1. VETERANS HEALTH ADMINISTRATION 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 24 July 2012

2. 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

3. VETERANS HEALTH ADMINISTRATION 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 3

4. VETERANS HEALTH ADMINISTRATION Clinical Case Registry Components 4 130 local registries built on local electronic medical record (EMR) at all VA facilities CCR EMR CCR EMR CCR EMR CCR EMR Local registry Case Identification Local Reports

5. VETERANS HEALTH ADMINISTRATION 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 5

6. VETERANS HEALTH ADMINISTRATION 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 6

7. VETERANS HEALTH ADMINISTRATION 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 7

8. VETERANS HEALTH ADMINISTRATION Clinical Case Registry Components 8 130 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

9. VETERANS HEALTH ADMINISTRATION 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 9 – 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

10. VETERANS HEALTH ADMINISTRATION Clinical Case Registry Components 10 130 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

11. VETERANS HEALTH ADMINISTRATION 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 11

12. VETERANS HEALTH ADMINISTRATION HIV Population in VA Care 12

13. VETERANS HEALTH ADMINISTRATION 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 13

14. VETERANS HEALTH ADMINISTRATION 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 14

15. VETERANS HEALTH ADMINISTRATION NQF Measures over Time 15

16. VETERANS HEALTH ADMINISTRATION NQF Measures over Time 16

17. VETERANS HEALTH ADMINISTRATION NQF Measures over Time 17

18. VETERANS HEALTH ADMINISTRATION NQF Measures: 2011 Measure National Number Eligible National Rate (%) 76 Large Facilities (≥100 patients) Minimum Facility Rate (%) Maximum Facility Rate (%) HBV Screening20,28298%86%100% HCV Screening20,28298%93%100% Antiretroviral Therapy18,53693%82%100% CD4 Testing20,28289%71%99% HBV Immunity/Vaccination18,87188%67%98% PCP Prophylaxis2,18476%14%100% LTBI Screening19,45575%40%99% HIV RNA Control17,68574%26%91% Syphilis Screening20,28265%16%98% 18

19. VETERANS HEALTH ADMINISTRATION HIV Patients with Diabetes over Time 19

20. VETERANS HEALTH ADMINISTRATION 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%* 20 * For this measure only, lower rates are better

21. VETERANS HEALTH ADMINISTRATION HEDIS Diabetes Care Measures Over Time 21

22. VETERANS HEALTH ADMINISTRATION HEDIS Diabetes Care Measures: 2011 Measure National Rate: HIV (%) 59 Large Facilities (≥25 HIV/Diabetes patients) National Rate: VA (%) 1 Minimum Facility Rate (%) Maximum Facility Rate (%) HgbA1c Testing91%78%100%98% LDL Testing92%85%100%97% Renal Monitoring87%71%100%95% Eye Exam78%58%93%90% Blood Pressure Control73%52%88%81% LDL Control60%36%78%69% Poor HgbA1c Control*21%39%7%17% 22 1 FY2011 VA Data from Office of Analytics and Business Intelligence, vaww.oqp.med.va.gov * For this measure only, lower rates are better

23. VETERANS HEALTH ADMINISTRATION 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. 23

24. VETERANS HEALTH ADMINISTRATION Thank You All HIV providers and local CCR Coordinators who make the data possible Population Health Staff Pam BelperioJoanne McDay Paula EdwardsLarry Mole Jim HalloranBarbara Phillips Vera KatsevaI-Chun Thomas Tim LoomisGale Yip AITC staff, NTEO staff, OIT staff For more information http://vaww.vistau.med.va.gov/VistaU/ccr/default.htm 24