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HEDIS® Tip Sheet

Acute Hospital Utilization (AHU)

Measure Description

For members 18 years of age and older, the risk-adjusted ratio of observed-to-expected acute inpatient and observation stay discharges during the measurement year.

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Notes

  • For Medicaid, only members ages 18-64 years of age are included.
  • This rate is reported as an observed count of hospital admissions over expected count (O/E Ratio).
    • An O/E Ratio below one indicates there were less acute hospital admissions than expected while an O/E Ratio greater than one indicates more acute hospital admissions occurred than expected.
  • This measure is risk-adjusted and looks at the predicted probability that the member may have an acute inpatient or observation stay during the year.
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Best Practices

  • Encourage patients to engage with their primary care provider for annual wellness visits, preventive screenings, and ongoing care coordination.
  • Proactively engage patients diagnosed with chronic conditions to prevent or minimize exacerbations and complications.
  • Coordinate support services for patients with chronic conditions or those experiencing exacerbations to improve stability and adherence.
  • Offer access options that support timely care, including extended clinic hours, telehealth availability, and nurse lines.
  • Ask patients about barriers or issues that may have contributed to hospitalization and discuss strategies to prevent future events.
  • Ensure timely post‑discharge follow‑up for patients after an acute inpatient or observation stay to support recovery and reduce readmissions.
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Exclusions

  • Outliers:
    • Commercial: Three or more inpatient or observation discharges during the measurement year.
    • Medicaid: Six or more inpatient or observation discharges during the measurement year. 
  • Nonacute inpatient stays during the measurement year.
  • Observation and inpatient discharges during the measurement year with any of the following:
    • A principal diagnosis of mental health or chemical dependence.
    • A principal diagnosis of live-born infant.
    • A maternity related diagnosis or a maternity related stay.
    • A planned hospital for any of the following:
      • Principal diagnosis of maintenance chemotherapy.
      • Principal diagnosis of rehabilitation.
      • An organ transplant.
      • Potentially planned procedure without a principal acute diagnosis.
    • Inpatient and observation stays with a discharge for death.
  • Members in hospice during the measurement year. 

Coding and Benefits Disclaimer

Providers and organizations must submit accurate and complete data in accordance with all billing, coding, and medical policy requirements. HEDIS guidance does not override official coding standards or guarantee reimbursement, as coverage is subject to applicable medical/coding policy and member-specific benefits.

Questions

Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.

NCQA Copyright Notice and Disclaimer
The HEDIS® measures and specifications were developed by and are owned by NCQA. The HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures and specifications. NCQA holds a copyright in these materials and can rescind or alter these materials at any time. These materials may not be modified by anyone other than NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make permitted adjustments of the materials does not constitute a modification. Any commercial use and/or internal or external reproduction, distribution and publication must be approved by NCQA and are subject to a license at the discretion of NCQA. Any use of the materials to identify records or calculate measure results, for example, requires a custom license and may necessitate certification pursuant to NCQA’s Measure Certification Program. Reprinted with permission by NCQA. © [2025] NCQA, all rights reserved.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Updated 8/28/2026