Physician Billing Research Articles

Exposure to procedural ionizing radiation and cancer risk among physicians.

Physicians in certain specialities are routinely exposed to procedural ionizing radiation. Their risk of cancer is unknown, including by cancer sub-types. To assess cancer risk among exposed physicians. This population-based case-control study was completed in Ontario, Canada, where healthcare is universal, using linkage of physician billing claims to a province-wide cancer registry. Up to five cancer-free physician controls were matched to each cancer-affected physician, by sex, and both age at and year of, entry into practice. Cumulative exposure to procedural ionizing radiation was captured by physician billing claims. Conditional logistic regression generated an odds ratio (OR) of cancer per 1000 procedures performed and as a binary exposure comparing physicians above the upper 95th percentile cumulative number of procedures (≥200) to those below this cut point. Mean (standard deviation) age of the 1265 cases and 5772 non-cancer controls was 39.7 (10.7) and 37.7 (9.0) years, and 45% and 49% were female, respectively. After a median (interquartile ranges) of 13.0 (6.9-20.4) and 12.5 (6.5-20.1) years of lookback among cases and controls, the OR of cancer was 1.02 (95% confidence interval 0.99-1.05; P = NS) per 1000 additional procedures performed. Modelling the cumulative exposure to procedures nonlinearly did not change the observed association (P > 0.40 for each). Comparing physicians above versus below the upper 95th percentile cumulative number of procedures, the OR of cancer was 1.23 (95% confidence interval 0.75-2.01, P = NS). Physician exposure to procedural ionizing radiation was not associated with a higher risk of cancer. Measures that minimize radiation exposure should continue.

Differences in Primary Total Shoulder Arthroplasty Volume, Reimbursement, Practice Styles, and Patient Populations Based on Surgeon Gender: A Temporal Analysis

BackgroundOrthopedic surgery has previously been shown to have a shortage of female physicians and a gender pay gap. However, this has not been thoroughly evaluated in the setting of shoulder surgery. The primary purpose of this study was to evaluate differences in total shoulder arthroplasty (TSA) volume, reimbursement, surgeon billing practices, and patient populations between male and female surgeons from 2013 to 2021. MethodsThe Medicare Physician and Other Practitioners database, a publicly available dataset that includes 100% of services billed to Medicare Part B was utilized. The database was queried for all billing episodes of Current Procedural Terminology (CPT) code 23472, which encompasses both anatomic and reverse primary TSA. Procedural volume, average inflation-adjusted reimbursement per TSA, physician billing information, and the patient demographics of each surgeon who performed TSAs were collected. Welch’s t-test and Kruskal-Wallis were utilized to compare male and female surgeons each year between 2013 and 2021. ResultsBetween 2013 and 2021, the proportion of TSAs performed by female surgeons nationally increased from 1.8% to 2.9% (+1.1%). This increase was greatest in the Northeast (2.0% to 6.1%), while a decrease was seen in the Midwest (1.9% to 1.6%). In 2021, there was no significant difference between male and female surgeons in the average inflation-adjusted reimbursement per TSA ($1,144.00 vs $1,143.00, p=0.792) and the average number of TSAs performed per surgeon (26.6 vs 23.1, p=0.105). Female TSA surgeons, on average, had less Medicare beneficiaries (348 vs 462, p<0.001), performed fewer annual services (1,817 vs 3,630, p<0.001), and performed fewer unique services (60 vs 76, p<0.001) compared to male surgeons. A higher proportion of female surgeon’s patient populations were non-White (24% vs 22%, p=0.028), female (61% vs 59%, p=0.001), and dual enrolled Medicare-Medicaid patients (13% vs 10%, p<0.001). However, there was no difference in the average patient complexity between male and female TSA surgeons based on hierarchical condition category (HCC) score (1.0783 vs 1.0732, p=0.228). ConclusionFemale representation within TSA surgery is increasing nationally, with the greatest representation in the Northeast and West and the lowest representation in the South and Midwest. Although female TSA surgeons perform a similar number of TSAs, receive comparable reimbursement per TSA, and have a similarly complex patient population as their male counterparts, they perform significantly fewer total and unique billable services annually. Additionally, female TSA surgeons tend to see more non-White, women, and dual Medicare-Medicaid enrolled patients.

Management of Plastic Surgery Complications at a Tertiary Medical Center after Aesthetic Procedures.

The aesthetic plastic surgery industry has seen tremendous growth, with Americans spending an estimated 20 billion dollars on procedures in 2020. However, the effect of complications from these procedures on the healthcare system is poorly understood. This study aims to create awareness regarding aesthetic procedure complications through the scope of plastic surgeons at a tertiary medical facility. A retrospective chart review was performed on patients who received care at a single academic tertiary referral center over 5 years for complications from a cash-paid aesthetic procedure at an outside facility. Physician and hospital billing data were analyzed for relevant encounters. Patients in this study (n = 40) presented to the emergency department most frequently with complications secondary to abdominoplasty (35%), breast augmentation (27.5%), and injectable fillers (17.5%). The most common complications were infection (32.5%) and wound dehiscence (22.5%). Of those evaluated, 50% required inpatient admission. Additionally, 42.5% required surgical intervention. The distribution of payors included Medicaid (55%), commercial insurance (30%), and Medicare (7.5%), and 7.5% were uninsured. For physician billing, the total gross collection ratio was 21.3%, whereas the hospital billing total gross collection ratio was 25.16%. Larger referral hospitals are well-suited to support the aesthetic community with complication management; however, the care required to serve this population is resource-intensive. These data advocate for thorough closed-loop patient-surgeon communication regarding risk-benefit analysis and detailed courses of action should complications arise. Likewise, stronger communication between ambulatory surgical centers and tertiary referral centers may also help minimize complications and subsequent healthcare needs.

Minor Ailments and Pharmacist Management in Ontario, Canada: Attachment and Primary Care

Minor ailments (MA) are health conditions that can be managed with minimal prescribed treatment and/or self-care strategies. In Ontario, Canada, pharmacists were given authority to deliver service for thirteen MAs on January 1, 2023, with an additional six MAs on October 1, 2023. This study aims to identify patterns of MA service provision and describe characteristics of recipients of MA services. A cross-sectional analysis of linked health administrative data, including pharmacist billing for MA services, patient demographics, and physician and hospital billing data, was conducted. Delivery of MA services prescribed in Ontario from January 1 to December 31, 2023 were analyzed with key demographics (age, sex, income, new arrival status, comorbidity), health care utilization (ED, hospitalization) and primary care attachment. In 2023, 547,673 (3.6%) Ontario residents received at least one MA service, with the top 5 services being urinary tract infections (199,282), conjunctivitis (153,021), herpes labialis (46,659), allergic rhinitis (41,521), and dermatitis (39,365). Compared to all Ontario residents, the MA service recipients were more likely to be people with a higher rate of ED visits (41.7% vs. 32.4%), comorbidities (17.5% vs. 9.7%), higher incomes (highest income quintile, 23.1% vs. 20.1%; lowest income quintile, 16.5% vs. 19.4%), and hospitalizations (23.6% vs. 17.6%), and less likely to be newcomers to Ontario (8.7% vs. 13.1%). They were more likely to be attached to a primary care provider (91.3% vs. 84.7%). This study provides insight into early users of this program, and sheds light on those with systemic vulnerabilities and equity deserving groups.

Model-based algorithms to ascertain smoking in administrative health data: a registry-based validation study

Objectives We developed a machine-learning model-based algorithm (MBA) for smoking in Administrative Health Data (AHD). The validity of this MBA was compared to a rule-based algorithm (RBA). Approaches The study included adults (≥18 years) from a clinical registry containing self-reported current smoking from 2017 to 2020 in Manitoba, Canada. Clinical data were linked to up to five years of hospitalization, physician billing claims, and prescription medication records. The RBA was based on diagnosis codes for tobacco use and nicotine dependence medication. MBAs, constructed using random forest (RF) models, included these indicators in addition to comorbid condition diagnoses and sociodemographic factors. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), and 95% confidence intervals (CIs) were estimated. Results The cohort comprised 24,718 individuals (88.6% female); prevalence of current smokers was 10.0%. The RBA had sensitivity of 27.3% (95% CI: 24.2-30.7), specificity of 96.6% (95% CI: 96.1-97.0), and PPV of 47.2% (95% CI: 42.9-51.5). The MBA had sensitivity of 68.6% (95% CI: 65.1-71.9), specificity of 76.3% (95% CI: 75.2-77.3), and PPV of 24.3% (95% CI: 23.2-25.6). NPV was high irrespective of algorithms. Stratified analyses revealed similar estimates for males and females, and the number of years of AHD did not affect the MBA results. ConclusionsAn RF-based MBA for smoking ascertainment in linked AHD sources improved sensitivity compared to the RBA. However, the RBA excelled in specificity and PPV. ImplicationBalancing accurate smoker identification with the risk of false positives is crucial when choosing an algorithm to ascertain current smokers using AHD.

Centre-Specific Variation in Atrial Fibrillation Ablation-Treatment Rates in a Universal Single-Payer Healthcare System

BackgroundDisparities in atrial fibrillation ablation rates have been studied previously, with a focus on either patient characteristics or systems factors, rather than geographic factors. The impact of electrophysiology (EP) centre practice patterns on ablation rates has not been well studied. MethodsThis population-based cohort study used linked administrative datasets covering physician billing codes, hospitalizations, prescriptions, and census data. The study population consisted of patients who visited an emergency department with a new diagnosis of atrial fibrillation, in the period 2007-2016, in Ontario, Canada. Patient characteristics, including age, sex, medical history, comorbidities, socioeconomic factors, closest EP centre within 20 km, and distance to the nearest centre, were used as predictors in multivariable logistic regression models to assess the relationship between living in a location around specific EP centres and ablation rates. ResultsThe cohort included 134,820 patients, of whom 9267 had an ablation treatment during the study period. Patients undergoing ablation treatment were younger, had a lower Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) score, lived closer to EP centres, and had fewer comorbidities than those who did not receive ablation treatment. Wide variation occurred in ablation rates, with adjacent census divisions having ablation rates up to 2.6 times higher. Multivariate regression revealed significant differences in ablation rates for patients who lived in a location around certain EP centres. The odds ratios for living in a location closest to specific centres ranged from 0.78 (95% confidence interval: 0.68-0.89) to 1.60 (95% confidence interval:1.34-1.90). ConclusionsLiving near specific EP centres may significantly affect a patient’s likelihood of receiving ablation treatment, regardless of factors such as age, gender, socioeconomic status, prior medical history, and distance to EP centres.

Antibiotic Prescription Rates For Respiratory Tract Infections Treated In The Outpatient Sector Based On Routine Data From A German Health Insurance Company

Acute uncomplicated upper respiratory tract infections (RTIs) are common reasons for antibiotic prescriptions in the outpatient sector, although>90% are of viral origins and mostly self-limiting. Germany has a low antibiotic prescription rate compared to other European countries, but there are regional differences. Disease-specific quality indicators (QI) developed by the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) address the prescription rates (target <20%) and choice of antibiotic (target>80%) in a general practitioner population. The aim of this analysis was to operationalise the ESAC-Net-QI using secondary data from a health insurance company at the level of diseases and healthcare facilities, as well as to analyse areas for improvement. The underlying database comprises the panel physician billing, hospital and prescription data in accordance with German law (§§ 295, 300 and 301 SGB V) of the Barmer health insurance company for the year 2022. Categorical features are presented as frequency and percentage. Maximum specificity was aimed, hence potentially risky disease courses were excluded. The overall RTI prescription rate of antibiotics was 25% in 2022 before applying inclusion and exclusion criteria (1,197,568/4,720,786). After applying the algorithm, the prescription rate for all RTI cases dropped to 6% (80,786/1,365,646). When specific RTI indications are considered, 35% (13,465/38,913) of acute bronchitis and acute sinusitis cases (4,971/14,051) received an antibiotic prescription each. At the facility level, 38% of practices (1,396/3,705) treating acute bronchitis and 41% of practices (539/1,300) treating acute sinusitis achieved the target of<20% antibiotic prescriptions. Only 29% of all RTI cases with antibiotic prescriptions (23,733/80,786) received a first-choice antibiotic. Our analysis indicates that the ESAC-Net-QI for RTIs can be calculated at case and facility levels using routine health insurance data. For specific RTIs, there were indications of improvement potential in the frequency and selection of prescribed antibiotics.

Fine Particulate Matter Components and Risk of Rheumatoid Arthritis: A Large General Canadian Open Cohort Study.

Exposure to fine particulate matter (PM2.5) has been linked to many diseases. However, it remains unclear which PM2.5 chemical components for these diseases, including rheumatoid arthritis (RA), are more harmful. This study aimed to assess potential associations between PM2.5 components and RA and quantify the individual effects of each chemical component on RA risk. An open cohort of 11,696,930 Canadian adults was assembled using Ontario administrative health data from January 2007 onward. Individuals were followed until RA onset, death, emigration from Ontario, or the end of the study (December 2019). Incident RA cases were defined by physician billing and hospitalization discharge diagnostic codes. The average levels of PM2.5 components (ammonium, black carbon, mineral dust, nitrate, organic matter, sea salt, and sulfate) for 5 years before cohort entry were assigned to participants based on residential postal codes. A quantile g-computation and Cox proportional hazard models for time to RA onset were developed for the mixture of PM2.5 components and environmental overall PM2.5, respectively. We identified 67,676 new RA cases across 130,934,256 person-years. The adjusted hazard ratios for the time to RA onset were 1.027 and 1.023 (95% confidence intervals 1.021-1.033 and 1.017-1.029) per every decile increase in exposures to all seven components and per 1 μg/m3 increase in the overall PM2.5, respectively. Ammonium contributed the most to RA onset in the seven components. Exposure to PM2.5 components was modestly associated with RA risk. Public health efforts focusing on specific components (eg, ammonium) may be a more efficient way to reduce RA burden.

Long-Term Cardiovascular Outcomes in Children and Adolescents With Hypertension

Hypertension affects 6% of all children, and its prevalence is increasing. Childhood hypertension tracks into adulthood and is associated with subclinical cardiovascular disease; however, there is a lack of evidence linking childhood hypertension to cardiovascular outcomes, which may contribute to underdiagnosis and undertreatment. To determine the long-term associated risk of major adverse cardiac events (MACE) among children diagnosed with hypertension. This was a population-based, retrospective, matched cohort study conducted from 1996 to 2022. The study included all children (aged 3-18 years) alive in Ontario, Canada, from 1996 to 2021, who were identified using provincial administrative health databases. Children with prior kidney replacement therapy were excluded. Incident hypertension diagnosis, identified by validated case definitions using diagnostic and physician billing claims. Each case was matched with 5 controls without hypertension by age, sex, birth weight, maternal gestational hypertension, prior comorbidities (chronic kidney disease, diabetes, cardiovascular surgery), and a propensity score for hypertension. The primary outcome was MACE (a composite of cardiovascular death, stroke, hospitalization for myocardial infarction or unstable angina, or coronary intervention). Time to MACE was evaluated using the Kaplan-Meier method and Cox proportional hazards regression. A total of 25 605 children (median [IQR] age, 15 [11-17] years; 14 743 male [57.6%]) with hypertension were matched to 128 025 controls without hypertension. Baseline covariates were balanced after propensity score matching, and prior comorbidities were uncommon (hypertension vs control cohort: malignancy, 1451 [5.7%] vs 7908 [6.2%]; congenital heart disease, 1089 [4.3%] vs 5408 [4.2%]; diabetes, 482 [1.9%] vs 2410 [1.9%]). During a median (IQR) of 13.6 (7.8-19.5) years of follow-up, incidence of MACE was 4.6 per 1000 person-years in children with hypertension vs 2.2 per 1000 person-years in controls (hazard ratio, 2.1; 95% CI, 1.9-2.2). Children with hypertension were at higher associated risk of stroke, hospitalization for myocardial infarction or unstable angina, coronary intervention, and congestive heart failure, but not cardiovascular death, compared with nonhypertensive controls. Children diagnosed with hypertension had a higher associated long-term risk of MACE compared with controls without hypertension. Improved detection, follow-up, and control of pediatric hypertension may reduce the risk of adult cardiovascular disease.

A more complete measure of vertical integration between physicians and hospitals.

To develop an accurate and reproducible measure of vertical integration between physicians and hospitals (defined as hospital or health system employment of physicians), which can be used to assess the impact of integration on healthcare quality and spending. We use multiple data sources including from the Internal Revenue Service, the Centers for Medicare and Medicaid Services, and others to determine the Tax Identification Numbers (TINs) that hospitals and physicians use to bill Medicare for services, and link physician billing TINs to hospital-related TINs. We developed a new measure of vertical integration, based on the TINs that hospitals and physicians use to bill Medicare, using a broad set of sources for hospital-related TINs. We considered physicians as hospital-employed if they bill Medicare primarily or exclusively using hospital-related TINs. We assessed integration status for all physicians who billed Medicare from 1999 to 2019. We compared this measure with others used in the existing literature. We conducted a simulation study which highlights the importance of accurately identifying integrated physicians when study the effects of integration. We extracted physician and hospital-related TINs from multiple sources, emphasizing specificity (a small proportion of nonintegrated physicians identified as integrated). We identified 12,269 hospital-related TINs, used for billing by 546,775 physicians. We estimate that the percentage of integrated physicians rose from 19% in 1999 to 43% in 2019. Our approach identifies many additional physician practices as integrated; a simpler TIN measure, comparable with prior work, identifies only 30% (3877) of the TINs we identify. A service location measure, used in prior work, has both many false positives and false negatives. We developed a new measure of hospital-physician integration. This measure is reproducible and identifies many additional physician practices as integrated.

Increased Virtual Visits to Physicians During the COVID-19 Pandemic and Estimated Impact on Physician Compensation: The Case of Lung and Colorectal Cancers, Chronic Obstructive Pulmonary Diseases, and Heart Failure in Alberta, Canada.

Introduction: The COVID-19 pandemic started in Alberta in March 2020 and significantly increased telehealth service use and provision reducing the risk of virus transmission. We examined the change in the number and proportion of virtual visits by physician specialty and condition (chronic obstructive pulmonary diseases [COPD], heart failure [HF], colorectal and lung cancers), as well as associated changes in physician compensation. Methods: A population-based design was used to analyze all processed physician claims comparing the number and proportion of virtual visits and associated physician billings relative to in-person between pre- (2019/2020) and intra-pandemic (2020/2021). Physician compensations were the claim amounts paid by the health insurance. Results: Pre-pandemic (intra-), there were 8,981 (8,897) lung cancer, 9,245 (9,029) colorectal, 37,558 (36,292) HF, and 68,270 (52,308) COPD patients. Each patient had totally 2.3-4.7 (of which 0.4-0.6% were virtual) general practitioner (GP) visits and 0.9-2.3 (0.2-0.7% were virtual) specialist visits per year pre-pandemic. The average number and proportion of per-patient virtual visits to GPs and specialists grew significantly pre- to intra-pandemic by 2,138-4,567%, and 2,201-7,104%, respectively. Given the lower fees of virtual compared with in-person visits, the reduction in physician compensation associated with the increased use of virtual care was estimated at $3.85 million, with $2.44 million attributed to specialist and $1.41 million to GP. Discussion: Utilization of telehealth increased significantly, while the physician billings per patient and physician compensation declined early in the pandemic in Alberta for the four chronic diseases considered. This study forms the basis for future study in understanding the impact of virtual care, now part of the fabric of health care delivery, on quality of care and patient safety, overall health service utilization (such as diagnostic imaging and other investigations), as well as economic impacts to patients, health care systems, and society.

Health Care Utilization and Direct Costs Prior to Subspecialty Care in Children with Chronic Pain Compared with Other Chronic Childhood Diseases: A Cohort Study

ObjectivesTo understand the burden associated with pediatric chronic pain (CP) on the healthcare system compared with other costly chronic diseases prior to subspecialty care. Study designIn this retrospective cohort study, we assessed all-cause healthcare utilization and direct healthcare costs associated with pediatric CP (n=91) compared with juvenile-onset arthritis (JA, n=135), inflammatory bowel disease (IBD, n=90), type 1 or type 2 diabetes (T1D, n=475, T2D, n=289), anxiety (n=7,193) and controls (n=273) two and five years prior to patients entering subspecialty care in Manitoba, Canada. Linked data from physician encounters, emergency department visits, hospitalizations, and prescriptions were extracted from administrative databases. Differences in healthcare utilization and direct healthcare costs associated with CP versus the other conditions were tested using negative binomial and zero-inflated negative binomial regression models, respectively. ResultsAfter adjustment for age at diagnosis, sex, location of residence, and socioeconomic status, CP continued to be associated with the highest number of consulted physicians and subspecialists and the highest number of physician billings compared with all other conditions (p<0.01, respectively). CP was significantly associated with higher physician costs than JA, IBD, T1D, T2D, or controls (p<0.01, respectively); anxiety was associated with the highest physician and prescription costs among all cohorts (p<0.01, respectively). ConclusionCompared with chronic inflammatory and endocrinologic conditions, pediatric CP and anxiety were associated with substantial burden on the healthcare system prior to subspecialty care, suggesting a need to assess gaps and resources in the management of CP and mental health conditions in the primary care setting.

Validation of case-ascertainment algorithms using health administrative data to identify people who inject drugs in Ontario, Canada

ObjectivesHealth administrative data can be used to improve the health of people who inject drugs by informing public health surveillance and program planning, monitoring, and evaluation. However, methodological gaps in the use of these data persist due to challenges in accurately identifying injection drug use (IDU) at the population level. In this study, we validated case-ascertainment algorithms for identifying people who inject drugs using health administrative data in Ontario, Canada. Study Design and SettingData from cohorts of people with recent (past 12 months) IDU, including those participating in community-based research studies or seeking drug treatment, were linked to health administrative data in Ontario from 1992 to 2020. We assessed the validity of algorithms to identify IDU over varying look-back periods (ie, all years of data [1992 onwards] or within the past 1–5 years), including inpatient and outpatient physician billing claims for drug use, emergency department (ED) visits or hospitalizations for drug use or injection-related infections, and opioid agonist treatment (OAT). ResultsAlgorithms were validated using data from 15,241 people with recent IDU (918 in community cohorts and 14,323 seeking drug treatment). An algorithm consisting of ≥1 physician visit, ED visit, or hospitalization for drug use, or OAT record could effectively identify IDU history (91.6% sensitivity and 94.2% specificity) and recent IDU (using 3-year look back: 80.4% sensitivity, 99% specificity) among community cohorts. Algorithms were generally more sensitive among people who inject drugs seeking drug treatment. ConclusionValidated algorithms using health administrative data performed well in identifying people who inject drugs. Despite their high sensitivity and specificity, the positive predictive value of these algorithms will vary depending on the underlying prevalence of IDU in the population in which they are applied.

Identifying patients with diagnosed cirrhosis in administrative health databases: a validation study.

Case ascertainment algorithms were developed and validated to identify people living with cirrhosis in administrative health data in Manitoba, Canada using primary care electronic medical records (EMR) to define the reference standards. We linked provincial administrative health data to primary care EMR data. The validation cohort included 116,675 Manitobans aged >18 years with at least one primary care visit between April 1998 and March 2015. Hospital records, physician billing claims, vital statistics, and prescription drug data were used to develop and test 93 case-finding algorithms. A validated case definition for primary care EMR data was the reference standard. We estimated sensitivity, specificity, positive and negative predictive values (PPV, NPV), Youden's index, area under the receiver operative curve, and their 95% confidence intervals (CIs). A total of 116,675 people were in the validation cohort. The prevalence of cirrhosis was 1.4% (n = 1593). Algorithm sensitivity estimates ranged from 32.5% (95% CI 32.2-32.8) to 68.3% (95% CI 68.0-68.9) and PPV from 17.4% (95% CI 17.1-17.6) to 23.4% (95% CI 23.1-23.6). Specificity (95.5-98.2) and NPV (approximately 99%) were high for all algorithms. The algorithms had slightly higher sensitivity estimates among men compared with women, and individuals aged ≥45 years compared to those aged 18-44 years. Cirrhosis algorithms applied to administrative health data had moderate validity when a validated case definition for primary care EMRs was the reference standard. This study provides algorithms for identifying diagnosed cirrhosis cases for population-based research and surveillance studies.

Development and validation of thromboembolism diagnostic algorithms in children with cancer from real-world data.

To evaluate the accuracy of diagnostic algorithms developed using the International Classification of Diseases (ICD-9-CM and ICD-10-CA) diagnostic codes and physician billing codes for thromboembolism (TE) from health administrative data compared to chart review diagnoses of TE in children with cancer. Using data linkage between the Pediatric Oncology Group of Ontario Network Information System (Ontario pediatric cancer registry) and various administrative data housed at ICES, eight algorithms were developed including a single reference to one of the billing codes, multiple references with varying time intervals, and combinations of various billing codes during primary cancer therapy for the whole cohort and, for early (<04/2002) and later (≥04/2002, solely ICD-10 codes) periods. Reference standard was chart review data from prior studies (from 1990 to 2016) among children (≤19 years) with cancer and radiologically confirmed TE. Records of 2056 patients diagnosed with cancer at two participating sites during study period were reviewed; 112 had radiologically confirmed TE. The algorithm with addition of anticoagulation utilization codes was the best performing algorithm (sensitivity = 0.76;specificity = 0.85). With use of ICD-10 only codes, sensitivity of the same algorithm improved to 0.84 with specificity of 0.80. This study provides a valid approach for ascertaining pediatric TE using real-world data. Research in pediatric thrombosis, especially cancer-related thrombosis, is limited mainly due to small-sized studies. Real-world data provide ready access to large and diverse populations. However, there are no validated algorithms for identifying thrombosis in real-world data for children. An algorithm based on combination of thrombosis and anticoagulation utilization codes had 76% sensitivity and 85% specificity to identify diagnosis of thrombosis in children in administrative data. This study provides a valid approach for ascertaining pediatric thrombosis using real-world data and offers a good avenue to advance pediatric thrombosis research.

Short-term mortality and palliative care use after delayed hospital discharge: a population-based retrospective cohort study

ObjectivesIn Canada, patients whose acute medical issues have been resolved but are awaiting discharge from hospital are designated as alternate level of care (ALC). We investigated short-term mortality and palliative...

Geospatial Evaluation of Disparities in Access to Cervical Spine Fusion in Metropolitan Areas Across the United States.

Retrospective study with epidemiologic analysis of public Medicare data. The purpose of this study is to use geospatial analysis to identify disparities in access to cervical spine fusions in metropolitan Medicare populations. Cervical spine fusion is among the most common elective procedures performed by spine surgeons and is the most common surgical intervention for degenerative cervical spine disease. Although some studies have examined demographic and socioeconomic trends in cervical spine fusion, few have attempted to identify where disparities exist and quantify them at a community level. Center for Medicare and Medicaid Services physician billing and Medicare demographic data sets from 2013 to 2020 were filtered to contain only cervical spine fusion procedures and then combined with US Census socioeconomic data. The Moran Index geospatial clustering algorithm was used to identify statistically significant hotspot and coldspots of cervical spine fusions per 100,000 Medicare members at a county level. Univariate and multivariate analysis was subsequently conducted to identify demographic and socioeconomic factors that are associated with access to care. A total of 285,405 cervical spine fusions were analyzed. Hotspots of cervical spine fusion were located in the South, while coldspots were throughout the Northern Midwest, the Northeast, South Florida, and West Coast. The percent of Medicare patients that were Black was the largest negative predictor of cervical spine fusions per 100,000 Medicare members ( β =-0.13, 95% CI: -0.16, -0.10). Barriers to access can have significant impacts on health outcomes, and these impacts can be disproportionately felt by marginalized groups. Accounting for socioeconomic disadvantage and geography, this analysis found the Black race to be a significant negative predictor of access to cervical spine fusions. Future studies are needed to further explore potential socioeconomic barriers that exist in access to specialized surgical care. Level III-retrospective.

Estimating the completeness of physician billing claims for diabetes case ascertainment: a multiprovince investigation.

Previous research has suggested that how physicians are paid may affect the completeness of billing claims for estimating chronic disease. The purpose of this study is to estimate the completeness of physician billings for diabetes case ascertainment. We used administrative data from eight Canadian provinces covering the period 1 April 2014 to 31 March 2016. The patient cohort was stratified into two mutually exclusive groups based on their physician remuneration type: fee-for-service (FFS), for those paid only on that basis; and non-fee-for-service (NFFS). Using diabetes prescription drug data as our reference data source, we evaluated whether completeness of disease case ascertainment varied with payment type. Diabetes incidence rates were then adjusted for completeness of ascertainment. The cohort comprised 86 110 patients. Overall, equal proportions received their diabetes medications from FFS and NFFS physicians. Overall, physician payment method had little impact upon the percentage of missed diabetes cases (FFS, 14.8%; NFFS, 12.2%). However, the difference in missed cases between FFS and NFFS varied widely by province, ranging from -1.0% in Nova Scotia to 29.9% in Newfoundland and Labrador. The difference between the observed and adjusted disease incidence rates also varied by province, ranging from 22% in Prince Edward Island to 4% in Nova Scotia. The difference in the loss of cases by physician remuneration method varied across jurisdictions. This loss may contribute to an underestimation of disease incidence. The method we used could be applied to other chronic diseases for which drug therapy could serve as reference data source.

Health care system costs related to potentially inappropriate medication use involving opioids in older adults in Canada

BackgroundOlder adults are at risk of potentially inappropriate medication use given polypharmacy, multimorbidity, and age-related changes, which contribute to the growing burden associated with opioid use. The objective of this study was to estimate the costs of health service utilization attributable to opioid use and potentially inappropriate medication use involving opioids in older adults in a public health care system.MethodsThe sample included 1201 older adults consulting in primary care, covered by the public drug plan, without a cancer diagnosis and opioid use in the year before interview. Secondary analyses were conducted using two data sources: health survey and provincial administrative data. Health system costs included inpatient and outpatient visits, physician billing, and medication costs. Unit costs were calculated using annual financial and activity reports from 2013–2014, adjusted to 2022 Canadian dollars. Opioid use and potentially inappropriate medication use involving opioids were identified over 3 years. Generalized linear models with gamma distribution were employed to model 3-year costs associated with opioid use and potentially inappropriate medication use involving opioids. A phase-based approach was implemented to provide descriptive results on the costs associated with each phase: i) no use, ii) opioid use, and iii) potentially inappropriate medication use involving opioids.ResultsOpioid use and potentially inappropriate medication use involving opioids were associated with adjusted 3-year costs of $2,222 (95% CI: $1,179-$3,264) and $8,987 (95% CI: $7,370-$10,605), respectively, compared to no use. In phase-based analyses, costs were the highest during inappropriate use.ConclusionsPotentially inappropriate medication use involving opioids is associated with higher costs compared to those observed with opioid use and no use. There is a need for more effective use of health care resources to reduce costs for the health care system.

Sex Disparities in Operating Room use Among Cataract Surgeons: A 10-Year Retrospective Population-Based Analysis

To evaluate sex differences in operating room (OR) time and case volumes among comprehensive cataract surgeons in Ontario, Canada's most populated province. Retrospective, population-based cohort study. Physician billing data of active comprehensive cataract surgeons between 2010 and 2019 were analyzed to identify all cataract surgeries in this timeframe. The number of OR days and case volume were the primary outcomes. Data were stratified by surgeon sex and career stage. Between 2010 and 2019, approximately 1.05 million cataract surgeries were performed in Ontario. There were an average of 195 ± 3 comprehensive cataract surgeons per year, of which 39 ± 5 were female. The proportion of female surgeons increased from 16.8% of all surgeons in 2010 to 24.4% in 2019. The greatest proportion of male surgeons were in the late phase of their career, whereas the greatest proportion of female surgeons were in the early stage of their career. On average, male surgeons had 44.9 ± 1.90 OR days per year and females had 32 ± 1.90 OR days per year, resulting in female surgeons averaging 12.45 ± 1.90 fewer OR days per year. This OR distribution remained consistent across career stages. Average case volumes per OR day were similar across sexes, but male surgeons performed on average 172.7 ± 30.6 more surgeries per year. Despite performing similar average case volumes per OR day, female surgeons had less OR time compared to their male counterparts per year, and this remained consistent across career stages and over the 10-year period. Metrics for OR allocation and use should be well defined and transparent.