2011 11th IEEE International Conference on Data Mining Workshops
An Analysis of Treatment Patterns:
A Case Study on Carpal Tunnel Syndrome
Ching Lien and Silvia Figueira
Department of Computer Engineering
Santa Clara University
Santa Clara, CA 95053-0566, US
{clien;sfigueira}@scu.edu
Abstract— Workers’ compensation is a form of medical
insurance provided by employers to their employees. Workers’
compensation databases have a complete picture of each case,
including treatments, treatment costs, and treatment duration,
and analyzing their data can be extremely helpful to identify
patterns and possibly determine the correlation between
diseases and treatments and also the correlation between
different treatments. These correlations have several benefits,
including the decrease in insurance costs, by making the
process of authorization more accurate and less wasteful. Also,
patterns enable prediction, which may help insurance
companies to estimate costs and to detect irregularities and/or
special cases, which may last longer or consume more
resources. One problem in analyzing such data is the fact that
medical information is not precise, e.g., different codes can be
used for similar procedures. However, although not precise,
the relationship between diseases and treatments seem to have
some consistency, which might enable the correlation. In this
paper, we present a method for analyzing workers’
compensation data to obtain information on correlation among
diseases, treatments and expected costs. We present a study on
Carpal Tunnel Syndrome to show that consistency enables
prediction and the development of guidelines for treatment
authorization.
Keywords-association rules, temporal patterns, Carpal
Tunnel Syndrome
I. INTRODUCTION
Workers’ compensation is a form of medical insurance
provided by employers to their employees. Typically, after
an employee is injured at work, the employee is examined by
a medical professional, who requests appropriate treatments.
Once these requests are certified, patients receive medical
treatments. The treatments may last for some time until the
employee recovers. At the end, insurance companies and
employers share the medical costs. The interesting fact about
workers’ compensation is the fact that each case is entirely
coordinated by one entity.
Considering that worker’s compensation databases have
a complete picture of each case, including treatments,
treatment costs, and treatment duration, analyzing their data
can be extremely helpful to identify patterns and possibly
determine the correlation between diseases and treatments
and also the correlation between different treatments. These
correlations have several benefits, including the decrease in
insurance costs, by making the certification process more
accurate and less wasteful. Also, patterns enable prediction,
978-0-7695-4409-0/11 $26.00 © 2011 IEEE
DOI 10.1109/ICDMW.2011.25
which may help insurance companies to estimate costs, and
to detect irregularities and/or special cases, which may last
longer or consume more resources.
To determine these correlations, we propose a method for
analyzing workers’ compensation data and identifying
patterns. We demonstrate our method by analyzing Carpal
Tunnel Syndrome cases. A popular data mining technique,
association-rule mining, is applied to find patterns in the data
set. Association-rule mining was introduced in [1] by
Agrawal et al, and is widely used in the analysis of retail
transactions or modeling of purchase behaviors. The goal of
association-rule learning is to discover meaningful
relationships among a set of transaction items. The most
popular algorithm for mining association rules is Apriori [2],
which is used in our experiments.
Association-rule learning is a well-researched topic,
which has been used in many domains, including medical
databases. For mining medical billing data, the authors in [3]
apply the Apriori algorithm to discover rules between
diagnosis and treatments. In [4], the author introduces an
algorithm that uses constrains to reduce the number of rules,
searches for association rules on a training set, and finally
validates them on an independent test set. However the
relationships among medical treatments remain unaddressed
in these papers. Since the data set consists of patients’
treatment records, it would be meaningful to find sequential
patterns. In [5], the authors extract time-annotated sequences
to help assessing the effectiveness of a therapy using their
own mining software, but they do not provide details on the
algorithm used. In this paper, we apply the Apriori
algorithm to discover not only association rules but also
association rules related to time for Carpal Tunnel Syndrome
cases, which is the most common reported diagnose in
workers’ compensation injuries.
This paper is organized as follows. Section 2 presents
the methodology. Section 3 explains the experimental setup.
Section 4 describes our results. Section 5 shows the
significance of the findings to the insurance industry.
Section 6 concludes.
II. METHODOLOGY
A. Grouping
Since different types of patients present different
patterns, in order to identify those patterns, it is necessary to
partition patients into groups. We tried to partition patients
into 3 groups based on the total amount spent, but the
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patterns were not obvious compared to those patterns found
if patients were grouped according to Carpal Tunnel Release
Surgery, the most expensive treatment. Therefore we
divided patients in two groups: NS, non surgery patients,
and S, surgery patients. However, the distribution of
surgery patients’ total spending has two peaks which imply
two sub-groups. Therefore we further divided the surgery
group into 2 sub-groups according to patients’ total
spending: LCS, low-cost surgery patients, and HCS, high-
cost surgery patients.
B. Running the Apriori Algorithm
After partitioning patients into groups, the next step is to
run the Apriori algorithm in order to come up with frequent
treatments and co-occurrences of treatments. Co-
occurrences enable automatic authorization.
C. Adding Time Notation to Data Items
To find association rules related with time, we add
timestamps to data items. In our experiment, each entry is
time-stamped since the date of service and the date of injury
provide the month the treatment was performed after injury,
which we attach to the treatment. For example, a given
patient’s treatment list before adding time notation may be
“physical therapy, physical therapy assessment, Carpal
Tunnel Release Surgery, and anesthesia”. The list shows
the treatments this given patient ever had. It consists of
treatments without duplicates. Now after attaching time
notation, the treatment list might become “physical therapy
(0), physical therapy assessment (0), physical therapy (1),
Carpal Tunnel Release Surgery (2), anesthesia (2), physical
therapy (3), physical therapy (4), physical therapy (5), and
physical therapy (6)”. The number in the parenthesis
indicates in which month the patient performed such
treatment. Therefore this patient had sessions of physical
therapy in his/her first, second, fourth, fifth, sixth, and
seventh month.
D. Running the Apriori Algorithm Again
When each treatment is time annotated, the next step is
to run the Apriori algorithm again to uncover co-
occurrences of treatments. Since treatments are time
annotated, it is easy to see the duration of a treatment and
the sequence of treatments, which enable the identification
of anomalies.
III. EXPERIMENTAL SETUP
In our experiment, association rules are mined from real-
life medical data sets to uncover the most frequent
treatments for Carpal Tunnel Syndrome, to reveal the
relationships among treatments, and to understand the
evolution of treatments for the disease. Note that results are
obtained with minimum medical knowledge.
A. Tools and Data Preparation
We used a statistical computing software environment, R
[6]. R is a free language and software environment for
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statistical computing. It provides various statistical
techniques and can produce statistical graphs. Besides,
package arules [7] is loaded into R when running the Apriori
algorithm. Package arules is a computational environment
specialized in analyzing transaction data and patterns, and it
was used to mine frequent itemsets and association rules in
our experiment.
Data was provided by a workers’ compensation
management company. Before data was passed to the
research team, all personal information was removed. In
order to focus on the disease, i.e., Carpal Tunnel Syndrome,
data sets were filtered based on the International
Classification of Disease (ICD) codes. There are
approximately 13,000 records of claims for Carpal Tunnel
Syndrome from year 2006 to 2008. A record consists of the
following fields: entry id, patient id, treatment, service date
and injury date. Entry id and patient id are used for
differentiating records and patients. Treatment is used as
both the antecedent and consequent of rules. Service date is
the date the patient had the treatment. Injury date is the date
the patient was injured. Note that the injury date is not
precise since patients might not recall the date they were
injured.
B. Definitions
Basically, the goal of association-rule mining is to
discover the co-occurrence of two events and describe it in a
simple, probabilistic way. For example, A and B are two
events, and A and B have nothing in common. The pattern
is defined as: if A occurs, then B will also occur with
probability p. Or we can put it: A Ÿ B.
In our experiment, we use the standard definition of
association rules [1]. Let I = {i1, i2, …, im} be a set of
distinct items, and D = {T1, T2, …, Tn} be a set of
transactions. D is a transaction database over I. A subset of
I containing k distinct items is called a k-itemset. Let X and
Y be two itemsets, X, Y ⊆ I, and X Y = {}. An association
rule is an implication denoted as X Ÿ Y, where X is called
antecedent and Y consequent of the rule. The size of a rule
is the total number of items in X and Y. In order to select
interesting rules among possible rules, two important
measures are utilized: support and confidence. Consider an
itemset Z, support(Z) is defined as the fraction of rows that
satisfy Z in D. In other words, support(Z) is P(Z). The
support of a rule X Ÿ Y, support(X Ÿ Y), is defined as
support (X Y). Confidence is defined as accuracy. Given
two itemsets, X and Y, confidence(X Ÿ Y) is defined as the
fraction of rows that satisfy Y among those rows which also
satisfy X. Therefore, confidence(X Ÿ Y) =
support(X Y)/support(X) = P(Y|X).
The problem of association-rule mining is defined as
finding all rules {X Ÿ Y} such that support(X Ÿ Y)   and
confidence (X Ÿ Y)  , given a set of items I, a transaction
database D over I, support threshold , and confidence
threshold .
 IV. A CASE STUDY: WORKERS’ COMPENSATION AND TABLE I. 5 MOST FREQUENT TREATMENTS FOR CARPAL TUNNEL
SYNDROME PATIENTS
CARPAL TUNNEL SYNDROME
We want to discover rules related to Carpal Tunnel Treatment Number of Total amount Average
incidences spent($) cost per
Release Surgery due to the fact that such surgery is more (per (/overall patient($)
expensive than other treatments. These results can be helpful patient) spending)
in treatment authorization requests and payment decisions
for patients who have the disease. 1 Required reports 1,495 (3.37) 17,248.03(2%) 11.54
A. Carpal Tunnel Syndrome Patients Overall 2 Therapeutic 1,317 (2.97) 33,545.43(3%) 25.47
1) Description Statistics: We loaded the arules package procedure
in the R environment and read the patients’ data. We found 3 Myofascial 1,194(2.70) 46,813.11(4%) 39.21
that there were 443 distict patients and 330 different release
treatment codes in total. 4 Office visit, est 864 (1.95) 46,113.81(4%) 53.37
patient
The top five most frequent treatments are in Table 1.
5 Application of a 811 (0.18) 6,831.65(1%) 8.42
The most frequent treatment is required reports. This modality to 1 or
matches our expectation. After employees are injured, they more areas
go to doctors who need to file reports with claims. Doctors
may also need to submit reports after treatments, for B. Divide Patients into 3 Groups and Find Association
example, surgery. Doctors might try some treatments to help Rules for Each Group
patients relieve their pain, such as therapeutic procedure and To simplify the process, “office visit” and “required
myofascial release, which are the second and third most reports” treatments are removed since they do not contain
frequent treatments. Myofascial release is a manual massage meaningful treatment information.
technique with the goal of relieving pain and increasing the From this point on, we divide patients into 3 groups: Non
range of motion [8], a common treatment for Carpal Tunnel Surgery (NS) patients, Low-Cost-Surgery (LCS) patients
Syndrome patients. The fourth most frequent treatment is who spent less than $5,500, and High-Cost-Surgery (HCS)
office visit (established patient) since employees visit patients who spent more or equal to $5,500. Figure 1 shows
doctors regularly during the treatments. The fifth most the distribution of the total amount spent by surgery patients.
frequent treatment, application of a modality, is a type of There are two peaks, indicating 2 sub-groups in the surgery
physical therapy which aims at relieving patients’ pain. group, and between the two peaks is a dent which is between
2) Association Rules Related to Carpal Tunnel Release $5,500 and $6,000. Therefore we partition surgery patients
Surgery: The reason why we focus on Carpal Tunnel accordingly. Those who spent less than $5,500 are Low-
Release Surgery (Neuroplasty and/or transposition; median Cost-Surgery (LCS) patients, and those who spent equal to
nerve at carpal tunnel) is that there were 125 (28%) patients or more than $5,500 are High-Cost-Surgery (HCS) patients.
performing this surgery with a total amount spent of We find there are 255 NS patients, 84 LCS patients, and 41
$281,228.59 (26% of the sum of all patients’ spending). HCS patients. 63 patients are excluded because they had
The average cost of such surgery is $2,249.83. This is a only “office visit” or “required reports” treatments.
relatively expensive treatment for Carpal Tunnel Syndrome
patients and is reserved for the most severe patients after TABLE II. CARPAL TUNNEL RELEASE SURGERY AS AN ANTECEDENT
trying weeks of non-surgical treatments. We were Antecedent Consequent Support Confidence
interested only in association rules in which Carpal Tunnel
1 Carpal Tunnel Required 0.25 0.89
Release Surgery is either the antecedent or consequent of Release Surgery reports
the rule and, for simplicity, the size of the rule is limited to
2. Our support threshold is 0.1 and confidence threshold is TABLE III. CARPAL TUNNEL RELEASE SURGERY AS A CONSEQUENT
0.8. Rules with Carpal Tunnel Release Surgery, as
Antecedent Consequent Support Confidence
antecedent are in Table 2 and, as consequent, are in Table 3,
respectively. 1 Anesthesia Carpal Tunnel 0.19 0.84
Rule (Carpal Tunnel Release Surgery) Ÿ (Required
Release Surgery

reports) means that patients who have surgery will have 89%
of chance to be asked to file reports. This makes sense
because, after surgery, doctors who perform the surgery
usually need to submit some reports with the claim. For the
rule (Anesthesia) Ÿ (Carpal Tunnel Release Surgery),
anesthesia is for all procedures on nerves, muscles, tendons,
fascia, and bursae of forearm, wrist, and hand. This rule
implies that if a patient has such anesthesia, the chance for
him/her to have the surgery is 84%. It also makes sense
since performing the surgery requires anesthesia on that
hand.

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 5500 TABLE V. ASSOCIATION RULES FOR NS PATIENTS
Antecedent Consequent Support Confidence
1 Physical therapy Physical 0.15 0.97
assessment therapy
2 Needle Nerve 0.36 1.0
electromyography conduction
3 Nerve conduction, Physical 0.06 1.0
Physical therapy therapy
assessment
4 Needle Nerve 0.08 1.0
electromyography, conduction
Physical therapy

2) LCS Patients: These are patients who had at least one

Carpal Tunnel Release Surgery and spent less than $5,500
in total. There are 84 patients in this group.
Figure 1. Histogram of surgery patients’ sum a) Description Statistics: The five most frequent
treatments are in Table 6 below. The most frequent
1) NS Patients
treatment is physical therapy, which is prescribed by
a) Description Statistics: The five most frequent physicians to help relieve pain. Since patients have surgery,
treatments are in Table 4 below. The most frequent most of the time they will need anesthesia as shown in the
treatment is physical therapy which makes sense since these third and fourth most frequent treatments. The second and
patients feel the pain so physicians try physical therapy to fifth treatments are diagnostic tests: nerve conduction and
help relieve their pain. From the second to the fourth most physical therapy assessment.
frequent treatments are diagnostic exams: nerve conduction,
b) Association Rules for LCS Patients: We set the
which is a test that reveals the nature of nerve injury [9],
support threshold to 0.3 and show the association rules in
needle electromyography, which is a diagnostic test “used
Table 7. Since every patient in this group has one or more
by physicians to determine neuromuscular disorders and
surgeries, the first rule says “everyone here has surgery”,
diseases such as Lou Gehrig’s disease and Carpal Tunnel
which is true. Patients may use wrist-hand orthosis to
Syndrome”[10], and radiologic exam- hand or wrist, a
restrict their hand movement before or after surgery.
common non-invasive inexpensive exam. Patients may use
Patients may also have diagnostic exams, such as nerve
wrist-hand orthosis to restrict their hand movement before
conduction and physical therapy assessment, before surgery,
or after surgery.
as shown in rules #4 and #5. It is clear that physicians may
b) Association Rules for NS Patients: There are 4 rules perform physical therapy assessment before or after sessions
for non surgery patients as shown in Table 5 below. It is of physical therapy and perform both before surgery, as
clear that in this case physicians perform some diagnostic shown in rules #8 and #9. It seems necessary for most
exams or tests, such as physical therapy assessment, needle patients to have anesthesia during surgery, as shown in rule
electromyography, and nerve conduction, together with or #6. Patients may also have physical therapy before or after
without prescribing physical therapy. surgery to relieve their pain, as shown in rule #7. Since
TABLE IV. 5 MOST FREQUENT TREATMENTS FOR NS PATIENTS anesthesia and surgery are performed at the same time, it is
obvious that physical therapy is performed before or after
Treatment Number Total amount Average both treatments, as shown in rule #10.
of spent($)(/overall cost per
incidences spending) patient($)
TABLE VI. 5 MOST FREQUENT TREATMENTS FOR LCS PATIENTS
(per
patient) Treatment Number of Total amount Average
incidences spent($)(/overall cost per
1 Physical therapy 1,326 30,918.06 (11%) 23.31 (per spending) patient($)
(5.2) patient)
2 Nerve conduction 834(3.27) 103,577.12 124.19
(39%) 1 Physical therapy 1,638(19.5) 36,387.38 (14%) 22.21
3 Needle 106 (0.42) 15,611.25 (6%) 147.28 2 Nerve 174 (2.07) 24,254.86 (9%) 139.39
electromyography conduction
4 Radiologic exam- 76 (0.30) 3,088.10 (1%) 40.63 3 Carpal Tunnel 147(1.75) 142,042.43(54%) 996.28
hand or wrist Release Surgery
5 Wrist hand 57 (0.22) 4,076.31 (2%) 71.51 4 Anesthesia 62 (0.74) 12,334.52 (5%) 198.94
orthosis 5 Physical therapy 44 (0.52) 1,822.67(1%) 41.42
assessment

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 TABLE VII. ASSOCIATION RULES FOR LCS PATIENTS Carpal Tunnel Release Surgery is the last resort to heal
Antecedent Consequent Support Confidence Carpal Tunnel Syndrome. That explains rules #14 to #17.
1 { Everyone } Carpal Tunnel 1.0 1.0
Release Surgery TABLE VIII. 5 MOST FREQUENT TREATMENTS FOR HCS PATIENTS
2 Wrist hand Carpal Tunnel 0.32 1.0 Treatment Number of Total amount Average
orthosis Release Surgery incidences spent($)(/overall cost per
3 Physical therapy Physical therapy 0.35 1.0 (per spending) patient($)
assessment patient)
4 Physical therapy Carpal Tunnel 0.35 1.0 1 Physical therapy 1,981 42,486.47 (14%) 21.45
assessment Release Surgery (48.32)
5 Nerve conduction Carpal Tunnel 0.44 1.0 2 Nerve conduction 189 (4.61) 21,439.38 (7%) 113.44
Release Surgery 3 Carpal Tunnel 139 (3.39) 134,675.46 968.89
6 Anesthesia Carpal Tunnel 0.60 1.0 Release Surgery (44%)
Release Surgery 4 INDIVID 80 (1.995) 4,516.03 (1%) 56.45
7 Physical therapy Carpal Tunnel 0.72 1.0 PROCEDURE
Release Surgery REQ
8 Physical therapy, Carpal Tunnel 0.34 1.0 CUMPUTER
Physical therapy Release Surgery EQUIP
assessment 5 Anesthesia 63 (1.54) 12,780.97 (4%) 202.87
9 Carpal Tunnel Physical therapy 0.34 1.0
Release Surgery, TABLE IX. ASSOCIATION RULES FOR HCS PATIENTS
physical therapy
assessment Antecedent Consequent Support Confidence
10 Anesthesia, Carpal Tunnel 0.47 1.0 1 {Everyone} Carpal Tunnel 1.0 1.0
physical therapy Release Surgery Release Surgery
2 {Everyone} Physical therapy 0.88 0.87
3) HCS Patients: These are patients who had one or 3 {Everyone} Anesthesia 0.83 0.83
more surgeries and spent at least $5,500. There are 41 4 Physical Carpal Tunnel 0.88 1.0
therapy Release Surgery
patients in this group. 5 Carpal Tunnel Physical therapy 0.88 0.88
a) Description Statistics: The five most frequent Release
treatments are in Table 8. These frequent treatments are Surgery
similar to LCS patients with only one treatment different 6 Anesthesia Carpal Tunnel 0.83 1.0
Release Surgery
which is the fourth most frequent treatment, INDIVID 7 Carpal Tunnel Anesthesia 0.83 0.88
PROCEDURE REQ CUMPUTER EQUIP. From the most Release
frequent treatment to the third most frequent treatment, they Surgery
are the same: physical therapy, nerve conduction and Carpal 8 Anesthesia Physical therapy 0.73 0.88
9 Physical Anesthesia 0.73 0.83
Tunnel Release Surgery. The fifth most frequent treatment therapy
is anesthesia which comes along with surgery. 1 Physical Carpal Tunnel 0.73 1.0
b) Association Rules for HCS Patients: The support 0 therapy, Release Surgery
threshold is 0.5 and we have the following association rules Anesthesia
in Table 9. Since every patient in this group had at least one 1 Nerve Carpal Tunnel 0.61 1.0
1 conduction Release Surgery
Carpal Tunnel Release Surgery, the first rule says “everyone 1 Physical Physical therapy 0.61 1.0
here has surgery”, which is true. 88% of these patients have 2 therapy
physical therapy and 83% have anesthesia. In rules #4 and assessment
#5, patients who have physical therapy may also have 1 Physical Carpal Tunnel 0.61 1.0
3 therapy Release Surgery
Carpal Tunnel Release Surgery and vice versa. Patients assessment
have physical therapy before or after surgery. It is also clear 1 Physical Carpal Tunnel 0.61 1.0
that patients who have anesthesia are those patients who 4 therapy, Release Surgery
have Carpal Tunnel Release Surgeries but not every surgery Physical
patient will have anesthesia, as shown in rules #6 and #7. therapy
assessment
These rules can explain the relation between physical 1 Anesthesia, Carpal Tunnel 0.51 1.0
therapy and anesthesia (rules #8 and #9): both treatments are 5 Nerve Release Surgery
related to surgery, as shown in rule #10. Patients may also conduction
have diagnostic exams, such as nerve conduction and 1 Anesthesia, Physical therapy 0.51 1.0
6 Physical
physical therapy assessment before surgery, as shown in therapy
rules #11 and #13. Physicians may evaluate patients’ assessment
condition before or after their sessions of physical therapy to 1 Anesthesia, Carpal Tunnel 0.51 1.0
see if these treatments are right for them, as shown in rule 7 Physical Release Surgery
#12. If the patient’s condition is still serious and does not therapy
assessment
respond to treatments according to physicians’ evaluation,

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 4) Comparison of Treatments among NS Patients, LCS
Patients, and HCS Patients: It is clear that patients with a
more severe condition tend to receive more treatments than
those with a less severe condition. Non-surgery patients
tend to have physical therapy to relieve their pain and
diagnostic exams to evaluate their condition. Since their
condition is not serious, there is no need for Carpal Tunnel
Release Surgery. On the other hand, some patients after
sessions of physical therapy or other non-surgical
treatments, which did not relieve their pain, have surgery to
fix the problem. In practice, a package for just injured
patients may contain diagnostic exams to evaluate their
conditions, such as physical therapy assessment, nerve
conduction, and needle electromyography, and sessions of
physical therapy. If the condition is serious or sessions of
physical therapy do not help, the patients may be
automatically authorized for a surgery package which may
include Carpal Tunnel Release Surgery, anesthesia, and
after-surgery physical therapy sessions.
C. Association Rules Related with Time
1) Basic Idea: If we want to find association rules
related with time, one possible way is to add time stamps to
data items. In our experiment, each treatment entry is time-
stamped. Since each treatment has a date of service and a
date of injury, we can obtain the month performed after
injury and attach it to the treatment. Then these time-
annotated entries are processed and analyzed by the Apriori
algorithm to discover time-based association rules. Since
these rules are related to time, we will present them in
patterns instead of antecedent and consequent pairs.
2) Temporal Patterns for NS Patients: The patterns are
shown in Table 10. NS patients usually have their physical
therapy assessment when they have their first physical
therapy, as seen in patterns #1, #2 and #7. They may also
have other diagnostic exams, such as needle
electromyography and nerve conduction, but still these
exams are performed when they have their first physical
therapy, in rules #5 and #6. Rule #8 says that needle
electromyography and nerve conduction are usually
performed together in the first 8 months. Patients tend to
have their physical therapy assessment and physical therapy
on their first, third, seventh, or eighth month, as shown in
rule #9, which means patients tend to start their physical
therapy sessions in these months.
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TABLE X. TEMPORAL PATTERNS FOR NS PATIENTS
Patterns Frequency
1 Physical therapy(0,1,2), Physical therapy 1.6%
assessment(0)
2 Physical therapy(0,1,6), Physical therapy 1.2%
assessment(0)
3 Physical therapy(0,1,2) 2.3%
4 Physical therapy(0,1,6) 1.2%
5 Physical therapy(0), Needle 1.2%
electromyography(0),Nerve conduction(0)
6 Physical therapy(1), Needle 1.2%
electromyography(1),Nerve conduction(1)
7 Physical therapy(1,2), Physical therapy 1.6%
assessment(1)
8 {Needle electromyography and Nerve 1.2%
conduction}(0,1,2,3,4,5,6,7)
9 {Physical therapy and Physical therapy 1.2%
assessment}(0,2,6,7)
3) Temporal Patterns for LCS Patients: Table 11
exhibits the temporal patterns for LCS patients. Some
patterns are similar to those found for NS patients. For
example, according to patterns #6 and #7, physical therapy
assessment is performed in the month of the first physical
therapy, and needle electromyography and nerve conduction
are both performed in the same month. The main difference
is that NS patients do not have a Carpal Tunnel Release
Surgery. In patterns #1 and #2, surgery and anesthesia are
performed in the fifth or sixth month, followed by physical
therapy sessions. The last pattern shows that patients
usually have their surgery in months fourth, fifth, sixth, and
eighth.
4) Temporal Patterns for HCS Patients: Table 12
reveals the temporal patterns for HCS patients. These
patterns can be divided in 2 parts: one is related to Carpal
Tunnel Release Surgery and the other is related to physical
therapy and physical therapy assessment. As for surgery,
anesthesia usually comes with it and patients usually have
their surgery between the third month and one year. In the
month following a surgery, patients have physical therapy
assessment and start to have physical therapy in the
following 4 months. Just like for the two other patient
groups, physical therapy assessment is performed in the
month of the first physical therapy and is usually performed
within one year.
 TABLE XI. TEMPORAL PATTERNS FOR LCS PATIENTS conditions, such as physical therapy assessment, nerve
Patterns Frequency conduction, and needle electromyography, and sessions of
1 {Surgery and Anesthesia}(5), Physical 6.0% physical therapy up to six months. If the evaluation of the
therapy(6,7) exam reveals the seriousness of the condition and at least
2 Surgery(4), Physical therapy(6,7) 6.0%
3 Physical therapy(3,5,6) 6.0%
three month sessions of physical therapy do not help, the
4 Physical therapy(5,6,7) 7.1% patients could be automatically authorized for a surgery
5 Physical therapy(9,10) 9.5% package which includes Carpal Tunnel Release Surgery,
6 Physical therapy(3), Physical therapy 6.0% anesthesia, one physical therapy assessment, and up to five-
assessment(3)
7 Needle electromyography(1), Nerve 6.0%
month sessions of after-surgery physical therapy.
conduction(1) D. Comparison between Association Rules and
8 {Surgery and Anesthesia}(3,4,5,7) 7.1%
Association Rules Related to Time
TABLE XII. TEMPORAL PATTERNS FOR HCS PATIENTS Association rules show the correlation among
Patterns Frequency treatments for Carpal Tunnel Syndrome patients, such as
1 {Surgery and Anesthesia}(2,5-9,11) 6.0% physical therapy and physical therapy assessment, or
2 {Surgery and Anesthesia}(3-8) 7.3%
physical therapy and surgery. However, if we add time
stamps to the treatment entries, and then apply the Apriori
3 {Surgery and Anesthesia}(5), Physical 7.3%
therapy(6-9), Physical therapy assessment(6) algorithm, we may find association rules related to time.
4 {Surgery and Anesthesia}(6), Physical 7.3% Since the pattern is time-annotated, it is possible for us to
therapy(5-7), Physical therapy assessment(5) discover both the duration of a certain treatment and the
5 {Surgery and Anesthesia}(7), Physical 7.3% sequence of treatments for patients and, thus, understand the
therapy(7-9), Physical therapy assessment(8)
evolution of this syndrome and estimate the time and
6 {Surgery and Anesthesia}(8), Physical 7.3%
therapy(10-12) possible expenses involved. For example, when running
7 {Surgery and Anesthesia}(11), Physical 7.3% association rules, we found that physical therapy and
therapy(12,13) physical therapy assessment occur together. After adding
8 Surgery(12), Physical therapy(13, 14) 7.3% time notation to each treatment, we found physical therapy
9 Surgery(15), Physical therapy(16, 17) 7.3% assessment is performed at the same time as the first session
10 {Physical therapy and Physical therapy 7.3% of physical therapy and there is only one time of physical
assessment}(0-13) therapy assessment and multiple sessions of physical
11 Physical therapy(0,1,7), Physical therapy 7.3%
assessment(0)
therapy.
12 Physical therapy(2,3), Physical therapy 7.3%
assessment(2) V. SIGNIFICANCE TO THE INSURANCE INDUSTRY
13 Physical therapy(5,6,7), Physical therapy 9.8% These extracted association rules related to time help us
assessment(5)
understand the evolution of Carpal Tunnel Syndrome.
14 Physical therapy(8,9), Physical therapy 9.5%
assessment(8) Therefore they are helpful in treatment authorization,
15 Physical therapy(11,12), Physical therapy 7.3% prediction, and fraud detection. Association rules without
assessment(11) time-annotation tell us which treatments happen together.
16 Physical therapy(12,13,14), Physical therapy 7.3% When a patient has just gotten injured, he/she could be
assessment(12)
automatically authorized a package containing diagnostic
exams, such as a hand/wrist x-ray and physical therapy
5) Comparison of Temporal Patterns among NS assessment, and a couple sessions of physical therapy
Patients, LCS Patients, and HCS Patients: There are according to Table 4 and Table 5. If the results from the
patterns shared by these three patient groups, such as diagnostic exams reveal the patient’s condition to be serious
“physical therapy assessment is performed in the month of or the patient’s condition does not respond to sessions of
the first physical therapy”, and “anesthesia usually comes physical therapy, the patient could be automatically
with surgery”. NS patients tend to have diagnostic exams authorized a Carpal Tunnel Release Surgery package, which
or tests in the very beginning. Surgery patients tend to have includes anesthesia, surgery, and sessions of physical
physical therapy for longer periods of time in order to therapy, based on Table 7 and Table 9.
relieve pain. When physical therapy does not help, patients With time-stamps, the analysis can include the timing
turn to Carpal Tunnel Release Surgery to fix the problem and consequently be more precise. Diagnostic exams can be
since it is the last resort. After surgery, they have sessions authorized in the first few months, and patients may have
of physical therapy. It is also clear that patients in the HCS Carpal Tunnel Release Surgery from the third month to a
group tend to have after-surgery physical therapy longer year or so, followed by up to three months of physical
than LCS patients do. In practice, just injured patients could therapy, according to Table 12. The insurance authorization
be automatically authorized a low-cost treatment package system can authorize Carpal Tunnel Release Surgery to
which may contain diagnostic exams to evaluate their patients only when the surgery request is made after or in

761
the third month, and the surgery package can indicate
anesthesia and surgery at the same time, and also a 3-month
session of physical therapy after the surgery. This way,
insurance companies can accurately estimate treatment
costs, and employers can accurately estimate the related
human resource cost. Needless to say, insurance companies
can also detect irregularities and save money. As a result,
the insurance cost and, consequently, the premium may
decrease.
VI. CONCLUSIONS
Data sets in workers’ compensation databases are
composed of medical claim data, which can be used to
provide correlation between diseases and treatments and
correlation between treatments. We developed a method to
partition and analyze data to identify these correlations.
From patients’ claim data sets, we applied association-rule
mining to obtain most frequent treatments and to reveal the
relationships and sequences of treatments for Carpal Tunnel
Syndrome, and we showed that consistency is a reality in this
data set.
ACKNOWLEDGMENT
We would like to thank Dr. Paulo Franca from DataCare
Corporation for the support and insightful discussions.
762
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