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PubMed1998

The Home Infusion Therapy/Relative Benefit Index: summary of an analysis using insurance claims data.

OBJECTIVES: The cost of providing services is the traditional criteria used by payers in making selective contracting decisions regarding home care providers in general, and home infusion therapy (HIT) vendors specifically for this analysis. This approach assumes comparable health outcomes, for which adequate measures often are unavailable. In practice, poor quality can result in a need for remedial services. The objective of this research is to develop a method to use health insurance claims data to incorporate the hidden costs of adverse outcomes into an analysis of the costs of a vendor's HIT. METHODS: The Home Infusion Therapy/Relative Benefit Index (HIT/RBI) model incorporates measures of both the cost of providing HIT services as well as the cost of remedial treatment for the adverse outcomes that may result from HIT care, eg, emergency room visits. The data source for the analysis is the health care claims for a sample of managed care patients of national insurer for the period 1990 to 1994. RESULTS: The analysis confirms that adverse clinical outcomes can lead to additional demand for remedial health care with resultant negative financial consequences. When the cost of the adverse outcomes is incorporated into the analysis, vendors who appeared to be low cost on the basis of HIT services, in fact were higher cost vendors, whereas vendors with a high cost of services but with few adverse events were low cost vendors. CONCLUSIONS: Payers should consider both the clinical and economic consequences of providing care into account in selecting vendors. The HIT/RBI model is a useful tool for incorporating the cost of adverse outcomes into a comprehensive comparison of the cost multiple vendors of HIT services.

Bacterial Infections↗
PubMed1998

Factors related to potentially preventable hospitalizations among the elderly.

OBJECTIVES: The authors examine whether the odds of having a hospitalization associated with an ambulatory care sensitive condition can be explained by observed differences in a Medicare beneficiary's predisposing, enabling, and need characteristics. METHODS: A multivariate cross-sectional analysis of Medicare's administrative inpatient claims data and the Medicare Current Beneficiary Survey was conducted on a nationally representative sample of Medicare beneficiaries. Each Medicare beneficiary's hospital utilization was classified into one of three categories: (1) no hospital admissions; (2) hospitalized, but no hospitalizations for a potentially preventable condition; and (3) at least one potentially preventable hospitalization. RESULTS: The results suggest that being older, black, or living either in a core standard metropolitan statistical area (SMSA) county or a rural county significantly increases the odds of a preventable hospitalization, whereas having attended college, or having only Medicare insurance coverage reduces the odds of a preventable hospitalization. Further, those individuals who assess their health status as poor, have had coronary heart disease, a myocardial infarction, or diabetes, and required assistance with two or more of the six basic activities of daily living are at a greater risk of a preventable hospitalization. CONCLUSIONS: Policy efforts aimed at reducing the number of preventable hospitalizations among the elderly should address the complex health care delivery needs of those Medicare beneficiaries who have special health care needs because they are very old, black, live in core SMSA or rural counties, have poor overall health status, and have physical limitations. Efforts to reduce the number of Medicare beneficiaries who experience a preventable hospitalization may be cost-effective as these beneficiaries may account for up to 17.4% of Medicare's reimbursement for inpatient, outpatient, and physician services in our data set.

Activities of Daily Living↗
PubMed1999

Use of claims data for research on treatment and outcomes of depression care.

BACKGROUND: Data sources such as medical insurance claims are increasingly used in outcomes research. In this report, we present opportunities and limitations associated with the use of such data for outcomes research in the area of depression. OBJECTIVES: The purpose of this report is to illustrate the use of administrative claims data in conducting research in the area of depression. Information in this report is intended to be helpful to both experienced health services researchers and to those who may be new to the field of either outcomes research or mental health research. FORMAT: This report covers measurement of outcomes, possible data sources, episode construction, and statistical methodologies that are appropriate when conducting depression research using claims data. Through examples and references, issues to be considered in each of these areas are examined and recommendations are made. Strengths and limitations of claims data will also be pointed out. CONCLUSIONS: The use of claims data to conduct outcomes research in depression should be carried out responsibly. Limitations with using claims data to identify patients with depression must be acknowledged and appropriate methodologies should be used. Still, these data sources provide a rich opportunity to conduct outcomes research in depression, and much can be learned using administrative claims data.

Depressive Disorder↗
PubMed2000

Agreement of Medicare claims and tumor registry data for assessment of cancer-related treatment.

BACKGROUND: Although health claims data are increasingly used in evaluating variations in patterns of cancer care and outcomes, little is known about the comparability of these data with tumor registry information. OBJECTIVES: To evaluate the agreement between Medicare claims and tumor registry data in measuring patterns of diagnostic and therapeutic procedures for older cancer patients. RESEARCH DESIGN: Analysis of a database linking Surveillance, Epidemiology and End Results (SEER) registry data and Medicare claims in patients aged > or =65 years with cancer. SUBJECTS: 361,255 Medicare patients with invasive breast, colorectal, endometrial, lung, pancreatic, and prostate cancer diagnosed between 1984 and 1993. MEASURES: Concordance of SEER files with corresponding Medicare claims. RESULTS: Medicare claims generally identified patients who underwent resection and radical surgery according to SEER (ie, concordance > or =85%-90%) but less likely biopsy or local excision (ie, concordance < or =50%). In some instances, claims also categorized patients as having more invasive surgery than was listed in SEER and also provided incremental information about the use of surgical treatment after 4 months. SEER files and, to a lesser degree, Medicare claims identified radiation therapy not included in the other data source, and Medicare files also captured a significant number of patients with codes for chemotherapy. CONCLUSIONS: Medicare files may be appropriate for studies of patterns of use of surgical treatment, but not for diagnostic procedures. The potential benefit of Medicare claims in identifying delayed surgical intervention and chemotherapy deserves further study.

Aged↗
PubMed2002

Construct validity of medicare chemotherapy claims: the case of 5FU.

BACKGROUND: The elderly are under represented in clinical trials of cancer therapy and the elderly who are enrolled may be unrepresentative. OBJECTIVE: To assess whether Medicare claims data might be used to understand the benefits and tolerance of chemotherapy in the general elderly population, the construct validity of Medicare 5FU claims for elderly colon cancer patients within the SEER-Medicare data set was determined. METHODS: In this validation study of Medicare chemotherapy claims from the linked the SEER-Medicare data set, the patterns of 5FU chemotherapy claims were evaluated for an incident cohort of elderly colon cancer patients (n = 15,039) during the 13 months following their diagnosis. Patterns of Medicare National Claims History (NCH) 5FU claims were evaluated with respect to prespecified patient-level disease and demographic factors from the data set. RESULTS: Twenty-two percent of patients had at least one detectable 5FU claim during the observation period. Among those patients, the median dose of 5FU was 1000 mg, the median interval between 5FU claims was 7 days, and the median number of claims during this period was 24. Multivariate regression revealed expected associations between demographic and disease factors and the likelihood of having a Medicare NCH 5FU claim. With increasing cancer stage, patients' likelihood of having a 5FU claim increased. Younger patients, married patients, white patients, patients with low comorbidity, and patients living in urban and less impoverished regions were each more likely to have 5FU claims. CONCLUSION: Because their pattern is consistent with the standard of medical care and with previously described associations with disease and demographic factors, it was concluded that Medicare NCH claims for 5FU administration in the SEER-Medicare data set exhibit construct validity. Criterion validation studies with an external gold standard should be pursued to determine the sensitivity and specificity of chemotherapy codes in the Medicare NCH files.

Adenocarcinoma↗
PubMed2002

Assessing comorbidity using claims data: an overview.

Comorbidity, additional disease beyond the condition under study that increases a patient's total burden of illness, is one dimension of health status. For investigators working with observational data obtained from administrative databases, comorbidity assessment may be a useful and important means of accounting for differences in patients' underlying health status. There are multiple ways of measuring comorbidity. This paper provides an overview of current approaches to and issues in assessing comorbidity using claims data, with a particular focus on established indices and the SEER-Medicare database. In addition, efforts to improve measurement of comorbidity using claims data are described, including augmentation of claims data with medical record, patient self-report, or health services utilization data; incorporation of claims data from sources other than inpatient claims; and exploration of alternative conditions, indices, or ways of grouping conditions. Finally, caveats about claims data and areas for future research in claims-based comorbidity assessment are discussed. Although the use of claims databases such as SEER-Medicare for health services and outcomes research has become increasingly common, investigators must be cognizant of the limitations of comorbidity measures derived from these data sources in capturing and controlling for differences in patient health status. The assessment of comorbidity using claims data is a complex and evolving area of investigation.

Algorithms↗
PubMed2002

Use of SEER-Medicare data for measuring cancer surgery.

BACKGROUND: The accuracy and completeness of the SEER-Medicare data for measuring cancer-related therapy have not been extensively evaluated. OBJECTIVES: To investigate the best method for measuring cancer-related surgery among patients in the SEER-Medicare database. SUBJECTS: A total of 149,970 incident cases of breast, colorectal, endometrial, lung, pancreatic, and prostate cancer diagnosed between 1991 and 1993.MEASURES The most invasive surgical procedure identified through Medicare's inpatient, physician, and hospital outpatient claims was compared with corresponding data from the SEER files. RESULTS: Agreement between the SEER and Medicare files was generally highest for resection and radical surgery (eg, kappa 0.70-0.90). While there was less agreement regarding no surgical therapy and biopsy individually, the concordance of the two sources in excluding cancer-directed surgery was high. Compared with inpatient data alone, using the combined inpatient, physician, and outpatient data increased concordance between SEER and Medicare for less invasive procedures. CONCLUSIONS: The agreement of SEER and Medicare data appears to be good for major surgical procedures and for excluding persons who did not undergo cancer-directed surgery. Both the SEER and the Medicare data captured a small number of surgeries not reported in the other file. Therefore, where possible, using both data sources will enhance identification of surgeries. Because the analysis was performed with linked data, the accuracy of surgical claims in Medicare data alone cannot be assessed.

Health Services Research↗
PubMed2002

Studying radiation therapy using SEER-Medicare-linked data.

BACKGROUND: Numerous studies have used the SEER or Medicare data to assess the use of radiation therapy. However, the completeness of these data has not been evaluated. METHODS: Using linked SEER-Medicare data, a cohort was created that included incident cases of breast, endometrial, lung, prostate, or rectal cancer from 1991 to 1996 in persons 65 years and older. For each of these cases, use of radiation therapy as an initial course of treatment reported from the SEER data was compared with use of radiation therapy in the months following diagnosis, as determined from the Medicare claims. RESULTS: Overall, there was a high agreement between SEER and Medicare sources for use of radiation therapy. Agreement was 88% for lung cancer, 93% for prostate cancer, 94% for rectal and breast cancers, and 95% for endometrial cancer. Within the Medicare files, radiation claims were found in MedPAR Physician Supplier Part B and Outpatient files. CONCLUSIONS: There is a high level of agreement between SEER and Medicare reporting of radiation treatments after a cancer diagnosis, suggesting that either source can be used to assess radiation-related treatment patterns. However, for the most complete ascertainment of radiation use, both SEER and Medicare sources should be used.

Aged↗
PubMed2002

Identifying and measuring hospital characteristics using the SEER-Medicare data and other claims-based sources.

The context in which health care is delivered may have an impact on the outcomes and processes of care. Researchers analyzing claims data that reflect care rendered at many institutions may wish to identify hospital characteristics such as bed size, teaching status, degree of specialization, and case volume to evaluate their influence on outcomes. The authors describe the resources available from administrative data for characterizing hospitals. The article focuses on analyses using the SEER-Medicare-linked data, but has direct relevance for investigators working with other sources of claims data. First, the authors focus on assessment of hospital case volume, which is the principal hospital attribute that can be obtained directly from the SEER-Medicare data files. Second, they assess the information regarding hospital characteristics that can be gleaned from the American Hospital Association (AHA) survey and the annual cost reports submitted to the Center for Medicare and Medicaid Services (CMS) by all certified hospitals. From a comparison of the responses of 4,434 hospitals to 1994 AHA and CMS surveys, the authors conclude that the two data sources contain very similar information, but that for most investigators, use of data from CMS cost reports will be preferable to use of AHA data because of higher survey-completion rates and public availability.

Aged↗
PubMed2005

Comparing the validity of different sources of information on emergency department visits: a latent class analysis.

BACKGROUND: Emergency department (ED) use in Quebec may be measured from varied sources, eg, patient's self-reports, hospital medical charts, and provincial health insurance claims databases. Determining the relative validity of each source is complicated because none is a gold standard. OBJECTIVE: We sought to compare the validity of different measures of ED use without arbitrarily assuming one is perfect. SUBJECTS: Data were obtained from a nursing liaison intervention study for frail seniors visiting EDs at 4 university-affiliated hospitals in Montreal. MEASURES: The number of ED visits during 2 consecutive follow-up periods of 1 and 4 months after baseline was obtained from patient interviews, from medical charts of participating hospitals, and from the provincial health insurance claims database. METHODS: Latent class analysis was used to estimate the validity of each source. The impact of the following covariates on validity was evaluated: hospital visited, patient's demographic/clinical characteristics, risk of functional decline, nursing liaison intervention, duration of recall, previous ED use, and previous hospitalization. RESULTS: The patient's self-report was found to be the least accurate (sensitivity: 70%, specificity: 88%). Claims databases had the greatest validity, especially after defining claims made on consecutive days as part of the same ED visit (sensitivity: 98%, specificity: 98%). The validity of the medical chart was intermediate. Lower sensitivity (or under-reporting) on the self-report appeared to be associated with higher age, low comorbidity and shorter length of recall. CONCLUSION: The claims database is the most valid method of measuring ED use among seniors in Quebec compared with hospital medical charts and patient-reported use.

Aged↗
PubMed1994

The cost of 1989 workers' compensation low back pain claims.

STUDY DESIGN: Cost data were gathered from computerized records of the Liberty Mutual Insurance Company for low back pain workers' compensation claims (N = 119,107) and for all claims (N = 731,087) initiated from 45 jurisdictions (states) during 1989. OBJECTIVE: This study provided more current, accurate, and additional information to estimate the costs and incidence associated with compensable low back pain compared with all compensation claims. METHODS: The first group of data included all compensable low back claims selected by specific codes: body part codes consisted of low back area, sacrum and coccyx, disc, and multiple trunk; injury codes consisted of strain, sprain, inflammation, rupture, hernia, fracture, and contusion. The second sample included all compensable claims, including both occupational injuries and illnesses. RESULTS: Low back pain cases represented 16% of all claims but 33% of all claims costs; 55.4% of the low back pain cases received medical payments only (i.e., did not receive indemnity payments for lost time). The mean cost per case for low back pain was $8321; median cost per case was $396. Medical costs represented 32.4% of the total costs; indemnity costs (i.e., payment for lost time) represented 65.8%. CONCLUSIONS: Since indemnity costs represent the greatest percentage of workers' compensation expenditure, the primary goal of low back pain management should be the prevention or reduction of prolonged disability.

Costs and Cost Analysis↗
PubMed1994

Factors that affect surgical rates in Iowa.

STUDY DESIGN: This study analyzed insurance claims to estimate the probability of medical and surgical treatments in different Iowa communities. The likelihood of surgical treatment was associated with patient characteristics of age and gender as well as hospital characteristics of size (number of beds), occupancy rate, and number of staff. OBJECTIVES: Our findings are being used by a study group of 25 physicians to understand the causes of variation in surgical rates for low back pain. Medical education and other interventions are being implemented. SUMMARY OF BACKGROUND DATA: Hospitalization rates for lower back operations in the United States increased by more than 20% from 1978 to 1985. Consequently, several studies in Iowa and the US have been initiated to examine the medical effectiveness of these treatments. METHODS: A logistic regression model was used to determine the factors associated with the likelihood of having a low back surgery in a population of Blue Cross/Blue Shield (BCBS) subscribers in Iowa. The outcome, or dependent variable, of interest was a hospitalization that resulted in a surgical procedure on a low back pain patient. RESULTS: Surgical rates for the treatment of low back pain are likely to be increased if a BCBS Iowa subscriber is female, older than 44 years of age, or if the surgery is performed in a hospital with either an occupancy rate less than 62%, with fewer than 774 staff members, fewer than 267 beds, or no residency programs.

Adult↗
PubMed1994

Analysis of automated administrative and survey databases to study patterns and outcomes of care.

Large computerized databases often arise from national surveys, insurance claims, and statewide health care registries. These databases are increasingly used to examine patterns of medical care and certain outcomes of care and may be helpful in planning clinical trials. They are highly representative of defined populations, but have limited clinical information. Methods have been developed to identify episodes of low back pain and to quantify the severity of unrelated, comorbid medical conditions. Pitfalls in analysis are discussed, including limitations of diagnosis and procedure coding, cross-sectional nature of most data, limited clinical detail, and the necessarily observational (not experimental) nature of any group comparisons. There is growing interest in expanding the clinical information in such databases, for both quality improvement and research purposes.

Cross-Sectional Studies↗
PubMed1997

Spine update. Administrative databases in spine research.

The use of administrative health care databases for the storage and retrieval of information is increasing. The data collection, entry, and collation follows a predictable process for hospital admissions. Many conclusions have been drawn from research performed using administrative databases. These conclusions can have significant and important implications for patients, providers, and society at large, to the extent that such data inform participants in the current health care policy debate. In an effort to better understand the significance of conclusions drawn from studies that rely on electronic administrative databases as their source of information, the present report addresses the process, strengths, weaknesses, and future plans for the use of administrative databases in spine research.

Databases, Factual↗
PubMed1999

Measurement of mammography rates for quality improvement.

To determine the best source of high-quality data related to mammography rates, a study was undertaken to compare chart audit and claims data from the Health Care Financing Administration's Ambulatory Quality Improvement Project. Because claims data captured a higher percentage of mammograms than chart audit data in this study, quality improvement projects should consider utilizing claims data only to ascertain mammography rates.

Aged↗
PubMedDate not supplied

Do women simply complain more? National patient injury claims data show gender and age differences.

The Swedish Counties Mutual Insurance (LOF) owns and operates the Swedish Patient Insurance Company, (PSR) a no-blame insurance system that compensates patients for injuries that result from errors in medical practice. We combined malpractice claims data (from PSR) with national hospital discharge registry data (National Board of Health and Welfare-Socialstyrelsen) and determined Swedish inpatient malpractice claims rates for the years 1996-2000. Women have higher claims rates than men, but their claims are adjudicated as valid more often than men's claims. The data are consistent with other lines of evidence suggesting poorer quality of care for women, e.g., heart disease, kidney disease, and cancer. Middle-aged (40- to 59-year-old) patients file malpractice claims at almost twice the national rate, whereas patients younger than 19 years and older than 80 years of age file at significantly below the average rate. Differences in claims rates have major financial and quality of care implications. Further studies are needed.

Adolescent↗
PubMedDate not supplied

Do health care managers know the comparative quality of their care?

Compared with other industries, health care is a high-risk industry. In this study, two national data sets on patient claims and a survey of improvement efforts in Swedish health care were used to investigate the linkage between how health care managers perceive their performance regarding adverse medical events and their performance as reflected in patient malpractice claims rates. The departments' focus on patient safety issues in their improvement efforts was also evaluated. Our results show that Swedish health care department managers underestimate their departments' frequency of adverse medical events relative to that of similar units. Also, there is no correlation between the managers' perception of adverse medical events and their actual frequency of patient malpractice claims. More research is needed on the use of patient-generated malpractice claims and claims rates to promote a higher awareness of the magnitude of the safety problems in health care.

Attitude of Health Personnel↗