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Incorporating linked healthcare claims to improve confounding control in a study of in-hospital medication use.

ABSTRACT: The Premier Perspective hospital billing database provides a promising data source for studies of inpatient medication use. However, in-hospital recording of confounders is limited, and incorporating linked healthcare claims data available for a subset of the cohort may improve confounding control. We investigated methods capable of adjusting for confounders measured in a subset, including complete case analysis, multiple imputation of missing data, and propensity score (PS) calibration.Methods were implemented in an example study of adults in Premier undergoing percutaneous coronary intervention (PCI) in 2004-2008 and exposed to either bivalirudin or heparin. In a subset of patients enrolled in UnitedHealth for at least 90 days before hospitalization, additional confounders were assessed from healthcare claims, including comorbidities, prior medication use, and service use intensity. Diagnostics for each method were evaluated, and methods were compared with respect to the estimates and confidence intervals of treatment effects on repeat PCI, bleeding, and in-hospital death.Of 210,268 patients in the hospital-based cohort, 3240 (1.5 %) had linked healthcare claims. This subset was younger and healthier than the overall study population. The linked subset was too small for complete case evaluation of two of the three outcomes of interest. Multiple imputation and PS calibration did not meaningfully impact treatment effect estimates and associated confidence intervals.Despite more than 98 % missingness on 24 variables, PS calibration and multiple imputation incorporated confounders from healthcare claims without major increases in estimate uncertainty. Additional research is needed to determine the relative bias of these methods.

SUBMITTER: Franklin JM

PROVIDER: S-EPMC4449313 | biostudies-literature | 2015 Jun

REPOSITORIES: biostudies-literature

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Incorporating linked healthcare claims to improve confounding control in a study of in-hospital medication use.

Franklin Jessica M JM Eddings Wesley W Schneeweiss Sebastian S Rassen Jeremy A JA

Drug safety 20150601 6

<h4>Introduction</h4>The Premier Perspective hospital billing database provides a promising data source for studies of inpatient medication use. However, in-hospital recording of confounders is limited, and incorporating linked healthcare claims data available for a subset of the cohort may improve confounding control. We investigated methods capable of adjusting for confounders measured in a subset, including complete case analysis, multiple imputation of missing data, and propensity score (PS) ...[more]

PMID: 25935198

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Project description:ImportancePresent-on-admission (POA) indicators in administrative claims data allow researchers to distinguish between preexisting conditions and those acquired during a hospital stay. The impact of adding POA information to claims-based measures of hospital quality has not yet been investigated to better understand patient underlying risk factors in the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision setting.ObjectiveTo assess POA indicator use on Medicare claims and to assess the hospital- and patient-level outcomes associated with incorporating POA indicators in identifying risk factors for publicly reported outcome measures used by the Centers for Medicare & Medicaid Services (CMS).Design, setting, and participantsThis comparative effectiveness study used national CMS claims data between July 1, 2015, and June 30, 2018. Six hospital quality measures assessing readmission and mortality outcomes were modified to include POA indicators in risk adjustment models. The models using POA were then compared with models using the existing complications-of-care algorithm to evaluate changes in risk model performance. Patient claims data were included for all Medicare fee-for-service and Veterans Administration beneficiaries aged 65 years or older with inpatient hospitalizations for acute myocardial infarction, heart failure, or pneumonia within the measurement period. Data were analyzed between September 2019 and March 2020.Main outcomes and measuresChanges in patient-level (C statistics) and hospital-level (quintile shifts in risk-standardized outcome rates) model performance after including POA indicators in risk adjustment.ResultsData from a total of 6 027 988 index admissions were included for analysis, ranging from 491 366 admissions (269 209 [54.8%] men; mean [SD] age, 78.2 [8.3] years) for the acute myocardial infarction mortality outcome measure to 1 395 870 admissions (677 158 [48.5%] men; mean [SD] age, 80.3 [8.7] years) for the pneumonia readmission measure. Use of POA indicators was associated with improvements in risk adjustment model performance, particularly for mortality measures (eg, the C statistic increased from 0.728 [95% CI, 0.726-0.730] to 0.774 [95% CI, 0.773-0.776] when incorporating POA indicators into the acute myocardial infarction mortality measure).Conclusions and relevanceThe findings of this quality improvement study suggest that leveraging POA indicators in the risk adjustment methodology for hospital quality outcome measures may help to more fully capture patients' risk factors and improve overall model performance. Incorporating POA indicators does not require extra effort on the part of hospitals and would be easy to implement in publicly reported quality outcome measures.

Dataset Information

Incorporating linked healthcare claims to improve confounding control in a study of in-hospital medication use.

Publications

Incorporating linked healthcare claims to improve confounding control in a study of in-hospital medication use.

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