Preferred provider organization claims showed high predictive value but missed substantial proportion of adults with high-risk conditions.
J Clin Epidemiol
; 58(6): 624-8, 2005 Jun.
Article
em En
| MEDLINE
| ID: mdl-16028341
BACKGROUND AND OBJECTIVE: We assessed the validity and utility of a claims-based ICD-9-CM algorithm for identifying preferred provider organization (PPO) enrollees ages 18-64 years at high risk for influenza complications. METHODS: PPO enrollees with >/= 2 encounters in an ambulatory setting or >/= 1 encounters in an inpatient or emergency room setting with ICD-9-CM diagnosis codes for the high-risk conditions were considered algorithm positive. Stratified random sampling was used to select 1,001 algorithm-positive and 330 algorithm-negative enrollees for medical chart abstractions. RESULTS: The prevalence of high-risk conditions using claims data was 2.5% compared to 18.2% according to medical records. The algorithm had a sensitivity of 12% and a specificity of 99%. Positive and negative predictive values were 87 and 84%, respectively. Sensitivity was twofold higher among adults aged 50-64 years than among younger adults (17 vs. 9%). Applying an algorithm definition of >/= 1 encounters in any setting resulted in an increased sensitivity, but captured a higher proportion of false positives. CONCLUSION: A claims-positive record was highly indicative of the presence of high-risk conditions, but such claims missed a large proportion of PPO enrollees with high-risk conditions. It is important to assess the validity of administrative data in different age groups.
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Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Revisão da Utilização de Seguros
/
Algoritmos
/
Organizações de Prestadores Preferenciais
/
Classificação Internacional de Doenças
/
Influenza Humana
Tipo de estudo:
Etiology_studies
/
Prognostic_studies
/
Risk_factors_studies
Limite:
Adolescent
/
Adult
/
Humans
/
Middle aged
Idioma:
En
Revista:
J Clin Epidemiol
Assunto da revista:
EPIDEMIOLOGIA
Ano de publicação:
2005
Tipo de documento:
Article
País de afiliação:
Estados Unidos