Assessing Quality of Care for Hospitalized Medicare Patients with Hip Fracture Using Coded Diagnoses from the Medicare Provider Analysis and Review Files

by Emmett B. Keeler, Katherine L. Kahn, Stanley S. Bentow

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HCFA developed a method for assessing quality of care for surgical patients using claims data. Coded diagnoses in the current or future admissions might indicate problems. The authors studied the validity of these methods by comparing actual bad outcomes in the medical record with bad outcomes defined by coded diagnoses in the claims, using data on 1229 patients hospitalized in 1985-6 with hip fracture from a previous RAND study. RAND's original study excluded patients with repeat procedures, so those codes could not be checked. For the HCFA codes that could be matched, the correspondence of codes to event in the medical record was weak, but some codes (pneumonia, hip joint infection and pulmonary embolism) were promising. Other codes, such as congestive heart failure, that might be bad outcomes were instead more related to history. Suggestions are given as to how the HCFA method could be improved.

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