Abstract
BackgroundIdentifying fall-related injuries and costs using healthcare claims data is cost-effective and easier to implement than using medical records or patient self-report to track falls. We developed a comprehensive four-step algorithm for identifying episodes of care for fall-related injuries and associated costs, using fee-for-service Medicare and Medicare Advantage health plan claims data for 2,011 patients from 5 medical groups between 2005 and 2009.MethodsFirst, as a preparatory step, we identified care received in acute inpatient and skilled nursing facility settings, in addition to emergency department visits. Second, based on diagnosis and procedure codes, we identified all fall-related claim records. Third, with these records, we identified six types of encounters for fall-related injuries, with different levels of injury and care. In the final step, we used these encounters to identify episodes of care for fall-related injuries.ResultsTo illustrate the algorithm, we present a representative example of a fall episode and examine descriptive statistics of injuries and costs for such episodes. Altogether, we found that the results support the use of our algorithm for identifying episodes of care for fall-related injuries. When we decomposed an episode, we found that the details present a realistic and coherent story of fall-related injuries and healthcare services. Variation of episode characteristics across medical groups supported the use of a complex algorithm approach, and descriptive statistics on the proportion, duration, and cost of episodes by healthcare services and injuries verified that our results are consistent with other studies.ConclusionsThis algorithm can be used to identify and analyze various types of fall-related outcomes including episodes of care, injuries, and associated costs. Furthermore, the algorithm can be applied and adopted in other fall-related studies with relative ease.Electronic supplementary materialThe online version of this article (doi:10.1186/s40621-015-0066-z) contains supplementary material, which is available to authorized users.
Highlights
Identifying fall-related injuries and costs using healthcare claims data is cost-effective and easier to implement than using medical records or patient self-report to track falls
We used both fee-for-service (FFS) Medicare data from Centers for Medicare and Medicaid Services (CMS) and Medicare Advantage (MA) health plan data, which required integrating datasets from different sources with variation in data format and availability. (For simplicity, we use the term “claims” to refer to data from both FFS Medicare and MA health plans, even though not all MA data are generated from requests for payment.) In particular, the algorithm involved the use of external cause of injury codes (E codes) as well as general ICD-9-CM diagnosis codes, and identified fall-related injuries as well as episodes of care so that both frequencies and costs of fall-related injuries could be examined in detail
We obtained Medicare FFS data, as well as comparable MA datasets from 5 health plans in 2 medical groups (We provide the descriptions of the datasets, data cleaning and combining process, and key variables used in the algorithm in Additional file 1: Appendix A since the information is important for understanding the results as well as for applying the algorithm in a different context)
Summary
We developed an algorithm to analyze fall-related outcomes for the ACOVEprime study, which involved a multicomponent intervention in primary care practices to improve the quality of care for falls (Ganz et al 2015; Wenger et al 2010). Using merged Medicare FFS and MA datasets, we developed an algorithm which involved four steps to identify episodes of care for fall-related injuries and associated costs. The second step of the algorithm involved identifying all fall-related incidents using claims and line items with diagnosis and procedure codes relevant to fractures or fall-related injuries. We classified these days as “(6) fall-related use of medical care.” We repeated this process until all fall-related incident days were examined and fall-related injury encounters were identified, where present, for all patients. We applied the process at differing levels for each of the five types of fall-related injury (that were identified in the second step of the algorithm). We repeated the whole process until all encounters were examined and episodes of care for fall-related injuries were identified, where present, for all patients. Total cost involved all costs during the duration of each episode of care, while attributable cost only included cost of claims for healthcare that had a fall-related diagnosis code
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