Development of an algorithm to identify fall-related injuries and costs in Medicare data

Abstract

Background: Identifying fall-related injuries and costs using healthcare claims data is cost-effective and easier to implement than using medical records or patient self-report to track falls. We developed a comprehensive four-step algorithm for identifying episodes of care for fall-related injuries and associated costs, using fee-for-service Medicare and Medicare Advantage health plan claims data for 2,011 patients from 5 medical groups between 2005 and 2009.

Methods: First, as a preparatory step, we identified care received in acute inpatient and skilled nursing facility settings, in addition to emergency department visits. Second, based on diagnosis and procedure codes, we identified all fall-related claim records. Third, with these records, we identified six types of encounters for fall-related injuries, with different levels of injury and care. In the final step, we used these encounters to identify episodes of care for fall-related injuries.

Results: To illustrate the algorithm, we present a representative example of a fall episode and examine descriptive statistics of injuries and costs for such episodes. Altogether, we found that the results support the use of our algorithm for identifying episodes of care for fall-related injuries. When we decomposed an episode, we found that the details present a realistic and coherent story of fall-related injuries and healthcare services. Variation of episode characteristics across medical groups supported the use of a complex algorithm approach, and descriptive statistics on the proportion, duration, and cost of episodes by healthcare services and injuries verified that our results are consistent with other studies.

Conclusions: This algorithm can be used to identify and analyze various types of fall-related outcomes including episodes of care, injuries, and associated costs. Furthermore, the algorithm can be applied and adopted in other fall-related studies with relative ease.

Keywords: Algorithm; Fall; Fall-related injury; HCPCS; ICD-9-CM; Medicare.

Fig. 1

Flow diagram for the third step of the algorithm. The flow diagram above consists of three different types of boxes and two types of arrows. Rounded rectangles represent start or end, rectangles represent processes, and diamonds represent decisions. When used alone, solid arrows represent the direction of flow. When both solid and dotted arrows originate from a decision box, they each represent responses of “yes” and “no”, respectively. For each iteration, start on the top left corner of the figure, at the shaded rounded rectangle with the outbound solid arrow, and end in one of the eight rounded rectangles on the far right. Six shaded rectangles refer to the different types of encounters while the other two refer to invalid cases. For each type of encounter, the final number of encounters is included in parenthesis

Fig. 2

Flow diagram for the fourth step of the algorithm. See Fig. 1 for descriptions of the different types of boxes and arrows. For each iteration, start on the top left corner of the figure, at the shaded rounded rectangle with the outbound solid arrow, and end in one of the two rounded rectangles on the far right. The shaded rounded rectangle refers to the identification of a new episode of care for fall-related injuries, while the other refers to invalid cases

Fig. 3

Representative example of an episode of care for fall-related injuries. ^a Beneficiaries seen in ED are identified by revenue center code values of 0450–0459 and 0981. ^b Other charges possibly associated with emergency rooms are identified by place of service code and BETOS code. ^c Primary diagnosis code. ^d Secondary diagnosis code. ^e External cause of injury code