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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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NQF Measures over Time

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100%

Antiretroviral TherapyHBV Immunity/VaccineHIV RNA ControlLTBI ScreeningSyphilis Screening

Year

Per

form

ance

rat

e

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NQF Measures over Time

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100%

PCP Prophylaxis

PCP Prophylaxis

Year

Per

form

ance

rat

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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%

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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%

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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

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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

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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

• .

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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