Steinwachs D M, Stuart M E, Scholle S, Starfield B, Fox M H, Weiner J P
Department of Health Policy and Management, Johns Hopkins University, School of Hygiene and Public Health, Baltimore, MD 21205-1901, USA.
Am J Med Qual. 1998 Summer;13(2):63-9. doi: 10.1177/106286069801300203.
This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaid's 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits documented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record visits to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the medical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims information). Conversely, medical records substantially understated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining average ambulatory use patterns, they are subject to significant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classified by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to understand the limitations of administrative data.
本研究比较了医疗补助付费索赔记录与病历中门诊护理就诊及诊断的记录情况。数据取自马里兰州医疗补助计划1988年的付费索赔档案，涉及2407名在该财政年度持续参保、因六种指标疾病之一至少有一次计费就诊且大部分护理由同一医疗机构提供的个人。抽样患者还根据其常规护理来源的病例组合调整成本进行了分层。由其常规护理来源保存的这些个人的病历由经过培训的护士审核员进行摘要提取，以比较索赔记录和病历信息。抽样患者的关联索赔和病历数据用于计算：（i）病历中记录的计费就诊百分比；（ii）病历就诊中日期和诊断均与索赔数据一致的百分比；（iii）病历就诊次数与计费索赔就诊次数的比率。分析中纳入的自变量包括居住地、常规护理来源的类型和成本、患者利用率水平以及抽样患者所依据的指标疾病。付费索赔中记录的就诊有90%在病历中有记录，其中82%的日期和诊断一致。与私人医生和社区卫生中心保存的病历相比，医院病历与索赔数据一致的百分比显著较低。病历中的就诊总量比索赔记录高2.6%。对于低成本医疗机构，索赔数据少报了病历中的就诊次数25%；对于低使用率患者（基于索赔信息），少报了41%。相反，对于农村患者，病历少报了计费就诊次数19%；对于高就诊率患者，少报了10%。尽管医疗补助索赔对于检查平均门诊使用模式相对准确且有用，但在比较按病例组合调整成本分类的医疗机构亚组和按使用率分类的患者亚组时，它们存在显著偏差。使用索赔数据进行分析和绩效评估的医疗补助计划需要了解行政数据的局限性。
