Emer-

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gency department physician-level and hospital-level variation in admission rates. Ann Emerg Med. 2013;61(6):638–43. Pines JM, Mutter RL, Zocchi MS. Variation in emergency department admission rates across the United States. Med Care Res Rev. 2013; 70(2):218–31. Wiler JL, Beck D, Asplin BR, Granovsky M, Moorhead J, Pilgrim R, et al. Episodes of care: is emergency medicine ready? Ann Emerg Med. 2012;59(5):351–7. Schuur JD, Brown MD, Cheung DS, Graff L 4th, Griffey RT, Hamedani AG, et al. Assessment of Medicare’s imaging efficiency measure for emergency department patients with atraumatic headache. Ann Emerg Med. 2012;60(3):280–90. Agency for Healthcare Research and Quality. Development of emergency department quality indicators (QI) (text version) [Internet]. Rockville (MD): AHRQ; 2009 Dec [cited 2013 Nov 7]. Available from: http:// www.ahrq.gov/news/events/ conference/2009/mcdonald2/ index.html Glickman S, Mehrotra A, Vissers R. Better methods, better numbers. Emergency Physicians Monthly [serial on the Internet]. 2013 Jun 7 [cited 2013 Nov 7]. Available from: http://www.epmonthly.com/ features/current-features/bettermethods-better-numbers/ Katz EB, Carrier ER, Umscheid CA, Pines JM. Comparative effectiveness of care coordination interventions in the emergency department: a systematic review. Ann Emerg Med. 2012;60(1):12–23. Lee DS, Schull MJ, Alter DA, Austin PC, Laupacis A, Chong A, et al. Early deaths in patients with heart failure discharged from the emergency department: a population-based analysis. Circ Heart Fail. 2010;3(2): 228–35. Czarnecki A, Chong A, Lee DS, Schull MJ, Tu JV, Lau C, et al. Association between physician followup and outcomes of care after chest pain assessment in high-risk patients. Circulation. 2013;127(13): 1386–94. Atzema CL, Austin PC, Chong AS, Dorian P. Factors associated with 90day death after emergency department discharge for atrial fibrillation. Ann Emerg Med. 2013;61(5): 539–48. Fisher ES, Shortell SM. Accountable care organizations: accountable for what, to whom, and how. JAMA. 2010;304(15):1715–6.


19 Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med. 2008;149(1):29–32. 20 Pines JM, Isserman JA, Hinfey PB. The measurement of time to first antibiotic dose for pneumonia in the emergency department: a white paper and position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2009;37(3):335–40. 21 Afshar N, Tabas J, Afshar K, Silbergleit R. Blood cultures for community-acquired pneumonia: are they worthy of two quality measures? A systematic review. J Hosp Med. 2009;4(2):112–23. 22 Bates DW, Goldman L, Lee TH. Contaminant blood cultures and resource utilization. The true consequences of false-positive results. JAMA. 1991;265(3):365–9. 23 Fordyce J, Blank FS, Pekow P, Smithline HA, Ritter G, Gehlbach S, et al. Errors in a busy emergency department. Ann Emerg Med. 2003;42(3):324–33. 24 Wheatley B. Regionalizing emergency care: workshop summary. Washington (DC): National Academies Press; 2010. 25 HealthGrades. HealthGrades 2012 emergency medicine in American hospitals [Internet]. Golden (CO): HealthGrades; 2012 [cited 2013 Nov 7]. Available from: http://hgarticle-center.s3-website-us-east1.amazonaws.com/05/2e/ 0d51596645d4a25641d1520b7b03/ HealthGradesEmergencyMedicine Report2012.pdf 26 Press Ganey [home page on the Internet]. South Bend (IN): Press Ganey; [cited 2013 Nov 12]. Available from: http://www.pressganey .com 27 Joint Commission. Patient flow through the emergency department. R3 Report [serial on the Internet]. 2012 Dec 19 [cited 2013 Nov 7]. Available from: http://www.joint commission.org/assets/1/18/ R3_Report_Issue_4.pdf 28 Pines JM, Hilton JA, Weber EJ, Alkemade AJ, Al Shabanah H, Anderson PD, et al. International perspectives on emergency department crowding. Acad Emerg Med. 2011;18(12):1358–70. 29 Creswell A. Emergency wait times tumble as four-hour target does the trick. Australian [serial on the Internet]. 2011 Sep 5 [cited 2013 Nov 7]. Available from: http:// www.theaustralian.com.au/

International emergency medicine: past and future.

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The Shodair Medical Genetics Department--recent past and future developments.

Measurement issues in preventive strategies: past, present, and future.

Past and future of emergency medicine education and training.

The past & future of academic emergency medicine.

Past, present and future of emergency care research.

Stormwater quality management in rail transportation--past, present and future.

Improving process quality for pediatric emergency department.

Measuring and improving cardiopulmonary resuscitation quality inside the emergency department.

Quality improvement projects based in the emergency department.

Assuring Quality Health Care in the Emergency Department.

Emergency Care at the Crossroads: Emergency Department Crowding, Payment Reform, and One Potential Future.

Radiology utilization in the emergency department: trends of the past 2 decades.

The future of quality measurement in the United States.

Emergency in emergency department.

Policy roundtable: Emergency department boarding and hospital quality.

Ranking trauma center quality: can past performance predict future performance?

Hospital quality: does past performance predict future performance?

Quality improvement primer part 2: executing a quality improvement project in the emergency department.

Using the past to predict the future: latent class analysis of patterns of health service use of older adults in the emergency department.

Emergency Department Crowding and Outcomes After Emergency Department Discharge.

Awareness in the emergency department.

Autism in the emergency department.