Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims

Context Continuing changes in the health care delivery system make it essen tial to monitor underuse of needed care, even for relatively well-insured p opulations. Traditional approaches to measuring underuse have relied on pat ient surveys and chart reviews, which are expensive, or simple single-condi tion claims-based indicators, which are not clinically convincing. Objective To develop a comprehensive, low-cost system for measuring underus e of necessary care among elderly patients using inpatient and outpatient M edicare claims. Design A 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indic ators likely to be associated with avoidable poor outcomes for 15 common ac ute and chronic medical and surgical conditions. An automated system was de veloped to calculate the indicators using administrative data. Setting and Subjects A total of 345253 randomly selected elderly US Medicar e beneficiaries in 1994-1996, Main Outcome Measures Proportion of beneficiaries receiving care, stratifie d by indicators of necessary care (n=40, including 3 for preventive care), and avoidable outcomes (n=6). Results For 16 of 40 necessary care indicators (including preventive care i ndicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly wors e than whites on 16 and better on 2; residents of poverty areas scored sign ificantly lower than nonresidents on 17 and higher on 1; residents of feder ally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all). Conclusions This claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantl y more underuse problems were detected in populations known to receive less -than-average medical care, The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on clai ms data.