Identifying controlled substance patterns of utilization requiring evaluation using administrative claims data

Published: November 1, 2004
Category: Bibliography > Papers
Authors: Finch MD, Haddox JD, Kim SS, Parente ST, Rector TS, Schloff LA, Seifeldin R
Countries: United States
Language: null
Types: Care Management
Settings: Hospital

Am J Manag Care 10:783-790.

HSI Network LLC, USA

OBJECTIVES: To develop a systems approach to identify, for further evaluation, patients with potential controlled substance misuse or mismanagement using software queries applied to administrative health claims data.

STUDY DESIGN: Retrospective validation of the system using insurance claims.

PATIENTS AND METHODS: Data from administrative health claims databases representing nearly 7 million individuals younger than 65 years were used by multidisciplinary expert panels to develop and validate controlled substance patterns of utilization requiring evaluation (CS-PURE) criteria.

RESULTS: Thirty-four CS-PURE queries were developed in SAS and applied to administrative claims records to identify patients with potential controlled substance misuse or mismanagement. From these, we identified 10 CS-PURE with the highest expert agreement that intervention was warranted. Expert panel agree, ment that CS-PURE correctly identified cases ranged from 48% to 100%, with at least 50% agreement in 9 of 10 CS-PURE. The prevalence rates for CS-PURE ranged from 0.001% to 0.252%. This translates to identifying between 5 and 1116 patients for individual CS-PURE in a 500 000-member health plan.

CONCLUSIONS: We developed and empirically validated a group of queries using CS-PURE to identify patients with potential controlled substance misuse or mismanagement that would warrant further evaluation by the treating physician, a quality assurance function, or the medical director. Claims-based CS-PURE identification is generalizable to most health insurers with access to medical and pharmaceutical claims records. Although CS-PURE are not direct measures of misuse, they can direct attention to potential problems to determine if intervention is needed.

PMID: 15623267

Medication,Fraud and Abuse Detection,Resource Utilization,United States,Adolescent,Adult,Analgesics,Opioid/contraindications,Analgesics,Opioid/therapeutic use,Benzodiazepines/contraindications,Benzodiazepines/therapeutics use,Carisoprodol/contraindications,Carisoprodol/therapeutic use,Databases as Topic,Drug Prescriptions/statistics & numerical data,Drug and Narcotic Control/organization & administration,Managed Care Programs/standards,Middle Aged,Prevalence,Substance-Related Disorders/epidemiology,Substance-Related Disorders/prevention & control

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