200 An Explicit Set of Emergency Care Sensitive Conditions

Abstract

Emergency care sensitive conditions (ECSCs), or conditions for which timely access to high-quality emergency care impacts morbidity and mortality, have been proposed as a useful framework to build emergency quality measures. We aimed to identify, using a modified Delphi panel process, a list of common conditions likely to be ECSCs. In addition to developing a universal set of ECSCs, we sought to identify those relevant to the VA. We conducted a two-phased approach where we first identified the candidate set of ECSCs and next utilized an expert panel to select the final set of ECSCs. We started with the 92 ECSCs identified by the Panel of Emergency Sensitive Conditions (PESC). One critical limitation of the PESC approach was that all ICD-10 subcodes under a parent diagnosis group were included. Some diagnosis groups represented extremely heterogeneous ICD-10 subcodes. Consequently, the panel process may have produced different results for some diagnosis groups if subcodes had been provided. Additionally, more than half the conditions were panel suggestions that were not subjected to expert review and ratings. Phase 1: Code review A two-physician panel reviewed all 3-character (parent) level ICD-10-CM diagnosis groups (n=1,903). Diagnosis groups were included if they met the following criteria: (1) diagnosis groups already selected by PESC (n=90), (2) diagnosis groups clinically similar but not rated by PESC (n=70), and (3) new diagnosis groups recommended by panelists during the “round zero” meeting (n=7). Next, the two-physician panel reviewed all subcodes (n=13,937) for the 167 parent diagnosis groups to ensure they represented conditions for which rapid diagnosis and timely emergency care intervention would impact patient outcomes. Subcodes indicating subsequent encounters or sequelae were excluded (n=8,792). Subcodes indicating pediatric, chronic, or subacute conditions were excluded (n=446). 4,699 subcodes remained. The 167 parent diagnosis groups were then reclassified into 66 clinically discrete condition groups. Phase 2: Expert panel A multidisciplinary expert panel (n=8) used modified Delphi methods to systematically identify a set of ECSCs. For each condition group, panelists rated the subsequent impact of timely, emergency care on each condition’s mortality and morbidity (scale 1-9; no impact to strong impact) and the condition’s relevance to the average Veteran seeking emergent care in the VA (scale 1-9; no relevance to strong relevance). The panel members then met via teleconference, reviewed the ratings, and voted again by using an iterative process of discussion over two days. Panelists suggested additional candidate conditions groups (n=5), which were rated on the second day. For the mortality and morbidity rating questions, a mean rating score of 7 or higher indicated the condition was considered an ECSC. A mean rating score of 4 or higher indicated the condition was considered of importance to the VA. Among 71 candidate ECSCs, the panel rated 41 conditions as ECSCs for both mortality and morbidity, rated 10 conditions as ECSCs for morbidity only, and rated 45 as relevant to the Veteran population. Useful as a measure of ED quality and as a means of identifying the role of EDs in systems-level performance, this set of ECSCs can ultimately inform policy decisions regarding the organization of emergency care systems to best serve patients in times of crisis.