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Registry Data Collection in Pediatric VADs: Challenges and OpportunitiesINTERMACS Eighth Annual Meeting
May 5, 2014
David Rosenthal, MD
Stanford Children’s Health
Disclosures
• Research support for Berlin Heart
Post-Approval Study
Heart FailureHeart
Failure
Scope• Discussing Pediatric
Cardiology care
environment
(resemblance to
adult circumstances
possible but
unintentional)
• Taking population-
based perspective
rather than just VAD
VADVAD
Transplant
Transplant
Types of Registries
• Procedure/Therapy-based
• Disease-based
• Population-based
Purposes of Registries
• Support Quality Measurement
• Provide Feedback to Clinicians/Institutions
for Quality Improvement
• Conduct Clinical Research
• Evaluate healthcare access
and outcome disparities
Registry Financial Support
• Researchers
• Research Consortia
• NPO’s
• Government Agencies
• IndustryWikipedia.com
Delicate Balance
Michelangelo: artforbreakfast.org
Funding
Investigators
Context
Registries vs. RCT’s
• RCT
– Best for assessment of
therapeutic efficacy
• Registry
– Therapeutic effectiveness
– Safety/harm of therapy
– Generalizability to
populations
• Key Difference
– Registries do not
randomize
Ho, Circulation 2008, 1675-84
RegistryRegistry
VAD RCT Costs• Berlin Heart EXCOR trial
– $6,200,000 for 109 subjects
– 95 non-IDE subjects
– $30,000 - $57,000 per patient
• Berlin Heart PAS
– Less rigorous auditing required
– Estimated cost $2,000,000
– 50 subjects
– $40,000 per subject
VAD Registry Costs: Intermacs• 28 months from 12/10- 3/13
– $6,170,000
– $2.6M/year
• Size of registry at that time
– 2000 enrollments/year
– 5,570 total accruals
– 140 active hospitals
• $350 - $500 per new pt
• Does not include data entry costs at sites:
– ($1,000-$2,000 per patient)
Registry Quality• What can be done to ensure high
quality data in a registry?
– Comprehensive enrollment (minimize
missing cases)
• Adherence to well specified enrollment
critieria
– Ensure data completeness
• Varies very widely depending upon the
field
– e.g 1 year QOL vs. Implant date
• Enhanced by regular audits
• Data definitions important
• Workflow critical, compared to clinical
workflow
• Training of those who collect/enter data
Both AHA and AHRQ have published guidelines to assist this process.
The more boxes you check, the more expensive the process becomes
Enhancing Registry Value
• Data Linkages
– Claims data:
• Hospital utilization
• Mortality
• Operates effectively at large scales
– Other clinical registries
• Disease registry linked to procedure registry
• Integration to EHR
– Improved workflow
– However, EHR vendor development goals are to differentiate
product rather than to enhance interoperability
Key Questions In Pediatric VADs
Key Questions In Pediatric VADs
Who Should Get a VAD?
• Risk Factor/Patient selection
• Comparison with HF medical group
• Comparison with immediate
transplantation group
Relevant Registries
• INTERMACS/Pedimacs: VAD procedure and
follow-up
• PHTS: Heart Transplant listing and follow-up
• PHIS+: Pediatric Hospital data
• STS: surgical procedures and hospital stay
• PCMR: cardiomyopathy outpatient registry
• Pediatric heart failure: not yet
Robust Registry Environment
• Adequate numbers of registries
• Problems
– Overlapping scope
• proliferating analyses
• Inefficient workflow
– Definitions not coordinated
– Linkages not optimal
Road Ahead
• Continue the difficult work of building
participation in pediatric VAD, and
transplant registries, and of enrolling
patients
• Fill in gaps in pediatric HF
• Balance privacy and site concerns, while
enhancing linkages between registries
A Pressing Need• Develop infrastructure to coordinate
these registries
– This is currently the most
obvious missing piece in the
ecosystem and one that
threatens long-term
sustainability
– Requires support from
a convening body, likely
a major financial supporter of registries
NIH: wikipedia.org