Validation of claims-based diagnostic and procedure codes for cardiovascular and gastrointestinal serious adverse events in a commercially-insured population.

PURPOSE: To validate administrative claims codes with medical chart review for myocardial infarction (MI), ischemic stroke, and severe upper gastrointestinal (UGI) bleed events in a large, commercially-insured US population. METHODS: These validation studies were part of a larger study examining the risk of MI, ischemic stroke, and severe UGI bleeds in patients receiving a new prescription of selective cyclooxygenase (COX)-2 inhibitors (coxibs) and non-over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs), between 1 July 2002 and 30 September 2004. Patients from the study cohort and other health plan members from the HealthCore Integrated Research Database(SM) (HIRD) experiencing these events were selected for these studies. The positive predictive value (PPV) of each of the claims code algorithms, using medical chart review as the gold standard, was calculated. RESULTS: Two hundred charts per event were abstracted. The PPV for MI was 88.4% (177/200; 95%CI, 83.2-92.5%); PPV for ischemic stroke was 87.4% (175/200; 95%CI, 82.0-91.7%); PPV for severe UGI bleed was 56.5% (109/193; 95%CI, 49.2-63.6%). Refining the ischemic stroke claims algorithm resulted in a PPV of 95.5% (95%CI, 91.0-98.2%); refining the claims algorithm for severe UGI bleed resulted in a PPV of 87.8% (95%CI, 78.7-94.0%). CONCLUSION: The results suggest that, for certain adverse events, claims data can serve as the basis for pharmacoepidemiology research and drug safety surveillance in the US.

Disparities in medical care among commercially insured patients with newly diagnosed breast cancer: opportunities for intervention.

BACKGROUND: African-American women have increased breast cancer mortality compared with white women. Diagnostic and treatment gaps may contribute to this disparity. METHODS: In this retrospective, longitudinal cohort study, Southern US health plan claims data and linked medical charts were used to identify racial disparities in the diagnoses, treatment, and mortality of commercially insured women with newly diagnosed breast cancer. White women (n = 476) and African-American women (n = 99) with newly diagnosed breast cancer were identified by breast cancer claims codes (International Classification of Diseases, Ninth Revision, Clinical Modification codes 174, 233.0, 238.3, and 239.3) between January 2000 and December 2004. Race, diagnoses (breast cancer stage, estrogen/progesterone receptor [ER/PR]-positive status), treatment (breast-conserving surgery, antiestrogen therapy, and chemotherapy interruption or reduction), and all-cause mortality were assessed from medical charts. Multivariate regression analyses were adjusted for age, geography, and socioeconomic status to test the association of race with diagnoses/treatment. RESULTS: White women were older (P < .001) and had higher rates of diagnosis at stage 0/I (55.2% vs 38.4%; P < .05) than African-American women. More white women had positive ER/PR status (75% vs 56% African-American; P = .001) and received antiestrogen therapy if they were positive (37.2% vs 27.3% African-American; P < .001). White women received slightly more breast-conserving surgery and chemotherapy dose modification than African-American women (P value nonsignificant). African-American women had a higher mortality rate (8.1%) than white women (3.6%; P = .06). In adjusted analyses, African-American women were diagnosed at later stages (odds ratio, 1.71; P = .02), and white women received more antiestrogen therapy (odds ratio, 2.1; P = .03). CONCLUSIONS: Disparities in medical care among patients with newly diagnosed breast cancer were evident between African-American women and white women despite health plan insurance coverage. Interventions that address the gaps identified are needed.

The effects of rheumatoid arthritis on labor force participation, work performance, and healthcare costs in two workplace samples.

OBJECTIVE: To assess the workplace costs of rheumatoid arthritis (RA) from the employer perspective. METHOD: Samples included 4485 manufacturing firm (MF) employees (109 with RA) and 915 commercially insured (CO) subscribers (333 with RA). Respondents completed the Health and Work Performance Questionnaire (HPQ) and the Health Assessment Questionnaire (HAQ). The effects of RA were estimated using regression analysis. RESULTS: RA was associated with increased probability of no longer working (CO), increased effort to maintain work performance (CO), increased sickness absence (MF), and increased non-RA pharmacy costs (CO). RA was not associated with hours worked or hourly wage. Indirect costs of RA did not exceed direct medical costs. CONCLUSIONS: Indirect costs of RA to employers are significant and warrant further research to increase our understanding of the contribution of different RA treatment interventions to optimizing workforce productivity.

A randomized study to decrease the use of potentially inappropriate medications among community-dwelling older adults in a southeastern managed care organization.

BACKGROUND: Despite progress in describing the problem of potentially inappropriate medication (PIM) use, there have been few prospective studies demonstrating that interventions with specific medication criteria can make a difference in decreasing the use of problematic drugs in older adults. OBJECTIVE: To design an intervention study to change physician behavior regarding PIM prescribing to older patients. STUDY DESIGN AND METHODS: A prospective randomized block design was used during an 18-month period from January 2001 to June 2002. The study population was primary care physicians (n = 355) in the Medicare + Choice product line of a southeastern managed care organization and their patients 65 years and older. There were 170 physicians in the treatment group and 185 in the control group. Physicians were assigned to the treatment or usual-care, groups using a randomization table, and each group included physicians who had and had not prescribed a PIM. RESULTS: Approximately 71% (84/118) of the physicians in the intervention group who prescribed a PIM completed and faxed back at least 1 potentially inappropriate medication form to the managed care organization. On 15.4% (260/1692) of the medication forms, physicians made some change regarding PIM use. CONCLUSIONS: Although many studies have addressed medication use among older adults, intervention studies aimed at influencing physician prescribing in this population are limited. This study describes a low-cost, replicable method to contact and educate physicians on drug therapy issues in older adults.

A comprehensive approach to percutaneous injury prevention during phlebotomy: results of a multicenter study, 1993-1995.

OBJECTIVE: To examine a comprehensive approach for preventing percutaneous injuries associated with phlebotomy procedures. DESIGN AND SETTING: From 1993 through 1995, personnel at 10 university-affiliated hospitals enhanced surveillance and assessed underreporting of percutaneous injuries; selected, implemented, and evaluated the efficacy of phlebotomy devices with safety features (ie, engineered sharps injury prevention devices [ESIPDs]); and assessed healthcare worker satisfaction with ESIPDs. Investigators also evaluated the preventability of a subset of percutaneous injuries and conducted an audit of sharps disposal containers to quantify activation rates for devices with safety features. RESULTS: The three selected phlebotomy devices with safety features reduced percutaneous injury rates compared with conventional devices. Activation rates varied according to ease of use, healthcare worker preference for ESIPDs, perceived "patient adverse events," and device-specific training. CONCLUSIONS: Device-specific features and healthcare worker training and involvement in the selection of ESIPDs affect the activation rates for ESIPDs and therefore their efficacy. The implementation of ESIPDs is a useful measure in a comprehensive program to reduce percutaneous injuries associated with phlebotomy procedures.

Epidemiology of injuries by needles and other sharp instruments: minimizing sharp injuries in Gynecologic and Obstetric Operations

Surgical and obstetric HCWs and epidemiologists will benefit from working together to describe the frequency and circumstances of percutaneous injuries in operating and delivery rooms. Rates of percutaneous injury vary among institutions, and attending and resident surgeons are among those at greatest risk for injury. Gynecologic surgery appears to have one of the highest rates of injury of the surgical specialties, and rates of injury vary by procedure within a given specialty. Suture needles cause the majority of injuries. Certain actions such as holding tissue while suturing or cutting are associated with a higer risk of injury. Many percutaneous injuries appear to be preventable. Epidemiologic data can be used to develop strategies based on the industrial hygiene model to reduce the incidence of percutaneous injury ant to collect and disseminate data on the efficacy of new preventive measures. Potentially safer instruments and suture needles, technique modification strategies, and personal protective equipment such as cut-resistant gloves and finger protective strips are now available. Scientific assessment is needed of these and other new measures to determine whether they will decrease the risk of percutaneous injury, be acceptable to users, be cost effective, and avoid adverse consequenmces to patients or HCWs