Claims Data Outcomes Analysis

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Understanding “Proxy” Measurements

Brent Metfessel MD

By Brent A. Metfessel MD, MS, CMP™ (Hon)

Medical claims data has clear limitations for outcomes analysis and quality reportage.

Such data only deals with the process of care and does not have information directly pertaining to outcomes except where specified in the ICD-9 codes. 

Thus, one must rely in many cases on proxy measures for outcomes. Proxy measures are process of care metrics that can imply certain outcomes, such as length of an illness episode.

The following are some ways to ascertain outcomes of care using claims data:

·         Complications of care:  The ICD-9 codes directly contain language for denoting outcomes.  There exist codes for wound infection and dehiscence, miscarriage in pregnancy, and general surgical complications.  The coding of a major infection in a cancer patient on chemotherapy is another example of complications-based outcomes obtainable through claims data.

·         Procedure re-performances:  Two coronary artery stent procedures within a six month to a year period may imply failure of the first stent.  However, a medical record check may ultimately be needed since it could also be a stent placed in a new vessel.  Returns to the operating room within a few days of a surgical operation, or an outpatient procedure that turns into an inpatient stay within a few days also implies poor outcomes.

·         Readmission rates:  Two or more hospitalizations for the same episode of care within 30 to 60 days also imply poor outcomes.

·         Episode length analysis:  The length that an episode of care lasts can be compared between providers.  Shorter episodes for acute illnesses imply better outcomes unless it is due to the expiration of a patient or poor access to care.

·         Medication prescribing patterns:  In some conditions the drugs prescribed may imply certain outcomes.  A rheumatoid arthritis patient that needs Remicade® probably has a more severe form of the illness.  Frequent antibiotic switching for an infectious disease such as pneumonia either implies a resistant organism or difficulties in quality of care.

·       Emergency room and hospital utilization:  Frequent ER use or hospitalizations for chronic conditions such as asthma or congestive heart failure imply a poor outcome from outpatient treatment.


How reliable are these proxy measures in evaluating medical outcomes?  


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One Response

  1. 18% of Executives Use Patient-Reported Outcomes

    Health Catalyst recently released results from a survey of healthcare executives’ use of patient-reported outcomes (PROs). Here are some key findings from the report:

    • 18% of executives always use PROs to guide clinical care.
    • Nearly 3 in 4 who said they rarely/never use PROs plan to begin using them in 1-3 years.
    • 36% of respondents said “time and/or money” was the most significant barrier to using PROs.
    • 1 in 4 said difficulty fitting PROs into clinicians’ daily workflow is the greatest barrier.
    • Technology was listed as the most significant barrier to PRO use by 15% of respondents.
    • 59% selected “chronic care tracking” when asked to list areas in which they use PROs.

    Source: Health Catalyst, August 2, 2016


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