The National Quality Forum (NQF) has initiated a new project on risk adjustment for socioeconomic status (SES), race, and ethnicity in measuring and reporting on health care quality measures.  The project will develop a set of recommendations related to risk adjustment for health care outcome and resource use performance measures, particularly for SES.  An Expert Panel will be convened to analyze the issues and methodological considerations, as well as alternative solutions. The recommendations will address if, when, and how outcome and resource use performance measures should be adjusted for SES, race, and ethnicity. The recommendations also will address NQF’s measure evaluation criteria and guidance for endorsement as national voluntary consensus standards.

Risk adjustment is the process of controlling for intrinsic patient factors that could influence outcomes used as performance measures for assessing healthcare services and providers. It is accepted practice to adjust for differences in patient severity of illness at the start of care because patients with more comorbidities and severity of illness are expected to have poorer outcomes than their more healthy counterparts. There is less agreement about adjusting for SES and inherent patient factors such as race, ethnicity, and gender that may be related to disparities in care.

Although empirical relationships between SES, race, and ethnicity and outcomes have been demonstrated, they may be confounded with quality of care issues (e.g., disparities in care practices or failing to provide patient-centered care based on those factors). NQF’s current measure evaluation criteria indicate that factors related to disparities in care should not be included in risk adjustment models for outcome performance measures; rather, performance measures should be stratified to identify disparities in care.

In light of the continued use of and call for additional outcome performance measures, questions have arisen on the use, effects, and impact of including socioeconomic status in risk adjustment for outcome performance measures. In an environment of pay-for-performance and transparency of performance data, views on risk adjustment have become more polarized. There are at least two divergent views on adjusting for differences in SES, race, and ethnicity: 1) adjustment obscures potential problems in equitable care and outcomes, and 2) adjustment is essential for fair comparisons among providers of healthcare services when factors beyond their control influence patient outcomes. Two basic principles will ground this work: 1) outcomes matter to both patients and healthcare providers, and 2) sound measurement science is essential to identifying “real” differences in quality among healthcare providers.

This work will build on NQF’s experience with endorsing outcome performance measures and reviewing a variety of approaches to risk adjustment as well as work on disparities. NQF has endorsement criteria specifically related to risk adjustment for outcome performance measures, has engaged multistakeholder discussions about the inclusion of SES in risk adjustment, and conducted recent work on disparities, including a white paper that touched on the topic of SES and risk adjustment.

NQF is seeking nominations for the project’s Expert Panel, which are due on October 22, 2013.  The Expert Panel will be comprised of 20-25 individuals representing multiple stakeholders, including measurement experts, patients and consumers, purchasers, providers, and policy makers. A majority of those stakeholders will be methodological experts in measurement science, risk adjustment, health services research and economics, and disparities.  The Expert Panel is scheduled to meet on January 15-16, 2014 and the project is expected to conclude around June 2014.  Instructions for nominations are available on the NQF website.


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