Linked claims and medical records for cancer case management : evaluation of mammography abnormalities.
BACKGROUND
Failure to obtain the requisite follow-up of patients with abnormal mammograms may delay cancer diagnosis and impact outcome. Up to 20% of women do not receive timely recommended follow-up. The current study tested the accuracy of the linkage of payer claims and clinical data to identify the appropriate treatment for patients with abnormal mammograms.


METHODS
Electronic medical records in a staff model practice that was affiliated with a single health payer were scanned to identify the Breast Imaging Reporting and Data System (BI-RADS(R)) code for all mammograms. For each woman with a BI-RADS code 0, 3, 4, or 5 mammogram, the payer claims were searched for follow-up breast procedures (imaging, biopsy, and surgery) occurring within 2 months for BI-RADS code 0, 4, and 5 mammograms and within 8 months for BI-RADS code 3 mammograms. For women with >1 abnormal mammogram during the study period, only follow-up for the first abnormal mammogram was examined. The medical records of cases defined by claims as not having recommended follow-up care were reviewed to determine the accuracy of claims analyses.


RESULTS
A total of 17,329 women underwent 23,721 mammograms between January 1, 2001 and December 31, 2003. BI-RADS codes 0, 3, 4, or 5 occurred in 1,490 mammograms (6.3%). Among 1,206 women with a first abnormal mammogram who were eligible for claims follow-up, 16% did not receive recommended follow-up care. Medical record review demonstrated that the claims search accurately identified follow-up care in 97% of these cases.


CONCLUSIONS
Administrative claims supplemented with BI-RADS data were found to accurately identify the follow-up care of patients with abnormal mammograms. Case management using this method may assist physicians in ensuring that all patients receive appropriate care.
Eberl
Margaret M
MM
Department of Family Medicine, State University of New York at Buffalo, Buffalo, New York, USA.
Watroba
Nancy
N
Reinhardt
Marc
M
Pomerantz
Jay
J
Serghany
Joseph
J
Broffman
Gregory
G
Fox
Chester H
CH
Mahoney
Martin C
MC
Edge
Stephen B
SB
D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000628:therapy; D002985:Clinical Protocols; D016208:Databases, Factual / Q000706:statistics & numerical data*; D003695:Delivery of Health Care; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007345:Insurance Claim Review; D008327:Mammography; D008498:Medical Record Linkage; D010349:Patient Compliance