Claims research could boost evidence base for quality improvement

Claims research that examines particular conditions, patients with high utilization rates and physicians with high referral rates may advance the evidence base for quality improvement, according to a study published online Nov. 6 in The Journal of the American College of Radiology.

James W. Begun, PhD, of the University of Minnesota in Minneapolis, and colleagues designed a study in which the characteristics that distinguish higher and lower CT use by patients and referring physicians in a population of members of a large health insurance plan were investigated.

“Since its introduction in the 1970s, CT scanning has become an important tool in medical imaging,” the researchers explained. “However, CT scans are not harmless procedures, and there are questions of appropriateness as well as overutilization. Among the ways to explore high utilization is the analysis of insurance claims of private health insurers.”

Begun and colleagues examined 310,467 CT scans from 2009-10 in a health plan that serves approximately 1.5 million government and commercial members. Patients who used CT scans and their referring physicians were classified into utilization categories. Characteristics that differentiated higher utilization categories from lower were then distinguished.

Findings indicated the patient characteristics that determined higher from lower utilization rates were being male, older age, seeing more total providers, using more prescription and total resources, classified as frail, having higher treatment group severity, and having government insurance.

Among the physicians who ordered scans, characteristics that distinguished higher from lower referrals for CT scans were being male, board-certified, in group practice, and in particular specialties.

Ownership interest was associated with higher claim volumes in a curvilinear manner but was not associated with claims per physician. Higher total referral counts were associated with single-specialty practice type and larger group size.

Four external reviewers found that the study’s findings generally aligned with their expectations based on their professional experience, meaning that there are plausible explanations for the profile characteristics of higher utilizing patients and referring physicians that are consistent with logical medical decision-making.

The findings from the claims data reveal that a small proportion of patients are exposed to a larger number of CT scans. Additionally, the aggregate-level review of claims for CT scans in the health plan showed no glaring anomalies in associations of patient and referring physician characteristics with higher utilization.

“Claims research that targets particular conditions, aggregates of patients with high utilization rates and physicians with high referral rates, and research that tests measures of ownership interest would advance the evidence base quality for improvement,” wrote Begun and colleagues.

Finer-grained analyses are needed in the future to better scrutinize potential overutilization or uncritical utilization issues, the study’s authors said.