Modifiable Areal Unit Problems for Infectious Disease Cases Described in Medicare and Medicaid Claims, 2016-2019

Abstract

Introduction: Modifiable Areal Unit Problems are a major source of spatial uncertainty, but their impact on infectious diseases and epidemic detection is unknown.

Methods: CMS claims (2016-2019) which included infectious disease codes learned through Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) were extracted and analysed at two different units of geography; states and 'home to work commute extent' mega regions. Analysis was per member per month. Rolling average above the series median within geography and agent of infection was used to assess peak detection. Spatial random forest was used to assess region segmentation by agent of infection.

Results: Mega-regions produced better peak discovery for most, but not all agents of infection. Variable importance and Gini measures from spatial random forest show agent-location discrimination between states and regions.

Conclusion: Researchers should defend their geographic unit of report used in peer review studies on an agent by-agent basis.

Figure 1:

Mega region commuter extents with state outlines and ZCTA detail.

Figure 2:

Top 20 PMPM monthly moving average above the median by geography type and agent.

Figure 3:

Model variable importance with choice agents.