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					VA and Non-VA Databases
     and Their Uses
         Part 1


 Nancy Petersen, PhD
 Michael Johnson, PhD


   February 10, 2004
                          1
    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

                                                  2
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

                                                           3
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?)

                                                4
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

                                          5
  Local, Regional, National VA
  Databases
Austin Automation Center (National)   Hines (National)
NPCD, PTF, OPC, DSS
                                      PBM




                                                                     Little Rock VISN 16 (Regional)
                                                                     Data Warehouse




                                      ….                 ..
 VAMC’s (Local)                                               (VISN 16)
 VISTA   DHCP

                                                                                                6
Veterans Information Resource Center
(VIREC) www.virec.research.med.va.gov
   HSR&D 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@VIREC.RESEARCH.MED.VA.GOV



                                           7
    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
                                          8
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
        patient’s hospital stay)
            Availability same as for procedure file   9
Patient Treatment Files                (3)


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



                                              10
    Patient Treatment Files   (4)


   Demographic information
       Scrambled SSNs
       Age
       Race
       Gender
       Marital status
       Income
       County of residence
                                    11
    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


                                                          12
    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




                                                        13
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
                                                                 14
    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)
                                                   15
    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
                                                       16
    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
                                   17
     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



                                          18
    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

                                               19
    Outpatient Clinic Files            (2)


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



                                              20
    Outpatient Clinic Files       (3)


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


                                        21
    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




                                                      22
    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




                                                 23
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)
                                                          24
    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


                                                      25
    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
                                           26
     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
                                             27
    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
                                                  28
     BIRLS Death Files       (3)

   Updated quarterly
   Created in 1972
   High degree of accuracy has been
    reported in literature
       1980’s
   Our experience has shown that BIRLS
    and PTF (disposition type = dead, with
    or without autopsy) should both be
    used to identify deaths
                                         29
    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
                                                 30
    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


                                               31
    National Death Index (3)

   Matching criteria
       SSN
       First name
       Last name
       Father’s surname
       Date of birth


                               32
    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)
                                              33
    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

                                           34
    Veteran Population Files   (2)



   Age
   Gender
   Period of service
   State
   County



                                     35
    Veteran Population Files   (3)



   EXCEL
   CD-ROM
   Full documentation




                                     36
    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

                                                  37
    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


                                                    38
    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

                                                     39
    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


                                        40
    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)


                                                                    41
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)


                                                              42
    PBM
   See handouts
       Proc contents of data elements
       Example records




                                         43
    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


                                                            44
    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?


                                          45
Data warehouse architecture
                                                           VHA VISN Data Warehouse Architecture
                                                                  Conceptual Framework
                                                                                                                              User
                                                                                                                           Presentat-
                                                                                                                               ion


       VISTA,                                                    Data/Content                  OLAP and
                                                                 Management,                   Middle Tier
    Future: ERP,                                                 Interchange                   Services
   Other Corporate                                               Services
      Systems,              Extract,        Transform,
  External Systems,         Staging            Load
   Heterogeneous
     Data Types

                                                                                                                            Informat-
                                                                                                                               ion
                                                                                                                             Delivery

   Extraction, Staging, Transformation, and Loading Services

                                                                                                                 Actions, Decisions,
                                                                                                                 Forecasts, Models,
     Italics-- Future                                                                                            E-health, Business
                                                                                                                 Transformation



                  Corporate Metadata Services: ERWIN, ETL Tool, OLAP Tool, Corporate Data Registry, XML/XMI (for interchange)
                                     Network, Security, and Systems Management Services
                                                 Knowledge Management Services
                 Strategy, Business Drivers, Principles, Standards, Policies, Change Management, and Processes




                                                                                                                                        46
    VISN 16 Data warehouse
   Contents
   CV Risk project, example




                               47
    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

                                     48

				
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