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American Journal of Medical Quality, Vol. 17, No. 5, 171-174 (2002)
DOI: 10.1177/106286060201700502
© 2002 American College of Medical Quality

Can We Be Certain of PRO Accuracy and Accountability? Inaccurate "Report Cards" Generated by Medicare Claims Data as a Marker for Laboratory Testing in Diabetic Patients

Todd Gruber, MD, MPH

MCP, Hahnemann School of Medicine, and Medical Director, Long Branch Health Center, Monmouth Medical Center, Long Branch, NJ, grudr{at}aol.com

Benjamin Rudnitsky, MD

PGY-II Medical Resident, Monmouth Medical Center, Long Branch, NJ

Quality of care attributed to individual physicians will be made public more frequently in the future. Inaccurate reports could damage physicians both professionally and financially. Using claims data for services rendered to Medicare patients from 1997 through 2000, The New Jersey Peer Review Organization (PRO) reported the percentage of each physician's patients who received testing for HgB Alc and for lipid profiles. We reviewed the patient records kept by these physicians to calculate the actual percentage of patients who received these tests. A statistically significant difference existed between the PRO's data and our results. Use of claims data as a marker for services provided can lead to inaccurate inferences about the quality of care provided by individual physicians, which can have potentially negative consequences to these providers.

Key Words: Billing • database • diabetes • Medicare • peer review organization • quality • report cards


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