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VETERANS HEALTH ADMINISTRATION
Clinical Case Registries (CCR):Local and National Registries to Improve HIV CareLisa I. Backus MD PhDPopulation Health/Office of Public HealthDepartment of Veterans Affairs
24 July 2012
VETERANS HEALTH ADMINISTRATION
Overview
• Definition and history of HIV registry in VA• Describe current HIV registry - Clinical Case Registry (CCR) • Utility of CCR in population health: Impact on quality of care
– National Quality Forum (NQF) HIV measures– Health Plan Employer Data and Information Set (HEDIS)
measures for care of diabetics
2
VETERANS HEALTH ADMINISTRATION 3
History
Registry is an active list of patients with a disease/condition of interest
• 1992 - VA started Immunology Case Registry (ICR) largely for utilization oversight
• 2000 - ICR transferred to Center for Quality Management (now absorbed into Population Health)
• 2004 - CCR debuted for HIV• 2006 - CCR applied to hepatitis C population (CCR:HCV)
demonstrating that the extensible CCR architecture can be used with other populations
VETERANS HEALTH ADMINISTRATION 4
Clinical Case Registry Components
130 local registries built on local electronic medical record (EMR) at all VA facilities
CCR
EMR
CCR
EMR
CCR
EMR
CCR
EMR
Local registry Case IdentificationLocal Reports
VETERANS HEALTH ADMINISTRATION 5
Case Identification
• Local software scans EMR nightly to identify “pending” patients who potentially have HIV based on – ICD9 codes– Positive antibody or Western Blot results
• All “pending” patients reviewed locally to ensure– Appropriate confirmatory testing– Linkage to care– Appropriate patients added to the registry
VETERANS HEALTH ADMINISTRATION 6
Local Population Reporting
Administrative/Operations• Utilization: Inpatient, Lab, Outpatient Visits, Pharmacy,
Radiology
Clinical - Patient characteristics• Body mass index (BMI)• Comorbidities• Demographics• Liver function: APRI, FIB-4, MELD, MELD-Na• Renal function: CrCl, eGFR, MDRD
VETERANS HEALTH ADMINISTRATION 7
Local Population Reporting
Clinical - Care characteristics • Current inpatient list• Clinic follow-up report: who has/has not been seen in
selected clinic • Combined meds and labs report: who did/did not get meds
of interest and who did/did not get labs of interests with lab results in a specified range
• Patient medication history: assess adherence• Procedure report: who did/did not get specified procedure
VETERANS HEALTH ADMINISTRATION 8
Clinical Case Registry Components
130 local registries built on local electronic medical record (EMR) at all VA facilities
Nightly data
sweep
CCR
EMR
CCR
EMR
CCR
EMR
CCR
EMR
Local registry functions/reports
VETERANS HEALTH ADMINISTRATION 9
Data Extract for Transmission to National Database
• Nightly sweep of any new data on all registry patients• When new patient added, first nightly data sweep includes
back pull of all available data in specified domains
– Allergy– Autopsy– Demographic– EKG– IV data– Laboratory– Microbiology– Non VA meds– Outpatient pharmacy– Outpatient visit
– Pathology– Problem list– Purchased care– Radiology– Registry information– Skin test– Unit dose– Vaccine– Vitals
VETERANS HEALTH ADMINISTRATION 10
Clinical Case Registry Components
130 local registries built on local electronic medical record (EMR) at all VA facilities
Data clean-up
National Reports
Population Health Palo Alto VA Medical Center
Nightly data
sweep
CCR
EMR
CCR
EMR
CCR
EMR
CCR
EMR
Local registry functions/reports
Internet
Clinicians
VACO
VA Intranet
Conferences
Patients
National CCR
VISNs
VETERANS HEALTH ADMINISTRATION 11
National Reports
• National reports cover multiple aspects of HIV population and HIV care– Demographics– Comorbidities– Quality of care
• Reported on national, VISN (regional) and facility level– Posted on VA INTRAnet– Facility level data directly emailed to clinicians and
administrators, available at national meetings
VETERANS HEALTH ADMINISTRATION 12
HIV Population in VA Care
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5,000
10,000
15,000
20,000
25,000
30,00024,191 25,271
HIV population in VA care
Year
VETERANS HEALTH ADMINISTRATION 13
HIV Population in Care: 2011
• Average age 54, >70% 50 or older, >30% 60 or older• 97% Male• 49% African American, 37% White, 7% Hispanic• High rates of comorbidities
– Medical: 53% Hypertension, 50% Dyslipidemia, 26% HCV, 14% Diabetes, 13% COPD, 12% CAD, 11% CKD
– Psychiatric: 55% Depression, 30% Anxiety, 16% PTSD– Substance abuse: 47% Tobacco, 34% Alcohol, 28% Stimulants
VETERANS HEALTH ADMINISTRATION 14
NQF Measures of HIV Care
• HBV screening ever• HCV screening ever• HBV immunity or vaccination if not immune ever• LTBI screening ever• Syphilis screening every 12 months• CD4 testing every 6 months• ARV therapy if nadir CD4<500/AIDS-OI• PCP prophylaxis within 90 days of CD4<200• HIV RNA control on most recent test if on ARVs
VETERANS HEALTH ADMINISTRATION 15
NQF Measures over Time
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10%20%30%40%50%60%70%80%90%
100% HCV ScreeningHBV ScreeningCD4 Testing
Year
Per
form
ance
rat
e
VETERANS HEALTH ADMINISTRATION 16
NQF Measures over Time
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10%20%30%40%50%60%70%80%90%
100%
Antiretroviral TherapyHBV Immunity/VaccineHIV RNA ControlLTBI ScreeningSyphilis Screening
Year
Per
form
ance
rat
e
VETERANS HEALTH ADMINISTRATION 17
NQF Measures over Time
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10%20%30%40%50%60%70%80%90%
100%
PCP Prophylaxis
PCP Prophylaxis
Year
Per
form
ance
rat
e
VETERANS HEALTH ADMINISTRATION 18
NQF Measures: 2011
MeasureNational Number Eligible
National Rate (%)
76 Large Facilities(≥100 patients)
Minimum Facility Rate (%)
Maximum Facility Rate (%)
HBV Screening 20,282 98% 86% 100%
HCV Screening 20,282 98% 93% 100%
Antiretroviral Therapy 18,536 93% 82% 100%
CD4 Testing 20,282 89% 71% 99%
HBV Immunity/Vaccination 18,871 88% 67% 98%
PCP Prophylaxis 2,184 76% 14% 100%
LTBI Screening 19,455 75% 40% 99%
HIV RNA Control 17,685 74% 26% 91%
Syphilis Screening 20,282 65% 16% 98%
VETERANS HEALTH ADMINISTRATION 19
HIV Patients with Diabetes over Time
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5001,0001,5002,0002,5003,0003,5004,000
HIV Patients with Diabetes in VA Care
Year
14.3%
11.1%
VETERANS HEALTH ADMINISTRATION 20
HEDIS Diabetes Care Measures
• HgbA1c testing every 12 months• LDL testing every 12 months• Renal monitoring – urine screen for nephropathy, renal
clinic visit, treatment with ACE/ARB• Eye exam every 12 months or negative exam in previous
12 months• Blood pressure control on most recent BP <140/90• LDL control <100 mg/dL• Poor HgbA1c control >9.0%*
* For this measure only, lower rates are better
VETERANS HEALTH ADMINISTRATION 21
HEDIS Diabetes Care Measures Over Time
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100%
HgbA1c TestingLDL TestingRenal MonitoringEye ExamBlood Pressure ControlLDL ControlPoor HgbA1c Control*
Year
Perf
orm
ance
rat
e
*for this measure only, lower rates are better
VETERANS HEALTH ADMINISTRATION 22
HEDIS Diabetes Care Measures: 2011
Measure
National Rate:
HIV (%)
59 Large Facilities(≥25 HIV/Diabetes patients)
National Rate:
VA (%)1Minimum
Facility Rate (%)Maximum
Facility Rate (%)
HgbA1c Testing 91% 78% 100% 98%
LDL Testing 92% 85% 100% 97%
Renal Monitoring 87% 71% 100% 95%
Eye Exam 78% 58% 93% 90%
Blood Pressure Control 73% 52% 88% 81%
LDL Control 60% 36% 78% 69%
Poor HgbA1c Control* 21% 39% 7% 17%
1FY2011 VA Data from Office of Analytics and Business Intelligence, vaww.oqp.med.va.gov
* For this measure only, lower rates are better
VETERANS HEALTH ADMINISTRATION 23
Registries Matter
• Increased local CCR use associated with better quality of care on NQF measures
– Backus et al (2010) National Quality Forum performance measures for HIV/AIDS care: The Department of Veterans Affairs’ experience, Archives of Internal Medicine, 170(14): 1239-1246
• Association - so not necessarily causal• CCR use may be marker of program committed to improving
quality• Given time constraints on providers, however, difficult to
envision providers would spend time using registry if they did not think it improved their practice
• .
VETERANS HEALTH ADMINISTRATION 24
Thank You
• All HIV providers and local CCR Coordinators who make the data possible
• Population Health StaffPam Belperio Joanne McDayPaula Edwards Larry MoleJim Halloran Barbara PhillipsVera Katseva I-Chun ThomasTim Loomis Gale Yip
• AITC staff, NTEO staff, OIT staff• For more information
http://vaww.vistau.med.va.gov/VistaU/ccr/default.htm
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