Preferred provider organization claims showed high predictive value but missed substantial proportion of adults with high-risk conditions.
OBJECTIVE
We assessed the validity and utility of a claims-based ICD-9-CM algorithm for identifying preferred provider organization (PPO) enrollees ages 18-64 years at high risk for influenza complications.


METHODS
PPO enrollees with >/= 2 encounters in an ambulatory setting or >/= 1 encounters in an inpatient or emergency room setting with ICD-9-CM diagnosis codes for the high-risk conditions were considered algorithm positive. Stratified random sampling was used to select 1,001 algorithm-positive and 330 algorithm-negative enrollees for medical chart abstractions.


RESULTS
The prevalence of high-risk conditions using claims data was 2.5% compared to 18.2% according to medical records. The algorithm had a sensitivity of 12% and a specificity of 99%. Positive and negative predictive values were 87 and 84%, respectively. Sensitivity was twofold higher among adults aged 50-64 years than among younger adults (17 vs. 9%). Applying an algorithm definition of >/= 1 encounters in any setting resulted in an increased sensitivity, but captured a higher proportion of false positives.


CONCLUSIONS
A claims-positive record was highly indicative of the presence of high-risk conditions, but such claims missed a large proportion of PPO enrollees with high-risk conditions. It is important to assess the validity of administrative data in different age groups.
Ahmed
Faruque
F
Division of Prevention Research and Analytic Methods, Epidemiology Program Office, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30341-3717, USA. fahmed@dc.gov
Janes
Gail R
GR
Baron
Roy
R
Latts
Lisa M
LM
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000465:Algorithms; D054598:Blue Cross Blue Shield Insurance Plans; D002318:Cardiovascular Diseases / Q000453:epidemiology; D006453:Hemoglobinopathies / Q000453:epidemiology; D006801:Humans; D016867:Immunocompromised Host; D007252:Influenza Vaccines / Q000008:administration & dosage; D007251:Influenza, Human / Q000150:complications* / Q000517:prevention & control; D007345:Insurance Claim Review / Q000706:statistics & numerical data*; D038801:International Classification of Diseases / Q000706:statistics & numerical data*; D007674:Kidney Diseases / Q000453:epidemiology; D008171:Lung Diseases / Q000453:epidemiology; D008875:Middle Aged; D011243:Preferred Provider Organizations; D015203:Reproducibility of Results
D007252:Influenza Vaccines