URSA-PHU-008: Percent Potentially Preventable ED and IP Admits

  • Published on May 20, 2026
  • 9 minute(s) read
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Measure Description

Among all emergency department visits and inpatient admissions, the percent that are potentially preventable.

Metadata

  • Measure Identifier: URSA-PHU-008
  • Measure Type: Rate Measure
  • Temporal Structure: Event
  • Component Class: Normal-Form
  • Case Field: Encounter ID
  • Observation Field: Encounter ID
  • Target Direction: Down

Denominator Description

One per hospital inpatient admission or emergency department visits.

Numerator Description

Hospital inpatient admissions or emergency department visits that meet the criteria for potentially preventable encounter.

Published Fields

  • Data Model Keys

    • Encounter ID -- The internal database identifier (used, e.g., for joins and primary keys) for the encounter. (See also [URSA-CORE] Encounter)
    • Patient ID -- The internal database identifier (used, e.g., for joins and primary keys) for the patient. This value is typically mastered, i.e., all records for the same patient, regardless of the source data system from which that record originated, should have the same Patient ID value. (Note that while the mastered Patient ID value might resemble a local identifier used in one of the upstream data sources, this does not indicate any special priority of that source system in determining the characteristics of the patient.) (See also [URSA-CORE] Patient)
    • Facility Provider ID -- The internal database identifier (used, e.g., for joins and primary keys) for the facility provider. (See also [URSA-CORE] Facility Provider)

  • Date Fields

    • Encounter Start Date
    • Encounter End Date
    • Encounter LOS in Elapsed Midnights
    • Encounter LOS in Distinct Calendar Days
    • Is Multi-Day Encounter
    • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
    • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)

  • Encounter Fields

    • Is Emergency Department Visit without IP Admit
    • Ursa Encounter Type Tier 1 Category
    • Ursa Encounter Type Tier 2 Category
    • Is Surgery Encounter -- Indicates an encounter in which the patient underwent surgery; identified by the presence, among the documents associated with an encounter, of a surgical HCPCS code or a revenue center code for operating room setting care.
    • Ursa Surgery Encounter Type Category

  • Clinical Services Fields

    • Primary HCPCS Procedure HCPCS Code
    • Primary HCPCS Procedure Short Description
    • Primary HCPCS Procedure AHRQ CCS Single-Level Procedure Category Code
    • Primary HCPCS Procedure AHRQ CCS Single-Level Procedure Category Description

  • Diagnosis Fields

    • Principal Discharge Diagnosis ICD-10-CM Code
    • Principal Discharge Diagnosis ICD-10-CM Description
    • Principal Discharge Diagnosis AHRQ CCS Single-Level Diagnosis Category Code
    • Principal Discharge Diagnosis AHRQ CCS Single-Level Diagnosis Category Description
    • Principal Discharge Diagnosis AHRQ CCS Multi-Level Diagnosis Category Tier 1 Code
    • Principal Discharge Diagnosis AHRQ CCS Multi-Level Diagnosis Category Tier 1 Description

  • Billing and Claims Fields

    • MS-DRG Code -- The standard 3-digit Medicare Severity Diagnosis Related Group code; MS-DRG codes should include leading zeros.
    • MS-DRG Description -- The natural language description of a standard 3-digit Medicare Severity Diagnosis Related Group code.
    • MS-DRG MDC Code -- The two-digit numeric code representing the Major Diagnostic Category for a given DRG based on condition type and body region; 01 = Nervous system, 02 = Eye, 03 = Ear/Nose/Throat, 04 = Respiratory System, etc. (See also [URSA-CORE] MDC Description)
    • MS-DRG MDC Description -- The natural language description of the two-digit Major Diagnostic Category (MDC) Code that classifies DRGs based on condition type and body region; 01 = Nervous system, 02 = Eye, 03 = Ear/Nose/Throat, 04 = Respiratory System, etc. (See also [URSA-CORE] MDC Code)
    • CMS Patient Discharge Status Code -- The standard 2-digit CMS Patient Discharge Status code; 01 = Discharged to Home or Self Care, etc. Patient Discharge Status codes should include leading zeros.
    • CMS Patient Discharge Status Description -- The natural language description of a standard CMS Patient Discharge Status code. (See also [URSA-CORE] CMS Patient Discharge Status Code)

  • Financial Fields

    • Primary Plan Allowed Amount -- The maximum amount that the payor agrees to pay the provider for a service or product, typically governed by a contract. The Allowed Amount for a claim or billing record is calculated by adding the Contractual Adjustment Amount (which is typically negative) to the Charge Amount. Adding the total Non-Contractual Adjustment Amount to the Allowed Amount yields the Total Due Amount. On billing records, which may identify up to three plans responsible for payment, the Primary Plan Allowed Amount, Secondary Plan Allowed Amount, and Tertiary Plan Allowed Amount fields identify the amounts paid by the primary, secondary, and tertiary plans listed on the bill, respectively. (See also [URSA-CORE] Charge Amount, [URSA-CORE] Contractual Adjustment Amount, [URSA-CORE] Non-Contractual Adjustment Amount, [URSA-CORE] Total Due Amount)
    • Primary Plan Paid Amount -- The amount actually paid by the health plan to the provider for a service or product. Subtracting the plan paid amount from the total due amount typically yields the patient responsibility amount. On billing records, which may identify up to three plans responsible for payment, the Primary Plan Paid Amount, Secondary Plan Paid Amount, and Tertiary Plan Paid Amount fields identify the amounts paid by the primary, secondary, and tertiary plans listed on the bill, respectively; the total paid by any and all plans on a bill is identified by the Any Plan Paid Amount field.
    • Total Plan Paid Amount from All Plans
    • Patient Paid Amount -- The amount paid by the patient to the provider for health care services or products.

  • Numerator Fields

    • Is PPHE Encounter
    • PPHE Category -- A categorical classification of the type of potentially preventable hospital encounter (PPHE). Each encounter is assigned to one of the following mutually exclusive categories based on which preventability criteria it meets:
      [01] ACS Hospital Inpatient Admission – The admission meets one or more AHRQ Prevention Quality Indicator (PQI) criteria (ambulatory care sensitive condition).
      [02] Hospital Inpatient Admission with Prior Related Encounter – The admission was preceded by a related encounter (prior ED visit, prior admission, or prior SNF stay) within defined lookback windows.
      [03] High Probability Preventable ED Visit with Inpatient Admission – An ED visit classified as high-probability preventable that also resulted in an inpatient admission.
      [04] High Probability Preventable ED Visit without Inpatient Admission – An ED visit classified as high-probability preventable that did not result in an inpatient admission.
      [05] Multiple Preventable Criteria Met – The encounter qualifies under more than one of the above criteria simultaneously.
      [99] Unclassifiable or Missing Data – The encounter could not be classified due to missing or ambiguous data.
    • Is ACS Hospital Inpatient Admission -- A hospital inpatient admission that meets the numerator criteria for one or more AHRQ Prevention Quality Indicators (PQIs 01, 02, 03, 05, 07, 08, 09, 10, 11, 12, 14, 15, 16). These are conditions for which high-quality outpatient care can potentially prevent hospitalization or for which early intervention can prevent complications or more severe disease. Qualification is determined by the principal discharge diagnosis matching an AHRQ PQI numerator value set, subject to age eligibility, non-newborn transfer-admit source exclusion, and PQI-specific procedure and diagnosis exclusions (e.g., cardiac procedures, immunocompromised state, kidney disease with dialysis access). Also known as an Ambulatory Care Sensitive (ACS) admission.
    • Is Hospital Inpatient Admission with Prior Related Encounter -- A binary indicator (1/0) identifying a hospital inpatient admission that was preceded by one or more related healthcare encounters within defined lookback windows. Specifically, the admission must have at least one of the following:
      [01] A prior ED visit (that did not itself result in an inpatient admission) within 2–7 days prior to the admission date, provided no intervening admission or SNF stay occurred between the ED visit and the index admission.
      [02] A prior hospital inpatient admission with a discharge date either (a) within 7 days prior to the index admission, or (b) within 30 days prior with a matching principal discharge diagnosis (at the AHRQ CCS single-level category). Prior admissions with a CMS discharge status code on the "Index Admission Exclusions for Readmission Measure" value set are excluded from consideration.
      [03] A prior SNF stay with a discharge date within 14 days prior to the index admission, provided no intervening admission occurred between the SNF discharge and the index admission.
    • Is High Probability Preventable ED Visit with Inpatient Admission -- A binary indicator (1/0) identifying an ED visit that is classified as high-probability preventable AND that resulted in the patient being admitted to hospital inpatient status. An ED visit is deemed "high probability preventable" when any of the following conditions are met (based on NYU Emergency Department Algorithm [NYUEDA] classification of the principal discharge diagnosis):
      [01] The principal diagnosis has a ≥67% pooled probability of being preventable (due to inappropriate setting and/or preventable condition), AND the visit did not involve a high-intensity E&M service (which would suggest clinical complexity warranting ED care); OR
      [02] The principal diagnosis has a ≥67% probability of representing a preventable condition (regardless of other factors).

These thresholds can be customized per client request. In this data mart, the encounter grain is the parent hospital inpatient admission encounter that contains the ED visit.

  • Is High Probability Preventable ED Visit without Inpatient Admission -- A binary indicator (1/0) identifying an ED visit that is classified as high-probability preventable AND that did NOT result in the patient being admitted to hospital inpatient status. The same preventability logic applies as described for "Is High Probability Preventable ED Visit with Inpatient Admission" (≥67% NYUEDA-based probability threshold which can be customized per client request, with high-intensity E&M exclusion for the inappropriate-setting pathway). These encounters represent ED utilization that may have been avoidable through timely ambulatory care, urgent care access, or chronic disease management.
  • ACS Admission PQI Category -- A categorical field identifying which specific AHRQ Prevention Quality Indicator (PQI) criterion the ambulatory care sensitive (ACS) admission meets. Values are:
    [01] PQI 01 Diabetes Short-Term Complications
    [02] PQI 02 Perforated Appendix
    [03] PQI 03 Diabetes Long-Term Complications
    [04] PQI 05 Older Adult COPD or Asthma
    [05] PQI 07 Hypertension
    [06] PQI 08 Heart Failure
    [07] PQI 09 Low Birth Weight
    [08] PQI 10 Dehydration
    [09] PQI 11 Bacterial Pneumonia
    [10] PQI 12 Urinary Tract Infection
    [11] PQI 14 Uncontrolled Diabetes
    [12] PQI 15 Younger Adult Asthma
    [13] PQI 16 Diabetic Lower-Extremity Amputation
    [97] Multiple PQI Criteria Met

This field is NULL for encounters that are not ACS admissions (i.e., where is_acs_hospital_inpat_admission = 0). Each PQI is determined by AHRQ-specified principal diagnosis value sets, age thresholds, and exclusion criteria (transfer admits, cardiac procedures, immunocompromised state, condition-specific exclusion diagnoses).

  • Prior Encounter Scenario Category -- A hospital inpatient admission with one or more of the following: (1) prior ED visit within 7 days prior to admission; (2) prior hospital inpatient admission with discharge date within 7 days prior to admission or within 30 days prior to admission and with similar principal discharge diagnoses; or (3) prior SNF stay with discharge date within 14 days prior to admission.
  • Preventable ED Visit Scenario Category -- A categorical field classifying the reason an ED visit is considered high-probability preventable, based on NYU Emergency Department Algorithm (NYUEDA) diagnosis-level probabilities. Values are:

[01] High Probability of Preventable ED Visit Due to Inappropriate Setting Only – The principal diagnosis has a ≥67% probability of representing an inappropriate use of the ED setting (i.e., the condition could have been treated in a lower-acuity setting), but does NOT independently meet the preventable condition threshold. The visit also did not involve a high-intensity E&M service.
[02] High Probability of Preventable ED Visit Due to Preventable Condition Only – The principal diagnosis has a ≥67% probability of representing a preventable condition (i.e., the condition itself could have been prevented with adequate ambulatory care), regardless of setting appropriateness or E&M intensity.
[03] High Probability of Preventable ED Visit Due to Pooled Probability of Inappropriate Setting and/or Preventable Condition – The principal diagnosis meets the ≥67% threshold on the combined/pooled preventability probability (inappropriate setting + preventable condition), and the visit did not involve a high-intensity E&M service, but does not independently meet either the setting-only or condition-only threshold at ≥67%.
[04] Not High Probability of Preventable ED Visit – The diagnosis was classifiable via NYUEDA but did not meet any ≥67% preventability threshold.
[99] Unclassifiable or Missing Data – The principal diagnosis could not be matched to the NYUEDA reference table.

  • Measure Fields
    • Denominator