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PubMed2007

Adventure tourism and adventure sports injury: the New Zealand experience.

The primary aims of this study were to establish a client injury baseline for the New Zealand adventure tourism and adventure sport sector, and to examine patterns and trends in claims for injury during participation in adventure activities. Content analysis of narrative text data for compensated injuries occurring in a place for recreation and sport over a 12-month period produced over 15,000 cases involving adventure tourism and adventure sport. As found in previous studies in New Zealand, highest claim counts were observed for activities that are often undertaken independently, rather than commercially. Horse riding, tramping, surfing and mountain biking were found to have highest claim counts, while hang gliding/paragliding/parasailing and jet boating injuries had highest claim costs, suggesting greatest injury severity. Highest claim incidence was observed for horse riding, with female claimants over-represented for this activity. Younger male claimants comprised the largest proportion of adventure injuries, and falls were the most common injury mechanism.

Adult↗
PubMed2006

The use of disease-modifying agents among multiple sclerosis patients enrolled in medicare from 1995 to 2002 and the impact of medicare part D: analysis of claims data from the medicare current beneficiary survey.

OBJECTIVES: The goals of this analysis were as follows:(1) identify the prevalence of access barriers to disease-modifying agents (DMAs) used in the United States for the treatment of multiple sclerosis (MS), (2) identify the relationship between patient characteristics and use of DMAs, and (3) interpret the results in the context of Medicare Part D. METHODS: Using claims data from the Medicare Current Beneficiary Survey (MCBS) 1992 to 2001, we identified beneficiaries with a diagnosis of MS on > or =4 claims. To adapt for the bimodality of the claims distribution and to capture the majority of MS claims, > or =4 claims were used. We estimated the mean out-of-pocket price of prescription medications and prevalence of perceived economic barriers to address the hypothesis that the expansion of Medicare to include an out-patient drug benefit will decrease beneficiaries' burden of MS. RESULTS: A total of 416 patients with MS were identified with the MCBS claims data. Furthermore, data for 3 DMAs used to manage MS were available: interferon beta-1b, interferon beta-1a, and glatiramer acetate. Data were available for interferon beta-1b for the years 1995 to 2002, and for interferon beta-1a and glatiramer acetate for the years 1999 to 2002. The mean out-of-pocket price per prescribing event (typically 30 days) for interferon beta-1b was US $44.40 from 1995 to 1998 and US $15.08 from 1999 to 2002. Between 1999 and 2002, the mean out-of-pocket price per prescribing event for interferon beta-1a was US $84.74; for glatiramer acetate during the same period, it was US $114.90. Assuming complete compliance for the year, the mean out-of-pocket burden per patient for each medication using the 1999-to-2002 numbers would be US $1016.88 for interferon beta-1a, US $548.91 for interferon beta-1b, and US $1378.80 for glatiramer acetate. The annual prevalence of use of any DMA increased from 6.5% during the years 1995 to 1998 to 21.2% during the years 1999 to 2002. CONCLUSIONS: Our findings suggest that these MS patients, who were Medicare beneficiaries, faced considerable economic barriers to necessary health care, particularly prescription medications. Substantial differences existed in the out-of-pocket prices of DMAs between the 2 time periods analyzed. These differences could be expected to be attenuated by the expansion of Medicare to include a drug benefit (Part D), which will increase insurance coverage for DMAs and reduce the out-of-pocket burden of MS therapies.

Antirheumatic Agents↗
PubMed2006

Second-generation antidepressant discontinuation and depressive relapse in adult patients with bipolar depression: results of a retrospective database analysis.

BACKGROUND: To date, few postmarketing studies have addressed whether long-term prophylactic treatment with second-generation antidepressants (ADs) delays depressive episodes in patients with bipolar disorder. OBJECTIVE: The aim of this study was to compare the risk of depressive relapse between patients with bipolar disorder who took second-generation ADs>-6 months after depressive remission with those who discontinued AD use early. METHODS: Using a large US managed-care claims database, continuously enrolled bipolar subjects who took second-generation ADs after a depressive remission were identified between January 1, 1998, and December 31, 2002. Duration of AD and concurrent mood stabilizer use were based on coded diagnoses and pharmacy records. A Cox proportional hazards model was developed to predict time from depressive remission to next depressive relapse with continuous AD use, categorized as either >or=6 months or <6 months. Propensity scoring with greedy matching was used to help balance the observed background covariates and baseline disease severity between groups. RESULTS: Five hundred eighty-nine subjects met the inclusion criteria. A Kaplan-Meer estimate found that the median depressive relapse times for the continuous (ie, >or=6 months) and early discontinuation (ie, <6 months) AD treatment groups were 16.5 and 6.8 months, respectively (P<0.05). The Cox proportional hazards model with propensity score matching identified a significantly lower risk of depressive relapse over a 2-year period among those who continued AD treatment>or=6 months after remission, compared with those who discontinued treatment within 6 months (hazard ratio, 0.61 [95% CI, 0.42-0.88]; continuous vs early discontinuation, P<0.01). CONCLUSIONS: Continuous second-generation AD therapy for >or=6 months after depressive remission was associated with a lower risk of depressive relapse over a 2-year period in patients with bipolar depression. Given concerns regarding the risk of AD users with bipolar disorder switching to mania, an optimal prophylactic treatment after depressive remission should balance the risks between manic switching and depressive relapse.

Adolescent↗
PubMed2006

A naturalistic comparison of amoxicillin/clavulanate extended release versus immediate release in the treatment of acute bacterial sinusitis in adults: A retrospective data analysis.

BACKGROUND: Choosing the most effective treatment for acute bacterial sinusitis (ABS) is helpful to avoid treatment failure. To date, studies comparing antibiotic options for ABS have compared amoxicillin/clavulanate (AMX/CA) immediate release (IR) versus other antibiotics, but have not included AMX/CA extended release (XR). OBJECTIVE: The purpose of this study was to determine whether the clinical advantages of AMX/CA XR found in a clinical trial setting translate to a naturalistic setting, relative to AMX/CA IR. METHODS: Data for this retrospective analysis were obtained from a managed care benchmark database that included >25 million patients from >30 health plans covering 7 US census divisions. Data from all patients aged > or =18 years with an index diagnosis of ABS between July 1, 2001, and December 31, 2003, were included. Episodes of ABS were classified as treatment successes (no additional prescriptions for antibiotics, ABS-related emergency department [ED] visits, or ABS-related inpatient hospitalizations within 30 days after the index prescription) or failures (> or =1 subsequent antibiotic prescription, an ABS-related ED visit, or an ABS-related inpatient hospitalization within 30 days after the index prescription). Treatment failures were subclassified as early or late. Mean costs were assessed for medical claims linked with a primary diagnosis of ABS and antibiotic pharmacy claims within the follow-up time period (through February 28, 2004). Descriptive statistics for demographic characteristics, utilization patterns, and success rates were calculated for each cohort. A multivariate general linear regression model was developed to assess differences in costs between the 2 cohorts. RESULTS: : Of the patients with an index antibiotic prescription filled within 3 days of ABS diagnosis (n = 241,511), a total of 3224 in the AMX/CA XR cohort (mean [SD] age, 41.8 [11.6] years; women, 57.7%) and 23,638 in the AMX/CA IR cohort (mean [SD] age, 41.9 [11.6] years; women, 62.7%) were included in the analysis. The rate of treatment success in patients treated with AMX/CA XR was 82.8% versus 81.0% in patients treated with AMX/CA IR (P < 0.015). Treatment success costs were significantly lower than treatment failure costs regardless of an early or late designation and ranged from 98 dollars to 110 dollars per episode (P < 0.001). After adjustment for background covariates, the mean cost of treating an episode of ABS was significantly lower for patients receiving AMX/CA XR versus those receiving AMX/CA IR (166.32 dollars vs 177.34 dollars [US 2004 dollars]; P < 0.001), representing a mean cost savings of 11.02 dollars per patient treated with AMX/CA XR over AMX/CA IR for ABS, regardless of treatment outcome. CONCLUSIONS: The results from this data analysis suggest that AMX/CA XR had significantly higher treatment success in ABS relative to AMX/CA IR in this naturalistic setting. AMX/CA XR was associated with significantly decreased total ABS-related costs in these adults.

Acute Disease↗
PubMed2004

The art of directing a workers' compensation claim: personal observations on the role of the workers' compensation claim adjuster.

Workers' compensation claims are becoming more complex and expensive every day. One of the contributing factors for the increase is the aging workforce as well as federal legislation such as the Americans with Disabilities Act (ADA) and the Family and Medical Leave Act (FMLA). The workforce is aging, mobile, and educated about their rights. The key to avoiding spiraling costs is a strong safety and claims program that is sponsored by senior management,valued by the employees, and implemented by the entire company.

Eligibility Determination↗
PubMed2004

Application of a single sampling plan for auditing medical-claim payments made by Taiwan National Health Insurance.

National Health Insurance (NHI) has been implemented in Taiwan for nearly a decade. Owing to growing demand for medical-care, effective sampling auditing is a key factor in obtaining reasonably priced medical-care services. This investigation proposes a conceptual framework "medical-claim payment auditing (MCPA) procedure" based on the "Military Standard 105E (MIL-STD-105E) single sampling plan" for establishing an objective criterion for making medical-claim payments fairly. The MCPA procedure contributes to the following: (1) meeting international standards of sampling technology; (2) reducing the sampling ratio and consequently auditing costs; and (3) encouraging healthcare providers to honestly apply their medical-claim payments thus avoid wasting medical resources.

Financial Audit↗
PubMed2006

The impact of unrecognized bipolar disorders among patients treated for depression with antidepressants in the fee-for-services California Medicaid (Medi-Cal) program: a 6-year retrospective analysis.

INTRODUCTION: The cost of unrecognized bipolar disorders over time is unknown. METHODS: Ten years of data from the California Medicaid program were used to identify depressed patients initiating new episodes of antidepressant therapy and with 6+ years of post-treatment data. Recognized bipolar (RBP) patients received a BP diagnosis or used mood stabilizers in the pre-index period. Unrecognized bipolar (UBP) patients received an initial BP diagnosis or used a mood stabilizer in the post-index period. Depression-only (MDD) patients had no BP diagnosis or mood stabilizer use. Three analyses were conducted: (1) regression models of cost per year, (2) a regression model of aggregate cost over 6 years and (3) a time trend analysis of the costs for UBP patients. RESULTS: 14,809 patients were identified: RBP 14.5%, UBP 28.2% and MDD 57.3%. The growth in costs per month for UBP patients over 6 years (171%) far exceeds the growth for RBP and MDD patients (82% and 95%, respectively). RBP and MDD patients cost 2316 dollars and 1681 dollars less per year in the 6th year relative to UBP patients (p<0.0001 for both estimates). The cost per month increased by 91 dollars for each month of delayed diagnosis (p=0.011). Costs for UBP patients increased by 10 dollars per month prior to their initial BP diagnosis (p<0.001) and by -1.01 dollars thereafter (p=0.006 for the change in slope). LIMITATIONS: Classification of patients based on diagnosis or mood stabilizer use using paid claims data is inexact. CONCLUSIONS: Early diagnosis of bipolar disorders may significantly reduce health care cost.

Adult↗
PubMed2006

The accuracy of Minimum Data Set diagnoses in describing recent hospitalization at acute care facilities.

OBJECTIVES: The Minimum Data Set (MDS) is the resident assessment instrument used to guide clinical care, reimbursement, and assess quality in long-term care facilities. This database has been used in many studies, although the accuracy of many data elements remains unknown. This study evaluated the accuracy of the MDS diagnosis variables with respect to the diagnoses for recent hospitalization from Medicare claims data. DESIGN: Retrospective cohort study. SETTING: 945 skilled nursing facilities in Ohio. PARTICIPANTS: 17,294 residents admitted from an acute care facility during 2000. MEASUREMENTS: Eleven diagnoses listed in the MDS were compared with Medicare hospital discharge claims. Specifically, each MDS diagnosis was compared to the primary diagnosis, the list of secondary diagnoses, and the Diagnosis Related Group (DRG). RESULTS: Claims diagnoses were listed in the MDS with an average frequency of 79% (range: 31%-94%) for the primary diagnosis, 66% (range: 33%-90%) for any diagnosis, and 71% (range: 31%-94%) for the DRG. MDS diagnoses were listed as the primary diagnosis, any diagnosis, and DRG with an average frequency of 20% (range: 6%-81%), 62% (range: 41%-86%), and 19% (range: 7%-84%), respectively, with only hip fracture listed more than 80% of the time. CONCLUSION: The sensitivity of the MDS for listing diagnoses from recent hospitalization appears good for most diagnoses. However, except for hip fracture, the MDS has poor predictive value with regard to the primary reason for the preceding hospitalization; this may have implications for resident care planning and the utility of this database in long-term care research.

Activities of Daily Living↗
PubMed2004

Pharmacy and medical claims data identified migraine sufferers with high specificity but modest sensitivity.

OBJECTIVE: Claims data are often used to identify and monitor individuals with particular conditions, but many health conditions are not easily recognizable from claims data alone. Patient characteristics routinely available in claims data were used to develop model-based claims signatures to identify migraineurs. STUDY DESIGN AND SETTING: A validated telephone interview was administered to 23,299 continuously enrolled managed care members aged 18-55 to identify 1,265 migraineurs and 1,178 controls. Responses were linked to medical and prescription claims. Claims variables were evaluated for sensitivity, specificity, and positive and negative predictive value in predicting migraine status. Regression models for predicting migraine status were developed. RESULTS: Regression-based claims signature models were successful in case-finding, as indicated by fairly sizable odds ratios (OR). In the full model (including demographic, medical, pharmacy, and comorbidity claims variables), a claim for a migraine drug, gender, and a claims-based headache diagnosis were strongly associated with migraine case status (OR=3.9, 3.2, and 3.0, respectively). CONCLUSION: Using either medical or pharmacy claims provided highly specific and moderately sensitive case-findings. Strategies that combined medical and pharmacy information improved sensitivity and may increase the usefulness of claims for identifying migraine and improving the quality of migraine care.

Adolescent↗
PubMed2005

Preferred provider organization claims showed high predictive value but missed substantial proportion of adults with high-risk conditions.

BACKGROUND AND OBJECTIVE: We assessed the validity and utility of a claims-based ICD-9-CM algorithm for identifying preferred provider organization (PPO) enrollees ages 18-64 years at high risk for influenza complications. METHODS: PPO enrollees with >/= 2 encounters in an ambulatory setting or >/= 1 encounters in an inpatient or emergency room setting with ICD-9-CM diagnosis codes for the high-risk conditions were considered algorithm positive. Stratified random sampling was used to select 1,001 algorithm-positive and 330 algorithm-negative enrollees for medical chart abstractions. RESULTS: The prevalence of high-risk conditions using claims data was 2.5% compared to 18.2% according to medical records. The algorithm had a sensitivity of 12% and a specificity of 99%. Positive and negative predictive values were 87 and 84%, respectively. Sensitivity was twofold higher among adults aged 50-64 years than among younger adults (17 vs. 9%). Applying an algorithm definition of >/= 1 encounters in any setting resulted in an increased sensitivity, but captured a higher proportion of false positives. CONCLUSION: A claims-positive record was highly indicative of the presence of high-risk conditions, but such claims missed a large proportion of PPO enrollees with high-risk conditions. It is important to assess the validity of administrative data in different age groups.

Adolescent↗
PubMed2005

Detecting Medicare abuse.

This paper identifies which types of patients and hospitals have abusive Medicare billings that are responsive to law enforcement. For a 20% random sample of elderly Medicare beneficiaries hospitalized from 1994 to 1998 with one or more of six illnesses that are prone to abuse, we obtain longitudinal claims data linked with social security death records, hospital characteristics, and state/year-level anti-fraud enforcement efforts. We show that increased enforcement leads certain types of types of patients and hospitals to have lower billings, without adverse consequences for patients' health outcomes.

Fraud↗
PubMed2005

Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.

OBJECTIVE: The aim of this study was to measure the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain. DESIGN: This study is a retrospective analysis of claims data from a managed-care health plan over a 4-year period. The use rates of advanced imaging, surgery, inpatient care, and plain-film radiographs were compared between employer groups with and without a chiropractic benefit. RESULTS: For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (-32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (-37.2%); plain-film radiography (-23.1%); and inpatient care (-40.1%). On a per-patient basis, the rates were reduced by the following: surgery (-13.7%); CT/MRI (-20.3%); plain-film radiography (-2.2%); and inpatient care (-24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (-49.4%); CT/MRI (-45.6%); plain-film radiography (-36.0%); and inpatient care (-49.5%). Per patient, the rates were surgery (-31.1%); CT/MRI (-25.7%); plain-film radiography (-12.5%); and inpatient care (31.1%). All group differences were statistically significant. CONCLUSION: For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Adolescent↗
PubMed2005

Incidence of and survival after mammary tumors in a population of over 80,000 insured female dogs in Sweden from 1995 to 2002.

The main objective of this study was to describe the incidence of mammary tumors (MTs) and the survival after MTs, in female dogs between 3 and 10 years of age (insured for veterinary care and with life insurance in a Swedish animal-insurance company) from 1995 to 2002. Measures of incidence are presented crudely, by breed and across age categories and birth cohorts (1991-1998). The survivals until MT diagnosis and after a MT diagnosis were computed. The overall incidence for any MT claim was 111 dogs per 10,000 dog-years at risk (DYAR). The overall MT rate in the 1992 and 1993 birth cohorts was 154 dogs per 10,000 DYAR. The incidence for any MT claim increased with age and varied by breed, from 319 dogs per 10,000 DYAR in the English springer spaniel to 5 dogs per 10,000 DYAR in the rough-haired collie. At the ages 6, 8 and 10 years, 1%, 6% and 13% respectively, of all females had at least one MT claim. The MT mortality was 6 deaths per 10,000 DYAR and increased with age. The overall-case fatality was 6%.

Animals↗
PubMed2005

Roll-out of a nurse-led welfare benefits screening service throughout the largest Local Health Care Co-operative in Glasgow: an evaluation study.

OBJECTIVE: To evaluate the roll-out of a nurse-led Attendance Allowance (AA) screening programme in 24 general practices located within the largest Local Health Care Co-operative in Glasgow. STUDY DESIGN: Evaluation study METHODS: Six hundred and thirty participants aged over 64 years who, in the nurses' clinical judgement, appeared to have care needs were recruited opportunistically by community nurses over a 15-month period. A money advice worker contacted all potential underclaimers offering a home visit to assess for unclaimed benefits. The main outcome measured was the total amount of unclaimed AA, linked benefits and grants. RESULTS: Three hundred and sixty-three participants and 13 relatives were awarded a total of 1,136,424.10 pounds. Of this, 1,016,908.70 pounds was on a recurrent annual basis and 119,515.44 pounds was awarded as lump sums. CONCLUSIONS: This method of benefits assessment (community-nurse-led pre-AA screening followed by a home visit from a money advice worker) would appear to be an efficient and effective method of income maximization that could be rolled out nationally within primary care settings located in deprived areas.

Aged↗
PubMed2004

Medical malpractice as an epidemiological problem.

The notion that the tort liability system deters negligence in health care has been invoked to make the "business case for patient safety." However, existing data on the relationship between hospital adverse events and malpractice claims typically are interpreted as evidence that the tort system does not deter negligence because of the poor fit between those who are negligently injured and those who sue. Using a familiar analogy from epidemiology--the problem of false positives in screening tests for rare diseases--and data from two large studies of medical injuries and malpractice claims in the United States, this paper presents an argument that the standard interpretation overlooks a complexity in the data. Although most malpractice claims do not actually involve a negligent injury, a patient who suffers a negligent injury is more than 20 times more likely, on average, to file a claim than a patient who does not. However, because malpractice claiming is a rare event with many false positives, for the average hospital or group practice, even substantial improvements in rates of negligent injury will not lead to a large reduction in claims rates. These findings suggest that the strength of the business case for patient safety depends on the perspective from which one views the data.

Humans↗
PubMed2006

Assistance provided abroad to insured travellers from Australia following the 2004 Asian tsunami.

BACKGROUND: On 26 December 2004, the Asian tsunami hit countries around the Indian Ocean rim, particularly around its earthquake-associated epicentre off Indonesia. A number of popular tourist destinations for Australian travellers are located in this region. This study was designed to investigate travel insurance claims reported by travellers from Australia following the Asian tsunami and to examine the role of travel insurance and emergency assistance companies. METHODS: In December 2005, all claims reported, following the Asian tsunami on 26 December 2004, to a major Australian travel insurance company were examined for those claims associated with the Asian tsunami. RESULTS: Twenty-two tsunami-related claims were submitted of which nine travellers (40.9%) used the travel insurance company's emergency assistance service. Four travellers (18.2%) cancelled their trip to Asia, mainly to Thailand. Five travellers (27.3%), who were already abroad, also curtailed their trip as a result of the tsunami. Half of travellers (50.0%) were claiming loss of personal belongings. Of those using the emergency assistance service, five travellers (22.7%) sought policy and claiming advice, two (9.1%) sought assistance with flight rearrangements, and one (4.5%) sought situation advice. There was also assistance provided following the death of one insured traveller as a direct consequence of the tsunami, which included a lump sum payment to the deceased estate. The mean refund, where a travel insurance claim was paid, was Australian dollars (AUD)2234 (SD=AUD5755). CONCLUSIONS: This study highlights the importance of travellers taking out appropriate travel insurance, which provides for emergency assistance. Travel insurance agencies do play some role after emergencies, such as the Asian tsunami. This assistance predominantly involves dealing with cancellation of travellers' intended visits to the affected area, but does also involve some assistance to travellers affected by the crisis. Travellers should be advised to seek travel health advice well before departure overseas and to ensure that they are aware of travel advisories for their destination.

Adult↗
PubMed2005

Description of the immunization information database: a tool for investigating allegations made against childhood immunizations.

This paper describes the Immunization Information Database (IID). The IID is designed for cataloguing and systematically analyzing allegations that give rise to public concern regarding the safety, efficacy, and appropriateness of routine childhood immunizations. We describe the IID's eight data tables (Immunization Type; Claim; Claim Basis; Claimant; Source Documentation; Source Type; Claim Analysis; and Claim Analysis Type), and explain how these tables function to create a conceptual map of existing allegations.

Child↗