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The impact of clinical vs administrative claims coding on hospital risk-adjusted outcomes
Emily C O'Brien1, Shuang Li1, Laine Thomas1
1Duke Clinical Research Institute, Durham, North Carolina.
Insights
Comparing clinical registry and administrative claims data for non-ST-segment elevation myocardial infarction patients revealed differences in comorbidity prevalence but comparable hospital outcomes. This suggests both data sources can inform risk-adjusted performance metrics.
Area of Science:
- Cardiology
- Health Services Research
- Data Science in Healthcare
Background:
- Clinical registries and administrative claims data are used to assess hospital performance.
- Differences in data sources may impact the accuracy of comorbidity assessment and risk-adjusted outcomes.
- Understanding these differences is crucial for reliable quality measurement.
Purpose of the Study:
- To compare comorbidity prevalence and hospital risk-adjusted outcomes using clinical registry data versus administrative claims data.
- To evaluate the impact of data source on the identification of hospital outliers for mortality and readmission.
Main Methods:
- Linked clinical data from the CRUSADE registry for non-ST-segment elevation myocardial infarction (NSTEMI) patients (≥65 years) with Medicare claims.
- Coded eight common comorbid conditions and compared prevalence between registry and claims data.
- Calculated hospital-level observed-to-expected ratios and outlier status for 30-day mortality and readmission using logistic generalized estimating equations.
Main Results:
- Agreement on comorbidity prevalence varied (e.g., 67.8% for myocardial infarction, 89.3% for diabetes).
- Multivariable model performance for mortality and readmission was similar across data sources (c-statistics 0.59-0.71).
- Hospital ratings for mortality and readmission were highly comparable (R² > 0.97), with most outliers identified by both data sources.
Conclusions:
- Significant differences exist in individual comorbidity prevalence based on data source (registry vs. claims).
- Despite these differences, hospital-level risk-adjusted outcomes for mortality and readmission were comparable.
- Findings support the use of both data sources for assessing hospital performance, with awareness of potential discrepancies in comorbidity coding.
Background:
Comorbid condition and hospital risk-adjusted outcomes prevalence were compared based on clinical registry vs administrative claims data.
Hypothesis:
Risk-adjusted outcomes will vary depending on the source of comorbidity data used.
Methods:
Clinical data from hospitalized Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines (CRUSADE) non-ST-segment elevation myocardial infarction (NSTEMI) patients ≥65 years was linked to Medicare claims. Eight common comorbid conditions were coded and compared between registry data (derived from medical record review) and claims data; hospital-level observed vs expected ratios and outlier status for 30-day readmission and mortality were calculated using logistic generalized estimating equations for clinical vs claims data.
Results:
Of 68 199 NSTEMI patients, 48.1% were female, 86.9% were white, and median age was 78. Degree of agreement between data sources for comorbid condition prevalence was 67.8% for myocardial infarction and 89.3% for diabetes. Overall, multivariable model performance was similar: Medicare mortality c-statistics is 0.69 vs CRUSADE is 0.71; readmission c-statistics is 0.59 for both. Hospital ratings were similar regardless of data source (mortality, R2 = 0.97863; readmission, R2 = 0.97858). Eighty-two hospitals were mortality outliers in claims-based models; of these, 70 were outliers in registry-based models. Forty-five hospitals were readmission outliers in claims-based models; of these, 39 were outliers in registry-based models.
Conclusions:
There were significant differences in individual comorbid condition prevalence when derived from registries vs claims, but hospital-level outcomes were comparable.
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