Specificity and sensitivity of claims-based algorithms for identifying members of Medicare plus Choice health plans that have chronic medical conditions

被引:160
作者
Rector, TS
Wickstrom, SL
Shah, M
Thomas Greeenlee, N
Rheault, P
Rogowski, J
Freedman, V
Adams, J
Escarce, JJ
机构
[1] Vet Adm Med Ctr, Ctr Chron Dis Outcomes Res, Minneapolis, MN 55417 USA
[2] Ctr Hlth Care Policy & Evaluat, Eden Prairie, MN USA
[3] Blue Cross & Blue Shield Minnesota, Eagan, MN USA
[4] USAF, MSC, Washington, DC 20330 USA
[5] RAND Corp, Arlington, VA USA
[6] Abramson Ctr Jewish Life, Polisher Res Inst, N Wales, PA USA
[7] RAND Corp, Santa Monica, CA USA
[8] Univ Calif Los Angeles, David Geffen Sch Med, Los Angeles, CA USA
[9] RAND Corp, Santa Monica, CA USA
关键词
medical informatics; claim review; algorithms; specificity and sensitivity;
D O I
10.1111/j.1475-6773.2004.00321.x
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
Objective. To examine the effects of varying diagnostic and pharmaceutical criteria on the performance of claims-based algorithms for identifying beneficiaries with hypertension, heart failure, chronic lung disease, arthritis, glaucoma, and diabetes. Study Setting. Secondary 1999-2000 data from two Medicare+Choice health plans. Study Design. Retrospective analysis of algorithm specificity and sensitivity. Data Collection. Physician, facility, and pharmacy claims data were extracted from electronic records for a sample of 3,633 continuously enrolled beneficiaries who responded to an independent survey that included questions about chronic diseases. Principal Findings. Compared to an algorithm that required a single medical claim in a one-year period that listed the diagnosis, either requiring that the diagnosis be listed on two separate claims or that the diagnosis to be listed on one claim for a face-to-face encounter with a health care provider significantly increased specificity for the conditions studied by 0.03 to 0.11. Specificity of algorithms was significantly improved by 0.03 to 0.17 when both a medical claim with a diagnosis and a pharmacy claim for a medication commonly used to treat the condition were required. Sensitivity improved significantly by 0.01 to 0.20 when the algorithm relied on a medical claim with a diagnosis or a pharmacy claim, and by 0.05 to 0.17 when two years rather than one year of claims data were analyzed. Algorithms that had specificity more than 0.95 were found for all six conditions. Sensitivity above 0.90 was not achieved all conditions. Conclusions. Varying claims criteria improved the performance of case-finding algorithms for six chronic conditions. Highly specific, and sometimes sensitive, algorithms for identifying members of health plans with several chronic conditions can be developed using claims data.
引用
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页码:1839 / +
页数:22
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