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PubMed1997

Life table mortality analysis of parkinsonian signs in a community population of older people.

BACKGROUND: A community based mortality review of individuals with parkinsonism is evaluated by a comparative life table analysis. RESULTS: Individuals with parkinsonism had an increased mortality over a nine year follow up. The presence of a gait disturbance is an additional mortality factor. However, the absence of gait disturbance is a far stronger factor for improved survival in parkinsonism than is the adverse factor of a gait disturbance being present. Bradykinesia, tremor and rigidity had no significant additional mortality effect. CONCLUSIONS: Careful risk selection should lead to a favorable mortality result. Credits can be given to those without gait disturbances and extra debits assessed to those with gait disorders.

Aged↗
PubMed2005

Responses of hospital utilization review staff to reimbursement denials.

Utilization review (UR) is a strategy used by the managed care industry to monitor and control utilization of health care resources. The concurrent UR process requires that hospital staff report clinical information to payers, who either certify or deny reimbursement. Conflicts may arise when hospital staff disagree with denial decisions. The authors analyzed the various responses of a medical center UR staff to payer denials and found that although denials were not frequent, they were perceived negatively by hospital staff. Improving and standardizing communication among providers, payers, and patients is one means of reducing conflict and frustration in the event of reimbursement denial.

Academic Medical Centers↗
PubMed1995

Reduction mammaplasty: criteria for insurance coverage.

The guidelines by which insurers determine eligibility for coverage of reduction mammaplasty must rely largely on only subjective materials, yet they often apply strict criteria ranging from minimum resection weights to outright refusal to compensate. I have reviewed the data from 100 consecutive reduction mammaplasties performed by me over the last 2 years. Body weight, combined specimen weight, and height relationships were studied. Patient-identifiable questionnaires regarding the presence or absence of preoperative regional discomforts were sent to the same group. It was not possible to construct a useful formula that would verify either subject complaints of discomfort or the prospect for their relief based on body dimension or specimen weight. This study suggests that a graded, three-level minimum specimen weight standard for body weights less than 70 kg, 70 to 79 kg, and over 80 kg would be more equitable.

Body Height↗
PubMed2000

Identification of in-hospital complications from claims data. Is it valid?

OBJECTIVES: This study examined the validity of the Complications Screening Program (CSP) by testing whether (1) ICD-9-CM codes used to identify a complication are coded completely and accurately and (2) the CSP algorithm successfully separates conditions present on admission from those occurring in the hospital. METHODS: We compared diagnosis and procedure codes contained in the Medicare claim with codes abstracted from an independent re-review of more than 1,200 medical records from Connecticut and California. RESULTS: Eighty-nine percent of the surgical cases and 84% of the medical cases had their CSP trigger codes corroborated by re-review of the medical record. For 13% of the surgical cases and 58% of the medical cases, the condition represented by the code was judged to be present on admission rather than occurring in-hospital. The positive predictive value of the claim was greater than 80% for the surgical risk pool, suggesting the value of the CSP as a screening tool. CONCLUSIONS: The CSP has validity as a screen for most surgical complications but only for 1 medical complication. The CSP does not have validity as a "stand-alone" tool to identify more than a few in-hospital surgery-related events. The addition of an indicator to the Medicare claim to capture the timing of secondary diagnoses would improve the validity of the CSP for identifying both surgical and medical in-hospital events.

Aged↗
PubMed2002

Complications of regional anesthesia: an overview.

Perhaps the clearest picture of the numbers and types of injuries from regional anesthesia is provided by the ASA Closed Claims Project database. In reviewing these data, it is valuable to keep in mind, of course, that the lack of a denominator makes the calculation of incidence impossible. For the decade of the 1990s, 308 claims were associated with regional anesthesia (versus 642 claims associated with general anesthesia). The percentage of these claims for patient death (10%) continued its steady decline from more than 20% in the 1970s and 13% in the 1980s. The primary reason for death remains cardiac arrest associated with neuraxial blockade, though this now represents only 30% of the deaths as opposed to 61% in the 1970s and 40% in the 1980s. There were 71 permanent disabling injuries among the 308 claims. The most common of these (23%) was associated with nerve blocks of the eye (13 retrobulbar, 3 peribulbar), and typically the injury entailed loss of vision. Second in frequency (21%) were pain-management related claims involving, for example, neuraxial opiates or neurolytic blocks. Third in frequency (20%) were nerve injuries associated with neuraxial and peripheral blocks followed by epidural hematomas (13%).

Anesthesia, Conduction↗
PubMed2002

Using Medicare data to estimate the prevalence of breast cancer screening in older women: comparison of different methods to identify screening mammograms.

OBJECTIVES: To compare different methods for defining screening mammograms with Medicare claims and their impact on estimates of breast cancer screening rates. METHODS: Medicare outpatient facility and physician claims for 61,962 women in 1993 and 59,652 women in 1998 were reviewed for evidence of receipt of screening mammography. We compared the estimates of screening mammography use derived from CPT (Current Procedure Terminology) codes to categorize mammograms as screening or diagnostic versus using an algorithm that uses CPT codes plus breast-related diagnoses in the prior two years. We also compared estimates obtained from review of physician claims alone, facility claims alone, or the combination of the two sources of claims. RESULTS: Use of physician claims alone produced estimates of screening rates similar to rates calculated from use of both physician and outpatient (facility) claims. In 1993, the CPT code for screening mammography underestimated the rate of screening compared to estimates generated by using the algorithm (8.3 percent versus 18.0 percent prevalence, p<0.001). By 1998, the screening prevalence rate generated from using the CPT code for screening mammography more closely approximated the rate generated by the algorithm (23.0 percent versus 25.1 percent). By all methods of estimating screening mammography with Medicare claims, its prevalence increased substantially between 1993 and 1998. CONCLUSION: Providers increased their use of the screening mammography code in their charges to Medicare during the 1990s. This has improved the claims' ability to distinguish screening from diagnostic mammograms, but screening rates computed with claims continue to fall below those generated from self-reports of mammography use among general populations of older women.

Aged↗
PubMed1993

Accuracy of coding in Medicare part B claims. Cataract as a case study.

We studied the accuracy of Medicare part B coding for cataract extraction to provide validation for research involving Medicare data. Hospital and physician office records associated with a sample of 802 paid claims for cataract surgery were reviewed. The sample was randomly selected from 118,420 Medicare part B claims for cataract surgery submitted by physicians in an 11-state sample during the first quarter of 1988. Medical records were successfully obtained for 796 cataract surgery episodes (99.2%), of which 794 (99.7%) indicated that cataract extraction had been performed. In the remaining two cases, cataract surgery was attempted but aborted. In 24 (3%) of the 794 cases, the surgical approach (intracapsular or extracapsular) indicated in the operative note differed from the coded on the physician's bill. In all cases in which the operative note indicated a secondary procedure performed at the time of surgery, the billing information was in agreement. We conclude that, at least in the case of cataract surgery, the Medicare part B database is 99% accurate (95% confidence interval, +/- 0.6%) for cataract surgery having occurred and 96% accurate (95% confidence interval, +/- 1.4%) in terms of surgical approach.

Cataract Extraction↗
PubMed1987

Obtaining clinical data on the appropriateness of medical care in community practice.

We sought the voluntary cooperation of a randomly selected sample of community physicians and hospitals in five states for a study of how appropriately they performed coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy. Ninety percent of 913 sampled physicians (n = 819) consented to a review of up to 20 of their 1981 Medicare patients' records. These physicians represented seven different specialties and subspecialties and performed 4988 procedures, 92% of the desired sample. Only three of 230 hospitals did not participate. We attribute our method's success primarily to the formation of a network to connect the branches of the profession, respect for office and hospital practice routine, confidentiality, and the development of carefully designed medical record abstraction systems. We conclude that, with effort, cooperative research among disparate segments of the medical community can become a reality even if the topic studied is relatively sensitive.

Community Health Services↗
PubMedDate not supplied

Evidence of inappropriate application of autologous cartilage transplantation therapy in an uncontrolled environment.

Autologous chondrocyte transplantation is a new procedure developed for the treatment of focal articular cartilage defects of the knee. The exact indications and limitations of this procedure have not yet been completely defined through prospective, randomized studies. The purpose of this study was to examine the indications and contraindications for surgery in consecutive cases initially rejected for reimbursement of surgical expenses by insurance companies, but now on appeal, to assess whether patients referred by the physicians met the procedure criteria. Twenty-four consecutive candidates were referred for adjudication when the recommending orthopaedic surgeon appealed a rejection by a medical reviewer. The factors examined included the number and size of the cartilage lesions, the presence of tricompartmental arthritis, transplantation proposed for patellar lesions, patient age, and sagittal plane deformity. In 23 of 24 cases (96%) the indications for the procedure were not met or specific contraindications were present. In 15 of 24 cases (63%) there were multiple contraindications. The results of this study underscore the importance of controlled, application-limited experience before the release of new procedures for widespread clinical applications. The uncontrolled use of this procedure may negatively skew the overall results for this technique, prejudicing a procedure that may be successful for the correct indications.

Adolescent↗
PubMed1996

Malpractice claims against emergency physicians in Massachusetts: 1975-1993.

This study reviewed 549 malpractice claims filed against emergency physicians in Massachusetts from 1975 through 1993, with a total of $39,168,891 of indemnity and expense spent on the 549 closed claims. High-risk diagnostic categories (chest pain, abdominal pain, wounds, fractures, pediatric fever/meningitis, epiglottitis, central nervous system bleeding, and abdominal aortic aneurysm) accounted for 63.75% of all closed claims and 64.23% of the total indemnity and expense spent on closed claims. Missed myocardial infarction (chest pain) claims accounted for 25.47% of the total cost of closed claims but only 10.38% of closed claims. The number of claims for missed myocardial infarction increased in the post-1988 closed claim group compared to the pre-1988 group; fractures and wounds were significantly less frequent in the post-1988 group. The frequency of high-risk claims decreased in the post-1988 group, largely because of the decline in fracture and wound claims. The category of missed myocardial infarction had a larger percentage of claims closed with indemnity payment than without indemnity payment. This parameter may serve as a marker for the overall seriousness of claims associated with a particular allegation, unlike the average cost per claim, which may be skewed by a few large awards.

Diagnostic Errors↗
PubMed2002

Methods for claims-based pharmacoeconomic studies in psychosis.

Pharmacoeconomic studies using claims data are frequently employed to compare the healthcare costs associated with competing drugs. Different methodological approaches with varying limitations for evaluating claims data are reviewed within the context of psychosis. Intent-to-treat paradigms and mirror-image designs have limitations that can bias comparisons of health resource use and can be addressed through the use of drug treatment episodes. Health resource use is better measured in financial rather than volume amounts, to account for service intensity. However, financial measures reported in claims records need to be carefully chosen. Between-group comparisons are frequently affected by selection bias, and within-group comparisons are often limited by period bias. While selection bias can be addressed by controlling for patient factors such as disease severity, and period bias by controlling for trend, devising appropriate control measures from the limited information in claims data can be challenging. Healthcare data are often skewed, which affects statistical testing. While skewed data are commonly handled through log transformation, this method has serious limitations, potentially distorting pharmacoeconomic comparisons. Determining the most appropriate methods for claims-based data involves careful evaluation of the alternate approaches to best achieve the goals of a pharmacoeconomic investigation.

Antipsychotic Agents↗
PubMed2006

Closed claims review of anesthesia for procedures outside the operating room.

PURPOSE OF REVIEW: The demand for anesthesia services is increasing due to more complex procedures being performed outside the operating room. We reviewed the literature and closed malpractice claims in the American Society of Anesthesiologists' Closed Claims database to assess liability and injury associated with anesthesia for procedures outside the operating room (nonoperating-room anesthesia, n = 24) compared with intra-operative surgical anesthesia (operating room, n = 1927) claims. RECENT FINDINGS: A higher proportion of patients in nonoperating-room anesthesia claims underwent monitored anesthesia care (58 vs. 6%, P < 0.001) and were at the extremes of age (50 vs. 19%, P = 0.003) than in operating room claims. Half of the nonoperating-room anesthesia claims occurred in the gastrointestinal suite. Inadequate oxygenation/ventilation was the most common specific damaging event in nonoperating-room anesthesia claims (33 vs. 2% in operating room claims, P < 0.001). The proportion of death was increased in nonoperating-room anesthesia claims (54 vs. 24%, P = 0.003). Nonoperating-room anesthesia claims were more often judged as having substandard care (P = 0.003) and being preventable by better monitoring (P = 0.007). SUMMARY: Nonoperating-room anesthesia claims had a higher severity of injury and more substandard care than operating room claims. Inadequate oxygenation/ventilation was the most common mechanism of injury. Maintenance of minimum monitoring standards and airway management training is required for staff involved in patient sedation.

Ambulatory Surgical Procedures↗
PubMed1996

Chronic arthropathy and musculoskeletal symptoms associated with rubella vaccines. A review of 124 claims submitted to the National Vaccine Injury Compensation Program.

OBJECTIVE: To report the outcome of 124 claims of chronic arthropathy associated with rubella vaccine submitted to the National Vaccine Injury Compensation Program. METHODS: Medical records and testimony were reviewed separately by physicians and Special Masters to determine the clinical diagnosis and eligibility for compensation under the Program. RESULTS: Among the 124 subjects with chronic arthropathy, the onset occurred between 1 week and 6 weeks after the rubella vaccination in 72, and < 1 week or > 6 weeks after the vaccination in 52. Various conditions developed in the 2 onset groups (1-6 weeks postvaccination, < 1 week or > 6 weeks postvaccination), including, respectively, unspecified arthritis (n = 29, n = 1), specified arthritis (n = 11, n = 19), arthralgia (n = 24, n = 7), fibromyalgia (n = 4, n = 11), and multiple symptoms with minimal arthralgia or myalgia (n = 4, n = 14). Concordance of medical recommendations by Program physicians and Special Masters' decisions in 56 completed claims was 91%, with awards mainly to patients with chronic unspecified arthritis and arthralgia. CONCLUSION: The Program and the US Court of Federal Claims have accepted a causal relationship between currently used rubella vaccine in the US and some chronic arthropathy with an onset between 1 week and 6 weeks after vaccine administration.

Adolescent↗
PubMed1999

Controlling workers' compensation medical care use and costs through utilization management.

Little is known about the performance of utilization management (UM) programs, which are now widely used within the workers' compensation system to contain medical costs and improve quality. UM programs focus largely on hospital care and rely on preadmission and concurrent reviews to authorize hospital admissions and continued stays. We obtained data from a large UM program representing a national sample of 9319 workers' compensation patients whose medical care was reviewed between 1991 and 1993. We analyzed these data to determine the denial rate for hospital admission and outpatient surgery and the frequency of length-of-stay restrictions among hospitalized patients. The denial rate was approximately 2% to 3% overall, but many of the denials were later reversed. On average, the UM program reduced the length of stay by 1.9 days relative to the number of days of care requested. The estimated gross cost savings resulting from reduced hospitalization time and decreased outpatient care was approximately $5 million. UM programs may offer a viable approach to cost containment within the workers' compensation system. Their value as a tool to improve the quality of care for workers' compensation patients remains to be demonstrated.

Adult↗
PubMed2006

Medicolegal aspects of error in pathology.

OBJECTIVE: To discuss the various ways error is defined in surgical pathology. To identify errors in pathology practice identified by an analysis of pathology malpractice claims. DESIGN: Three hundred seventy-eight pathology malpractice claims were reviewed. Nuisance claims and autopsy claims were excluded; 335 pathology claims remained and were analyzed to identify repetitive patterns of specimen type and diagnostic category. SETTING: All pathology malpractice claims reported to The Doctors Company of Napa, Calif, between 1998 and 2003. RESULTS: Fifty-seven percent of malpractice claims involved just 5 categories of specimen type and/or diagnostic error, namely, breast specimens, melanoma, cervical Papanicolaou tests, gynecologic specimens, and system (operational) errors. Sixty-three percent of claims involved failure to diagnose cancer, resulting in delay in diagnosis or inappropriate treatment. CONCLUSION: A false-negative diagnosis of melanoma was the single most common reason for filing a malpractice claim against a pathologist. Nearly one third involved melanoma misdiagnosed as Spitz nevus, "dysplastic" nevus, spindle cell squamous carcinoma, atypical fibroxanthoma, and dermatofibroma. While breast biopsy claims were a close second to melanoma, when combined with breast fine-needle aspiration and breast frozen section claims, breast specimens were the most common cause of pathology malpractice claims. Cervical Papanicolaou test claims were third in frequency behind melanoma and breast; 98% involved false-negative Papanicolaou tests. Forty-two percent of gynecologic surgical pathology claims involved misdiagnosed ovarian tumors, and 85% of these were false-negative diagnoses of malignancy. The most common cause of system errors was specimen "mix-ups" involving breast or prostate needle biopsies.

California↗
PubMed1996

Coprescription of terfenadine and erythromycin or ketaconazole: an assessment of potential harm.

PURPOSE: In a retrospective study, the authors used a pharmacy claims database to analyze the rate of coprescription of terfenadine and erythromycin or ketaconazole. STUDY PERIOD: The investigators reviewed claims filed for these drugs between January 1, 1990, and June 30, 1993. The time period allowed for comparison of coprescription rates before and after the Food and Drug Administration (FDA) required the manufacturer of terfenadine to inform the medical community of potentially serious adverse interactions. RESULTS: There were 5,802 coprescription events for terfenadine and erythromycin and 150 coprescription events for terfenadine and ketaconazole. Rates per 100,000 terfenadine users demonstrated large declines about 18 months after initial regulatory action. Coprescription events of terfenadine with either erythromycin or ketaconazole continued to occur despite regulatory action. CONCLUSIONS: Results of this study suggest important roles for the pharmacist as a risk manager, disseminating information about newly published drug interactions. Both health providers and patients are audiences for the pharmacist's drug expertise. The delay in physician reaction to new information from pharmaceutical companies and the federal government suggests an early, strong role for the pharmacist in changing prescribing behavior.

Anti-Allergic Agents↗
PubMed1995

Adequacy of national mortality data for internal hospital use: a case study.

OBJECTIVE: The study investigated the value of using national or regional data bases to examine care in a specific hospital. DATA SOURCES: The following data sources were included: (1) the results of the 1992 HCFA analysis of the index hospital for patients hospitalized in fiscal year 1990; (2) the 1989 Medicare Provider Analysis and Review (MEDPAR) file; and (3) clinical information from bypass surgery patients in Wisconsin and from the index hospital. PRINCIPAL FINDINGS: The assessment of the mortality rates in the index hospital for all conditions combined and for CABG patients differed depending on what data base was used and how the data were analysed. The national data were most useful in establishing that the coding practices for all patients and the mortality rate for intra-aortic balloon patients differed between the index hospital and other hospitals. The regional clinical data base for bypass surgery patients was used to establish that the high mortality rates for intra-aortic balloon patients were due to patient selection. CONCLUSIONS: National claims data must be analysed carefully before applying results to an individual hospital. Even a careful analysis is more for raising questions about care at a specific hospital rather than for reaching definitive conclusions.

Aged↗
PubMed2005

Comparison of disability duration of lumbar intervertebral disc disorders among types of insurance in Korea.

The incidence of work-related musculoskeletal disorder including low back pain sharply increased since 2000 in Korea. The objectives of the present study are to compare disability duration of lumbar intervertebral disc displacement among types of insurances, and to obtain its appropriate duration. The medical records of all patients whose final diagnosis in discharge summary of chart was lumber specified intervertebral disc displacement (LIVD) in 6 large general hospitals in Korea were reviewed to compare the length of admission and disability among different types of insurances. The information on age, gender, the length of admission, the length of follow-up for LIVD, occupation, operation, combined musculoskeletal diseases, and type of insurance was investigated. 552 cases were selected and analyzed to calculate arithmetic mean, median, mode, and geometric mean of disability duration. There was a significant difference in the length of admission and disability among types of insurance after controlling covariates such as age and combined diseases by the analysis of covariance. The length of admission in cases of IACI and AI was much longer than that of HI, and the length of disability in cases of IACI was much longer than that of HI. Prolonged duration of admission and disability was not assumed due to combined diseases, complication or other unexplainable personal factors in cases of those with industrial accidents compensation insurance and automobile insurance. This means that proper management of evidence-based disability duration guidelines is urgently needed in Korea.

Adult↗