VA and NonVA Databases and Their Uses Part 1

1
VA and Non-VA Databases and Their UsesPart 1

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• Nancy Petersen, PhD
• Michael Johnson, PhD

February 10, 2004
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Overview and Plan for Presentations

• Part I February 10, 2004
• Introductory Remarks
• VA databases Nancy and Mike
• National Patient Care Databases
• BIRLS Death File
• Veteran Population
• Pharmacy Benefits Management Files
• Data warehouses
• NonVA database
• National Death Index

3
Overview and Plan (2)

• Part II February 24, 2004
• More VA databases
• Jen Campbell Decision Support System
• Diana Urbauer External Peer Review Program
• Mike National Surgical Quality Improvement
  Program
• Some non-VA databases
• Iris Wei/Mike Medicare and Medicaid
• Jessica Davila Surveillance, Epidemiology, and
  End-Results Program (SEER) Files

4
Why databases?

• HSR and HCQCUS has a long history of using large,
  administrative databases
• Health care system studies VA perfect for this
• Large regional or national populations
• Data already collected (cheaper than primary data
  collection)
• Data not intended for research (is this a
  problem?)

5
VISTA Veterans Information System Technology
Architecture

• Local VAMC Computer system aka Decentralized
  Hospital Computer Program (DHCP)
• Patient and hospital operations info
• Computerized Patient Record System (CPRS)
• Source of data for regional and national databases

6
Local, Regional, National VA Databases
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Veterans Information Resource Center (VIREC)
www.virec.research.med.va.gov

• HSRD Center (Hines) provides information to
  researchers about database access, validity,
  reliability
• Data access and training
• Resource Guides for NPCD, PTF, OPC, DSS, PBM,
  others
• Data Issues Briefs
• List server for HSR Data mailing list
• LISTSERV_at_VIREC.RESEARCH.MED.VA.GOV

8
Patient Treatment Files (1)

• PTF
• Discharge databases
• Fiscal year (e.g., FY00 discharge dates of
  10/1/99 to 9/30/00)
• Austin mainframe
• FY70 forward
• HCQCUS UNIX version
• FY88 - FY03
• FY82 - FY87 subsets

9
Patient Treatment Files (2)

• 4 types of files on Austin mainframe
• Main (hospital stay info)
• Surgery file (surgical suite)
• Procedure file (non-surgical suite procedures)
• Partial information FY84 - FY87
• Full information FY88 - present
• Bed section (each bed section within a patients
  hospital stay)
• Availability same as for procedure file

10
Patient Treatment Files (3)

• Basic information
• VA Station Number
• Veterans Integrated Service Network (VISN)
• Dates of admission and discharge
• Dates of surgeries and procedures

11
Patient Treatment Files (4)

• Demographic information
• Scrambled SSNs
• Age
• Race
• Gender
• Marital status
• Income
• County of residence

12
Patient Treatment Files (5)

• Clinical information
• First-listed diagnosis
• Principal diagnosis (admitting diagnosis)
• FY95 forward
• Primary diagnosis (longest length of stay)
• Pre - FY95
• 9 associated diagnoses

13
Patient Treatment Files (6)

• Clinical information
• Surgical Procedure Files
• 5 surgical procedures (ICD-9) per visit to the
  operating room
• Multiple procedures (ICD-9) performed in areas
  other than surgical suite

14
Patient Treatment Files (7)

• Limitations
• No lifestyle information such as smoking, alcohol
  abuse unless coded by MD/coder
• No functional status
• No lab, X-ray results
• Care outside VA that is not paid for by VA is not
  captured
• outside care paid by VA is in Contract Files
• lack same level of detail as PTF files

15
Patient Treatment Files (8)

• Advantages
• Unique patient identifier (scrambled SSN)
• Longitudinal follow-up
• Merge with other VA databases
• Unscrambled SSN is available
• Over 15 years inpatient data
• Cohort studies
• Risk-adjustment (demographic variables, 1st
  listed diagnosis, comorbidities)

16
Patient Treatment Files (9)

• Uses
• 14-day readmission for specific cohorts
• Patterns of use of inpatient care
• bed days of care, lengths of stay
• discharge rate
• multi-stay ratio
• Geographic variation among VISNs, Census Bureau
  regions/divisions
• Case-mix differences

17
Extended Care Files

• Discharge databases
• VA long-term care facilities
• VA nursing homes
• VA domiciliaries
• Contract nursing home care
• State nursing homes
• Same structure as PTF files
• Austin mainframe

18
VA Census Files

• Patients not yet discharged at end of FY
• Similar format to PTF, excluding discharge info
• Count of patients treated in FY
• Austin mainframe

19
Outpatient Clinic Files (1)

• OPC
• Visits to staff at VA outpatient clinics
• VA medical centers
• Free-standing VA community clinics
• FY80-FY85, 20 sample
• Since then, 100 of patient visits
• 35 - 60 million records per FY

20
Outpatient Clinic Files (2)

• Basic information
• VA Station Number
• Veterans Integrated Service Network (VISN)
• Dates of clinic visit
• Type of clinic (clinic stop)

21
Outpatient Clinic Files (3)

• Demographic information
• Scrambled SSN
• Age
• Eligibility
• Means Test
• County of residence
• Race (not always coded)

22
Outpatient Clinic Files (4)

• Clinical information
• 11 ICD-9 diagnosis codes
• FY97 - present
• 15 CPT codes for outpatient procedures
• Partial procedure files FY90 - FY96
• Full procedure files FY97 - present

23
Outpatient Clinic Files (5)

• Limitations
• No lab, X-ray results
• Outpatient care received outside VA that is not
  paid for by VA is not captured
• Diagnoses only available since 1997

24
Outpatient Clinic Files (6)

• Advantages
• Unique patient identifier (scrambled SSN)
• Longitudinal follow-up
• Merge with other databases
• Uses
• Volume and patterns of utilization
• visits to primary care clinics
• visits to ER and urgent care (may indicate lack
  of continuity of care)

25
Outpatient Clinic Files (7)

• Uses (continued)
• visits to specialists
• use of lab and X-rays
• use of procedures
• Examples
• and type of cardiac tests and procedures
• association between pneumonia vaccination and
  subsequent hospitalization for pneumonia

26
Contract Files

• Care by non-VA providers paid for by VA
• Inpatient
• Extended care
• Outpatient care (fee-basis)
• Less detailed than information from VA settings
• More complete picture of utilization

27
BIRLS Death Files (1)

• Beneficiary Identification and Records Locator
  Subsystem
• Collected by Veterans Benefits Administration
• Deaths reported to VBA by VAMC, families, funeral
  directors
• Supplemented by information from Social Security
  Administration

28
BIRLS Death Files (2)

• Basic information
• SSN
• Name
• Gender
• Dates of military service
• Date of birth
• Date of death
• Cause of death is NOT useful
• only coded as natural or unnatural

29
BIRLS Death Files (3)

• Updated quarterly
• Created in 1972
• High degree of accuracy has been reported in
  literature
• 1980s
• Our experience has shown that BIRLS and PTF
  (disposition type dead, with or without
  autopsy) should both be used to identify deaths

30
National Death Index (1)

• Death record information submitted by State vital
  statistics offices to National Center for Health
  Statistics
• Use to determine if persons in studies have died
• Name of state where death occurred
• Date of death
• Death certificate number
• Cause of death available from NDI Plus

31
National Death Index (2)

• Includes deaths from 1979 forward
• Deaths are added to NDI annually, approximately 1
  year after a particular calendar year
• In Spring 2004, deaths from 2002 are available

32
National Death Index (3)

• Matching criteria
• SSN
• First name
• Last name
• Fathers surname
• Date of birth

33
National Death Index (4)

• Use of NDI and NDI Plus requires application
  process for approval
• Fees are involved
• 350 initial submission of user records, 100
  subsequent submissions
• For each year of death searched, 1st 2500 user
  records 0.30 NDI, 0.36 NDI Plus
• Each additional record, 0.15 (NDI), 0.21 (NDI
  Plus)

34
Veteran Population Files (1)

• Estimates
• 1990 to 2003
• Projections
• 2004 forward to 2030
• No listing by name or SSN
• Deaths and separations from military service

35
Veteran Population Files (2)

• Age
• Gender
• Period of service
• State
• County

36
Veteran Population Files (3)

• EXCEL
• CD-ROM
• Full documentation

37
Pharmacy Benefits Management (PBM)

• National pharmacy dispensing records beginning
  FY1999
• IV and unit dose (inpatient) prescription orders
  filled in a VA facility
• Outpatient prescription orders filled at a VA
  pharmacy or Consolidated Mail Outpatient Pharmacy
  (CMOP)
• Extracted monthly from VISTA

38
PBM

• Selected lab test results for certain classes
• CV200 - Calcium Channel Blockers
• Creatinine
• HS502 - Oral Hypoglycemics
• Glucose
• HgbA1c
• Transferase Aspartate (SGOT)
• Transferase Alanine Amino (SGPT)
• Not usable/available for research

39
PBM

• Located in Hines, Ill.
• Not directly accessible for researchers
• Available by request
• IRB approved study
• Summary of study protocol
• Completed PBM request form online
• Can search records for you to identify patients
  or link a finder file to pull records

40
PBM

• Documentation from VIREC
• Bibliography of research using VA pharmacy data
• Contact Francesca Cunningham, PharmD
  (708-786-7862)
• PBM website vaww.pbm.med.va.gov

41
PBM

• Example uses
• Source of information to identify patients with
  disease conditions
• Case ascertainment
• Diabetes (Selby, 2001)
• Comorbidity definitions, risk-adjustment
• Chronic Disease Score/Rx Risk (Von Korff, 1992
  Johnson RE 1994 Clark 1995)
• Rx-Risk-V (CDS for VA system Sloan, 2003)

42
PBM

• Study patterns of use of drugs for a given
  condition
• Adherence to prescribed regimen or guidelines
• Anti-hypertensives (Christensen 1997)
• Schizophrenia, depression (Chen 2000, 2001 - VA)
• Costs of pharmaceutical care
• Pharmacoeconomics
• System level effects
• Associations of pharmacy costs with total
  healthcare costs (Stroupe 2000)

43
PBM

• See handouts
• Proc contents of data elements
• Example records

44
Data warehouses

• Another source of clinical data
• Some VISNs (regional network level) aggregate the
  VISTAs from their VAMCs
• Inpatient and outpatient diagnoses and procedures
  (PTF, OPC)
• Pharmacy, laboratory, vital signs
• Some text fields (progress notes, clinical tests)
• Access is limited

45
Data warehouses

• VISN 16 (ours) Gulf Coast network
• VISN 20 Pacific Northwest
• VISN 22 West Coast
• VISN 7 Atlantic Southeast
• VISN 2 Upstate New York
• Others?

46
Data warehouse architecture
47
VISN 16 Data warehouse

• Contents
• CV Risk project, example

48
Websites

• VIREC - www.virec.research.med.va.gov
• Austin AC - vaww.aac.va.gov
• PBM - vaww.pbm.med.va.gov
• DSS - vaww.dss.med.va.gov
• HERC www.herc.research.med.va.gov
• KLFmenu klfmenu.med.va.gov