Establishing criteria for emergency department-based episode of care definitions: a modified Delphi study

Authors

• Keith E. Kocher, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA [email protected].
• Aimee D. Myers, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
• Tracy H. Urech, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.
• Steven Asch, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.
• Andrew Admon, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
• Brian S. Fuehrlein, Mental Health Service Line, VA Connecticut Healthcare System, West Haven, Connecticut, USA.
• Cameron J. Gettel, Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
• Neil Patel, National Emergency Medicine Office, VHA Healthcare Operations Center, Washington, District of Columbia, USA.
• Jesse M. Pines, US Acute Care Solutions LLC, Canton, Ohio, USA.
• Nicholas S. Potochny, Integrated Veteran Care Office, US Department of Veterans Affairs Veterans Health Administration, Washington, District of Columbia, USA.
• Amber K. Sabbatini, Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA.
• Megan Vanneman, Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.
• Michael J. Ward, Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.
• Anita Vashi, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.

Document Type

Journal Article

Publication Date

3-4-2026

Journal

BMJ open

Volume

16

Issue

3

DOI

10.1136/bmjopen-2025-111727

Keywords

Emergency Departments; HEALTH SERVICES ADMINISTRATION & MANAGEMENT; Health Care Costs; Patient Care Management; Quality in health care

Abstract

OBJECTIVE: DESIGN: Traditional encounter-based analyses overlook downstream costs and complications that follow emergency department (ED) care. To enable more comprehensive evaluations, we developed standardised episode of care definitions for five common, high-cost conditions: chest pain, congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD) and suicidality.A two-round modified Delphi panel study was conducted following a literature review and evidence synthesis. Using structured surveys with anonymous feedback, panellists rated candidate criteria. To be retained in the final episode definitions, criteria were required to meet a predefined validity threshold without panellist disagreement. Data were analysed descriptively, and meeting deliberations were recorded and reviewed thematically. SETTING: Virtual, supported by an online survey platform. PARTICIPANTS: A multidisciplinary panel of 11 experts in emergency medicine and relevant clinical specialties with 9 members participating in each round. OUTCOMES: Criteria to determine inclusion, exclusion (including pre-trigger, post-trigger and event exclusion) and risk-adjustment standards for constructing ED-based episodes of care. RESULTS: Candidate criteria were presented to the panel by condition: 30 for chest pain, 54 for CHF, 30 for COPD, 79 for pneumonia and 375 for suicidality. Following deliberations and re-rating, the number of valid criteria was reduced, primarily in the episode exclusion category. Thematic analysis highlighted trade-offs between episode exclusion criteria and the use of risk adjustment to account for heterogeneity. CONCLUSIONS: Operational definitions for ED-based episodes of care for five conditions were established. These may support healthcare administrators, policymakers and researchers in evaluating variation in ED care delivery and its downstream cost and outcomes.

APA Citation

Kocher, Keith E.; Myers, Aimee D.; Urech, Tracy H.; Asch, Steven; Admon, Andrew; Fuehrlein, Brian S.; Gettel, Cameron J.; Patel, Neil; Pines, Jesse M.; Potochny, Nicholas S.; Sabbatini, Amber K.; Vanneman, Megan; Ward, Michael J.; and Vashi, Anita, "Establishing criteria for emergency department-based episode of care definitions: a modified Delphi study" (2026). GW Authored Works. Paper 8937.
https://hsrc.himmelfarb.gwu.edu/gwhpubs/8937

Department

Emergency Medicine