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Discordance of Databases Designed for Claims Payment versus Clinical Information Systems: Implications for Outcomes Research
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1993
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The study aimed to assess whether insurance claims data are suitable for clinical outcomes research in ischemic heart disease. A concordance study of 12,937 patients undergoing cardiac catheterization at a tertiary center compared 12 prognostic predictors between clinical records and claims data using two‑by‑two tables and kappa statistics. Agreement ranged from 0.83 for diabetes to 0.09 for unstable angina, and claims data missed over half of patients with key prognostic conditions, indicating that claims data lack essential diagnostic and prognostic information and are inadequate for risk adjustment in outcome studies.
Objective: To determine the suitability of insurance claims information for use in clinical outcomes research in ischemic heart disease. Design: Concordance study of two databases. Setting: Tertiary care referral center. Patients: A total of 12 937 consecutive patients hospitalized for cardiac catheterization for suspected ischemic heart disease between July 1985 and May 1990. Interventions: Two-by-two tables were used to compute overall and measures of agreement comparing clinical versus claims data for 12 important predictors of prognosis in patients with ischemic heart disease. Measurements: Kappa statistics (agreement adjusted for chance agreement) were used to quantify agreement rates. Results: Agreement rates between the clinical and claims databases ranged from 0.83 for the diagnosis of diabetes to 0.09 for the diagnosis of unstable angina ( values). Claims data failed to identify more than one half of the patients with prognostically important conditions, including mitral insufficiency, congestive heart failure, peripheral vascular disease, old myocardial infarction, hyperlipidemia, cerebrovascular disease, tobacco use, angina, and unstable angina, when compared with the clinical information system. Conclusions: Our results suggest that insurance claims data lack important diagnostic and prognostic information when compared with concurrently collected clinical data in the study of ischemic heart disease. Thus, insurance claims data are not as useful as clinical data for identifying clinically relevant patient groups and for adjusting for risk in outcome studies, such as analyses of hospital mortality.