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VOLUME 4, ISSUE 2  
 2021 

 

STAKEHOLDER  PERSPECTIVES 

Miller T.A, Wurdeman S. Value and applicability of large administrative healthcare databases in prosthetics and orthotics outcomes research. Canadian 

Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.4. https://doi.org/10.33137/cpoj.v4i2.35958 

This article has been invited and reviewed by Co-Editor-In-Chief, Dr. Silvia Ursula Raschke. 
English proofread by: Karin Ryan, M.A., B.Sc., P.T. 
Managing Editor: Dr. Hossein Gholizadeh 
 

SPECIAL ISSUE 

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1 

Miller TA, Wurdeman S. Value and applicability of large administrative healthcare databases in prosthetics and orthotics outcomes research. Canadian Prosthetics 
& Orthotics Journal. 2021; Volume 4, Issue 2, No.4. https://doi.org/10.33137/cpoj.v4i2.35958 

 

 

 
STAKEHOLDER  PERSPECTIVES 

 

VALUE AND APPLICABILITY OF LARGE ADMINISTRATIVE HEALTHCARE DATABASES IN 

PROSTHETICS AND ORTHOTICS OUTCOMES RESEARCH 

Miller TA.1,2 *, Wurdeman S.1,3
 

 

1 Department of Clinical and Scientific Affairs, Hanger Clinic, Austin, Texas, USA. 
2 College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina, USA. 
3 Department of Biomechanics, The University of Nebraska at Omaha, Omaha, Nebraska, USA.   

 

 

 

 

  

 

 

 

 

 

INTRODUCTION 

Health economics is a broad field of study with applications 

that focus on issues related to efficiency, effectiveness, 

equity, behavior and, ultimately, the value of healthcare 

services. The goal of health economics and outcomes 

research (HEOR) is to improve healthcare decision making 

for clinicians, managers, policy makers, payers, and 

patients. One aspect of HEOR that often comes to mind are 

the methods that assess cost and utilization (e.g. cost-

effectiveness analysis or CEA). Understanding costs and 

utilization patterns can help define benefits of certain 

interventions, improve market access and establish the 

value of services or devices. However, additional areas of 

HEOR such as applications in health technology 

assessment, health service delivery and process of care, 

and patient-centered research can also lend themselves to 

better understanding the value of services or devices.1,2  

 

Much of this data can be extracted and analyzed from 

administrative healthcare data. This paper is meant to 

provide a stronger understanding of administrative 

healthcare data analysis, an area that has been scarcely 

examined within orthotics and prosthetics (O&P) despite the 

wealth of information available within such data.  

In the absence of high-value clinical data, the availability 

and quality of administrative healthcare data could be vital 

in the generation of evidence for O&P services. Several 

studies have assessed treatment interventions for those 

who require an ankle foot orthosis or a prosthesis, by using 

large databases in terms of epidemiology,3,4 clinical 

outcomes,5 and costs of treatment or utilization.6 Practical 

methods are needed by clinicians and researchers to 

address questions about the risks, benefits, and costs of 

interventions that inform the value of O&P health services. 

While randomized controlled trials (RCTs) remain a gold 

standard to establish efficacy and safety; they are not ideal 

for discovering effective or efficient treatment or for 

incorporation of the patient experience into clinical decision-

making.7 Furthermore, conducting double blind RCT 

research is not always possible in O&P, which means our 

healthcare system lacks a comprehensive understanding of 

the incorporation of O&P devices into rehabilitation.  

 
OPEN  ACCESS Volume 4, Issue 2, Article No.4. 2021 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

The goal of health economics and outcomes research is to improve healthcare decision 

making. In the absence of high-value clinical data, the availability and quality of 

administrative healthcare data could be vital in the generation of evidence for orthotics 

and prosthetics services. The purpose of this article is to provide a stronger 

understanding of administrative healthcare data analysis, an area that has been 

scarcely examined within prosthetics and orthotics despite the wealth of information 

available within such data. Examples of common datasets in this arena currently 

available are provided, as well as an overview of the limitations and advantages of 

studies utilizing such datasets.  

CITATION 

Miller TA, Wurdeman S. Value and applicability of 

large administrative healthcare databases in 

prosthetics and orthotics outcomes research. 

Canadian Prosthetics & Orthotics Journal. 2021; 

Volume 4, Issue 2, No.4. 

https://doi.org/10.33137/cpoj.v4i2.35958 

KEYWORDS 

Health Economics, Prosthetics, Orthotics, Outcomes 

Research, Rehabilitation 

 

 

* CORRESPONDING AUTHOR 

Taavy A Miller, PhD, CPO 

Department of Clinical and Scientific Affairs, Hanger Clinic, Austin, 
Texas, USA. 
E-Mail: tamiller@hanger.com 

ORCID ID: https://orcid.org/0000-0001-7117-6124 

Special Issue: Health Economics in Prosthetics & Orthotics 

https://doi.org/10.33137/cpoj.v4i2.35958
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v4i2.35958
mailto:tamiller@hanger.com
https://orcid.org/0000-0001-7117-6124


 

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Miller TA, Wurdeman S. Value and applicability of large administrative healthcare databases in prosthetics and orthotics outcomes research. Canadian Prosthetics 
& Orthotics Journal. 2021; Volume 4, Issue 2, No.4. https://doi.org/10.33137/cpoj.v4i2.35958 

ISSN: 2561-987X 
VALUE AND APPLICABILITY OF LARGE ADMINISTRATIVE HEALTHCARE DATABASES  

Miller & Wurdeman, 2021 CPOJ 

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Real world evidence (RWE) studies, which capture 

effectiveness, and RCTs should be considered 

complementary to answer important healthcare questions. 

The use of prosthetic or orthotic devices aims to reduce the 

negative effects of disability (e.g. loss of work, isolation, and 

decreased independence) and alleviate burden on the 

healthcare system by improving treatment of conditions 

(e.g. stroke, amputation) that often require long-term 

rehabilitation or interaction with the healthcare system. 

Studies that use administrative health data are another way 

to generate information that contribute to the knowledge of 

O&P services.  

Administrative data are real world data that can be 

leveraged to generate RWE as opposed to highly controlled 

and selective RCTs. Administrative data reflect the 

heterogeneous nature of populations. Specifically, claims 

data (i.e. billing data) or hospital discharge data (e.g. the 

Healthcare Cost and Utilization Project or HCUP) are 

typically referred to as secondary data sources because 

these data were not collected or generated for current 

research applications but rather for administrative use. 

While this may lead to some limitations in available 

information (e.g. limited functional data), they are often 

reported as reliable and consistent due to the nature and 

regulation of billing.8 It is worth noting though that the 

reliability of billing data is limited by the accuracy or integrity 

of the input. As more studies use administrative data, it 

highlights the increasing importance to be meticulous and 

aware of the data (e.g. diagnosis code, billing codes or L-

codes) that are submitted for billing purposes. 

A wide range of data elements comprise an administrative 

dataset. There are demographic variables (e.g. gender, 

race, age) and contextual factors (e.g. region of care, type 

of insurance), provider information (e.g. physician number), 

International Classification of Disease (ICD) diagnosis 

codes, Current Procedural Terminology (CPT), and 

Diagnosis-Related Group (DRG) codes. The year of the 

data dictates which diagnosis codes are used as ICD Ninth 

revision (ICD-9) was updated to the tenth revision (ICD-10) 

and implemented for billing in 2015. Due to this breadth of 

information, large administrative databases are appropriate 

and provide meaningful insight given the correct question, 

such as questions regarding national patterns of care or to 

determine resource expenditures. Yet, these large 

databases are not without limitations either.  

KEY CONSIDERATIONS AND APPLICATIONS 

Administrative data are a unique source of information 

whose advantages and disadvantages for the scope of 

healthcare research have been extensively discussed.8,9 

Briefly, a few limitations to be aware of are: conditions 

(diagnoses) must be diagnosed to be present, diagnosed 

conditions represent services provided but may not show 

potential need, conversely diagnosis codes not requiring 

services may not be recorded on a given claim, presence of 

a diagnosis does not inform on severity of the condition, and 

there is limited physiological data (i.e. blood pressure or 

functional mobility). Administrative databases are also often 

set up to be able to differentiate and characterize different 

lines of service within healthcare (e.g. services provided 

through an orthopedic surgeon versus vascular surgeon). 

Unfortunately, currently it is not possible to distinguish 

services provided by an orthotist/prosthetist versus another 

healthcare provider as O&P services are not differentiated 

from durable medical equipment for administrative data 

purposes.  

However, there are advantages of studies that employ 

administrative data that can be leveraged through strong 

design methods. Advantages include validity of the data 

such as admission dates and procedure codes, systematic 

collection over time, cost data is reflected (charges or paid 

amounts), large samples allow for analysis of more rare 

conditions, and depending on the data it may be linked to 

other data sources (e.g. Medicare data can be linked to the 

national death index or national surveys).8 Because 

administrative health data contain large numbers of patients 

over long periods of time, as opposed to cross-sectional 

databases, they are useful to study disease associations 

with rare risk factors and heterogeneous populations. 

Specifically, in O&P, there is increasing demand for value-

based evidence from studies that contain larger samples 

and information about the economic impact of 

treatment.5,6,10  

When considering a research study using administrative 

data, in addition to the advantages and limitations 

discussed, it is also important to be aware of different 

characteristics of these databases. First, it is critical to 

consider the claims process. Health insurance claims data 

are based on information generated from the billing process 

for the purpose of payment when a patient utilizes health 

services. This includes inpatient services, outpatient 

services, emergency department visits, prescription drug 

utilization and laboratory utilization (e.g. blood work). Once 

the claim is reviewed by a payer, it is both accepted and 

paid, or not accepted. Therefore, coverage may vary from 

plan to plan and payer to payer. From the research 

perspective, often a claims dataset contains data that are 

adjudicated, meaning it is a complete set of data that 

represents services covered. For example, in prosthetics, if 

the office visit does not include a billable event (e.g. an 

alignment adjustment), then it will not be reflected in the 

data. However, while the patient maintains insurance 

coverage on a single plan (e.g. a Medicare beneficiary), it is 

possible to track the patient’s journey from a hospitalization 

(i.e. inpatient services) to provision of a prosthesis or 

orthosis (i.e. outpatient services) and gain perspective on 

the overall utilization or pattern of care.  

 

https://doi.org/10.33137/cpoj.v4i2.35958


 

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Miller TA, Wurdeman S. Value and applicability of large administrative healthcare databases in prosthetics and orthotics outcomes research. Canadian Prosthetics 
& Orthotics Journal. 2021; Volume 4, Issue 2, No.4. https://doi.org/10.33137/cpoj.v4i2.35958 

ISSN: 2561-987X 
VALUE AND APPLICABILITY OF LARGE ADMINISTRATIVE HEALTHCARE DATABASES  

Miller & Wurdeman, 2021 CPOJ 

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A second critical point to be aware of is the source of the 

claims. In general, there are two main sources in the US: 

commercial sources (e.g. private insurance) or non-

commercial sources (e.g. Medicare or Veteran’s Health 

Administration). It is important to consider your research 

question and identify the target population to answer the 

question. For O&P research, information gleaned from each 

of the different sources has the potential to inform different 

areas of care.   

There are several different databases available that may 

provide good insight for O&P research, each with specific 

considerations depending on the research question (Table 

1). These databases have varying requirements for access 

and cost. It is critical to have clear questions, transparency, 

and clarity in defining selection criteria when initiating a 

study. These decisions will help define which administrative 

databases will be the best match for the study purposes.  

CONCLUSION 

In O&P rehabilitation care, we need to continue to be 

proactive in HEOR or risk further trailing behind other areas 

of healthcare. The way we as a field come together and 

agree upon how to capture, assess, and communicate 

value will determine our future as we differentiate ourselves 

from durable medical equipment. As we continue to be 

proactive in our investigations of HEOR we will be able to 

lead and enhance the assessment and value of O&P 

interventions, as well as demonstrate positive long-term 

outcomes for individuals who use O&P devices. 

CALL TO ACTION 

Administrative data is, in general, a largely unexplored area 

of research for O&P. There are gaps in our knowledge 

regarding the health economic impact of O&P services and 

more evidence is needed on the effectiveness of O&P care. 

With increased reliance upon claims data from a payer and 

policy perspective, O&P clinicians and administrative 

persons need to be cognizant of an increased need for 

consistent coding across the profession. Clinicians and 

office administrators all play a role through daily work flow 

by enhancing quality control processes with regards to 

coding. Our industry organizations (e.g.: the American 

Orthotic and Prosthetic Association and the American 

Academy of Orthotists and Prosthetists) should take charge 

to implement standards and quality control processes 

surrounding coding to be adapted by professionals. The 

industry organizations should continue to work to separate 

orthotics and prosthetics from durable medical equipment 

as this will allow for cleaner claims analysis related to 

orthotic and prosthetic care. Orthotic and prosthetic schools 

should be teaching the role claims data can play in policy 

decisions to help drive the value of accurate and specific 

coding. To address gaps related to clinical practice 

guidelines and standards of care, communication between 

O&P providers, various specialists (e.g. surgeons, 

physiatrist) and physical therapists all involved in patient 

care is important to continue to optimize and standardize 

Table 1: Databases that contain prosthetic and orthotic services and/or patients that may require prosthetic or orthotic devices based on 

individual condition.  

Dataset Type of Data Geographic area Source Access 

Medicare 
Billing claims of public 
program   

National  Noncommercial 

Must request access 
for patient level data 
but summary data may 
be public, fees vary 

Medicaid 

Billing claims public 
program for those with 
limited income and 
resources, includes 
nursing home care 

State based, varies by 
state 

Noncommercial 
Must request access 
per state, fees vary 

IBM Watson (Marketscan) 

Billing claims for privately 
insured individuals, most 
often through 
employment 

National Commercial 
Must request access, 
fees vary 

IQVIA (Pharmetrics) 

Billing claims for privately 
insured individuals, most 
often through 
employment 

National Commercial 
Must request access, 
fees vary 

Veteran’s Health 
Administration  

Department of Veteran’s 
Affairs data, claims and 
aggregate data 

National Noncommercial 
Some datasets are 
publicly available 

Healthcare Cost & Utilization 
Project (HCUP) 

A family of databases- 
discharge data 

National and state  
Contains data from both 
commercial and 
noncommercial 

Most datasets are 
publicly available after 
completing online 
training, fees may 
apply 

 

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Miller TA, Wurdeman S. Value and applicability of large administrative healthcare databases in prosthetics and orthotics outcomes research. Canadian Prosthetics 
& Orthotics Journal. 2021; Volume 4, Issue 2, No.4. https://doi.org/10.33137/cpoj.v4i2.35958 

ISSN: 2561-987X 
VALUE AND APPLICABILITY OF LARGE ADMINISTRATIVE HEALTHCARE DATABASES  

Miller & Wurdeman, 2021 CPOJ 

Special  

 

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clinical practice protocols. Improved communication and 

active roles in billing and coding will in turn help produce 

effective and reliable databases for HEOR.  

ACKNOWLEDGEMENTS 

None. 

DECLARATION OF CONFLICTING 

INTERESTS 

The authors declare no conflict of interest. 

SOURCES OF SUPPORT 

None. 

REFERENCES 

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DOI: 10.1097/JPO.0000000000000234  

3.Ziegler-Graham K, Mackenzie EJ, Ephraim PL, Travison TG, 

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5.Dobson A, El-Gamil A, Shimer M, DaVanzo JE. Economic value 

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6.Miller TA, Paul R, Forthofer M, Wurdeman SR. Impact of time to 

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10.1097/PHM.0000000000001473  

7.Horn SD, DeJong G, Deutscher D. Practice-based evidence 

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9.Memtsoudis SG. Limitations associated with the analysis of data 

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2019; 31. DOI: 10.1097/JPO.0000000000000232 

 

AUTHORS SCIENTIFIC BIOGRAPHY 

Taavy Miller, PhD, CPO, is a research 

scientist within Hanger’s Department of 

Clinical and Scientific Affairs. Dr. Miller 

has broad experience working as a 

certified orthotist/prosthetist at large 

hospital-based systems and in private 

practice as well as teaching P&O at the 

university level. Dr. Miller holds a 

doctoral degree in Health Services 

Research with an emphasis in health 

economics and epidemiology. Her 

research focuses on health equity, 

reducing disparities and improving access through the assessment 

of health outcomes and effectiveness using administrative, clinical 

and patient reported data. She has published several studies in 

peer-reviewed journals and presented abstracts at national and 

international conferences.  

Shane Wurdeman, PhD, CP, is the 

Director of Clinical Research within 

Hanger’s Department of Clinical and 

Scientific Affairs. He entered the field of 

O&P as a technician before 

transitioning to working as an 

orthotist/prosthetist and finally into his 

role as a principal investigator. Dr. 

Wurdeman holds a BS in physics, an 

MS in prosthetics and orthotics, and a 

PhD in biomechanics. He has co-

authored more than 40 peer-reviewed 

manuscripts, published 3 book chapters, and presented more than 

100 conference abstracts within the field of orthotic and prosthetic 

rehabilitation. He is a fellow with distinction of the American 

Academy of Orthotists and Prosthetists, from whom he was 

recognized in 2020 with their prestigious Academy Research 

Award. He currently serves as the Research Director for the 

American Orthotic and Prosthetic Association and Chair of the 

Center for Orthotic and Prosthetic Learning. He has been 

supported by private grants as well as government grants from the 

National Institutes of Health and Department of Defense. 

 

 

 

 

https://doi.org/10.33137/cpoj.v4i2.35958

