To investigate magnitude and sources of discrepancy in quality metrics using claims versus electronic health record () data.
Assessment of proportions of HbA1c and testing for people ascertained as diabetic from the respective sources. Qualitative interviews and review of s of discrepant cases.
Claims submitted to Rhode Island Medicaid by three practice sites in 2013; program‐coded extraction; manual review of selected s.
Of 21,030 adult Medicaid beneficiaries attributed to a primary care patient at a site by claims or data, concordance on assignment ranged from 0.30 to 0.41. Of patients with concordant assignment, the ratio of patients ascertained as diabetic by versus claims ranged from 1.06 to 1.14. For patients with concordant assignment and diagnosis, the ratio based on versus claims ranged from 1.08 to 18.34 for HbA1c testing, and from 1.29 to 14.18 for lipid testing. Manual record review of 264 patients discrepant on diagnosis or testing identified problems such as misuse of ‐9 codes, failure to submit claims, and others.
Claims data underestimate performance on these metrics compared to documentation, by varying amounts. Use of claims data for these metrics is problematic.