Was sagen uns Wiedereinweisungen über die Qualität der stationären Versorgung?

Quality assurance in hospital care increasingly focuses on evaluation of outcome. Problems arise with displaying results of medical care beyond discharge. In this context hospital readmissions are often used as outcome variable. But it is unclear whether readmissions are meaningful indices of quality of hospital care and if so, where to get valid data on readmissions. We used claims data of the regional health insurance fund in Saxony-Anhalt (AOK Saxony-Anhalt) from 2002 and 2003 (850,000 insured; nearly 300,000 cases per year). All hospital admissions of a insured person are identified by an anonymous id-number independent of the admitting hospital. By this way we can analyze readmissions individually. Readmission are frequent events in hospital care. Nearly one third of all patients were admitted at least a second time in 2003. 18 % of all hospital cases are readmissions within 30 days after discharge. Readmissions concentrated on chronically ill, oncological, or multimorbid patients. Many of the readmissions take place in the context of planned therapies or post-operative treatment. 'Revolving-door patients' with multiple readmissions point to problems in cooperation of ambulatory and hospital care. By defining tracer diagnoses and specific causes of readmissions unplanned readmissions may be identified as a quality indicator of suboptimal care. Readmissions don't express suboptimal care per se. But taking into account methodological aspects a tracer approach with defining specific unplanned readmissions may provide meaningful outcome indicators. These can be derived from claims data fast, routinely, and with low costs. Further validation of the approach is needed.

The influence of motor vehicle legislation on injury claim incidence

BACKGROUND

Although there have been numerous strategies to prevent motor vehicle collisions and their subsequent injuries, few have been effective in preventing motor vehicle injury claims. In this paper, we examine the role of legislation and compensation system in altering injury claim incidence.

METHODS

The population base for our natural experiment was all Saskatchewan, Manitoba, British Columbia and Quebec residents who submitted personal injury claims to their respective motor vehicle insurance provider from 1990 to 1999. The provinces of Saskatchewan and Manitoba switched from Tort to pure No-Fault insurance on January 1, 1995 and on March 1, 1994 respectively. British Columbia maintained tort insurance and Quebec maintained pure no-fault insurance throughout the entire 10-year period.

RESULTS

The conversion from tort insurance to pure no-fault motor vehicle insurance resulted in a five-year 31% (RR = 0.69; 95% CI 0.68-0.70) reduction in total injury claims per 100,000 residents in Saskatchewan and a five-year 43% (RR = 0.57; 95% CI 0.56-0.58) reduction in Manitoba. At the same time, the province of British Columbia retained tort insurance and had a five-year 5% reduction (RR = 0.95; 95% CI 0.94-0.99). Quebec, which retained pure no-fault throughout the entire 10-year period, had less than one third of the injury claims per 100,000 residents than the tort province of British Columbia.

INTERPRETATION

The conversion from tort to pure no-fault legislation has a large influence in reducing motor vehicle injury claim incidence in Canada. Legislative system and injury compensation scheme have an observable impact on injury claim incidence and can therefore have significant impact on the health care system.

Work-Related Disability in Canadian Nurses

PURPOSE

To determine factors contributing to high registered nurse (RN) injury claim rates in Canadian hospitals.

DESIGN

Cross-sectional study of secondary 1998-99 data for RNs (N = 8,044) in Ontario, Canada, linked at the hospital level (n = 127).

METHODS

Descriptive statistics, correlations, and logistic regression analyses were conducted.

RESULTS

The odds of a high RN lost-time claim rate increased by 70% for each quartile increase in the percentage of RNs reporting more than 1 hour of overtime per week. The odds of a high RN musculoskeletal lost-time claim rate decreased by 64% for every one unit increase in the hospital-level score on the nurse-physician relationship subscale.

CONCLUSIONS

To retain and optimize scarce hospital nursing resources, strategies to address overtime, sick time, and nurse-physician relationships might provide fiscal and human benefits.

Expanded state-funded family planning services: estimating pregnancies averted by the Family PACT Program in California, 1997-1998

OBJECTIVES

The California Family Planning, Access, Care, and Treatment Program was implemented in 1997 to provide family planning services for uninsured, low-income women and men. We estimated the impact on fertility of providing 500 000 women with contraceptives.

METHODS

Paid claims and medical record review data were used to estimate pregnancies averted. Pregnancies women experienced while enrolled in the program and pregnancies they would have experienced given methods used before enrollment were modeled as a Markov process.

RESULTS

One year of Family Planning, Access, Care, and Treatment services averted an estimated 108 000 unintended pregnancies that would have resulted in 50 000 unintended births and 41 000 induced abortions.

CONCLUSIONS

Providing contraceptives to low income, medically indigent women significantly reduced the number of unintended pregnancies in California.

Cognitive Decline in High-Functioning Older Persons Is Associated with an Increased Risk of Hospitalization

OBJECTIVES

To examine hospital use for patients with evidence of cognitive decline indicative of early cognitive impairment.

DESIGN

Medicare Part A hospital utilization data were linked to data from the MacArthur Research Network on Successful Aging Community Study to examine the association between baseline cognition and decline in cognitive function over a 3-year period and any hospitalization over that same period.

SETTING

New Haven, Connecticut, and East Boston, Massachusetts.

PARTICIPANTS

Subjects (N=598) were from two sites of the MacArthur Research Network on Successful Aging Community Study, a 7-year cohort study of community-dwelling older persons with high physical and cognitive functioning.

MEASUREMENTS

Multivariate logistic regression was used to determine the association between any hospitalization over 3 years (1988-91) as the outcome variable and baseline cognitive function and decline in cognition over 3 years as primary predictor variables. Decline was based upon repeated (1988 and 1991) measures of delayed verbal recall and the Short Portable Mental Status Questionnaire (SPMSQ).

RESULTS

Of 598 subjects, 48 died between 1988 and 1991. No baseline (1988) delayed recall scores or change in recall scores (1988-91) were associated with hospitalization. Although 48.2% declined on verbal memory scores, decline was not associated with risk of hospitalization. Of 494 subjects with complete 3-year data, 31.2% declined at least one point on the SPMSQ, and 4.7% declined more than two points. Among individuals aged 75 and older at baseline, the adjusted odds ratio for hospitalization for those who declined more than 2 points compared with those who declined less was 7.8 (95% confidence interval=2.0-30.8).

CONCLUSION

Although specific memory tests were not associated with hospitalization, high-functioning older persons who experienced decline in overall cognitive function were more likely to be hospitalized. Variation in baseline cognitive function in this high-functioning cohort did not affect hospitalization, but additional research is needed to evaluate associations with other healthcare costs.

The sensitivity of Medicare data for identifying incident cases of invasive melanoma (United States)

BACKGROUND

The completeness of Medicare claims for identifying patients with melanoma for purposes of conducting population-based studies of melanoma is unknown.

METHODS

Using a linked Surveillance, Epidemiology, and End Result (SEER) tumor registry-Medicare database, the sensitivity of Medicare claims for identifying 5372 patients age > or =65 years diagnosed with invasive melanoma between 1992 and 1996 was determined. Sensitivity was calculated as the proportion of incident cases of melanoma reported by SEER that was also captured by Medicare claim diagnostic codes.

RESULTS

The overall sensitivity of combined Part A and Part B Medicare for incident cases of melanoma was 90.1%. Part B Medicare and Part A Medicare alone had 89.5% and 16.5% sensitivity respectively. Sensitivity was lower for patients with unrecorded Breslow depth and for patients with unstaged or distant stage melanoma.

CONCLUSIONS

Medicare Part B claims have a high sensitivity for detecting melanoma incidence; Medicare Part A has low sensitivity. This sharply contrasts with published studies of other cancers, for whom Part A rather than Part B Medicare captures the predominant portion of incident cases. Medicare Part B or combined Part A and Part B administrative data is a potentially valuable resource for population-based melanoma research in the elderly. Further research characterizing the specificity and predictive value of Medicare data is needed to assess the potential implications of false positive melanoma diagnostic codes.

Light at the end of the tunnel for denials management

Denials management is too important to a provider's financial health to be addressed haphazardly. The Six Sigma performance-improvement methodology can ensure your organization receives the full payment to which it is entitled.

Monitoring trends in waiting periods in Canada for elective surgery: validation of a method using administrative data

BACKGROUND

Provincial governments require timely, economical methods to monitor surgical waiting periods. Although use of prospective procedure-specific registers would be the ideal method, a less elaborate system has been proposed that is based on physician billing data. This study assessed the validity of using the date of the last service billed prior to surgery as a proxy for the beginning of the post-referral, pre-surgical waiting period.

METHOD

We examined charts for 31,824 elective surgical encounters between 1992 and 1996 at an Ontario teaching hospital. The date of the last service before surgery (the last billing date) was compared with the date of the consultant's letter indicating a decision to book surgery (i.e., to begin waiting).

RESULTS

Several surgical specialties (but excluding cardiac, orthopedic and gynecologic) had a close correlation between the dates of the last pre-surgery visit and those of the actual decision to place the patient on the waiting list. Similar results were found for 12 of 15 individually studied procedures, including some orthopedic and gynecological procedures.

CONCLUSION

Used judiciously, billing data is a timely, inexpensive and generally accurate method by which provincial governments could monitor trends in waiting times for appropriately selected surgical procedures.

Orthodontic care in an insured population in Washington: demographic factors

Few studies have used insurance claims data to investigate demographic factors related to orthodontic care. This study sought to describe age and sex distributions in a large, insured population in Washington. Additionally, the demand for orthodontic care was evaluated with respect to county population, and the impact of the availability of orthodontists was investigated. All orthodontic claims in 2001 were retrieved from the Washington Dental Service database, along with associated provider and patient information. A total of 102,984 claims were included in this study. A large percentage of subjects (86%) were less than 20 years old, with most patients in their early teens. Overall, about 64% of all orthodontic patients were female. The demand for orthodontic treatment was the highest in the counties with the largest populations. Although there was considerable variation in the data, the number of orthodontic claims submitted by general dentists tended to decline as the availability of orthodontists increased.

Cardiovascular disease in patients with schizophrenia in Saskatchewan, Canada

BACKGROUND

Studies have shown that patients with schizophrenia have higher rates of cardiovascular disease and mortality compared with the general population. However, population-based data on the prevalence, incidence, and mortality of cardiovascular disease are needed.

METHOD

In this retrospective cohort study, the Saskatchewan Health databases were searched for all patients diagnosed with schizophrenia (ICD-9 code 295) in 1994 or 1995. 3022 subjects were identified. For each subject, 4 age- and sex-matched comparison individuals were selected randomly among residents of the province who had no diagnosis of schizophrenia or any other mental disorders and who received no prescriptions for antipsychotic medications. Prevalence of cardiovascular morbidity during 1994 and 1995 and incidence of cardiovascular morbidity and mortality during the follow-up period of January 1996 through March 1999 were analyzed.

RESULTS

Concerning prevalence of morbidity in schizophrenia patients, significantly increased risk-adjusted odds ratios were as follows: arrhythmia, 1.5 (95% CI = 1.2 to 1.8); syncope, 4.0 (95% CI = 2.0 to 7.9); heart failure, 1.7 (95% CI = 1.4 to 2.2); stroke, 2.1 (95% CI = 1.6 to 2.7); transient cerebral ischemia, 2.6 (95% CI = 1.7 to 3.7); and diabetes, 2.1 (95% CI = 1.8 to 2.4). Odds of acute myocardial infarction, ischemic heart disease, and ventricular arrhythmias were not significantly different from those for the comparison group. Concerning incidence of morbidity and mortality in the patients, adjusted relative risk was significantly increased for ventricular arrhythmia, 2.3 (95% CI = 1.2 to 4.3); heart failure, 1.6 (95% CI = 1.2 to 2.0); stroke, 1.5 (95% CI = 1.2 to 2.0); diabetes, 1.8 (95% CI = 1.2 to 2.6); all-cause mortality, 2.8 (95% CI = 2.3 to 3.4); and cardiovascular mortality, 2.2 (95% CI = 1.7 to 2.8).

CONCLUSIONS

Persons with schizophrenia appear to be at greater risk for cardiovascular morbidity and mortality than those in the general population.

The impact of the SARS epidemic on the utilization of medical services: SARS and the fear of SARS

Using interrupted time-series analysis and National Health Insurance data between January 2000 and August 2003, this study assessed the impacts of the severe acute respiratory syndrome (SARS) epidemic on medical service utilization in Taiwan. At the peak of the SARS epidemic, significant reductions in ambulatory care (23.9%), inpatient care (35.2%), and dental care (16.7%) were observed. People's fears of SARS appear to have had strong impacts on access to care. Adverse health outcomes resulting from accessibility barriers posed by the fear of SARS should not be overlooked.

The effect of alcoholism treatment on medical care use

OBJECTIVE

The objective of this study was to assess changes in outpatient and inpatient medical care utilization associated with outpatient and inpatient treatment of alcohol abuse by comparing alcoholics who engaged in treatment to alcoholics who presented for, but did not engage in, treatment.

RESEARCH DESIGN

Claims and encounter data of 29,122 adults receiving benefits from both a behavioral managed care company and its parent medical care insurance company who had a diagnosis of alcoholism were analyzed. The nontreated alcoholics in this sample (n = 13,133) were used for comparison and to control for historical time trend in medical utilization across the study years 1993-1999. A longitudinal over-dispersed Poisson regression model was fit by the generalized estimating equation method to compare differences in medical utilization before and after outpatient and inpatient alcoholism treatment.

RESULTS

The pattern of medical utilization before and after alcoholism treatment appears basically symmetric. There is a gradual increase, which accelerates in the year before treatment and then falls off rapidly for the first year after treatment and then falls more gradually. Such a pattern does not suggest any net savings over time. The area under the curve before treatment is basically equivalent to that after treatment. Slopes of medical utilization for both treatment groups before 1 year before treatment were statistically similar to the control groups, but during 1 year before treatment, both treatment groups' outpatient utilization increased 1.25% and inpatient utilization increased 1.8% relative to the nontreated group. The slopes posttreatment showed differential effects over time of inpatient versus outpatient alcoholism treatment on inpatient and outpatient medical utilization.

CONCLUSIONS

Although a clear increase in medical utilization before treatment and a decrease in utilization after treatment was found, it is not clear if the change is linked to changes in the status of the individuals as they prepare to enter alcoholism treatment or if there is a real causal effect of the alcoholism treatment.

Older Adults' Reports of Formal Care Hours and Administrative Records

PURPOSE

Personal assistance care is a Medicaid benefit in New York, but few data are available on its prevalence and contribution to home care. We examined these issues in a New York City sample by assessing older adults' reports of weekly home care hours and Medicaid billing records.

DESIGN AND METHODS

With help from New York City's Human Resources Administration, we identified all respondents in an ongoing population-based survey of Medicare enrollees who were receiving Medicaid-reimbursed personal assistance care in 1996.

RESULTS

Of respondents in the sample, 10.3% (185 of 1,902 alive through 1996) had Medicaid claims for personal assistance care. The mean was 46.1 hr/week for reported hours and 40.1 hr/week for administrative claims. Accuracy of reported hours was evident in a high correlation (r =.91; p <.001) between respondent reports and authorized claims, and a consistently high and mostly constant ratio of billed to reported hours across all categories of activities of daily living disability.

IMPLICATIONS

In this urban, low income, and mostly minority sample, older adults' reports of weekly formal care hours were valid when matched against administrative records. Respondent reports of formal care hours were valid even in complex care situations.

Population-based hepatitis C surveillance and treatment in a national managed care organization

OBJECTIVES

To use a national population-based automated claims database to study the testing rate, prevalence, and prescribing patterns for chronic hepatitis C.

STUDY DESIGN

A retrospective descriptive study that analyzes medical and pharmacy automated claims from affiliated health plans in 4 regions of the United States.

METHODS

Data were collected from 11 UnitedHealth Group-affiliated health plans (3.9 million members) from January 1, 1997, to December 31, 1999. Medical claims were used to identify persons tested for hepatitis C virus (HCV). Persons with chronic HCV were identified through medical and pharmacy claims. Patterns of drug use and treatment were analyzed, including prescribing physician specialty and proportion of patients receiving baseline and follow-up testing.

RESULTS

Of 27,871 members tested for HCV (0.7%), 1869 (6.7%) were diagnosed as having chronic HCV. Tested patients were more likely to be female (odds ratio [OR], 1.1) and older (> or = 25 years; OR, 4.1). Of 3259 patients with HCV, most were male (OR, 1.8) and older (> or = 25 years; OR, 32.0). Of these patients, 33.6% (n = 670) of men and 25.2% (n = 319) of women received treatment. Combination therapy users were more likely to undergo baseline (OR, 4.8) and follow-up (OR, 6.2) testing compared with interferon alfa monotherapy users.

CONCLUSIONS

Of the total population, 0.7% were tested for HCV, of whom 6.7% were diagnosed as having chronic HCV. Although women were more likely to undergo testing, prevalence and therapy rates for chronic HCV were higher in men. Most patients did not receive recommended baseline and follow-up testing, and the approximate 30% therapy rate suggested that many patients with HCV remain untreated.

Using claims data to examine patients using practice-based Internet communication: is there a clinical digital divide?

Background

Practice-based Internet communication allows patients to obtain health information, ask questions, and submit requests through a personalized Web site. While such online tools also bring great promise for educating patients with the goal of fostering behavior change, it is important to examine how individuals currently using such services differ from those who do not.

Objective

The study used administrative information to characterize a population of patients communicating with a medical practice through the Internet during the end of 1999 and through 2000.

Methods

Patient claims data generated during clinical encounters from January 1999 through May 2000 were examined to measure the relationship between patient demographics, frequency of visits, specific acute diagnoses, and specific chronic diagnoses and the use of online communication with the practice.

Results

Ten percent of patients, and 13.2% of patients 18 years or older, used the practice Web site. There were differences in use of the practice Web site by age and insurance status, but not by gender. Use of the practice Web site was similar or higher among patients having a diagnosis for a variety of acute and chronic conditions compared to those not having such a diagnosis. Patients with more clinic visits were more likely to use the Web-based service.

Conclusions

Patients using practice-based Internet communication and having significant health risks can be identified through the use of administrative data, presenting an opportunity to test online educational efforts to improve health.

Factors associated with pattern of care before surgery for breast cancer in Quebec between 1992 and 1997

BACKGROUND

Practice guidelines for breast cancer emphasize the importance of establishing an accurate diagnosis using a minimum number of procedures and selecting optimal treatment regimens. Understanding the determinants of waiting time is essential to develop optimum interventions to reduce delay.

OBJECTIVES

The purpose of this study is to estimate the extent to which variability in 1) the number of procedures before surgery and 2) waiting time from initial procedure to surgery are explainable by factors related to the woman, to the provider, and to the care setting.

RESEARCH DESIGN

Records of physicians' fee-for-service claims were obtained for 23,370 women undergoing breast cancer surgery in Quebec between 1992 and 1997. Multilevel logistic regression was used to determine predictors of having multiple procedures before surgery. Hierarchical linear regression models were used to identify predictors of waiting time, separately for women with lymph node involvement and without this involvement.

RESULTS

Overall, 23% of the women had 3 or more procedures before surgery with significant variation found across hospitals and surgeons. Number of procedures was a strong predictor of waiting time. Waiting time also varied by stage, age, comorbidity, a history of benign disease, surgical setting, calendar time, month of initial procedure, and hospital teaching status.

CONCLUSION

Although variability in waiting time was more strongly influenced by the characteristics of the women rather than by physician- or hospital-related factors, most variation remained unexplained by the factors included in this study. To reduce overall waiting time, strategies would need to be systemically applied.

Retrospective cohort study of diabetes mellitus and antipsychotic treatment in a geriatric population in the United States

OBJECTIVES

The objective of this study was to investigate risk of diabetes among elderly patients during treatment with antipsychotic medications.

DESIGN

We conducted a longitudinal, retrospective study assessing the incidence of new prescription claims for antihyperglycemic agents during antipsychotic therapy.

SETTING

Prescription claims from the AdvancePCS claim database were followed for 6 to 9 months.

PARTICIPANTS

Study participants consisted of patients in the United States aged 60+ and receiving antipsychotic monotherapy. The following cohorts were studied: an elderly reference population (no antipsychotics: n = 1,836,799), those receiving haloperidol (n = 6481) or thioridazine (n = 1658); all patients receiving any conventional antipsychotic monotherapy (n = 11,546), clozapine (n = 117), olanzapine (n = 5382), quetiapine (n = 1664), and risperidone (n = 12,244), and all patients receiving any atypical antipsychotic monotherapy (n = 19,407).

MEASUREMENTS

We used Cox proportional hazards regression to determine the risk ratio of diabetes for antipsychotic cohorts relative to the reference population. Covariates included sex and exposure duration.

RESULTS

New antihyperglycemic prescription rates were higher in each antipsychotic cohort than in the reference population. Overall rates were no different between atypical and conventional antipsychotic cohorts. Among individual antipsychotic cohorts, rates were highest among patients treated with thioridazine (95% confidence interval [CI], 3.1- 5.7), lowest with quetiapine (95% CI, 1.3-2.9), and intermediate with haloperidol, olanzapine, and risperidone. Among atypical cohorts, only risperidone users had a significantly higher risk (95% CI, 1.05-1.60; P = 0.016) than for haloperidol. Conclusions about clozapine were hampered by the low number of patients.

CONCLUSION

These data suggest that diabetes risk is elevated among elderly patients receiving antipsychotic treatment. However, causality remains to be demonstrated. As a group, the risk for atypical antipsychotic users was not significantly different than for users of conventional antipsychotics.

National health data warehouse: issues to consider

A national data warehouse that links public and private data could be used to monitor trends in healthcare costs, utilization, quality of care, and adherence to quality guidelines and changes in treatment protocols. The development of the data warehouse, however, would require overcoming a number of political and technical challenges to gain access to private insurance data. This article outlines recommendations from a national conference sponsored by the Agency for Healthcare Research and Quality (AHRQ) on the private sector's role in quality monitoring and provides an operational outline for the development of a national private sector health data warehouse.

Effect of loss control service on reported injury incidence

INTRODUCTION

A retrospective analysis evaluated the effectiveness of an insurance carrier's flexible loss control service strategy in reducing workers' compensation policyholders' reported injury and illness claims.

OBJECTIVES

To assess the effects of a loss control service strategy on workers' compensation claim frequency rates, on medical-only claim rates, on severity-claim rates, and on claim cost among a group of California employers.

METHODS

Eighty-two small- and medium-sized companies with workers' compensation policies expiring in 1999 were randomly selected from a population of policyholders assigned to loss control consultants for two or more years. Claim performance data were obtained for each company's first expired in-force policy year and its 1999 expired policy year. The retrospective design was combined with a control component based on a randomly selected comparison group of 45 companies whose first policy year with the insurer expired in 1999 and who received safety services from the loss control staff.

RESULTS

The flexible loss control consultation service strategy was associated with lower average claim rates and costs. Companies assigned to a loss control consultant for two or more years (the "outcome group") had an average claim rate of 1.24 per $10,000 premium, compared with a rate of 1.62 in the "initial group" and a rate of 1.60 in the "comparison group." The average severity-claim rate of the outcome group was 0.32, compared with the initial-year and comparison-group means of 0.48 and 0.46, respectively. The average medical-only claim rate was 0.92, compared with the initial- and comparison-group means of 1.14 and 1.14. The outcome group's average loss ratio was over 10% lower than that of the initial and comparison groups. Statistical analysis indicated that differences among the groups' claim rates and severity-claim rates were [F=(2,206) 4.938, P=0.008] and [F=(2,206) 8.208, P<0.001], respectively.

CONCLUSIONS

A loss control service strategy that provides service flexibility and develops partnership between employer and consultant can help reduce the frequency and severity of workers' compensation claims. Barriers to consultation service flexibility, both internal and external, should be identified and removed to enhance service efficacy.

Rates of claims for cumulative trauma disorder of the upper extremity in Ontario workers during 1997

Surveillance of work-related cumulative trauma disorder of the upper extremity (CTDUE) requires valid and reliable claim extraction strategies and should examine for confounding and interaction. This research estimated crude and specific rates of CTDUE claims in Ontario workers during 1997 while acknowledging misclassification and testing for confounding and interaction. Lower and upper limit event estimates were obtained by means of an algorithm applied to the Ontario Workplace Safety and Insurance Board (OWSIB) database and were combined with "at-risk" estimates obtained from the Canadian Labour Force Survey (LFS). Poisson regression was used to evaluate confounding and interaction. The method used to identify CTDUE claims had a substantial impact on the magnitude of rates, female to male rate ratios, the most commonly affected part of the upper extremity and the highest risk occupational categories. Poisson regression identified sex interactions. It allowed rigorous evaluation of the data and indicated that rates should be examined separately for men and women. Researchers should clearly define extraction strategies and examine the impact of misclassification.

[Estimation of disease-specific costs in a dataset of health insurance claims and its validation using simulation data]

PURPOSES

To estimate disease-specific costs in a dataset of health insurance claims with multiple diagnoses with known aggregate cost per claim and unknown disease-specific cost of each diagnosis using PDM (Proportional Disease Magnitude) method, validate its accuracy using simulation data with Monte Carlo method and improve its accuracy by developing an adjustment formula.

METHODS

Developed simulation data with pre-assigned disease-specific costs, applied PDM method using arithmetic means of per-diem-per-disease cost as magnitude, validated its accuracy by observing the correlation between estimates by PDM method and known disease-specific costs and formulated an adjustment formula to improve accuracy. The reproducibility of the findings was assessed using Monte Carlo method by repeating the same procedures.

RESULTS

The observed arithmetic means of per-diem-per-disease cost did not match well with actual values resulting in unsatisfactory accuracy. However, when the observed means were adjusted with a formula in which the observed mean is multiplied by (observed mean/overall mean) in the power of 2, PDM method yielded an accurate estimate of disease-specific cost. The accuracy was reproduced by Monte Carlo method with 0.9 or above R square value and slope of regression line in 76, 56 out of 100 iterations respectively.

CONCLUSIONS

PDM method proved to be an objective, reproducible and accurate method for estimation of disease-specific costs of health insurance claims.

Agreement Between Insurance Claim and Self-Reported Hospital and Emergency Room Utilization Data Among Persons with Diabetes

As part of a retrospective evaluation of a diabetes management program, the agreement between self-reported and insurance claim data on hospitalization and emergency room utilization was examined. Data agreement on hospitalization or emergency room visits between the two collection modes was evaluated through the use of simple agreement proportions and the kappa agreement statistic. A total of 1,230 participant responses were studied. The proportions of patients with hospitalization or emergency room visits were indistinguishable between the self-reported and medical claims data, and kappa statistics also indicated good-to-excellent agreement between data sets. The percentages of participants whose self-reported hospitalization and emergency room utilization exactly matched data derived from insurance claims were high (89.1% and 87.2%, respectively). Furthermore, the kappa statistics of agreement for the number of hospitalizations (0.6366) and emergency room visits (0.5390) indicate good agreement between self-reported and insurance claim data. The results of this study suggest either self-reported or insurance claims data can be used to evaluate the impact of health care interventions on hospital or emergency room utilization.

Incidence of outpatient physician claims for upper gastrointestinal symptoms among new users of celecoxib, ibuprofen, and naproxen in an insured population in the United States

OBJECTIVE

The aim of this study was to compare the risk of outpatient medical claims for UGI symptoms among new users of celecoxib versus ibuprofen, and naproxen.

METHODS

The study was conducted using LifeLink, an insurance claims database of approximately 1.8 million employees, dependents, and retirees in the United States. Patients newly treated with a prescription of celecoxib, ibuprofen, or naproxen between June 1, 1999, and June 30, 2001, were included. A patient with an upper GI (UGI) symptom was any individual with an outpatient physician claim for dyspepsia (ICD-9 = 536.8), abdominal pain (789.0), or nausea/vomiting (787.0). Incidence was determined using person-time analysis. Multivariate analyses were conducted using Poisson and Cox regression models.

RESULTS

The cohort consisted of patients prescribed celecoxib (n = 68,939), ibuprofen (n = 71,456), or naproxen (n = 50,014). At baseline, celecoxib users were older and more likely to have a history of UGI or cardiovascular conditions. The incidence rate of any UGI symptom was 0.46 per 1,000 patient-days for celecoxib, 0.70 for ibuprofen, and 0.62 for naproxen. After adjusting for confounding factors using Poisson regression, the ibuprofen rate was 48% higher than the celecoxib rate (incidence rate ratio (IRR) = 1.48; 95% CI = 1.39-1.58; p < 0.001), whereas the naproxen rate was 40% higher (IRR = 1.40; 95% CI = 1.31-1.49; p < 0.001). The association between drug use and UGI symptoms was confirmed by Cox regression analysis; the hazard ratios were 1.21 (95% CI = 1.13-1.29; p < 0.001) for ibuprofen and 1.15 (95% CI = 1.07-1.23; p < 0.001) for naproxen relative to celecoxib. Younger age, female sex, medical history of UGI, cardiovascular and renal conditions, and higher baseline average healthcare expenditures for the 12-month period preceding the index prescription were also significantly associated with an increased incidence of UGI symptoms.

CONCLUSIONS

Celecoxib use is associated with a significantly decreased risk of outpatient physician claims for UGI symptoms compared with commonly used prescription nonspecific nonsteroidal anti-inflammatory drugs.

Estimates of incidence rates with longitudinal claims data

OBJECTIVE

To estimate incidence rates of the 3 major chronic eye diseases--diabetic retinopathy (DR), glaucoma, and age-related macular degeneration (ARMD)--by using longitudinal claims data from Medicare.

METHODS

Longitudinal cases were ascertained by using a national probability sample of Medicare beneficiaries aged 65 years and older in 1991 who initially had none of the eye diseases documented. After adjusting for death and enrollment in a health maintenance organization, claims filed by optometrists or ophthalmologists with an International Classification of Diseases, Ninth Revision, Clinical Modification code for all forms of DR, glaucoma, and ARMD were used to indicate diagnosis.

RESULTS

Annual incidence rates for the 3 conditions after the first year of observation ranged from 14.3% to 17.7% (higher earlier) across an 8-year longitudinal follow-up. Incidence rates among those with diabetes mellitus for any form of DR varied between 3.8% and 6.5%, while those for glaucoma varied between 4.6% and 7.8% and those for ARMD varied between 7.5% and 9.3%.

CONCLUSIONS

Longitudinal claims data after the first year provide relatively stable estimates of incidence rates on an annual basis. These estimates are comparable with those of the few population-based studies available.

Declining trends in work-related morbidity and disability, 1993-1998: a comparison of survey estimates and compensation insurance claims

OBJECTIVES

This study compared trends in the incidence of work-related morbidity and disability across 3 sources of surveillance data in a Canadian province.

METHODS

Time series estimates of workplace injuries and work-related disability based on 2 panel surveys in the province of Ontario, Canada, for the period 1993-1998 were compared with rates of work-related injury and illness compensation claims during the same period.

RESULTS

Lost-time compensation claims declined by 28.8% over this 6-year period. The incidence of self-reported work-related injury declined by 28.2%, and the self-reported incidence of work absence for work-related causes declined by 32.2%.

CONCLUSIONS

Parallel reductions in work-related morbidity were seen in 3 independent data sources. These results support an interpretation that there has been an important reduction in injury risk in Ontario workplaces over the past decade.

An analysis of one potential form of health care fraud in Canada

Health insurance fraud is a potential source of expense, injustice and adverse events in medical care. We examined one type of such fraud: false claims for prescription benefits after the death of the beneficiary. Of 335,536 elderly people in Ontario who died between Jan. 1, 1991, and Jan. 1, 1997, we identified 113 for whom 1 or more prescription drug benefit claims (about 1 per 3000 deaths) were submitted more than 1 year after their death. Claims for expensive medications were rare, as were those for addictive medications. Our findings suggest that this type of health care fraud occurs infrequently and that countermeasures are unlikely to substantially reduce medication abuse in Canada.

The relationship of unions to prevalence and claim filing for work-related upper-extremity musculoskeletal disorders

BACKGROUND

Unionization has been found to be related to higher filing of workers' compensation (WC) claims, but the extent of the relationship and the relationships to other variables have not been previously reported.

METHODS

Telephone interviews were conducted with both a population-based and WC-based samples of musculoskeletal disorder (MSD) cases.

RESULTS

Workers at unionized facilities were 5.7 times (95% CI 2.5-13.1) more likely to file a claim for WC, despite a comparable rate of MSD cases. Higher filing was also associated with several measures of MSD severity (1.8-14.1 odds ratios), economic sector (OR = 10.1 for manufacturing), hourly (vs. salary) wages (OR = 2.6), and for having a personal physician (OR = 2.5). Unions appeared to have a protective effect on social effects of work-related MSD.

CONCLUSIONS

Unions appear to improve filing of work-related MSD, particularly for less severe conditions. The higher filing does not appear to be a case of "moral hazard," but rather improved and earlier reporting, as is advocated by early intervention approaches to reducing MSD.

Influences of ethnicity, treatment, and comorbidity on breast cancer survival in Hawaii

The purpose of this study was to examine factors contributing to the ethnic discrepancies in breast cancer survival described previously. Through the use of the Hawaii Tumor Registry and insurance claims data, 1,052 breast cancer patients' survival times were examined in relation to demographics, disease characteristics, comorbidity, and treatment patterns as compared to national guidelines for breast cancer treatment. In stepwise and hierarchical Cox regression models, TNM stage was the strongest predictor of survival and explained all of the ethnic survival differences. In addition, comorbidity and treatment patterns were significant in predicting survival. In this population of health plan members, ethnic differences in survival were not a result of differential treatment, but due to variations in early detection. These results support the hypothesis that pre-existing conditions and treatment patterns are related to breast cancer survival even after controlling for stage at diagnosis indicating the usefulness of insurance claims data in this research field.

Work injuries among Finnish farmers: a national register linkage study 1996-1997

BACKGROUND

Farming is one of the most injury-prone occupations in Finland as it is in other countries. Our goals were to describe work injuries of Finnish farmers and to compare occupational injury rates between various subgroups.

METHODS

A national cohort of 69,629 full-time farmers and their 11,657 compensated injuries were identified from an insurance company database. Cohort data were merged with a population census and farm register. Relative incidence rates were calculated using Poisson regression.

RESULTS

Men had higher injury rates than women, except with regard to injuries caused by animals. Dairy and hog farming were the riskiest activities, and injury rates increased with the number of dairy cows.

CONCLUSIONS

One-half of insured farmers in Finland are full-time farmers, which may have lead to underestimation of risk in Finnish injury statistics. Dairy farming is of particular concern because it is both common and has a high injury rate.

Malpractice claims analysis yields widely applicable principles

We received 50 claims of medical negligence in pediatric cardiology. From the analysis, patterns were identified and recommendations for improvement were found that apply generally to healthcare. Less than half (38%) of the claims were found to be medically meritorious. The impression of substandard care was often (7/50) created by an erroneous attribution of cause of death at autopsy. Both structured learning for caregivers and education of the public will reduce the frequency of malpractice forms-both valid and frivolous. Caregivers should document more effectively. The current tort system neither deters nor compensates as it was intended. The assignment of blame to a single individual is usually not in concert with the reality of modern medicine. Good health care is not a passive behavior; active participation by the public is required.

Workers' compensation claims related to natural rubber latex gloves among Oregon healthcare employees from 1987-1998

BACKGROUND

Occupational reaction to natural rubber latex (NRL) glove use by healthcare employees has been an area of increasing concern. Unfortunately, there is little data demonstrating the prevalence and severity of actual reactivity to NRL.

METHOD

Occupational reaction to NRL was estimated using workers' compensation claims filed by healthcare employees in Oregon for the period of 1987-1998. For the first ten years, these claims were estimated by source and conditions consistent with NRL glove reactions, while in the last two years a specific code developed in 1997 for NRL glove reactions was also employed.

RESULTS

The claim rate was on average 0.58 per 10,000 healthcare workers annually, which constituted 0.29% of all workers' compensation claims. The most common condition experienced was dermatitis (80%) and most common body part affected was the hands (55.4%). The majority of claimants, 45 (69.2%), reported taking less than a month off work, suggesting most reactions were minor in nature, although one fatality was reported. The average NRL claim cost was $8,309.48. Overall the average cost per insured healthcare worker was approximately $0.50 per year. The occupational groups with the highest number of claims were nurses (30.8% of claimants) and nursing aides and orderlies (24.6% of claimants).

CONCLUSIONS

In comparison with other workers' compensation claims filed by healthcare workers during this period, 0.25% of the total was potentially related to NRL gloves. The rare incidence of respiratory and ocular claims is inconsistent with the hypothesis that asthmatic or conjunctival reactions to NRL gloves are common.

Utilization and outcomes of the implantable cardioverter defibrillator, 1987 to 1995

BACKGROUND

The patterns of adoption of the implantable cardioverter defibrillator (ICD) and the outcomes of its use have not been well documented in general, unselected populations. The purpose of this study was to document the impact of the ICD in widespread clinical practice.

METHODS

We identified ICD recipients by use of the hospital discharge databases of Medicare beneficiaries for 1987 through 1995 and of California residents for 1991 through 1995. The index admission for each patient was linked to previous and subsequent admissions and to mortality files to create a longitudinal patient profile.

RESULTS

The rate of ICD implantations increased >10-fold between 1987 and 1995, as both the number of hospitals performing the procedure and the volume of ICD implantations per hospital rose. Mortality rates within 30 days of ICD implantation decreased from 6.0% to 1.9%, and mortality rates within 1 year fell from 19.3% to 11.4%. Surgical interventions to revise or replace the ICD within the first year remained about 5%, however, and cumulative expenditures at 1 year ($46,000-$51,000) changed very little. ICD implantation rates varied >3-fold among different regions of the United States.

CONCLUSIONS

ICD use has expanded markedly during the study period, with improved mortality rates, but medical expenditures and rates of surgical revision remain high for ICD recipients.

Health care resource utilization and the impact of anemia management in patients with chronic kidney disease

BACKGROUND

Limited information exists on resource utilization patterns and overall patient management of chronic kidney disease (CKD) before the initiation of dialysis therapy.

METHODS

A retrospective claims analysis from January 1997 to December 1999 was conducted using a managed care database on 1,936 incident dialysis patients, examining the 12 months preceding dialysis initiation to evaluate whether managed care patients with CKD are receiving expected interventions and appropriate management of CKD.

RESULTS

Mean age was 66.8 years, 46% were women, 91.2% had claims for facility services, 97.6% had claims for professional services, and 95.7% had claims for outpatient pharmacy, with mean costs per patient of $26,204, $9,623, and $1,503, respectively. Sixty-two percent of patients were hospitalized, averaging 1.3 admissions annually ($14,818/admission; average, 7.8 d/admission). Despite high overall resource use, treatments for preparation for dialysis therapy, appropriate tests, and nutritional supplements (eg, phosphate binders, B-complex combinations, and vitamins with iron) were administered infrequently. Comorbid conditions, such as anemia (47.4%) and diabetes (53%), were appropriately addressed with erythropoietin (10.5%) and angiotensin-converting enzyme inhibitors (38%) in only a minority of cases. In preparation for dialysis therapy, only 20.8% underwent a vascular access procedure.

CONCLUSION

Although patients consumed significant amounts of resources during the 12 months before dialysis initiation, many were not using expected resources for the appropriate management of CKD. A number of opportunities exist to improve predialysis care through better management of these conditions.

The value of the periodic executive health examination: experience at Bank One and summary of the literature

The executive physical examination has been advocated in the United States for almost 100 years. A MEDLINE search of the literature found very few studies that document the potential impact of a worksite physical examination program on medical and disability costs. Bank One has performed executive physical examinations at its corporate headquarters' medical department since 1983. Approximately 65% of eligible executives voluntarily participate in the program annually. Medical claims and short term disability data were available for a total of 1773 executives who were eligible for a physical examination for a consecutive 3-year period. For three consecutive years after the initial physical examination, the Bank paid a total of $5361 for medical claims for periodic health examination participants (PHE) in contrast to $6426 paid for medical claims for non-periodic health examination participants (NPHE). PHE participants experienced an average 0.93 (or 2.78 for 3 years) short-term disability days absent per year in comparison with an average of 1.34 (or 4.02 for 3 years) short-term disability days absent for NPHE. The net return on investment for a worksite-based executive health examination which cost approximately $400 per executive whose total compensation (salary and benefits) is at least $125,000 is estimated to be 2.3:1, which compares favorably with other preventive health programs.

Linking Birth Certificates with Medicaid Data To Enhance Population Health Assessment

This study linked birth certificates with Minnesota Medicaid deliveries in order to identify Medicaid births. This article describes the link between methodology and results. Medicaid claims from 1997 were used to identify women with a delivery code. Identifiers for these women were linked to birth certificate files, with a match rate of 93.2 percent. Women's match status did not differ by maternal age. Women in some border counties matched at much lower rates than the rest of the population. The methodology was effective in linking Medicaid and birth certificate data and will be implemented as a data linkage protocol for Minnesota.

Public Health Surveillance Approaches in Oregonʼs Medicaid Population

The development of methods for public health surveillance in Medicaid populations is an important goal for public health practice. In Oregon, we developed approaches to case finding using claims and self-reported data obtained from the Medicaid beneficiary population. Disease rosters, derived from claims data, form the basis for analyses pertaining to particular health conditions. Self-reported information obtained through a telephone survey forms the basis for analyses pertaining to behavioral risk factors, disease history, and other information not available in claims data. We also describe some projects in which we plan to use combined claims and survey data. We describe our experiences with using these techniques and provide examples from projects in progress or planned. Our initial experiences suggest that these approaches enhance our ability to conduct public health surveillance in Oregon's Medicaid population.

A descriptive analysis of disorders in patients 17 years following motor vehicle accidents

Whiplash-associated disorders (WAD) are described and analysed 17 years after involvement in a motor vehicle accident. A self-report questionnaire was mailed to 121 patients registered at emergency departments in Gothenburg in 1983 because of neck complaints following a car collision. The questionnaire contained items on symptoms referred to WAD, treatment, work disability, involvement in settlement of claims, medical disability and the Neck Disability Index (NDI). Of the 121 patients, 108 (89%) chose to participate in the present study. Fifty-nine (55%) had residual disorders referable to the original accident. Neck pain, radiating pain and headache were the most common symptoms. One-third of the patients with residual symptoms suffered from work disability, compared to 6% in the group of patients without residual disorders. All 25 patients who had reached a final claim settlement (42%) had a poor outcome, and 15 of the claiming patients had been assigned a medical disability ranging from 5 to 30%. Patients with WAD reported a significantly higher score on the NDI than those without residual disorders. There was no significant correlation between the patients' degree of medical disability and the scores on the NDI. The results of the study show that approximately half of the patients with neck complaints following motor vehicle accidents in Gothenburg in 1983 suffered frequent residual symptoms 17 years after the accident, mostly comprising neck pain, radiating pain, and headache. The residual disorders contributed to the patients' overall disability.

Measuring deception: test-retest reliability of physicians' self-reported manipulation of reimbursement rules for patients

This study examined the test-retest reliability of physicians' self-reported manipulation of reimbursement rules for patients. The test-retest reliability of self-report of three specific tactics were examined: (1) exaggerating the severity of patients' conditions, (2) changing a patient's official (billing) diagnosis, and (3) reporting signs or symptoms that patients did not have. The reliability of a scaled summary measure of physicians' manipulation of reimbursement rules was also assessed. Overall, the authors found high levels of test-retest agreement across all three items and the summary measure. These findings suggest that self-report can be used to produce reliable data on this controversial issue. Specifically, the three items reported here can be used to produce a reliable summary measure of physicians' manipulation of reimbursement rules to help patients obtain care that physicians perceive as necessary.

Using administrative data to study persons with disabilities

Administrative data result from administering health plans--tracking service utilization, paying claims, monitoring costs and quality--and have been used extensively for health services research. This article examines the strengths and limitations of administrative data for health services research studies of people with disabilities. Administrative data offer important advantages: encompassing large populations over time, ready availability, low cost, and computer readability. Questions arise about how to identify people with disabilities, capture disability-related services, and determine meaningful health care outcomes. Potentially useful administrative data elements include eligibility for Medicare or Medicaid through Social Security disability determinations, diagnosis and procedure codes, pharmacy claims, and durable medical equipment claims. Linking administrative data to survey or other data sources enhances the utility of administrative data for disability studies.

Mental health insurance claims among spouses of frequent business travellers

OBJECTIVES

Following up on two earlier publications showing increased psychological stress and psychosocial effects of travel on the business travellers this study investigated the health of spouses of business travellers.

METHODS

Medical claims of spouses of Washington DC World Bank staff participating in the medical insurance programme in 1997-8 were reviewed. Only the first of each diagnosis with the ninth revision of the international classification of diseases (ICD-9) recorded for each person was included in this analysis. The claims were grouped into 28 diagnostic categories and subcategories.

RESULTS

There were almost twice as many women as men among the 4630 identified spouses. Overall, male and female spouses of travellers filed claims for medical treatment at about a 16% higher rate than spouses of non-travellers. As hypothesised, a higher rate for psychological treatment was found in the spouses of international business travellers compared with non-travellers (men standardised rate ratios (RR)=1.55; women RR=1.37). For stress related psychological disorders the rates tripled for both female and male spouses of frequent travellers (>or= four missions/year) compared with those of non-travelling employees. An increased rate of claims among spouses of travellers versus non-travellers was also found for treatment for certain other diagnostic groups. Of these, diseases of the skin (men RR=2.93; women RR=1.41) and intestinal diseases (men RR=1.31; women RR=1.47) may have some association with the spouses' travel, whereas others, such as malignant neoplasms (men RR=1.97; women RR=0.79) are less likely to have such a relation.

CONCLUSION

The previously identified pattern of increased psychological disorders among business travellers is mirrored among their spouses. This finding underscores the permeable boundary between family relations and working life which earlier studies suggested, and it emphasises the need for concern within institutions and strategies for prevention.

Use of insurance claims data to assess outpatient antimicrobial therapy for gram-positive infections

With the increasing frequency of antibiotic-resistant gram-positive infections in the United States, many patients are being treated outside the hospital setting. The majority of studies on the cost of outpatient antimicrobial therapy involve retrospective medical record review or prospective data collection. These methods tend to be expensive and time consuming, and often fail to produce a sufficiently large sample size. Analysis of insurance claims data offers a convenient approach for studying the costs associated with outpatient therapy for gram-positive infections. To demonstrate this approach, a study of the cost of intravenous vancomycin home care therapy was conducted using claims data from a large insurance company.

Selecting data sources for substance abuse services research

In this article we discuss the strengths and weaknesses of using different types of data sources for alcohol and drug abuse services research. To do this, we describe four types of data sources used in substance abuse services research: surveys of organizations, medical records, claim and encounter data and program-level administrative data. For each, we outline where to obtain data, how each type has been used, and the advantages and challenges. This overview should allow investigators to think more critically about the datasets they now use; providers to understand the types of data sources most appropriate for specific research questions so as to participate more fully in research; and policy makers to interpret correctly results based on different types of data. Moreover, it should foster better communication among these stakeholders in collaborative projects to improve the effectiveness of services for people with addictions.

Economic burden of pneumonia in an employed population

OBJECTIVE

To estimate the overall economic burden of pneumonia from an employer perspective.

METHODS

The annual, per capita cost of pneumonia was determined for beneficiaries of a major employer by analyzing medical, pharmaceutical, and disability claims data. The incremental costs of 4036 patients with a diagnosis of pneumonia identified in a health claims database of a national Fortune 100 company were compared with a 10% random sample of beneficiaries in the employer overall population.

RESULTS

Total annual, per capita, employer costs were approximately 5 times higher for patients with pneumonia ($11 544) than among typical beneficiaries in the employer overall population ($2368). The increases in costs were for all components (eg, medical care, prescription drug, disability, and particularly for inpatient services). A small proportion (10%) of pneumonia patients (almost all of whom were hospitalized) accounted for most (59%) of the costs.

CONCLUSIONS

Patients with pneumonia present an important financial burden to employers. These patients use more medical care services, particularly inpatient services, than the average beneficiary in the employer overall population. In addition to direct health care costs related to medical utilization and the use of prescription drugs, indirect costs due to disability and absenteeism also contribute to the high cost of pneumonia to an employer.

Who cares for medicaid-enrolled children with chronic conditions?

OBJECTIVE

To estimate generalist, pediatric subspecialist, and any subspecialist use by Medicaid-enrolled children with chronic conditions and to determine the correlates of use.

METHODS

We analyzed Medicaid claims data collected from 1989 to 1992 from 4 states for 57 328 children and adolescents with 11 chronic conditions. We calculated annual rates of generalist, subspecialist, and pediatric subspecialist use. We used logistic regression to determine the association of demographics, urban residence, and case-mix (Adjusted Clinical Groups) with the use of relevant pediatric and any subspecialist care.

RESULTS

Most children with chronic conditions had visits to generalists (range per condition: 78%-90% for children with Supplemental Security Income [SSI] and 85%-94% for children without SSI) during the year studied. Fewer children visited any relevant subspecialists (24%-59% for children with SSI and 13%-56% for children without SSI) or relevant pediatric subspecialists (10%-53% for children with SSI and 3%-37% for children without SSI). In general, children who were more likely to use pediatric subspecialists were younger, lived in urban areas, were white (only significant for non-SSI children), and had higher Adjusted Clinical Groups scores. Use of any subspecialists followed a similar pattern except that urban residence is statistically significant only for children with SSI and the youngest age group does not differ from the oldest age group for children without SSI.

CONCLUSIONS

Children who had chronic conditions and were enrolled in Medicaid received a majority of their care from generalist physicians. For most conditions, a majority of children did not receive any relevant subspecialty care during the year and many of these children did not receive care form providers with pediatric-specific training.