Lalani Christina, Medina Frank, Oseran Andrew S, Liang Lichen, Song Yang, Butala Neel M, Kazi Dhruv S, Cohen David J, Strom Jordan B, Wadhera Rishi K, Yeh Robert W
Division of Cardiology (C.L., A.S.O., D.S.K., J.B.S., R.K.W., R.W.Y.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (C.L., F.M., A.S.O., L.L., Y.S., D.S.K., J.B.S., R.K.W., R.W.Y.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Circ Cardiovasc Qual Outcomes. 2025 May;18(5):e011991. doi: 10.1161/CIRCOUTCOMES.125.011991. Epub 2025 Mar 29.
Although Medicare Advantage (MA) plans provide coverage to >50% of Medicare beneficiaries, it is unclear whether MA claims can be used similarly to Medicare Fee-For-Service (FFS) claims for clinical outcomes assessment. In this study, we evaluate the accuracy of claims algorithms previously validated in FFS to assess comorbidities and outcomes in MA patients after aortic valve replacement.
We compared the concordance of 11 claims-based covariates (diabetes, hypertension, atrial flutter/fibrillation, myocardial infarction) and outcomes (stroke, disabling stroke, transient ischemic attack, major vascular complication, bleeding, permanent pacemaker implantation, death) among FFS and MA patients with the covariates and adjudicated outcomes in the multinational Evolut Low-Risk Trial (2016-2018). We used claims algorithms for 1-year outcomes and calculated sensitivity, specificity, positive predictive value, negative predictive value, and kappa, using adjudicated outcomes as the reference. We compared the kappa for MA versus FFS using the 2-sample -test with a significance level of <0.05.
Among 1139 US patients aged 65+ years old in the Evolut Low-Risk Trial, 782 patients (175 MA and 607 FFS) were linked to claims data and had complete comorbidity data. Among all covariates, claims algorithms for covariates had sensitivities ≥85% for identifying diabetes, atrial flutter/fibrillation, and hypertension in MA and FFS. For the outcomes, sensitivities were ≥85% for bleeding (comprehensive), permanent pacemaker implantation, and death. The kappa was higher in MA versus FFS for diabetes (=0.03) and hypertension (=0.025) but was lower in myocardial infarction (<0.0001). There was no statistically significant difference in the kappa agreement between MA versus FFS for any of the selected outcomes.
Medicare claims have a similar level of kappa agreement in MA versus FFS for most covariates and outcomes. As patients shift to MA, ascertainment of outcomes using Medicare claims in postapproval studies remains valid for select outcomes.
尽管医疗保险优势（MA）计划为超过50%的医疗保险受益人提供保险，但尚不清楚MA索赔是否可与医疗保险按服务收费（FFS）索赔类似地用于临床结局评估。在本研究中，我们评估了先前在FFS中验证的索赔算法在评估主动脉瓣置换术后MA患者的合并症和结局方面的准确性。
我们比较了FFS和MA患者中11个基于索赔的协变量（糖尿病、高血压、心房扑动/颤动、心肌梗死）和结局（中风、致残性中风、短暂性脑缺血发作、主要血管并发症、出血、永久性起搏器植入、死亡）与多国Evolut低风险试验（2016 - 2018年）中协变量和判定结局的一致性。我们使用索赔算法评估1年结局，并以判定结局为参考计算敏感性、特异性、阳性预测值、阴性预测值和kappa值。我们使用双侧检验比较MA与FFS的kappa值，显著性水平<0.05。
在Evolut低风险试验中的1139名65岁及以上美国患者中，782名患者（175名MA患者和607名FFS患者）与索赔数据相关联且具有完整的合并症数据。在所有协变量中，协变量的索赔算法在识别MA和FFS患者的糖尿病、心房扑动/颤动和高血压方面敏感性≥85%。对于结局，出血（综合）、永久性起搏器植入和死亡的敏感性≥85%。MA与FFS相比，糖尿病（=0.03）和高血压（=0.025）的kappa值较高，但心肌梗死的kappa值较低（<0.0001）。对于任何选定的结局，MA与FFS之间的kappa一致性没有统计学显著差异。
对于大多数协变量和结局，医疗保险索赔在MA与FFS中的kappa一致性水平相似。随着患者转向MA，在批准后研究中使用医疗保险索赔确定结局对于选定的结局仍然有效。
