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PubMed1993

Analysis of coronary angioplasty practice in the United States with an insurance-claims data base.

BACKGROUND: Coronary angioplasty is frequently performed in the United States, with more than 300,000 procedures in 1990. Despite the high rate of use of the procedure, there have been few studies addressing practice patterns. METHODS AND RESULTS: From a private insurance claims data base of 5.4 million individuals, a total of 2,101 patients who underwent coronary angioplasty during 1988-1989 were identified. Using their 4,578 hospital admission records and 87,578 outpatient claim records, with an average follow-up of 332 +/- 182 days, we compared patients' outcomes and charges according to whether they had an exercise stress test before the procedure, by sex, by region of the country, and by whether the angioplasty was performed in an institution with a training program. Only 29% of the study cohort had exercise testing before angioplasty; patients in the West (p = 0.001), those undergoing multivessel angioplasty (p = 0.00001), and those whose procedures were performed at sites with training programs (p = 0.04) were more likely to have a screening test, whereas women (p = 0.008) and those with a recent myocardial infarction (p = 0.00001) were less likely to have a screening test. The average length of stay for patients without myocardial infarction as a primary diagnosis was 5.6 days, with a total hospital charge of $15,027. In follow-up, 15.1% had coronary artery bypass surgery and 15% had at least one additional angioplasty procedure; the average follow-up charges were $4,879. Charges varied according to sex, region of the country, and academic status of the angioplasty institution. Certain outcomes showed variation by region of the country and academic status of the angioplasty institution. CONCLUSIONS: The relative lack of an objective definition of myocardial ischemia and the marked variability of use of procedures according to geographic region suggest the need for further implementation of established guidelines.

Age Factors↗
PubMed2006

An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with an acute myocardial infarction.

BACKGROUND: A model using administrative claims data that is suitable for profiling hospital performance for acute myocardial infarction would be useful in quality assessment and improvement efforts. We sought to develop a hierarchical regression model using Medicare claims data that produces hospital risk-standardized 30-day mortality rates and to validate the hospital estimates against those derived from a medical record model. METHODS AND RESULTS: For hospital estimates derived from claims data, we developed a derivation model using 140,120 cases discharged from 4664 hospitals in 1998. For the comparison of models from claims data and medical record data, we used the Cooperative Cardiovascular Project database. To determine the stability of the model over time, we used annual Medicare cohorts discharged in 1995, 1997, and 1999-2001. The final model included 27 variables and had an area under the receiver operating characteristic curve of 0.71. In a comparison of the risk-standardized hospital mortality rates from the claims model with those of the medical record model, the correlation coefficient was 0.90 (SE=0.003). The slope of the weighted regression line was 0.95 (SE=0.007), and the intercept was 0.008 (SE=0.001), both indicating strong agreement of the hospital estimates between the 2 data sources. The median difference between the claims-based hospital risk-standardized mortality rates and the chart-based rates was <0.001 (25th and 75th percentiles, -0.003 and 0.003). The performance of the model was stable over time. CONCLUSIONS: This administrative claims-based model for profiling hospitals performs consistently over several years and produces estimates of risk-standardized mortality that are good surrogates for estimates from a medical record model.

Aged↗
PubMed2006

An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with heart failure.

BACKGROUND: A model using administrative claims data that is suitable for profiling hospital performance for heart failure would be useful in quality assessment and improvement efforts. METHODS AND RESULTS: We developed a hierarchical regression model using Medicare claims data from 1998 that produces hospital risk-standardized 30-day mortality rates. We validated the model by comparing state-level standardized estimates with state-level standardized estimates calculated from a medical record model. To determine the stability of the model over time, we used annual Medicare cohorts discharged in 1999-2001. The final model included 24 variables and had an area under the receiver operating characteristic curve of 0.70. In the derivation set from 1998, the 25th and 75th percentiles of the risk-standardized mortality rates across hospitals were 11.6% and 12.8%, respectively. The 95th percentile was 14.2%, and the 5th percentile was 10.5%. In the validation samples, the 5th and 95th percentiles of risk-standardized mortality rates across states were 9.9% and 13.9%, respectively. Correlation between risk-standardized state mortality rates from claims data and rates derived from medical record data was 0.95 (SE=0.015). The slope of the weighted regression line from the 2 data sources was 0.76 (SE=0.04) with intercept of 0.03 (SE=0.004). The median difference between the claims-based state risk-standardized estimates and the chart-based rates was <0.001 (25th percentile=-0.003; 75th percentile=0.002). The performance of the model was stable over time. CONCLUSIONS: This administrative claims-based model produces estimates of risk-standardized state mortality that are very good surrogates for estimates derived from a medical record model.

Aged↗
PubMed1996

Impact of visit copayments on outpatient mental health utilization by members of a health maintenance organization.

OBJECTIVE: The authors examined the impact of increasing cost sharing on use of outpatient mental health services. METHOD: A quasi-experimental design was used to study outpatient utilization by members of a health maintenance organization (HMO) who were subject to increasing copayments for mental health visits (state government employees and dependents). Their outpatient mental health utilization was compared with that of similar HMO members who were not subject to cost sharing (federal government employees and dependents). Analyses compared both likelihood of any service use and number of visits per year among service users. RESULTS: Institution of $20/visit copayments was associated with a 16% decrease in likelihood of service use but no change in visit rate among service users. A subsequent copayment increase to $30/visit resulted in no significant change in likelihood of use but was associated with a 9% decrease in visits per year among those using services. The impact of the first copayment change on likelihood of using services did not vary according to level of clinical need (as measured by prior service use and psychotropic drug use). CONCLUSIONS: In this staff-model HMO, modest visit copayments significantly reduced initial access to mental health treatment and had a smaller effect on treatment intensity. Copayments restricted access regardless of clinical need. Designers of mental health benefits must consider the impact of copayments on those with the greatest need for treatment.

Ambulatory Care↗
PubMed1999

Rate of psychiatric illness 1 year after traumatic brain injury.

OBJECTIVE: Neurobehavioral symptoms are not uncommon after a traumatic brain injury. However, psychiatric syndromes per se have rarely been studied in patients with such an injury. The purpose of this study was to evaluate the type and extent of psychiatric syndromes in patients with traumatic brain injury. METHOD: One hundred ninety-six hospitalized adults were studied 1 year after a traumatic brain injury with the use of a two-stage psychiatric diagnostic procedure. Psychiatric diagnoses were made according to ICD-10 criteria on the basis of data from the Schedules for Clinical Assessment in Neuropsychiatry interview. RESULTS: Of 164 patients interviewed, 30 (18.3%) had an ICD-10 diagnosis of a psychiatric illness. Among the 120 patients who were 18-64 years old, 21.7% had a psychiatric illness, compared with 16.4% in a study of the general population. A depressive illness was present in 13.9% of the traumatic brain injury patients, compared with 2.1% of the general population, and panic disorder was present in 9.0%, compared with 0.8% of the general population. CONCLUSIONS: In comparison with the general population, a higher proportion of adult patients had developed psychiatric illnesses 1 year after a traumatic brain injury; the rates of depressive episode and panic disorder were significantly higher in the study group. A history of psychiatric illness, an unfavorable global outcome according to the Glasgow Outcome Scale, a lower score on the Mini-Mental State examination, and fewer years of formal education seemed to be important risk factors in the development of a psychiatric illness. Compensation claims, however, were not associated with the rate of psychiatric illness.

Adolescent↗
PubMed2000

The effect of copayments on drug and alcohol treatment following inpatient detoxification under managed care.

OBJECTIVE: The study examined the rate and duration of outpatient substance abuse treatment following inpatient detoxification under managed care. METHODS: Seven years of claims data from a large behavioral health care carve-out plan were used to identify patients. Rates and duration of formal substance abuse treatment following detoxification were calculated, and regression models were used to explore factors that may affect participation in treatment. RESULTS: Seventy-nine percent of the detoxification patients received formal substance abuse treatment, the majority within the week following discharge. Formal follow-up care lasted an average of ten weeks, with visits occurring on average about once a week. When other variables likely to influence participation in substance abuse treatment were controlled for, the level of outpatient copayments significantly affected the rate of participation in treatment. CONCLUSIONS: These findings indicate that the rate of participation in outpatient treatment after detoxification is high, but room for improvement remains. The results suggest that reducing copayment levels is one mechanism for increasing the likelihood that individuals with severe drug and alcohol problems will receive subsequent treatment. The need for such treatment is underscored by the severity of illness of those who undergo detoxification and the societal costs of untreated substance use disorders.

Adult↗
PubMed2001

Use and costs of ambulatory care services among Medicare enrollees with schizophrenia.

OBJECTIVE: The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia. METHODS: The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy. RESULTS: For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people. CONCLUSIONS: The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

Aged↗
PubMed2001

Using drug claims data to assess the relationship of medication adherence with hospitalization and costs.

OBJECTIVE: This naturalistic study used claims data to examine the relationship of medication nonadherence to hospital use and costs among severely mentally ill clients in Wisconsin. METHODS: Data for 619 clients were obtained from Medicaid drug and hospital claims, county records, and case managers as part of a larger study in eight county-based mental health systems. Study participants were eligible for Medicaid, had a severe and persistent mental illness, were 18 years or older, and were receiving neuroleptics, lithium, or antidepressants. Drug claims were analyzed for a 12-month period to determine how regularly clients obtained their medications. Regression analyses were used to assess the effects of irregular medication use on any hospitalization for psychiatric problems, the number of days hospitalized, and hospital costs. The analyses controlled for several risk factors. RESULTS: Among clients with schizophrenia or schizoaffective disorder, 31 percent used medications irregularly. The rates were 33 percent among those with bipolar disorder and 41 percent among those with other severe mental illnesses. In the total sample, irregular users had significantly higher rates of hospitalization than regular users (42 percent versus 20 percent), more hospital days (16 days versus four days), and higher hospital costs ($3,992 versus $1,048). Irregular medication use was one of the strongest predictors of hospital use and costs even after the analyses controlled for diagnosis, demographic characteristics, baseline functioning, and previous hospitalizations. CONCLUSIONS: The availability of drug claims data and the ability to use them in predictive analyses make them a potentially useful data source in studies of medication adherence among persons with severe mental illness.

Adult↗
PubMed2001

Lessons learned from trends in psychotropic drug expenditures in a canadian province.

Although prescription drug prices are lower in Canada than in the United States, trends indicate that there has nevertheless been a steep increase in expenditures on psychotropic drugs. Between 1992 and 1998, such expenditures increased by 216 percent; 61 percent of these expenditures were on antidepressants, 33 percent on antipsychotics, and less than 7 percent on anxiolytics. Most of the increase in costs in Canada is attributable to a greater use of newer agents and the higher prices of these agents. These trends are a reminder not only that the use of newer, more expensive psychotherapeutic agents has become a widely embraced part of care but also that lower drug prices do not necessarily insulate a health care system from rising expenditures. The authors' findings prompt the questions of whether the use of these newer agents meets practice guidelines and whether there are ways to control the increases in drug expenditures while ensuring high-quality care.

Cost Control↗
PubMed2004

Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness.

OBJECTIVES: This study examined Medicaid claims forms to determine the prevalence, severity, and co-occurrence of physical illness within a representative sample of persons with serious mental illness (N=147). METHODS: Representativeness of health problems in the study sample was established through comparison with a larger sample of persons with serious mental illness enrolled in Medicaid within the same state. Standardized annual costs were then assigned to Medicaid claims diagnoses, and individual health problem severity was measured as the sum of estimated treatment costs for diagnosed conditions. RESULTS: Seventy-four percent of the study sample (N=109) had been given a diagnosis of at least one chronic health problem, and 50 percent (N=73) had been given a diagnosis of two or more chronic health problems. Of the 14 chronic health conditions surveyed, chronic pulmonary illness was the most prevalent (31 percent incidence) and the most comorbid. Persons with chronic pulmonary illness were second only to those with infectious diseases in average annual cost of treatment ($8,277). Also, 50 percent or more of participants in eight other diagnostic categories had chronic pulmonary illness. A regression analysis identified age, obesity, and substance use disorders as significant predictors of individual health problem severity. CONCLUSIONS: Risk adjustment for physical health is essential when setting performance standards or cost expectations for mental health treatment. Excluding persons with chronic health problems from mental health service evaluations restricts generalizability of research findings and may promote interventions that are inappropriate for many persons with serious mental illness.

Adolescent↗
PubMed2004

Use of claims data to examine the impact of length of inpatient psychiatric stay on readmission rate.

OBJECTIVE: This study analyzed the impact of length of stay for inpatient treatment of psychiatric disorders on readmission rates. METHODS: Hospitalization data were obtained from the MarketScan data set collected by Medstat. The instrumental variable method, an econometric technique, was used to estimate the impact of length of stay on the rate of readmission for 5,735 persons who had at least one discharge with a primary diagnosis of a psychiatric disorder during 1997 and 1998. RESULTS: Decreasing length of stay below ten days led to an increase in the readmission rate during the 30 days after discharge. Decreasing the length of stay from seven to six days increased the expected readmission rate from.04 to.047 (17.5 percent), whereas decreasing length of stay from four to three days increased the readmission rate from.09 to.136 (51.1 percent). CONCLUSION: Decreasing length of stay for inpatient psychiatric treatment increased the readmission rate. The use of instrumental variables could help better estimate the value of mental health services when using observational data.

Adult↗
PubMed1992

Accuracy of diagnoses of schizophrenia in Medicaid claims.

Medical insurance claims are increasingly important as a source of data in monitoring health care utilization and patient outcomes and in identifying patient cohorts for research. In a study that attempted to verify that those with Medicaid claims for treatment of schizophrenia did indeed have the disorder, two psychiatrists evaluated clinical information obtained from primary mental health care providers in relation to DSM-III-R criteria. The psychiatrists classified 86.8 percent of 319 patients with claims for treatment of schizophrenia and 27.5 percent of 156 patients with claims for treatment of other psychiatric diagnoses as definitely or probably having schizophrenia. The authors conclude that most diagnoses of schizophrenia listed on Medicaid claims are accurate, but that a substantial number of individuals with schizophrenia may not be identified by claims data.

Algorithms↗
PubMed1997

Use of electroconvulsive therapy in the Medicare population between 1987 and 1992.

OBJECTIVE: Use of electroconvulsive therapy (ECT) in the Medicare population was examined to document trends and variations in the rate of use, expenditures, and patterns of treatment. METHODS: Medicare part B enrollment and claims data were used for a 5 percent nationally representative sample of Medicare beneficiaries for calendar years 1987 through 1992. Descriptive and multivariate analyses were performed. RESULTS: Weighted results showed that nationally the number of Medicare beneficiaries treated with ECT increased from 12,000 in 1987 to 15,560 in 1992. The rate of ECT use per 10,000 Medicare beneficiaries also increased from 4.2 to 5.1. Increases in use occurred among women, whites, and the disabled population (under age 65). Males, nonwhites, and the elderly did not share in the increase. Utilization and expenditure data showed an increase in outpatient ECT and a decrease in inpatient use between 1987 and 1992. The share of Medicare part B ECT expenditures in the outpatient setting increased steadily, from 7 percent in 1987 to 16 percent in 1992. Patients averaged eight ECT treatments, ranging from 6.7 in the West to 8.3 in the Northeast. CONCLUSIONS: The findings document that after a long period of declining use in the United States, ECT use in the Medicare population increased between 1987 and 1992. The analysis also documents a shift toward increasing use of outpatient ECT.

Adult↗