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Related Experiment Videos

Identifying controlled substance patterns of utilization requiring evaluation using administrative claims data.

Stephen T Parente1, Susan S Kim, Michael D Finch

  • 1HSI Network LLC, USA. sparente@csom.umn.edu

The American Journal of Managed Care
|December 30, 2004
PubMed
Summary

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New software queries identify patients with potential controlled substance misuse or mismanagement. These controlled substance patterns of utilization requiring evaluation (CS-PURE) criteria help flag individuals for further medical review.

Area of Science:

  • Health Informatics
  • Pharmacovigilance
  • Data Science in Healthcare

Background:

  • Identifying patients with potential controlled substance misuse or mismanagement is crucial for patient safety and effective healthcare.
  • Administrative health claims data offer a vast resource for identifying such at-risk populations.
  • Existing methods may not be sufficient for systematic identification and evaluation.

Purpose of the Study:

  • To develop and validate a systems approach using software queries on administrative health claims data.
  • To identify patients with potential controlled substance misuse or mismanagement for further evaluation.
  • To establish criteria for controlled substance patterns of utilization requiring evaluation (CS-PURE).

Main Methods:

  • A retrospective validation study using insurance claims data from nearly 7 million individuals younger than 65.

Related Experiment Videos

  • Multidisciplinary expert panels developed and validated CS-PURE criteria.
  • SAS software queries were applied to administrative claims records.

    • Main Results:

    • Thirty-four CS-PURE queries were developed, with 10 showing the highest expert agreement for warranted intervention (48%–100% agreement).
    • Prevalence rates for CS-PURE ranged from 0.001% to 0.252%, identifying 5 to 1116 patients per 500,000-member health plan.
    • The CS-PURE criteria successfully directed attention to potential issues requiring further assessment.

    Conclusions:

    • A validated set of CS-PURE queries can identify patients with potential controlled substance misuse or mismanagement for physician, quality assurance, or medical director review.
    • This claims-based identification method is generalizable to health insurers with access to medical and pharmaceutical claims data.
    • CS-PURE serves as an effective tool to flag potential problems, guiding interventions when necessary.