Clinical Case Registries (CCR):
Local and National Registries to Improve HIV Care
Lisa I. Backus MD PhD
Population Health/Office of Public Health
Department of Veterans Affairs
24VETERANS
July 2012
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
CCR
EMR
CCR
EMR
Local registry
Case Identification
Local Reports
CCR
EMR
CCR
EMR
130 local registries built on local electronic
medical record (EMR) at all VA facilities
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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
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Clinical Case Registry Components
CCR
EMR
CCR
Nightly
data
sweep
EMR
Local registry
functions/reports
CCR
EMR
CCR
EMR
130 local registries built on local electronic
medical record (EMR) at all VA facilities
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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
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–
–
–
–
–
–
–
Allergy
Autopsy
Demographic
EKG
IV data
Laboratory
Microbiology
Non VA meds
Outpatient pharmacy
Outpatient visit
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–
–
–
–
–
–
–
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Pathology
Problem list
Purchased care
Radiology
Registry information
Skin test
Unit dose
Vaccine
Vitals
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Clinical Case Registry Components
CCR
Internet
Data clean-up
VA Intranet
EMR
CCR
Nightly
data
sweep
EMR
National Reports
National CCR
Local registry
functions/reports
VACO
CCR
EMR
VISNs
CCR
EMR
Population Health
Palo Alto VA Medical Center
130 local registries built on local electronic
medical record (EMR) at all VA facilities
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Patients
Conferences
Clinicians
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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
HIV population in VA care
30,000
25,000
25,271
24,191
20,000
15,000
10,000
5,000
0
2004
2005
2006
2007
2008
2009
2010
2011
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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Performance rate
NQF Measures over Time
100%
HCV Screening
90%
HBV Screening
80%
CD4 Testing
70%
60%
50%
40%
30%
20%
10%
0%
2004
2005
2006
2007
2008
2009
2010
2011
Year
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NQF Measures over Time
Performance rate
100%
90%
Antiretroviral Therapy
80%
HBV Immunity/Vaccine
70%
HIV RNA Control
60%
LTBI Screening
50%
Syphilis Screening
40%
30%
20%
10%
0%
2004
2005
2006
2007
2008
2009
2010
2011
Year
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NQF Measures over Time
PCP Prophylaxis
100%
Performance rate
90%
80%
PCP Prophylaxis
70%
60%
50%
40%
30%
20%
10%
0%
2004
2005
2006
2007
2008
2009
2010
2011
Year
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NQF Measures: 2011
76 Large Facilities
(≥100 patients)
National
Rate
(%)
98%
Minimum
Facility Rate (%)
Maximum
Facility Rate (%)
HBV Screening
National
Number
Eligible
20,282
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%
Measure
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HIV Patients with Diabetes over Time
HIV Patients with Diabetes in VA Care
4,000
14.3%
3,500
3,000
11.1%
2,500
2,000
1,500
1,000
500
0
2004
2005
2006
2007
2008
2009
2010
2011
Year
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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
100%
90%
HgbA1c Testing
Performance rate
80%
LDL Testing
70%
Renal Monitoring
60%
Eye Exam
50%
Blood Pressure Control
40%
LDL Control
30%
Poor HgbA1c Control*
20%
*for this measure only, lower rates
are better
10%
0%
2004
2005
2006
2007
2008
2009
2010
2011
Year
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HEDIS Diabetes Care Measures: 2011
Measure
National
Rate:
HIV (%)
59 Large Facilities
(≥25 HIV/Diabetes patients)
Maximum
Facility Rate (%)
100%
National
Rate:
VA (%)1
HgbA1c Testing
91%
Minimum
Facility Rate (%)
78%
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%
98%
* For this measure only, lower rates are better
1FY2011
VA Data from Office of Analytics and Business Intelligence, vaww.oqp.med.va.gov
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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 Staff
Pam Belperio
Joanne McDay
Paula Edwards Larry Mole
Jim Halloran
Barbara Phillips
Vera Katseva
I-Chun Thomas
Tim 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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