Identification of Emergency Department Visits in Medicare Administrative Claims: Approaches and Implications
Open Access
- 19 November 2016
- journal article
- research article
- Published by Wiley in Academic Emergency Medicine
- Vol. 24 (4), 422-431
- https://doi.org/10.1111/acem.13140
Abstract
Objectives Administrative claims data sets are often used for emergency care research and policy investigations of healthcare resource utilization, acute care practices, and evaluation of quality improvement interventions. Despite the high profile of emergency department (ED ) visits in analyses using administrative claims, little work has evaluated the degree to which existing definitions based on claims data accurately captures conventionally defined hospital‐based ED services. We sought to construct an operational definition for ED visitation using a comprehensive Medicare data set and to compare this definition to existing operational definitions used by researchers and policymakers. Methods We examined four operational definitions of an ED visit commonly used by researchers and policymakers using a 20% sample of the 2012 Medicare Chronic Condition Warehouse (CCW ) data set. The CCW data set included all Part A (hospital) and Part B (hospital outpatient, physician) claims for a nationally representative sample of continuously enrolled Medicare fee‐for‐services beneficiaries. Three definitions were based on published research or existing quality metrics including: 1) provider claims–based definition, 2) facility claims–based definition, and 3) CMS Research Data Assistance Center (ResDAC ) definition. In addition, we developed a fourth operational definition (Yale definition) that sought to incorporate additional coding rules for identifying ED visits. We report levels of agreement and disagreement among the four definitions. Results Of 10,717,786 beneficiaries included in the sample data set, 22% had evidence of ED use during the study year under any of the ED visit definitions. The definition using provider claims identified a total of 4,199,148 ED visits, the facility definition 4,795,057 visits, the ResDAC definition 5,278,980 ED visits, and the Yale definition 5,192,235 ED visits. The Yale definition identified a statistically different (p < 0.05) collection of ED visits than all other definitions including 17% more ED visits than the provider definition and 2% fewer visits than the ResDAC definition. Differences in ED visitation counts between each definition occurred for several reasons including the inclusion of critical care or observation services in the ED , discrepancies between facility and provider billing regulations, and operational decisions of each definition. Conclusion Current operational definitions of ED visitation using administrative claims produce different estimates of ED visitation based on the underlying assumptions applied to billing data and data set availability. Future analyses using administrative claims data should seek to validate specific definitions and inform the development of a consistent, consensus ED visitation definitions to standardize research reporting and the interpretation of policy interventions.Keywords
This publication has 25 references indexed in Scilit:
- Advancing the Use of Administrative Data for Emergency Department Diagnostic Imaging ResearchAcademic Emergency Medicine, 2015
- Patient Returns to the Emergency Department: The Time-to-return CurveAcademic Emergency Medicine, 2014
- Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of CareJAMA, 2014
- Medicaid Increases Emergency-Department Use: Evidence from Oregon's Health Insurance ExperimentScience, 2014
- Emergency Department Visits After Surgery Are Common For Medicare Patients, Suggesting Opportunities To Improve CareHealth Affairs, 2013
- Contribution of Preventable Acute Care Spending to Total Spending for High-Cost Medicare PatientsJAMA, 2013
- Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patternsBMC Geriatrics, 2011
- Development, validation, and results of a measure of 30‐day readmission following hospitalization for pneumoniaJournal of Hospital Medicine, 2011
- Defining emergency department episodes by severity and intensity: A 15-year study of Medicare beneficiariesBMC Health Services Research, 2010
- An Administrative Claims Model Suitable for Profiling Hospital Performance Based on 30-Day Mortality Rates Among Patients With an Acute Myocardial InfarctionCirculation, 2006