Katz J N, Barrett J, Liang M H, Bacon A M, Kaplan H, Kieval R I, Lindsey S M, Roberts W N, Sheff D M, Spencer R T, Weaver A L, Baron J A
Robert Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts 02115, USA.
Arthritis Rheum. 1997 Sep;40(9):1594-600. doi: 10.1002/art.1780400908.
To examine the sensitivity and positive predictive value of Medicare physician claims for select rheumatic conditions managed in rheumatology specialty practices.
Eight rheumatologists in 3 states abstracted 378 patient office records to obtain information on diagnosis and office procedures. The Medicare Part B physician claims for these patient visits were obtained from the Health Care Financing Administration. The sensitivity of the claims data for a specific diagnosis was calculated as the proportion of all patients whose office records for a particular visit documented that diagnosis and who also had physician claims for that visit which identified that diagnosis. The positive predictive value was evaluated in a separate sample of 331 patient visits identified in Medicare physician claims. The positive predictive value of the claims data for a specific diagnosis was calculated as the proportion of patients with that diagnosis coded in the claims for a particular visit who also had the diagnosis documented in the medical record for that visit.
Ninety percent of abstracted office medical records were matched successfully with Medicare physician claims. The sensitivity of the Medicare physician claims was 0.90 (95% confidence interval [CI] 0.85-0.95) for rheumatoid arthritis (RA), 0.85 (95% CI 0.73-0.97) for systemic lupus erythematosus (SLE), and 0.85 (95% CI 0.78-1.0) for aspiration or injection procedures. The sensitivity for osteoarthritis (OA) of the hip or knee was < or = 0.50 if 5-digit codes specifying anatomic site were required. The sensitivity for fibromyalgia (FM) was 0.48 (95% CI 0.28-0.68). The positive predictive values were at least 0.90 for RA, SLE, and aspiration or injection procedures. Positive predictive values for FM and the 5-digit site-specific codes for OA of the knee were 0.83 (95% CI 0.66-1.0) and 0.88 (95% CI 0.75-1.0), respectively, while the positive predictive value of the 5-digit site-specific codes for OA of the hip was zero (95% CI 0-0.26). The positive predictive value of OA at any site was 0.83 (95% CI 0.76-0.90).
In specialty practice, Medicare physician claims had high sensitivity and positive predictive value for RA, SLE, OA without specification of anatomic site, and injection or aspiration procedures. The claims had lower sensitivity and predictive value for FM and for OA of the hip. The accuracy of Medicare physician claims for other conditions and in the primary care setting requires further investigation.
研究医疗保险医师索赔数据对于在风湿病专科诊所治疗的特定风湿性疾病的敏感性和阳性预测值。
来自3个州的8名风湿病学家提取了378份患者门诊记录，以获取诊断和门诊治疗程序方面的信息。这些患者就诊的医疗保险B部分医师索赔数据来自医疗保健财务管理局。特定诊断的索赔数据敏感性计算方法为：在特定就诊的所有患者中，门诊记录中有该诊断且医师索赔也认定该诊断的患者所占比例。阳性预测值在医疗保险医师索赔中确定的331例患者就诊的独立样本中进行评估。特定诊断的索赔数据阳性预测值计算方法为：在特定就诊的索赔中编码有该诊断的患者中，病历中也记录有该诊断的患者所占比例。
90%提取的门诊医疗记录与医疗保险医师索赔成功匹配。类风湿关节炎（RA）的医疗保险医师索赔敏感性为0.90（95%置信区间[CI]0.85 - 0.95），系统性红斑狼疮（SLE）为0.85（95%CI 0.73 - 0.97），抽吸或注射治疗为0.85（95%CI 0.78 - 1.0）。如果需要5位数字代码指定解剖部位，髋或膝骨关节炎（OA）的敏感性≤0.50。纤维肌痛（FM）的敏感性为0.48（95%CI 0.28 - 0.68）。RA、SLE和抽吸或注射治疗的阳性预测值至少为0.90。FM以及膝OA的5位数字部位特定代码的阳性预测值分别为0.83（95%CI 0.66 - 1.0）和0.88（95%CI 从0.75 - 1.0），而髋OA的5位数字部位特定代码的阳性预测值为零（95%CI 0 - 0.26）。任何部位OA的阳性预测值为0.83（95%CI 0.76 - 0.90）。
在专科诊所中，医疗保险医师索赔对RA、SLE、未指定解剖部位的OA以及注射或抽吸治疗具有较高的敏感性和阳性预测值。对于FM和髋OA，索赔的敏感性和预测值较低。医疗保险医师索赔对其他疾病以及在初级保健环境中的准确性需要进一步研究。
