The question of whether to adjust measures for SES has been discussed in the academic literature for decades and more recently by the policy community. The SES trial period, which began in April 2015,  has afforded NQF and its members, the federal government, measure developers, and the broader quality field the opportunity to learn more about the challenges in doing so. 

“A key early success of the trial is that has galvanized the measurement community on the need for better SES data,” said Helen Burstin, MD, NQF chief science officer. “As a result, we all have a much better understanding of the kinds of data needed to really unpack the impact of socioeconomic factors on patients and providers and we’re making progress to get it.”   

Among the data challenges revealed by the trial is the limited availability of patient-level data for SES factors, and that available proxies such as five-digit zip code level data may not be granular enough to identify meaningful patient differences. NQF is catalyzing efforts to bring better data to bear. For example, data at the nine-digit zip code may show more meaningful differences, but needs to be more readily available. Resolving this and other data challenges may help explain why measures with a clear conceptual basis for SES adjustment—that is, where risk adjustment may be appropriate and is supported by evidence in the literature—have not demonstrated an association in statistical analyses.

All measures submitted to NQF are considered for inclusion in the trial; to date this spans the areas of cost and resource use, readmissions, child health, and cardiovascular care. Currently, one measure focused on children with special healthcare needs has been adjusted for SES. 

NQF’s work has highlighted the dearth of appropriate variables for SES adjustment. NQF Standing Committees are working to balance a robust array of potential SES factors proposed by measure developers with current limits on the availability and accessibility of related SES data. As a result, some NQF stakeholders have called for NQF to consider establishing guidelines related to the SES factors that Standing Committees should consider. It is measure developers ultimately, however, that are responsible for the selection of the variables included in the risk-adjustment models of their measures.

“The results of the trial will be very important for guiding the national dialogue about whether measures should be adjusted for SES,” said Marshall Chin, co-chair of NQF’s Disparities Committee, which has a pivotal role in guiding the SES trial and analyzing its results. “We need better data and more innovative approaches to risk adjustment—and we’re pushing for both.”

NQF’s Disparities Standing Committee (PDF) is reviewing early results and is providing guidance on a path forward to improve the availability of SES variables.