Estimating Under-diagnosis of Patients in Chronically-ill Populations

Abstract

Diagnosis coding in administrative data is known to be inconsistent and incomplete, introducing inaccurate assessment of patients' health outcomes. The under-diagnosis of members with a target chronic condition reduces the correlation of that chronic condition with associated events. Yet, only a few studies have evaluated the extent of under-reporting of chronic conditions in administrative data. In this study, we developed a novel framework to identify latent members, or those who have not yet been identified with a target chronic condition through claims-based diagnosis but are likely to have some degree of the condition. We applied our innovative approach to estimate the prevalence of a chronic-related event, based on the population of observed and latent members. We provided a detailed illustration that treats incontinence as our target chronic condition while examining four types of incontinence-related events: urinary-tract infections (UTIs), slips and falls, dermatitis, and behavioral disruptions. All analysis relied on the 5% Medicare sample for a continuously enrolled cohort between 2014-2018. Using our novel approach, we were able to increase our identification of incontinence from the 11.2% diagnosed in 2018 to an estimated prevalence in 2018 of 34.7% among fee-for-service Medicare beneficiaries over the age of 65. Similarly, our estimation of UTIs associated with those with incontinence increased from 38% to 68%, from 20% to 41% for IAD, 22% to 54% for slips and falls, and from 26% to 57% for behavior disruptions.

The Prevalence of Incontinence and Its Association With Urinary Tract Infections, Dermatitis, Slips and Falls, and Behavioral Disturbances Among Older Adults in Medicare Fee-for-Service

“…[20][21][22] We hypothesize that the incontinent population identified through claims in the CMS data is likely to miss many of those with light or moderate incontinence because that is less likely to be diagnosed by a clinical professional and less likely to be identified as a comorbidity when compared to more severe incontinence. 23,24 The FI results in Table 1 also suggest that CMS data are missing many individuals with FI. The literature predicts that between half and three-fourths of those in SNFs with UI also experience FI.…”

“…Identifying the missing urinary and fecal incontinent members is a topic of other research. 23 We analyzed the prevalence of pertinent healthcare events and comorbid conditions within the incontinent population. The prevalence of UTIs, dermatitis, slips and falls, and behavioral disturbances was statistically significant higher for those with incontinence compared to those without.…”

“…Other studies have gone through painstaking effort to evaluate large amounts of clinical data to ascertain the true prevalence of UI 20–22. We hypothesize that the incontinent population identified through claims in the CMS data is likely to miss many of those with light or moderate incontinence because that is less likely to be diagnosed by a clinical professional and less likely to be identified as a comorbidity when compared to more severe incontinence 23,24…”

“…As reported in Table 1, FI was only documented in 16% of those with UI in nursing homes, 12% in SNFs, and 9% in home health. Identifying the missing urinary and fecal incontinent members is a topic of other research 23…”