1. Administrative Data and HCUP Tools Healthcare Cost and Utilization Project Using Administrative Data to Answer Policy Questions  December 4-5, 2008

2. Advancing Excellence in Health Care 2 Introductions Claudia Steiner, MD, MPH Research Medical Officer Agency for Healthcare Research and Quality

3. Advancing Excellence in Health Care 3 AHRQ – Agency within DHHS

4. Advancing Excellence in Health Care 4 The HCUP Partnership: A Voluntary Federal-State-Private Sector Collaboration 40 states 90% of all discharges WY

5. Advancing Excellence in Health Care 5 Current HCUP Partners Arizona Department of Health Services Arkansas Department of Health California Office of Statewide Health Planning & Development Colorado Hospital Association Connecticut Integrated Health Information (Chime, Inc.) Florida Agency for Health Care Administration Georgia Hospital Association Hawaii Health Information Corporation Illinois Department of Public Health Indiana Hospital&Health Association Iowa Hospital Association Kansas Hospital Association

6. Advancing Excellence in Health Care 6 Current HCUP Partners Kentucky Cabinet for Health and Family Services Maine Health Data Organization Maryland Health Services Cost Review Commission Massachusetts Division of Health Care Finance and Policy Michigan Health & Hospital Association Minnesota Hospital Association Missouri Hospital Industry Data Institute Nebraska Hospital Association Nevada Division of Health Care Financing and Policy, Department of Health and Human Services New Hampshire Department of Health & Human Services New Jersey Department of Health and Senior Services

7. Advancing Excellence in Health Care 7 Current HCUP Partners New York State Department of Health North Carolina Department of Health and Human Services Ohio Hospital Association Oklahoma Health Care Information Center for Health Statistics Oregon Association of Hospitals and Health Systems Rhode Island Department of Health South Carolina State Budget & Control Board South Dakota Association of Health Care Organizations Tennessee Hospital Association

8. Advancing Excellence in Health Care 8 Current HCUP Partners Texas Department of State Health Services Utah Department of Health Vermont Association of Hospitals and Health Systems Virginia Health Information Washington State Department of Health West Virginia Health Care Authority Wisconsin Department of Health and Family Services Wyoming Hospital Association

9. Advancing Excellence in Health Care 9 HCUP Is a Family of Databases, Tools, and Products HCUP Databases Research Publications User Support Software Tools EQUIPS

10. Advancing Excellence in Health Care 10 Administrative Data

11. Advancing Excellence in Health Care 11 The Foundation of Administrative Data is Billing Data Demographic Data DiagnosesProceduresCharges Billing UB-04 Form

12. Advancing Excellence in Health Care 12 The Flow of Inpatient Admissions Reception Discharge Summary Admit Provide Care Discharge Patient Record Medical Coder Bill Generated Scheduled Admission Patient Perspective Data Perspective Billing Dept Transfer/ From ED Transfer/ ED Admit

13. Advancing Excellence in Health Care 13 From Patient to Data Patient enters hospital Hospital sends billing data and any additional data elements to Data Organizations States store data in varying formats Billing record created AHRQ standardizes data to create uniform HCUP databases

14. Advancing Excellence in Health Care 14 General File Structure for Hospital Administrative Data Range of file sizes Range of file sizes – ~ 55,000 to 4.0 million records, depending on state Core set of variables Core set of variables – Generally available across most states State-specific variables State-specific variables – Vary by state – Allow specific analyses to be done Patient race/ethnicity – to examine disparities Patient race/ethnicity – to examine disparities Encrypted patient identifier – to examine readmissions Encrypted patient identifier – to examine readmissions

15. Advancing Excellence in Health Care 15 What Core Data Elements Are Included in Administrative Data? Patient demographics (age, sex) Diagnoses & procedures (ICD-9-CM, DRG) Expected payer Length of stay Patient disposition Admission source & type Dates of admission and discharge Hospital identifiers UB-04 Billing Form

16. Advancing Excellence in Health Care 16 What are Some State-Specific Data Elements? Race/Ethnicity Race/Ethnicity Patient county Patient county Patient ZIP Code Patient ZIP Code Severity of illness Severity of illness Birthweight Birthweight Procedure date (days from admission) Procedure date (days from admission) Primary payer details Primary payer details Secondary payer Secondary payer Detailed charges Detailed charges Patient identifiers, encrypted Patient identifiers, encrypted Physician identifiers, encrypted Physician identifiers, encrypted Physician specialty Physician specialty

17. Advancing Excellence in Health Care 17 Example: Payer Detail Varies by State PAY1_XPAY1 (HCUP Standard) ValueDescriptionValueDescription MMedicare1 DMedicaid2 B Blue Cross and Blue Shield 3Private Insurance I, S Other Insurance Comp; Self Ins HHMO-PPO PSelf-pay4 ZFree5No charge WWorkers' Comp 6Other CCHAMPUS E, NOther Government L, OOther 3, 5, A, F, G, J, K, Y UnknownMissing Other values AInvalid

18. Advancing Excellence in Health Care 18 Hospital Billing Data Have Benefits and Limitations Benefits Large sample size Large sample size Uniformity of coding Uniformity of coding Routine, regular collection Routine, regular collection Ease of access Ease of access All-payer All-payer Available at local, state, regional, national level Available at local, state, regional, national levelLimitations Differences in coding across hospitals Differences in coding across hospitals No data on individuals outside of hospital system No data on individuals outside of hospital system May not show complete episode of care May not show complete episode of care May not include all hospitals May not include all hospitals Lack revenue information Lack revenue information Sparse clinical details Sparse clinical details

19. Advancing Excellence in Health Care 19 Accessing Data Your own state data organization can provide: Your own state data organization can provide: – Most recent data – Data elements not released outside government e.g., patient identifiers, physician identifiers, linkage variables e.g., patient identifiers, physician identifiers, linkage variables To compare your data with other states: To compare your data with other states: – Obtain HCUP-formatted, uniform files through HCUP Central Distributor – Obtain other states’ data directly from other states – Can access summary statistics through HCUPnet National benchmarks National benchmarks

20. Advancing Excellence in Health Care 20 Obtain HCUP Data – Two Methods HCUP Central Distributor www.hcup- us.ahrq.gov/tech_assist/centdist.jsp HCUP Partner States http://www.hcup-us.ahrq.gov/partners.jsp

21. Advancing Excellence in Health Care 21 States Releasing SID through HCUP Central Distributor States Releasing SID through HCUP Central Distributor Arizona Arizona Arkansas Arkansas California** California** Colorado Colorado Florida Florida Hawaii Hawaii Iowa Iowa Kentucky Kentucky Maryland Maryland Massachusetts Massachusetts Michigan Michigan Nebraska Nebraska Nevada Nevada New Jersey New Jersey New York New York North Carolina North Carolina Oregon Oregon Rhode Island Rhode Island South Carolina South Carolina Utah Utah Vermont Vermont Washington Washington West Virginia West Virginia Wisconsin Wisconsin 1990 – 2007* * Not all states participate in all years. ** Special application process.

22. Advancing Excellence in Health Care 22 Nationwide Inpatient Sample (NIS)

23. Advancing Excellence in Health Care 23 What Is the Nationwide Inpatient Sample (NIS)? Nationwide Inpatient Sample (NIS) State Inpatient Databases (SID) Comprehensive hospital discharge data from states

24. Advancing Excellence in Health Care 24 Allows national and regional studies of inpatient hospital utilization and charges – generates national estimates Purpose of the NIS NIS Not recommended for state-level analyses

25. Advancing Excellence in Health Care 25 Statewide Data Systems Participating in NIS Data Year # of States States 19888CA, CO, FL, IA, IL, MA, NJ, WA 1989-199211+ AZ, PA, WI 1993-199417+ CT, KS, MD, NY, OR, SC 1995-199619+ MO, TN 1997-199822+ HI, UT, GA 199924+ ME, VA 200028+ KY, NC, TX, WV 200133+ MI*, MN, NE, RI, VT 200235+ NV, OH, SD [AZ not available] 200337+ AZ, IN, NH [ME not available] 200437+ AR [PA not available] 200537+OK [VA not available] 200638+VA

26. Advancing Excellence in Health Care 26 The NIS Can Be Used for Many Purposes Use of and charges for hospital services Use of and charges for hospital services Medical practice variation Medical practice variation Medical treatment effectiveness Medical treatment effectiveness Quality of care and patient safety Quality of care and patient safety Impact of health policy changes Impact of health policy changes Diffusion of medical technology Diffusion of medical technology Provides national and regional benchmarks to compare your own experience

27. Advancing Excellence in Health Care 27 National Emergency Department Sample (NEDS) Coming Soon...

28. Advancing Excellence in Health Care 28 Software Tools for Use with Administrative Data

29. Advancing Excellence in Health Care 29 HCUP Software Tools Clinical Classification System (CCS) ICD-9-CM CCS ICD-9-CM CCS ICD-10 CCS ICD-10 CCS CPT CCS CPT CCS Mental Health CCS Mental Health CCS Comorbidity Software Chronic Condition Indicators Procedure Classes Cost-to-Charge Ratios HCUPnet Hospital Market Structure (HMS) Flags Utilization Flags Quality Indicators Prevention QIs Prevention QIs Inpatient QIs Inpatient QIs Patient Safety QIs Patient Safety QIs Pediatric QIs Pediatric QIs Number of HCUP-related Software Tools: 15

30. Advancing Excellence in Health Care 30 Most AHRQ HCUP Tools Can Be Applied to Any Administrative Database SASD SEDD NIS KID SID Other Administrative Databases CCS Tools Comorbidity Procedure Classes Chronic Condition Indicator AHRQ QIs

31. Advancing Excellence in Health Care 31 Most AHRQ HCUP Tools Aid to Summarize Data SASD SEDD NIS KID SID Other Administrative Databases CCS Tools ICD-9-CM CCS ICD-10 CCS CPT CCS MH CCS Procedure Classes Chronic Condition Indicator

32. Advancing Excellence in Health Care 32 Most Tools Based On Medical Coding Classifications ICD-9-CM ICD-9-CM CPT CPT HCPCS HCPCS DRGs DRGs MDC MDC CCS CCS

33. Advancing Excellence in Health Care 33 Multiple Coding Systems ICD-9-CM ICD-9-CM CPT CPT HCPCS HCPCS DRGs DRGs MDC MDC CCS CCS Which coding system is appropriate for your policy analysis? Groupers Individual Codes

34. Advancing Excellence in Health Care 34 ICD-9-CM ICD-9-CM Diagnosis Codes ICD-9-CM Diagnosis Codes ICD-9-CM Procedure Codes ICD-9-CM Procedure Codes Included in both inpatient and outpatient databases Included in both inpatient and outpatient databases

35. Advancing Excellence in Health Care 35 Common Procedural Coding System – CPT & HCPCS CPT HCPCS Local Codes

36. Advancing Excellence in Health Care 36 The CCS collapses ICD-9-CM codes into a smaller number of clinically meaningful categories that can be more useful for presenting descriptive statistics than are individual ICD-9-CM codes. Clinical Classifications Software (CCS) 12,600 Diagnosis Codes and 3,500 Procedure Codes Clinical Classifications ICD-9-CM Diagnosis Codes

37. Advancing Excellence in Health Care 37 CCS for ICD-9-CM ICD-9-CM Codes Groups ICD-9-CM codes into clinically meaningful categories CCS Codes CCS 6: Hepatitis CCS 6: Hepatitis CCS 2: Septicemia 0031 0202 0223 0362 0380 0381 03810 03811 03819 0382 0383 03840 03841 03842 03843 03844 03849 0388 0389 0545 449 7907 0700 0701 0702 07020 07021 07022 07023 0703 07030 07031 07032 07033 0704 07041 07042 07043 07044 07049 0705 07051 07052 07053 07054 07059 0706 07070 07071 0709 57140 57141 57149 5731 5732 5733 Your data

38. Advancing Excellence in Health Care 38 Most AHRQ HCUP Tools Aid to Summarize Data SASD SEDD NIS KID SID Other Administrative Databases CCS Tools ICD-9-CM CCS ICD-10 CCS CPT CCS MH CCS Procedure Classes Chronic Condition Indicator

39. Advancing Excellence in Health Care 39 Kansas - 2006 Total number of discharges RankICD-9-CM diagnosis code and name 1.V30.00Single Lb In-Hosp W/O Cs27,705 2.V30.01Single Lb In-Hosp W Cs11,466 3.486Pneumonia, Organism Nos10,417 4.428.0Chf Nos (after Oct 1, 2002)7,536 5.414.01Crnry Athrscl Natve Vssl6,615 6.654.21Prev C-Delivery-Delivrd4,888 7.276.51Dehydration4,100 8.786.59Chest Pain Nec4,057 9.715.36Loc Osteoarth Nos-L/Leg3,949 10.664.11Del W 2 Deg Lacerat-Del 3,610

40. Advancing Excellence in Health Care 40 Colorado - 2006 State statistics - 2006 Colorado Rank order of CCS principal diagnosis category Total number RankCCS principal diagnosis category and name of discharges 1218Liveborn66,845 2193Trauma to perineum and vulva17,261 3195Other complications of birth, puerperium affecting management of the mother 13,733 4203Osteoarthritis13,178 5122Pneumonia (except that caused by tuberculosis and sexually transmitted diseases) 12,922 6205Spondylosis, intervertebral disc disorders, other back problems 9,639 7108Congestive heart failure, nonhypertensive8,042 8237Complication of device, implant or graft7,885 9101Coronary atherosclerosis7,879 1069Affective disorders7,311

41. Advancing Excellence in Health Care 41 U.S. - 2006 Total number of discharges RankCCS principal diagnosis category and name 1.218Liveborn4,288,954 2.122Pneumonia (except that caused by tuberculosis and sexually transmitted diseases) 1,218,467 3.101Coronary atherosclerosis1,198,274 4.108Congestive heart failure, nonhypertensive1,098,573 5.102Nonspecific chest pain856,948 6.193Trauma to perineum and vulva817,848 7.195Other complications of birth, puerperium affecting management of the mother 767,357 8.106Cardiac dysrhythmias749,182 9.203Osteoarthritis735,087 10.100Acute myocardial infarction675,121

42. Advancing Excellence in Health Care 42 North Carolina – 2000 - 2006

43. Advancing Excellence in Health Care 43 Procedure Classes Groups ICD-9-CM Codes into One of Four Categories to Distinguish Between Diagnostic/Therapeutic Procedures ICD-9-CM Procedure Codes Minor Diagnostic Minor Therapeutic Major Diagnostic Major Therapeutic

44. Advancing Excellence in Health Care 44 Procedure Classes Minor Diagnostic Minor Therapeutic Major Diagnostic Major Therapeutic Electrocardiogram (ICD-9-CM: 8952) Pacemaker (ICD-9-CM: 3778) CABG (ICD-9-CM: 3610) Pericardial Biopsy (ICD-9-CM: 3724) Cardiac Procedures

45. Advancing Excellence in Health Care 45 Chronic/Non-Chronic Indicator ICD-9-CM Diagnosis Codes Chronic Non- Chronic Groups ICD-9-CM Diagnosis Codes into Chronic or Non- Chronic Categories

46. Advancing Excellence in Health Care 46 Chronic/Non-Chronic Indicator ChronicNon- Chronic Food Poisoning (ICD-9-CM 0059) Diabetes (ICD-9-CM 25000) Chronic/ Non-Chronic

47. Advancing Excellence in Health Care 47 Probability of Readmission 6 HCUP SID, 2002

48. Advancing Excellence in Health Care 48 The Comorbidity Software is based on the ICD-9-CM coding scheme. This software creates about 30 variables that identify major comorbidities. * Elixhauser A, et al. Medical Care, Jan. 1998. Comorbidity Software* ICD-9-CM Codes, DRGs on Administrative Data Comorbidity Software 30 Comorbidity Classifications

49. Advancing Excellence in Health Care 49 Appends Indicator Flags for Each Comorbidity to Records Congestive heart failure Congestive heart failure Valvular disease Valvular disease Pulmonary circulation disorders Pulmonary circulation disorders Peripheral vascular disorders Peripheral vascular disorders Hypertension (uncomplicated and complicated) Hypertension (uncomplicated and complicated) Paralysis Paralysis Other neurological disorders Other neurological disorders Chronic pulmonary disease Chronic pulmonary disease Diabetes without chronic complications Diabetes without chronic complications Diabetes with chronic complications Diabetes with chronic complications Hypothyroidism Hypothyroidism Renal failure Renal failure Liver disease Liver disease Chronic peptic ulcer disease Chronic peptic ulcer disease CM_CHF = 0 or 1 CM_VALVE = 0 or 1 30 flags created and appended to each record

50. Advancing Excellence in Health Care 50 Appends Indicator Flags for Each Comorbidity HIV and AIDS HIV and AIDS Lymphoma Lymphoma Metastatic cancer Metastatic cancer Solid tumor without metastasis Solid tumor without metastasis Rheumatoid arthritis/collagen vascular diseases Rheumatoid arthritis/collagen vascular diseases Coagulation deficiency Coagulation deficiency Obesity Obesity Weight loss Weight loss Fluid and electrolyte disorders Fluid and electrolyte disorders Blood loss anemia Blood loss anemia Deficiency anemia Deficiency anemia Alcohol abuse Alcohol abuse Drug Abuse Drug Abuse Psychoses Psychoses Depression Depression

51. Advancing Excellence in Health Care 51 Utilization Flags Utilization Flag Software ICD-9-CM codes + UB-92 codes Reveals additional information about use of health care services Emergency Room Chest X-ray / CT Scan Intensive Care Unit Your data

52. Advancing Excellence in Health Care 52 30 Utilization Flags ICD-9-CM codes are not available for all services – there is some concern that some diagnostic procedures may be under- reported

53. Advancing Excellence in Health Care 53 HCUPnet – On-line Query System

54. Advancing Excellence in Health Care 54 HCUPnet: Quick, Free Access to HCUP Data Free, interactive online query system Free, interactive online query system Users generate tables of outcomes by diagnoses and procedures Users generate tables of outcomes by diagnoses and procedures Data can be cross-classified by patient and hospital characteristics Data can be cross-classified by patient and hospital characteristics Includes national, regional, and state data (for states that choose to participate) Includes national, regional, and state data (for states that choose to participate)http://hcup.ahrq.gov/hcupnet

55. Advancing Excellence in Health Care 55 HCUPnet Can Answer a Variety of Questions What percentage of hospitalizations for children are uninsured, by state? What percentage of hospitalizations for children are uninsured, by state? What are the most expensive conditions treated in U.S. hospitals? What are the most expensive conditions treated in U.S. hospitals? What is the trend in admissions for depression? What is the trend in admissions for depression? Will there be sufficient cases to do my analysis? Will there be sufficient cases to do my analysis? How do my estimates compare with HCUPnet (validation)? How do my estimates compare with HCUPnet (validation)?

56. Advancing Excellence in Health Care 56 DEMONSTRATION HCUPnet Demonstration

57. Advancing Excellence in Health Care 57 HCUP User Support Website Find detailed information on HCUP databases, tools, and products Find detailed information on HCUP databases, tools, and products Access HCUPnet Access HCUPnet Find comprehensive listing of HCUP-related publications, database reports, and fact books Find comprehensive listing of HCUP-related publications, database reports, and fact books Access technical assistance Access technical assistance http://www.hcup-us.ahrq.gov

58. Advancing Excellence in Health Care 58 Using HCUP Technical Assistance Active Technical Assistance Responds to inquiries about HCUP data, products, and tools Responds to inquiries about HCUP data, products, and tools Collects user feedback and suggestions for improvement Collects user feedback and suggestions for improvement E-mail: hcup@ahrq.gov hcup@ahrq.gov Phone: (866) 290-HCUP