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Profiling physician practice patterns using diagnostic episode clusters

D G Cave1

  • 1Managed Care Research Division, Hewitt Associates, Newport Beach, CA, USA.

Medical Care
|May 1, 1995
PubMed
Summary
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A new system profiles healthcare practice patterns using diagnostic clusters. Independent Practice Associations (IPAs) showed less expensive, less hospital-intensive care compared to Preferred Provider Organizations (PPOs).

Area of Science:

  • Health Services Research
  • Medical Informatics
  • Healthcare Management

Background:

  • Healthcare providers and plans require methods to profile practice patterns for resource management.
  • Understanding resource utilization in managing medical conditions is crucial for cost-effectiveness and quality of care.

Purpose of the Study:

  • To present and validate a novel profiling system for grouping International Classification of Diseases (ICD-9-CM) codes into clinically homogeneous diagnostic clusters.
  • To formulate diagnostic episode clusters (DECs) that link all services for a patient's condition within a defined timeframe.
  • To assess physician practice patterns and resource utilization based on patient severity, comorbidity, and age.

Main Methods:

  • Developed a profiling system grouping ICD-9-CM codes into 125 diagnostic clusters.

Related Experiment Videos

  • Formulated diagnostic episode clusters (DECs) incorporating severity-of-illness, comorbidity, and age indicators.
  • Analyzed claims data from a Preferred Provider Organization (PPO) and an Independent Practice Association (IPA), comparing DEC charges and utilization using t-tests.

    • Main Results:

    • Physician practice patterns varied significantly based on patient severity, comorbidity, and age.
    • Both PPO and IPA physicians allocated more resources to higher severity-of-illness patients.
    • IPA physicians demonstrated a less hospital-intensive and approximately 22% less expensive treatment pattern than PPO physicians, with significant reductions in hospital days and outpatient visits.

    Conclusions:

    • The diagnostic cluster methodology, forming DECs, is a valid approach for profiling treatment patterns.
    • IPA physicians' practice style was less hospital-intensive and more cost-effective than PPO physicians.
    • PPO physicians exhibited greater practice pattern variations compared to IPA physicians.