Eight loss, or other situations exactly where a colonoscopy could plausibly be indicated (see Appendix for full list).7 ETB Antagonist supplier Colonoscopies that did not meet the above criteria for any diagnostic process were viewed as D2 Receptor Inhibitor Synonyms screening colonoscopies and labeled as `potentially inappropriate’ if performed in adults aged 76 and older. We modified criterion 2 with the above algorithm to require a diagnosis constant with an indication for colonoscopy on either the colonoscopy claim or any claim in the prior three months. Colonoscopies that didn’t meet these modified criteria to get a diagnostic process had been labeled as `probably inappropriate’ screening colonoscopies if performed in adults aged 76 and older.JAMA Intern Med. Author manuscript; available in PMC 2013 December 06.NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptSheffield et al.PageTo define early repeat colonoscopy in subjects aged 705, we examined Medicare claims information from 01/01/2001 to 9/30/2008 to recognize previous procedures. If beneficiaries had multiple previous colonoscopies, we chosen the newest procedure. Beneficiaries who had undergone a negative colonoscopy23 and who did not have any indications for colonoscopy in 2008/2009 have been classified as possessing had an early repeat colonoscopy. These colonoscopies were labeled as `potentially inappropriate’ or `probably inappropriate’ based on the above algorithms. Early repeat colonoscopies in these using a family members history of colorectal cancer (ICD-9 diagnosis of V16.0) had been classified as appropriate. Colonoscopy Provider–We linked sufferers for the performing provider working with the NPI around the colonoscopy claim. Medicare Overall health Care Financing Administration provider specialty codes had been applied to categorize doctor specialty as gastroenterology, generalist, surgery, and other. Provider Volume: For each and every doctor, we calculated the volume of colonoscopies performed on Medicare enrollees from 10/1/2008/30/2009. Doctor volume was stratified into quartiles: 65, 6515, 11675, and 175. Patient Characteristics–Patient demographics obtained in the Denominator file incorporated age, sex, and race. A Charlson comorbidity score was estimated employing inpatient and outpatient claims files from the year before the 2008/2009 colonoscopy.24 The percentage of residents in the zip code with fewer than 12 years of education was utilized as a surrogate for patient education. Location of residence was classified as metropolitan, non-metropolitan, or rural. Location of service was classified as hospital-based facility, office, or ambulatory surgical center. Geographic Area–Hospital Service Regions (HSAs), described inside the Dartmouth Atlas of Overall health Care,25 were applied to assess geographic variation across 208 regions in Texas. Hospital referral regions25 (HRRs) had been utilised to assess geographic variation across 306 regions in the United states. Evaluation Descriptive statistics were employed to describe the percent of colonoscopies performed in Medicare individuals in 2008/2009 that have been potentially or probably inappropriate, stratified by patient and provider qualities. Two-level hierarchical generalized linear models (HGLM) adjusted for patient and provider qualities and clustering of sufferers within provider have been employed to identify independent predictors of potentially inappropriate colonoscopy. Two-level HGLMs provided estimates for every provider in the % of colonoscopies performed that have been potentially inappropriate, just after adjusting for patient sex, race/ethnic.