Ahmed Faruque, Janes Gail R, Baron Roy, Latts Lisa M
Division of Prevention Research and Analytic Methods, Epidemiology Program Office, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30341-3717, USA.
J Clin Epidemiol. 2005 Jun;58(6):624-8. doi: 10.1016/j.jclinepi.2004.11.020.
We assessed the validity and utility of a claims-based ICD-9-CM algorithm for identifying preferred provider organization (PPO) enrollees ages 18-64 years at high risk for influenza complications.
PPO enrollees with >/= 2 encounters in an ambulatory setting or >/= 1 encounters in an inpatient or emergency room setting with ICD-9-CM diagnosis codes for the high-risk conditions were considered algorithm positive. Stratified random sampling was used to select 1,001 algorithm-positive and 330 algorithm-negative enrollees for medical chart abstractions.
The prevalence of high-risk conditions using claims data was 2.5% compared to 18.2% according to medical records. The algorithm had a sensitivity of 12% and a specificity of 99%. Positive and negative predictive values were 87 and 84%, respectively. Sensitivity was twofold higher among adults aged 50-64 years than among younger adults (17 vs. 9%). Applying an algorithm definition of >/= 1 encounters in any setting resulted in an increased sensitivity, but captured a higher proportion of false positives.
A claims-positive record was highly indicative of the presence of high-risk conditions, but such claims missed a large proportion of PPO enrollees with high-risk conditions. It is important to assess the validity of administrative data in different age groups.
我们评估了一种基于索赔数据的国际疾病分类第九版临床修正版（ICD - 9 - CM）算法在识别18 - 64岁患流感并发症高风险的优先提供者组织（PPO）参保者方面的有效性和实用性。
在门诊环境中就诊≥2次，或在住院或急诊室环境中就诊≥1次且诊断编码符合ICD - 9 - CM高风险疾病标准的PPO参保者被视为算法阳性。采用分层随机抽样选取1001名算法阳性和330名算法阴性的参保者进行病历摘要分析。
基于索赔数据的高风险疾病患病率为2.5%，而根据病历记录为18.2%。该算法的灵敏度为12%，特异度为99%。阳性预测值和阴性预测值分别为87%和84%。50 - 64岁成年人的灵敏度比年轻成年人高两倍（17%对9%）。将算法定义为在任何环境中就诊≥1次会提高灵敏度，但会捕获更高比例的假阳性病例。
索赔阳性记录高度表明存在高风险疾病，但此类索赔遗漏了很大一部分患有高风险疾病的PPO参保者。评估不同年龄组行政数据的有效性很重要。
