Validation of a Medicare Claims-based Algorithm for Identifying Breast Cancers Detected at Screening Mammography.

BACKGROUND: The breast cancer detection rate is a benchmark measure of screening mammography quality, but its computation requires linkage of mammography interpretive performance information with cancer incidence data. A Medicare claims-based measure of detected breast cancers could simplify measurement of this benchmark and facilitate mammography quality assessment and research.
OBJECTIVES: To validate a claims-based algorithm that can identify with high positive predictive value (PPV) incident breast cancers that were detected at screening mammography. RESEARCH
DESIGN: Development of a claims-derived algorithm using classification and regression tree analyses within a random half-sample of Medicare screening mammography claims followed by validation of the algorithm in the remaining half-sample using clinical data on mammography results and cancer incidence from the Breast Cancer Surveillance Consortium (BCSC).
SUBJECTS: Female fee-for-service Medicare enrollees aged 68 years and older who underwent screening mammography from 2001 to 2005 within BCSC registries in 4 states (CA, NC, NH, and VT), enabling linkage of claims and BCSC mammography data (N=233,044 mammograms obtained by 104,997 women). MEASURES: Sensitivity, specificity, and PPV of algorithmic identification of incident breast cancers that were detected by radiologists relative to a reference standard based on BCSC mammography and cancer incidence data.
RESULTS: An algorithm based on subsequent codes for breast cancer diagnoses and treatments and follow-up mammography identified incident screen-detected breast cancers with 92.9% sensitivity [95% confidence interval (CI), 91.0%-94.8%], 99.9% specificity (95% CI, 99.9%-99.9%), and a PPV of 88.0% (95% CI, 85.7%-90.4%).
CONCLUSIONS: A simple claims-based algorithm can accurately identify incident breast cancers detected at screening mammography among Medicare enrollees. The algorithm may enable mammography quality assessment using Medicare claims alone.