Linking Provider Specialty and Outpatient Diagnoses in Medicare Claims Data: Data Quality Implications

With increasing use of real world data in observational health care research, data quality assessment of these data is equally gaining in importance. Electronic health record (EHR) or claims datasets can differ significantly in the spectrum of care covered by the data.

In our study, we link provider specialty with diagnoses (encoded in International Classification of Diseases) with a motivation to characterize data completeness.

We develop a set of measures that determine diagnostic span of a specialty (how many distinct diagnosis codes are generated by a specialty) and specialty span of a diagnosis (how many specialties diagnose a given condition). We also analyze ranked lists for both measures. As use case, we apply these measures to outpatient Medicare claims data from 2016 (3.5 billion diagnosis-specialty pairs). We analyze 82 distinct specialties present in Medicare claims (using Medicare list of specialties derived from level III Healthcare Provider Taxonomy Codes).

A typical specialty diagnoses on average 4,046 distinct diagnosis codes. It can range from 33 codes for medical toxicology to 25,475 codes for internal medicine. Specialties with large visit volume tend to have large diagnostic span. Median specialty span of a diagnosis code is 8 specialties with a range from 1 to 82 specialties. In total, 13.5% of all observed diagnoses are generated exclusively by a single specialty. Quantitative cumulative rankings reveal that some diagnosis codes can be dominated by few specialties. Using such diagnoses in cohort or outcome definitions may thus be vulnerable to incomplete specialty coverage of a given dataset.

We propose specialty fingerprinting as a method to assess data completeness component of data quality. Datasets covering a full spectrum of care can be used to generate reference benchmark data that can quantify relative importance of a specialty in constructing diagnostic history elements of computable phenotype definitions.