Emergency Department Utilization (EDU)

Assesses the rate of emergency department (ED) visits among commercial (18 and older) and Medicare (18 to 64, 65 and older) health plan members. As well as reporting observed rates, NCQA also specifies that plans report an expected count of ED visits, predicted using members’ prior and current health, among other factors. The observed event count and the expected event count are used to calculate a calibrated observed-to-expected (O/E) ratio that assesses whether plans had more, the same or fewer ED visits than predicted by their case mix, while accounting for incremental improvements across all plans over time. An O/E ratio below 1 indicates better-than-average performance and an O/E ratio above 1 indicates worse-than-average performance.

Why It Matters

ED visits are a high-intensity service and a cost burden on the health care system, as well as on patients. A 2020 study found aggregate costs for nationwide ED visits of $76.3 billion.¹ A significant number of ED events can even be treated in urgent or primary care settings. A 2024 study found that among adults ages 18 to 64 who utilized the ED, 24% did so for non-urgent reasons.² A high rate of ED utilization may indicate poor care management, inadequate access to care or lack of patient education surrounding care alternatives, resulting in ED visits that could have been prevented.^3,4 Plans can ensure that members receive appropriate, coordinated primary care to address preventable ED visits.

Historical Results – National Averages

Performance results for this measure are currently unavailable. Visit our Quality Compass page to explore data licensing options and gain access to detailed performance results for this measure.