Linked claims and medical records for cancer case management : Evaluation of mammography abnormalities

✍ Scribed by Margaret M. Eberl; Nancy Watroba; Marc Reinhardt; Jay Pomerantz; Joseph Serghany; Gregory Broffman; Chester H. Fox; Martin C. Mahoney; Stephen B. Edge

• Publisher: John Wiley and Sons
• Year: 2007
• Tongue: English
• Weight: 87 KB
• Volume: 110
• Category: Article
• ISSN: 0008-543X
• DOI: 10.1002/cncr.22808

✦ Synopsis

Abstract

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®) 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 1490 mammograms (6.3%). Among 1206 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. Cancer 2007. © 2007 American Cancer Society.