The influence of primary care quality on nursing home admissions in a multimorbid population with and without dementia in Germany: a retrospective cohort study using health insurance claims data

Background Multimorbidity poses a challenge for high quality primary care provision for nursing care-dependent people with (PWD) and without (PWOD) dementia. Evidence on the association of primary care quality of multimorbid PWD and PWOD with the event of a nursing home admission (NHA) is missing. This study aimed to investigate the contribution of individual quality of primary care for chronic diseases in multimorbid care-dependent PWD and PWOD on the duration of ongoing residence at home before the occurrence of NHA. Methods We conducted a retrospective cohort study among elderly care-dependent PWD and PWOD in Germany for six combinations of chronic diseases using statutory health insurance claims data (2007–2016). Primary care quality was measured by 21 process and outcome indicators for hypertension, diabetes, depression, chronic obstructive pulmonary disease and heart failure. The primary outcome was time to NHA after initial onset of care-dependency. Multivariable Cox proportional hazard models were used to compare the time-to-event between PWD and PWOD. Results Among 5876 PWD and 12,837 PWOD 5130 NHA occurred. With the highest proportion of NHA for PWD with hypertension and depression and for PWOD with hypertension, diabetes and depression. Average duration until NHA ranged from 6.5 to 8.9 quarters for PWD and from 9.6 to 13.5 quarters for PWOD. Adjusted analyses show consistent associations of the quality of diabetes care with the duration of remaining in one’s own home regardless of the presence of dementia. Process indicators assessing guideline-fidelity are associated with remaining in one’s home longer, while indicators assessing complications, such as emergency inpatient treatment (HR = 2.67, 95% CI 1.99–3.60 PWD; HR = 2.81, 95% CI 2.28–3.47 PWOD) or lower-limb amputation (HR = 3.10, 95% CI 1.78–5.55 PWD; HR = 2.81, 95% CI 1.94–4.08 PWOD) in PWD and PWOD with hypertension and diabetes, increase the risk of NHA. Conclusions The quality of primary care provided to care-dependent multimorbid PWD and POWD, influences the time individuals spend living in their own homes after onset of care-dependency before a NHA. Health care professionals should consider possibilities and barriers of guideline-based, coordinated care for multimorbid care-dependent people. Further research on quality indicator sets that acknowledge the complexity of care for multimorbid elderly populations is needed.

Nationwide Comprehensive Epidemiological Study of Rare Diseases in Japan Using a Health Insurance Claims Database

BackgroundMore than 7,000 diseases constitute what are called rare diseases, and they mostly have no specific treatment. Disease profiles, such as prevalence and natural history, among the population of a specific country are essential in determining for which disease to research and develop drugs. In Japan, disease profiles of fewer than 2,000 rare diseases, called Nanbyo, have been investigated. However, non-Nanbyo rare diseases remain largely uninvestigated. Accordingly, we reveal the prevalence and natural history of rare diseases among the Japanese population, using the National Database of Health Insurance Claims and Specific Health Checkups of Japan, which covered 99.9% of public health insurance claims from hospitals and 97.9% from clinics as of May 2015. Then, we compared them with the data reported in Orphanet. This cross-disease study is the first to analyze rare-disease epidemiology in Japan with high accuracy, disease coverage, and granularity.ResultsWe were provided with the number of patients of approximately 4,500 rare diseases by sex and age for 10 years with the permission of the Ministry of Health, Labour and Welfare. About 3,000 diseases have equivalent terms in Orphanet and other medical databases. The data show that even if the Nanbyo systems do not cover a rare disease, its patients survive in many cases. Moreover, regarding natural history, genetic diseases tend to be diagnosed later in Japan than they are in the West. The data collected for this research work are available in the supplement and the website of NanbyoData.ConclusionsOur research work revealed the basic epidemiology and the natural history of Japanese patients with rare diseases using a health insurance claims database. The results imply that the coverage of the present Nanbyo systems is inadequate for rare diseases. Therefore, fundamental reform might be needed to reduce unfairness between rare diseases. Moreover, most diseases in Japan follow a tendency similar to those reported in Orphanet. However, some diseases are detected later, partly because fewer clinical genetic tests are available in Japan than there are in the West. Finally, we hope that our data and analysis accelerate drug discovery for rare diseases in Japan.

Outcomes and costs of ureteroscopy, extracorporeal shockwave lithotripsy, and percutaneous nephrolithotomy for the treatment of urolithiasis: an analysis based on health insurance claims data in Germany

Purpose Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term health and economic outcomes based on claims data are rare. Our aim was to analyze URS, SWL, and PCNL regarding complications within 30 days, re-intervention, healthcare costs, and sick leave days within 12 months, and to investigate inpatient and outpatient SWL treatment as the latter was introduced in Germany in 2011. Methods This retrospective cohort study based on German health insurance claims data included 164,203 urolithiasis cases in 2008–2016. We investigated the number of complications within 30 days, as well as time to re-intervention, number of sick leave days and hospital and ambulatory health care costs within a 12-month follow-up period. We applied negative binomial, Cox proportional hazard, gamma and two-part models and adjusted for patient variables. Results Compared to URS cases, SWL and PCNL had fewer 30-day complications, time to re-intervention within 12 months was decreased for SWL and PCNL, SWL and PCNL were correlated with a higher number of sick leave days, and SWL and particularly PCNL were associated with higher costs. SWL outpatients had fewer complications, re-interventions and lower costs than inpatients. This study was limited by the available information in claims data. Conclusion URS cases showed benefits in terms of fewer re-interventions, fewer sick leave days, and lower healthcare costs. Only regarding complications, SWL was superior. This emphasizes URS as the most frequent treatment choice. Furthermore, SWL outpatients showed less costs, fewer complications, and re-interventions than inpatients.

A Strategy to Identify Event Specific Hospitalizations in Large Health Claims Databases

Background Health insurance claims data offer a unique opportunity to study disease distribution on a large scale. Challenges arise in the process of accurately analyzing these raw data. One important challenge to overcome is the accurate classification of study outcomes. For example, using claims data, there is no clear way of classifying hospitalizations due to a specific event. This is because of the inherent disjointedness and lack of context that typically come with raw claims data. Methods In this paper, we propose a framework for classifying hospitalizations due to a specific event. Results We then test this framework in a health insurance claims database with approximately 4 million US adults who tested positive with COVID-19 between March and December 2020. Our claims specific COVID-19 related hospitalizations proportion is then compared to nationally reported rates from the Centers for Disease Control by age and sex. Conclusions The proposed methodology is a rigorous way to define event specific hospitalizations in claims data. This methodology can be extended to many different types of events and used on a variety of different types of claims databases.

A Decision Support System with Artificial Intelligence and Natural Language Processing to Mitigate the Deduction Rate of Health Insurance Claims

Globally, 20% to 40% of medical resources are wasted, which could be avoided through professional audit of health insurance claims. The professional audit can pinpoint excessive use of unnecessary medicines and medical examinations. Taiwan’s National Health Insurance Bureau (TNHIB) deducts the weight that medical resources carry if regarded as unnecessary or abused when examining health insurance claims. The ratio of the deducted weight to the total weight claimed by a hospital is defined as the health insurance claim deduction rate (HICDR). A high HICDR increases the operating expenses of the hospital. In addition, it takes the hospital many resources to prepare and file appeals for the deduction. This study aims to: (1) minimize the weight deducted by the TNHIB for a hospital; and (2) facilitate efficient appeals to claim denials. It is expected that HICDR will be reduced through big data analytics. In this study, evidence-based medicine (EBM) is involved to clarify the debate, dilemmas, conflicts of interests in examining health insurance claims. A natural language method—latent Dirichlet allocation (LDA), was used to analyze patients’ medical records. The topics derived from the LDA are used as factors in the logistic regression model to estimate the probability of each claim to be deducted. The experimental results on various medical departments show that the proposed predictive model can produce accurate results, and lead to more than 41.7% reduction to the deduction of the health insurance claims. It is equivalent to more than a 750 thousand NT dollars saving per year. The efficiency of application is validated compared to the manual process that is time-consuming and labor intensive. Moreover, it is expected that this study will supplement the insufficiency of traditional methods and propose a new and effective solution to reduce the deduction rate.