Identifying Possible Indicators of Systematic Overuse of Health Care Procedures With Claims Data (original) (raw)

Overuse of Health Care Services in the United States

Archives of Internal Medicine, 2012

Background: Overuse, the provision of health care services for which harms outweigh benefits, represents poor quality and contributes to high costs. A better understanding of overuse in US health care could inform efforts to reduce inappropriate care. We performed an extensive search for studies of overuse of therapeutic procedures, diagnostic tests, and medications in the United States and describe the state of the literature.

Trends in the Overuse of Ambulatory Health Care Services in the United States

JAMA Internal Medicine, 2013

Background: Given the rising costs of health care, policymakers are increasingly interested in identifying the inefficiencies in our health care system. The objective of this study was to determine whether the overuse and misuse of health care services in the ambulatory setting has decreased in the past decade.

Effect of hospital utilization review on medical expenditures in selected diagnostic areas: an exploratory study

American Journal of Public Health, 1991

Quarterly claims data on 43 insured groups were analyzed through multivariate techniques to explore whether the effects of hospital inpatient utilization review vary across selected broad diagnostic areas. Findings suggest that utilization review was associated with decreases in expenditures of approximately 15 percent for diagnoses within the surgical area, a lesser decrease within the mental health area, and still lesser decrease within the medical area. However, these measurements are imprecise both because of the small numbers and the aggregated diagnoses in each category.

Identifying Patients at Risk of High Healthcare Utilization

AMIA ... Annual Symposium proceedings. AMIA Symposium, 2016

Objective. To develop a systematic and reproducible way to identify patients at increased risk for higher healthcare costs. Methods. Medical records were analyzed for 9,581 adults who were primary care patients in the University of Missouri Health System and who were enrolled in Medicare or Medicaid. Patients were categorized into one of four risk tiers as of October 1, 2013, and the four tiers were compared on demographic characteristics, number of healthcare episodes, and healthcare charges in the year before and the year after cohort formation. Results. The mean number of healthcare episodes and the sum of healthcare charges in the year following cohort formation were higher for patients in the higher-risk tiers. Conclusions. Retrospective information that is easily extracted from medical records can be used to create risk tiers that provide highly useful information about the prospective risk of healthcare utilization and costs.

Challenges of Using Medical Insurance Claims Data for Utilization Analysis

American Journal of Medical Quality, 2006

Research use of insurance claims data presents unique challenges and requires a series of value judgments which are intended to improve the data quality. In our sturdy, medical insurance claims from two large companies were combined to assess utilization of complementary and alternative medicine. Challenges included assessing and improving the quality of data, combining data from two different companies with dissimilar coding systems, and determining the most appropriate ways to describe utilization. This paper addresses four methodologic challenges in creating the analytic files: (1) conversion of claims into unique visits, (2) identification of incomplete claims data, (3) categorization of providers and locations of service, and (4) selecting the most useful measures of utilization and expenditures.

Healthcare Overuse: A Literature Review and Taxonomy Proposal

J. of Health Science, 2016

Healthcare overuse is the provision of care in which the benefits do not justify the harms and/or costs. Overuse literature is poorly categorized thus impeding research, practice, and policy to reduce overuse and improve healthcare quality. We developed an overuse taxonomy and searched for and reviewed the healthcare overuse literature in an attempt to better understand and categorize research on overuse practice and patterns. We found that more than two-thirds of articles were observational (70%), the most prevalent purpose of overuse was treatment/secondary prevention (69%), the most common type of overuse was overtreatment (73%), drivers of and methods to reduce overuse were each discussed in about 40% of abstracts, and the most frequently mentioned clinical area was pharmacy. A high volume of overuse literature exists. However, the majority of overuse research is observational, descriptive, and focuses on overtreatment and overprescribing rather than methods to reduce overuse. Some overuse is not labelled as such. Our taxonomy adequately organized the existing literature and identified areas where additional research efforts are most needed. A common taxonomy, such as ours, could help researchers categorize their work, assist clinicians and policymakers in identifying and implementing findings, and guide future research to improve healthcare quality.

Overuse and Systems of Care

Medical Care, 2013

Background: Current health care reform efforts are focused on reorganizing health care systems to reduce waste in the US health care system.