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Administrative Data and Hospice Care
Author Bios
Introduction
Health Insurance Data
Basis for Payment Data
Hospice Claims Data
The Medicare Model
Currently selected section: Claims Data Uses
Hospice & Palliative Care
Statistical Challenges
Correct Denominators
Starting the Clock
Costs of EOL Care
Conclusions


Chapter 18: Using Adminstrative Data to Study Hospice Care: Uses and Limitations of Claims Data
         

Researchers can use claims data to:

  • Identify diagnoses;
  • Identify procedures;
  • Broadly look at timing (specific days for hospital and physician, spans of days for hospice, home care, and SNF); and
  • Determine intensity of hospice care (routine, continuous, inpatient).

Unfortunately, claims data also have some considerable limitations:

  • You cannot identify a variety of detailed clinical factors that would help stratify patients into clinically meaningful groups.
  • You cannot determine cancer histology because histology is not codable.
  • You cannot reliably gauge cancer stage because codes for regional spread generally do not exist. While codes for distant spread exist (e.g. 197.7 is secondary malignant neoplasm of the liver), they are not consistently used.
  • You cannot reliably identify worsening existing disease other than through inference based on clinical treatment. For example, no code differentiates between mild congestive heart failure from serious CHF. Likewise, codes do not distinguish large tumors from small tumors. Thus, administrative data make it difficult to stratify patients by severity of illness for a specific condition though it is possible to stratify patients based on the number of comorbid conditions (see Klabunde, 2002 for review).
  • Treatment failure is difficult to identify, particularly when studying patients who do not elect to undergo more treatment (Earle, 2002). If a patient receives chemotherapy, has no obvious treatment and then begins chemotherapy again, it is probably reasonable to assume that the cancer recurred. If, however, the patient decides not to undergo additional treatment, administrative data will not distinguish that patient from patients whose cancer never recurred, except by diagnoses near death or entry into hospice.
  • No code exists for the intent of treatment. For example, radiation can be either therapeutic or palliative. Researchers may choose to assume that a patient with distant spread receiving radiation is being treated with an intent to control symptoms (since radiation alone will not control distant spread) but often the specific physical target of the radiation is not noted (e.g. brain, lung, primary tumor site). Likewise, a researcher's classification of the intent of the radiation may not match the patient's belief about the intent of the treatment.
  • Codings will not reflect diagnostic test or error. For example, if surgery is undertaken for suspected gall stones and, in the course of surgery, metastatic cancer is found, the diagnosis will be coded as cancer, as if it were known beforehand.
  • Administrative data can only identify services received (for which a bill was submitted), not services needed. Knowing that a patient received medication for pain control does not mean that the patient had his/her pain controlled. Likewise, patients with no pain medications may or may not have experienced pain.
  • Claims cannot tell the whole 'story' behind the pattern of services. Did a patient not receive care following protocol because his/her physician did not follow guidelines? Could a patient not physically tolerate a treatment or refuse treatment for some other reason? There is no code for 'declined X treatment.' Knowing care received does not provide information about care offered or the reasons why it was or was not accepted.


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