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PubMed2003

Cost savings for a preferred provider organization population with multi-condition disease management: evaluating program impact using predictive modeling with a control group.

Disease management programs have historically had difficulty demonstrating the financial value of their programs using statistically rigorous methods. This preliminary study utilized a predictive model built from a control group that consisted of individual employer groups whose benefits managers did not purchase disease management. The purpose of this evaluation was to examine the cost savings associated with Health Management Corporation's disease management program for asthma, diabetes, and coronary artery disease. Study and control group members were identified with exactly the same selection criteria as self-insured employer groups (n = 76,194) with preferred provider organization health plans that offered the disease management program. The study group consisted of members (n = 1,009) who were identified as having any of the three conditions and were eligible for the disease management program, regardless of the extent of their participation. The control group included members (n = 2,491) who were identified as having any of the same three conditions. The control group data were used to develop a predictive model designed to calculate expected medical claims costs for the study group. The gross savings of the disease management program was measured by calculating the difference between the expected medical claims costs predicted by the model and the actual medical claims costs for the study group. Preliminary analyses indicate that Health Management Corporation's disease management program produced a return on investment of $2.84: $1.00 and $1.45 gross savings per member per month.

Adolescent↗
PubMed2004

The differences between claim-based health risk adjustment models and cost prediction models.

There has been a significant increase in interest in using risk assessment tools with administrative claims data for provider profiling, provider payment, underwriting and disease/case management. The tools can be classified into two types: risk adjustment models and cost prediction models. The differences between the two models have not been well recognized. This paper explains the differences in terms of the objectives, the applications, and the accuracy of evaluations.

Insurance Claim Review↗
PubMed2002

Care after the onset of serious illness: a novel claims-based dataset exploiting substantial cross-set linkages to study end-of-life care.

To date, there has not been a study using a large, nationally representative group of patients with serious illness who are at risk for hospice use and who are followed forward in time to understand the determinants of hospice use. In this paper, we outline the development of a large new cohort of 1,221,153 Medicare beneficiaries newly diagnosed with 1 of 13 serious conditions in 1993, a cohort that can be used to study end-of-life care in the United States. In describing our methods, we illustrate the possible utility of Medicare claims for end-of-life research. The members of our cohort are followed forward for hospice and other health care use through December 1997, and for mortality through June 1999. Medicare claims data on their inpatient and outpatient hospital use is also collected. Based on the ZIP Codes and counties in which cohort members lived, we were also able to characterize the health care markets of cohort members, as well as obtain other socioeconomic information about them. Information about cohort member's health care providers is also available. Detailed health information about cohort members' spouses was also collected. We conclude by highlighting the types of analyses that can be conducted in this data set.

Cohort Studies↗
PubMed2006

Trends in healthcare use in the New York City region following the Terrorist Attacks of 2001.

BACKGROUND: In 2001, terrorism led to emotional stress, disruptions in adherence to treatments and access to services, and exposure to environmental contaminants in New York City (NYC). METHODS: To describe healthcare use following the terrorist attacks of 2001, we examined insurance claims for January 2000 to March 2002 among more than 2 million residents of the NYC region who were enrolled in the health plans of a large insurer, including overall use by care setting and use for selected conditions that may be associated with stress or other disaster consequences. For all enrollees and for those residing at varying distances from the World Trade Center (WTC), we compared observed use to expected use, based on comparable intervals in prior years and adjusted for seasonal and secular trends. RESULTS: Use declined across all care settings in the 3 weeks following September 11. From October 1 to December 31, 2001, outpatient visits rose beyond expected both overall and for specific cardiovascular, gastrointestinal, and dermatologic conditions. Declines in overall mental health service use began immediately after September 11 and were sustained through March 2002. Changes in healthcare use were more marked among those residing within 10 miles of the WTC than those residing at greater distances. CONCLUSIONS: A transient decline in visits across all settings occurred immediately after September 11, followed by a sustained increase in demand for health care for conditions that may be associated with stress or other disaster consequences.

Ambulatory Care↗
PubMed2005

Accuracy of prediction models in the context of disease management.

There has been a significantly increased interest in the adoption of prediction modeling by many disease and case management programs to risk stratify members in order to optimize the utilization of available clinical resources. Before adopting any prediction model, it is critical to understand how to evaluate the model's accuracy. This paper explains the basic concepts of prediction accuracy, the relevant parameters, their drawbacks, and their interpretations. It also introduces a new accuracy parameter termed "cost concentration," which indicates the model accuracy more explicitly in the context of disease management.

Disease Management↗
PubMed2001

Performance of comorbidity scores to control for confounding in epidemiologic studies using claims data.

Comorbidity is an important confounder in epidemiologic studies. The authors compared the predictive performance of comorbidity scores for use in epidemiologic research with administrative databases. Study participants were British Columbia, Canada, residents aged >or=65 years who received angiotensin-converting enzyme inhibitors or calcium channel blockers at least once during the observation period. Six scores were computed for all 141,161 participants during the baseline year (1995-1996). Endpoints were death and health care utilization during a 12-month follow-up (1996-1997). Performance was measured by using the c statistic ranging from 0.5 for chance prediction of outcome to 1.0 for perfect prediction. In logistic regression models controlling for age and gender, four scores based on the International Classification of Diseases, Ninth Revision (ICD-9) generally performed better at predicting 1-year mortality (c = 0.771, c = 0.768, c = 0.745, c = 0.745) than medication-based Chronic Disease Score (CDS)-1 and CDS-2 (c = 0.738, c = 0.718). Number of distinct medications used was the best predictor of future physician visits (R(2) = 0.121) and expenditures (R(2) = 0.128) and a good predictor of mortality (c = 0.745). Combining ICD-9 and medication-based scores improved the c statistics (1.7% and 6.2%, respectively) for predicting mortality. Generalizability of results may be limited to an elderly, predominantly White population with equal access to state-funded health care.

Aged↗
PubMed1999

Creating a computerized database from administrative claims data.

The creation of a computerized database from Medicaid administrative claims data for research purposes is described. Researchers should consult with computer experts at their institution before selecting software for data manipulation and conversion. It is essential to have an accurate layout of the file record before attempting to convert raw claims data into data sets or other data formats. The location of data elements within the claim will vary depending on whether the record comes from a provider, an institution, or a pharmacy. Each claim contains a common header, a variable header, and a claim detail section. The difficulty in analyzing data elements within a claim detail lies in locating the starting point of the claim detail section. So that data elements not in character or numeric formats can be converted, the file record layout must describe the exact format of each data element and its COBOL notation. A data element dictionary is necessary for translating data element coding into usable data. Data elements not necessary for any planned analysis must be eliminated. The data are then "cleaned" to remove any denied or reversed claims and claims that contain incomplete or erroneous data. Regardless of the format data are obtained in, an accurate file record layout and a data element dictionary are essential to the conversion of administrative claims data into a computerized database for data analysis and research purposes.

Database Management Systems↗
PubMed2002

Managed care and the judicial system: another avenue for reform?

Over the past several years the judiciary has become a major venue for challenging managed care. This article examines the present and potential effect of such litigation, focusing on the recent Supreme Court decision in Pegram v. Herdrich and class action litigation-filed under the Racketeer Influenced and Corrupt Organizations Act. The author concludes that although court-based reforms are a necessary and pragmatic response to managed care, they can result in only incremental changes. Litigation also cannot resolve the larger conflicts that result when a social welfare service such as health care is provided through a corporate model. Social workers need to look beyond the "next best" reform of managed care and advocate for more fundamental solutions to the inequities and inefficiencies in the provision of health care.

Consumer Advocacy↗
PubMed2004

Use of administrative healthcare claims to examine the effectiveness of trimethoprim-sulfamethoxazole versus fluoroquinolones in the treatment of community-acquired acute pyelonephritis in women.

OBJECTIVE: To evaluate the effectiveness of trimethoprim-sulfamethoxazole and fluoroquinolones in the treatment of community-acquired acute pyelonephritis. PATIENTS AND METHODS: We identified a population-based cohort of non-pregnant women aged 18-65 years, initially treated with trimethoprim-sulfamethoxazole or a fluoroquinolone for community-acquired pyelonephritis in an ambulatory care setting. Subjects were identified from a healthcare claims database in Manitoba, Canada for the period 15 February 1996 to 31 March 1999. Subsequent treatment failure, as evidenced by the provision of additional treatment up to 42 days post-diagnosis, was compared between the two treatments. RESULTS: A total of 1084 women met inclusion criteria: 653 (60.2%) treated with trimethoprim-sulfamethoxazole and 431 (39.8%) treated with a fluoroquinolone. Treatment outcomes were affected by subject age. At age 20, treatment with a fluoroquinolone resulted in a reduced probability of treatment failure compared with trimethoprim-sulfamethoxazole (odds ratio, 0.56; 95% CI, 0.33-0.97). At age 60, there was no difference in the probability of treatment failure (odds ratio, 1.61; 95% CI, 0.82-3.16). No other subject characteristics impacted comparative effectiveness; however, several characteristics increased the odds of treatment failure irrespective of the initial antibiotic. These included: recent urinary tract infection (odds ratio, 2.07; 95% CI, 1.14-3.57), recent antibiotic use (odds ratio, 1.40; 95% CI, 1.00-1.96;), and a treatment duration of less than 10 days (odds ratio, 2.18; 95% CI, 1.59-2.99). CONCLUSION: Younger subjects ( approximately 20 years) treated with fluoroquinolones were less likely to experience treatment failure than those treated with trimethoprim-sulfamethoxazole. Treatment durations of less than 10 days resulted in a higher probability of treatment failure regardless of the initial antibiotic.

Adolescent↗
PubMed2005

Criterion validity of Medicare chemotherapy claims in Cancer and Leukemia Group B breast and lung cancer trial participants.

To determine the accuracy with which Medicare claims data measure chemotherapy use in elderly Medicare beneficiaries with cancer, we performed a criterion validation study. We compared gold-standard clinical trial data for 175 elderly cancer patients treated in two Cancer and Leukemia Group B (CALGB) breast and lung cancer trials (i.e., 45 from trial 9344 and 130 from trial 9730) with contemporaneous ambulatory and in-patient Medicare health insurance claims data from Centers for Medicare and Medicaid Services (CMS). The breast trial participants studied were those elderly enrolled between 1995 and 1997 and treated with doxorubicin and cyclophosphamide or this combination with paclitaxel. The lung trial participants studied were those elderly enrolled between 1998 and 2000 and treated with paclitaxel and carboplatin or paclitaxel alone. Comparing CALGB data with Medicare claims, we found the crude sensitivity for chemotherapy administration was 93% (95% confidence interval [CI] = 88% to 96%). Individual chemotherapy agents had similarly high sensitivities, ranging from 81% (95% CI = 70% to 89%) for carboplatin to 91% (95% CI = 79% to 98%) for cyclophosphamide. Agent-specific specificities were 100%. CMS data reliably captured repeat administration of chemotherapy to within one cycle. Administrative Medicare claims data appear to be a valid source of information for chemotherapy administered to elderly Medicare beneficiaries with cancer.

Aged↗
PubMed2006

Frequency and cost of chemotherapy-related serious adverse effects in a population sample of women with breast cancer.

BACKGROUND: The number, nature, and costs of serious adverse effects experienced by younger women receiving chemotherapy for breast cancer outside of clinical trials are unknown. METHODS: From a database of medical claims made by individuals with employer-provided health insurance between January 1998 and December 2002, we identified 12,239 women 63 years of age or younger with newly diagnosed breast cancer, of whom 4075 received chemotherapy during the 12 months after the initial breast cancer diagnosis and 8164 did not. Diagnostic codes for eight chemotherapy-related adverse effects were identified. Total hospitalizations for all causes, hospitalizations or emergency room visits for adverse effects that are typically related to chemotherapy, and health care expenditures were compared between the two groups of women. All statistical tests were two-sided. RESULTS: Women who received chemotherapy were more likely than those who did not to be hospitalized or to visit the emergency room for all causes (61% versus 42%; mean difference = 19%, 95% confidence interval [CI] = 16.7% to 21.3%, P<.001) and for chemotherapy-related serious adverse effects (16% versus 5%, mean difference = 11%, 95% CI = 9.6% to 12.4%, P<.001). The percentages of chemotherapy recipients who were hospitalized or visited the emergency room during the year after their breast cancer diagnosis were 8.4% for fever or infection; 5.5% for neutropenia or thrombocytopenia; 2.5% for dehydration or electrolyte disorders; 2.4% for nausea, emesis, or diarrhea; 2.2% for anemia; 2% for constitutional symptoms; 1.2% for deep venous thrombosis or pulmonary embolus; and 0.9% for malnutrition. Chemotherapy recipients incurred large incremental expenditures for chemotherapy-related serious adverse effects (1271 dollars per person per year) and ambulatory encounters (17,617 dollars per person per year). CONCLUSIONS: Chemotherapy-related serious adverse effects among younger, commercially insured women with breast cancer may be more common than reported by large clinical trials and lead to more patient suffering and health care expenditures than previously estimated.

Adult↗
PubMed2002

Improving the process through which health plans and providers exchange performance-related mammography data.

The ability of health plans to bring about quality improvement is limited by the fact that physician networks are highly differentiated, with physician groups participating in many plans and plans contracting with many physician groups. The primary purpose of our study was to investigate the problems in the current system of quality monitoring by managed-care organizations (MCOs) at a large integrated health care delivery system (Montefiore Medical Center) and to develop ways of addressing these problems through collaboration among MCOs. The project began by mapping the current system for collecting, reporting, and using performance data to improve performance, using breast cancer screening as an example. We found that neither health plans nor providers were satisfied with the current system. From the perspective of the health plans, the current quality monitoring was costly and, more important, was not yielding appreciable increases in screening rates. From the providers' perspective, multiple health plan requests for chart pulls and other data collection activities cost them substantial amounts of time and money and generated multiple mailings of educational materials and reports, but rarely supplied meaningful information about their performance. From the perspective of the hospital, the current procedure of reporting from MCO to provider or center bypassed the institution's own quality monitoring and management structure and thus limited the institution's ability to assist in quality improvement. This study clearly showed the importance of collaboration among plans at a given provider site. Specifically, it pointed to the need for provider-oriented reporting of data, rather than plan-oriented reporting, to give physicians numbers that they believe. It also showed the need to engage the institution's own quality-management system to assist in bringing about improvements.

Cooperative Behavior↗
PubMed2004

Early retirement: does cause of invalidity influence rate of social security benefit processing in Zimbabwe?

BACKGROUND: The social security invalidity benefit programme in Zimbabwe is organized through a network of regional offices. There are no standard guidelines for assessing invalidity. Aim We tested whether cause of invalidity and place of residence influenced the rate of processing of invalidity benefit claims. METHOD: We carried out a retrospective cohort study involving 523 medically unadjudicated and a 25% (354/1431) random sample of medically adjudicated invalidity benefit claims at the Central Benefits Office of the National Social Security Authority in Zimbabwe. The outcome for the study was time from certification of invalidity to conclusion of medical adjudication of invalidity benefit claims. RESULTS: Compared with tuberculosis, HIV disease increased the rate of progress to final medical adjudication 2.6-fold, musculoskeletal diseases 1.9-fold, physical injuries 1.7-fold and chronic diseases 1.8-fold after adjusting for place of residence, industrial sector, gender and age. Compared with residing in Harare, residing in Chinhoyi, Gweru, Masvingo and Mutare regions reduced the rate of progress to final medical adjudication by 62, 69, 51 and 56%, respectively, after adjusting for cause of invalidity, industrial sector, gender and age. Compared with invalidity benefit claims from the services sector, those from the mining sector experienced a 45% reduction in rate of progress to final medical adjudication after adjusting for cause of invalidity, place of residence, gender and age. CONCLUSION: Cause of invalidity, place of residence and industrial sector had significant influences on the rate of progress to final medical adjudication of invalidity benefit claims.

Age Factors↗
PubMed2004

Injuries and liability related to central vascular catheters: a closed claims analysis.

BACKGROUND: To assess changing patterns of injury and liability associated with central venous or pulmonary artery catheters, the authors analyzed closed malpractice claims for central catheter injuries in the American Society of Anesthesiologists Closed Claims database. METHODS: All claims for which a central catheter (i.e., central venous or pulmonary artery catheter) was the primary damaging event for the injury were compared with the rest of the claims in the database. Central catheter complications were defined as being related to vascular access or catheter use or maintenance. Statistical analysis was performed using the chi-square test, Fisher exact test, or Z test (proportions) and the Kolmogorov-Smirnov test (payments). RESULTS: The database included 110 claims for injuries related to central catheters (1.7% of 6,449 claims). Claims for central catheter injuries had a higher severity of injury, with an increased proportion of death (47%) compared with other claims in the database (29%, P < 0.01). The most common complications were wire/catheter embolus (n = 20), cardiac tamponade (n = 16), carotid artery puncture/cannulation (n =16), hemothorax (n =15), and pneumothorax (n =14). Cardiac tamponade, hemothorax, and pulmonary artery rupture had a higher proportion of death (P < 0.05) compared with the rest of the central catheter injures. The proportion of claims for vascular access injury increased (47% to 84%) and use/maintenance injury decreased (53% to 16%) in 1994-1999 compared with 1978-1983 (P < 0.05). CONCLUSIONS: Claims related to central catheters had a high severity of patient injury. The most common complications causing injury were wire/catheter embolus, cardiac tamponade, carotid artery puncture/cannulation, hemothorax, and pneumothorax.

Catheterization, Central Venous↗
PubMed2004

Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claims analysis.

BACKGROUND: The authors used the American Society of Anesthesiologists Closed Claims Project database to identify specific patterns of injury and legal liability associated with regional anesthesia. Because obstetrics represents a unique subset of patients, claims with neuraxial blockade were divided into obstetric and nonobstetric groups for comparison. METHODS: The American Society of Anesthesiologists Closed Claims Project is a structured evaluation of adverse anesthetic outcomes collected from closed anesthesia malpractice insurance claims of professional liability companies. An in-depth analysis of 1980-1999 regional anesthesia claims was performed with a subset comparison between obstetric and nonobstetric neuraxial anesthesia claims. RESULTS: Of the total 1,005 regional anesthesia claims, neuraxial blockade was used in 368 obstetric claims and 453 of 637 nonobstetric claims (71%). Damaging events in 51% of obstetric and 41% of nonobstetric neuraxial anesthesia claims were block related. Obstetrics had a higher proportion of neuraxial anesthesia claims with temporary and low-severity injuries (71%) compared with the nonobstetric group (38%; P <or=0.01) and a lower proportion of claims with death or brain damage and permanent nerve injury compared with the nonobstetric group (P <or= 0.01). Cardiac arrest associated with neuraxial block was the primary damaging event in 32% of obstetric and 38% of nonobstetric neuraxial anesthesia claims involving death or brain damage. Eye blocks accounted for 5% of regional anesthesia claims. CONCLUSION: Obstetric claims were predominately associated with minor injuries. Permanent injury from eye blocks increased in the 1990s. Neuraxial cardiac arrest and neuraxial hematomas associated with coagulopathy remain sources of high-severity injury.

Adult↗