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Secondary Data Analysis:

Secondary Data Analysis:. Opportunities and Pitfalls. Who am I and why am I here?. Laurel A. Copeland, BS MPH PhD – VA Health Services Research & Development Investigator; UTHSCSA Department of Psychiatry Assistant Professor copelandl@uthscsa.edu http://czresearch.com/dropbox.

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Secondary Data Analysis:

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  1. Secondary Data Analysis: Opportunities and Pitfalls

  2. Who am I and why am I here? • Laurel A. Copeland, BS MPH PhD • – VA Health Services Research & Development Investigator; UTHSCSA Department of Psychiatry Assistant Professor • copelandl@uthscsa.edu • http://czresearch.com/dropbox

  3. What Can Secondary Data Analysis Do for You? • Provide preliminary data for grant proposals • Facilitate publication while you apply for grants • Explore new areas

  4. Shope JT, Copeland LA, Maharg R, Dielman TE, Butchart AT (1993). Health Education Quarterly 20: 373-390. Shope JT, Copeland LA, Dielman TE (1994). Alcoholism: Clin Exper Res 18: 726-733. Shope JT, Copeland LA, Marcoux BC, Kamp ME (1996). J Drug Educ, 26: 323-337. Shope JT, Copeland LA, Maharg R, Dielman TE (1996). Alcoholism: Clin Exper Res 20: 791-798. Copeland LA, Shope JT, Waller PF (1996). J School Health 66: 254-260. Barry KL, Fleming MF, Manwell L, Copeland LA (1997). J Fam Prac 45: 151-158. Zimmerman MA, Copeland LA, Shope JT, Dielman, TE (1997). J Youth Adolescence 26: 117-141. Barry KL, Fleming MF, Manwell L, Copeland LA, Appel, Scott (1998). Fam Med 30:366-371. Blow FC, Barry KL, BootsMiller BJ, Copeland LA, McCormick R, Visnic S (1998). J Psychiatric Research 32: 311-319. Valenstein M, Barry KL, Blow FC, Copeland LA, Ullman E (1998). Psychiatric Services 49: 1043-1048. Shope JT, Copeland LA, Kamp ME, Lang SW (1998). J Drug Educ 28: 185-197. Kales HC, Blow FC, Copeland LA, Bingham RC, Kammerer EE, Mellow AF (1999). Am J Psychiatry 156: 550-556. Blow FC, Barry KL, Copeland LA, McCormick R, Lehmann L, Ullman E (1999). Psychiatric Services 50: 390-394. Maio RF, Shope JT, Blow FC, Copeland LA, Gregor MA, Brockmann LM, Weber JE, Metrou ME (2000). Annals Emerg Med 35:252-7. Kales HC, Blow FC, Bingham RC, Copeland LA, Mellow AM (2000). Psychiatric Services 51: 795-800. Roberts JS, Blow FC, Copeland LA, Barry KL, Van Stone W (2000). J Ger Psychiatry Neurology 13: 78-86. Blow FC, Walton MA, Barry KL, Coyne JC, Mudd SA, Copeland LA (2000). JAGS 48: 769-774. Kales HC, Blow FC, Bingham RC, Roberts JS, Copeland LA, Mellow AM (2000). Am J Geriatric Psychiatry 8:301-309. Blow FC, Ullman E, Barry KL, Bingham CR, Copeland LA, McCormick R, Van Stone W (2000). Am J Orthopsychiatry 70: 389-400. Valenstein M, Copeland LA, Owen R, Blow FC, Visnic S (2001). J Clin Psychiatry 62: 545-551. Valenstein M, Copeland LA, Owen R, Blow FC, Visnic S (2001). Psychiatric Services 52: 1242-4. Duffy SA, Terrell, Jeff, Valenstein M, Ronis, David, Copeland LA, Connors, Mary (2002). Gen Hosp Psychiatry 24: 140-7. Valenstein M, Copeland LA, Blow FC, McCarthy JF, Zeber JE, Gillon L, Bingham CR, Stavenger T (2002). Med Care 40: 630-9. Hegedus, Andrea M, Copeland LA, Barry KL, Blow FC. (2002). American Journal of Orthopsychiatry 72: 331-340. Copeland LA, Blow FC, Barry KL (2003). Health Education & Behavior 30:305-21. Copeland LA, Zeber JE, Valenstein M, Blow FC (2003). Am J Psychiatry 160:1817-1822. Valenstein M, Blow FC, Copeland LA, McCarthy JF, Zeber JE, Gillon L, Bingham CR, Stavenger T (2004). Schizophr Bull 30: 255-64. Janz NK, Wren PA, Copeland LA, Lowery JC, Goldfarb SL, Wilkins EG. (2004). J Clin Oncology 22:3091-3098. Lambert MT, Terrell JE, Copeland LA, Ronis DL, Duffy SA. (2005). Nicotine & Tobacco Research 7:233-241. Copeland LA, Fletcher CE, Patterson J(2005). Military Medicine 170:602-606. Copeland LA, Elshaikh MA, Jackson J, Penner LA, Underwood III W (2005). Cancer 104:1372-1380. O'Neill JL, Flanagan PS, Zaleon CR, Copeland LA (2005). Pharmacotherapy 25:1560-1565. Pugh MJV, Copeland LA, Zeber JE, Cramer JA, Amuan MT, Cavazos JE, Kazis LE (2005). Epilepsia 46:1820-7. Copeland LA, Zeber JE, Rosenheck RA, Miller AL (2006). Med Care 44:110-116. Lambert MT, Copeland LA, Sampson N, Duffy SA (2006). Progress Neuropsychopharm Biol Psychiatry 30:919-23. Hopp FP, Woodbridge P, Subramanian U, Copeland LA, Smith D, Lowery JC (2006). Telemedicine and eHealth 12:297-307. Silveira MJ, Copeland LA, Feudtner C (2006). Am J Public Health 96:1243-1248. Zeber JE, Copeland LA, Grazier KL (2006). Military Medicine 171:619-26. Wilkins EG, Lowery JC, Copeland LA, Goldfarb SL, Wren PA, Janz NA (2006). Medical Decision Making 26:589-598. Copeland LA, Mortensen EM, Zeber JE, Pugh MJ, Restrepo MI, Dalack GW (2007). Progress Neuro-Psychopharm Biol Psychiatry 31:720-6 Alexander JA, Copeland LA, Metzger ME (2007). Clinical Toxicology 45(5):440-50. Kilbourne AM, Copeland LA, Zeber JE, Bauer MS, Lasky EC, Good CB (2007). Psychopharmacology Bulletin 40:104-15 Fletcher CE, Baker SJ, Copeland LA, Reeves PJ, Lowery JC (2007). Journal of Nursing Scholarship 39:358-62 Duffy SA, Copeland LA, Hopp FP, Zalenski RJ (2007). Journal of Palliative Medicine 10:1137-45 Mortensen EM, Restrepo MI, Copeland LA, Pugh JA, Anzueto AR, Cornell JE, Pugh MJ (2007). Pharmacotherapy 27: 1619-26 Kilbourne AM, Post EP, Bauer MS, Zeber JE, Copeland LA, Good CB, Pincus HA (2007). J Affective Disorders 102:145-51. Zeber JE, Copeland LA, Amuan ME, Cramer JA, Pugh MJ (2007). Epilepsy & Behavior 10:539-46. Mortensen EM, Pugh MJ, Copeland LA, Restrepo MI, Cornell JE, Anzueto A, Pugh JA (2008). Eur Respir J 31(3):611-7. Copeland LA, Zeber JE, Salloum IM, Pincus HA, Fine MJ, Kilbourne AM (2008). J Nerv Ment Disease 196:16-21. Leibowitz RQ, Jeffreys MD, Copeland LA, Noel PH (2008). Gen Hosp Psychiatry 30:100-3. Pugh MJ, Van Cott AC, Cramer JA, Knoefel JE, Amuan ME, Tabares J, Ramsay RE, Berlowitz DR; TIGER Team (2008). Neurology 70:2171-8. Zeber JE, Copeland LA, Good CB, Fine MJ, Bauer MS, Kilbourne AM (2008). J Affect Disord 107:53-62. Copeland LA, Zeber JE, Pugh MJ, Mortensen EM, Restrepo MI, Lawrence VA (2008). Annals Surg 248:31-8. Pugh MJ, Zeber JE, Copeland LA, Tabares JV, Cramer JA (2008). Psychiatric Services 59:925-8. Zeber JE, Copeland LA, Hosek BJ, Karnad AB, Lawrence VA, Sanchez-Reilly SE (2008). Crit Rev Oncology/Hematology 67:237-42. Mortensen EM, Restrepo MI, Copeland LA, Pugh JA, Anzueto AR (in press). Am J Med Sci Zeber JE, Copeland LA, McCarthy JF, Bauer MS, Kilbourne AM (in press). Am J Public Health Copeland LA, Miller AL, Welsh DE, McCarthy JF, Zeber JE, Kilbourne AM (in press). Am J Public Health My CV

  5. My CV without 2° Data • Shope JT, Copeland LA, Maharg R, Dielman TE, Butchart AT (1993). Health Education Quarterly 20: 373-390. • Shope JT, Copeland LA, Dielman TE (1994). Alcoholism: Clin Exper Res 18: 726-733. • Shope JT, Copeland LA, Marcoux BC, Kamp ME (1996). J Drug Educ, 26: 323-337. • Shope JT, Copeland LA, Maharg R, Dielman TE (1996). Alcoholism: Clin Exper Res 20: 791-798. • Copeland LA, Shope JT, Waller PF (1996). J School Health 66: 254-260. • Barry KL, Fleming MF, Manwell L, Copeland LA (1997). J Fam Prac 45: 151-158. • Zimmerman MA, Copeland LA, Shope JT, Dielman, TE (1997). J Youth Adolescence 26: 117-141. • Barry KL, Fleming MF, Manwell L, Copeland LA, Appel, Scott (1998). Fam Med 30:366-371. • Blow FC, Barry KL, BootsMiller BJ, Copeland LA, McCormick R, Visnic S (1998). J Psychiatric Research 32: 311-319. • Valenstein M, Barry KL, Blow FC, Copeland LA, Ullman E (1998). Psychiatric Services 49: 1043-1048. • Shope JT, Copeland LA, Kamp ME, Lang SW (1998). J Drug Educ 28: 185-197. • Kales HC, Blow FC, Copeland LA, Bingham RC, Kammerer EE, Mellow AF (1999). Am J Psychiatry 156: 550-556. • Blow FC, Barry KL, Copeland LA, McCormick R, Lehmann L, Ullman E (1999). Psychiatric Services 50: 390-394. • Maio RF, Shope JT, Blow FC, Copeland LA, Gregor MA, Brockmann LM, Weber JE, Metrou ME (2000). Annals Emerg Med 35:252-7. • Kales HC, Blow FC, Bingham RC, Copeland LA, Mellow AM (2000). Psychiatric Services 51: 795-800. • Roberts JS, Blow FC, Copeland LA, Barry KL, Van Stone W (2000). J Ger Psychiatry Neurology 13: 78-86. • Blow FC, Walton MA, Barry KL, Coyne JC, Mudd SA, Copeland LA (2000). JAGS 48: 769-774. • Kales HC, Blow FC, Bingham RC, Roberts JS, Copeland LA, Mellow AM (2000). Am J Geriatric Psychiatry 8:301-309. • Blow FC, Ullman E, Barry KL, Bingham CR, Copeland LA, McCormick R, Van Stone W (2000). Am J Orthopsychiatry 70: 389-400. • Valenstein M, Copeland LA, Owen R, Blow FC, Visnic S (2001). J Clin Psychiatry 62: 545-551. • Valenstein M, Copeland LA, Owen R, Blow FC, Visnic S (2001). Psychiatric Services 52: 1242-4. • Duffy SA, Terrell, Jeff, Valenstein M, Ronis, David, Copeland LA, Connors, Mary (2002). Gen Hosp Psychiatry 24: 140-7. • Valenstein M, Copeland LA, Blow FC, McCarthy JF, Zeber JE, Gillon L, Bingham CR, Stavenger T (2002). Med Care 40: 630-9. • Hegedus, Andrea M, Copeland LA, Barry KL, Blow FC. (2002). American Journal of Orthopsychiatry 72: 331-340. • Copeland LA, Blow FC, Barry KL (2003). Health Education & Behavior 30:305-21. • Copeland LA, Zeber JE, Valenstein M, Blow FC (2003). Am J Psychiatry 160:1817-1822. • Valenstein M, Blow FC, Copeland LA, McCarthy JF, Zeber JE, Gillon L, Bingham CR, Stavenger T (2004). Schizophr Bull 30: 255-64. • Janz NK, Wren PA, Copeland LA, Lowery JC, Goldfarb SL, Wilkins EG. (2004). J Clin Oncology 22:3091-3098. • Lambert MT, Terrell JE, Copeland LA, Ronis DL, Duffy SA. (2005). Nicotine & Tobacco Research 7:233-241. • Copeland LA, Fletcher CE, Patterson J(2005). Military Medicine 170:602-606. • Copeland LA, Elshaikh MA, Jackson J, Penner LA, Underwood III W (2005). Cancer 104:1372-1380. • O'Neill JL, Flanagan PS, Zaleon CR, Copeland LA (2005). Pharmacotherapy 25:1560-1565. • Pugh MJV, Copeland LA, Zeber JE, Cramer JA, Amuan MT, Cavazos JE, Kazis LE (2005). Epilepsia 46:1820-7. • Copeland LA, Zeber JE, Rosenheck RA, Miller AL (2006). Med Care 44:110-116. • Lambert MT, Copeland LA, Sampson N, Duffy SA (2006). Progress Neuropsychopharm Biol Psychiatry 30:919-23. • Hopp FP, Woodbridge P, Subramanian U, Copeland LA, Smith D, Lowery JC (2006). Telemedicine and eHealth 12:297-307. • Silveira MJ, Copeland LA, Feudtner C (2006). Am J Public Health 96:1243-1248. • Zeber JE, Copeland LA, Grazier KL (2006). Military Medicine 171:619-26. • Wilkins EG, Lowery JC, Copeland LA, Goldfarb SL, Wren PA, Janz NA (2006). Medical Decision Making 26:589-598. • Copeland LA, Mortensen EM, Zeber JE, Pugh MJ, Restrepo MI, Dalack GW (2007). Progress Neuro-Psychopharm Biol Psychiatry 31:720-6 • Alexander JA, Copeland LA, Metzger ME (2007). Clinical Toxicology 45(5):440-50. • Kilbourne AM, Copeland LA, Zeber JE, Bauer MS, Lasky EC, Good CB (2007). Psychopharmacology Bulletin 40:104-15 • Fletcher CE, Baker SJ, Copeland LA, Reeves PJ, Lowery JC (2007). Journal of Nursing Scholarship 39:358-62 • Duffy SA, Copeland LA, Hopp FP, Zalenski RJ (2007). Journal of Palliative Medicine 10:1137-45 • Mortensen EM, Restrepo MI, Copeland LA, Pugh JA, Anzueto AR, Cornell JE, Pugh MJ (2007). Pharmacotherapy 27: 1619-26 • Kilbourne AM, Post EP, Bauer MS, Zeber JE, Copeland LA, Good CB, Pincus HA (2007). J Affective Disorders 102:145-51. • Zeber JE, Copeland LA, Amuan ME, Cramer JA, Pugh MJ (2007). Epilepsy & Behavior 10:539-46. • Mortensen EM, Pugh MJ, Copeland LA, Restrepo MI, Cornell JE, Anzueto A, Pugh JA (2008). Eur Respir J 31(3):611-7. • Copeland LA, Zeber JE, Salloum IM, Pincus HA, Fine MJ, Kilbourne AM (2008). J Nerv Ment Disease 196:16-21. • Leibowitz RQ, Jeffreys MD, Copeland LA, Noel PH (2008). Gen Hosp Psychiatry 30:100-3. • Pugh MJ, Van Cott AC, Cramer JA, Knoefel JE, Amuan ME, Tabares J, Ramsay RE, Berlowitz DR; TIGER Team (2008). Neurology 70:2171-8. • Zeber JE, Copeland LA, Good CB, Fine MJ, Bauer MS, Kilbourne AM (2008). J Affect Disord 107:53-62. • Copeland LA, Zeber JE, Pugh MJ, Mortensen EM, Restrepo MI, Lawrence VA (2008). Annals Surg 248:31-8. • Pugh MJ, Zeber JE, Copeland LA, Tabares JV, Cramer JA (2008). Psychiatric Services 59:925-8. • Zeber JE, Copeland LA, Hosek BJ, Karnad AB, Lawrence VA, Sanchez-Reilly SE (2008). Crit Rev Oncology/Hematology 67:237-42. • Mortensen EM, Restrepo MI, Copeland LA, Pugh JA, Anzueto AR (in press). Am J Med Sci • Zeber JE, Copeland LA, McCarthy JF, Bauer MS, Kilbourne AM (in press). Am J Public Health • Copeland LA, Miller AL, Welsh DE, McCarthy JF, Zeber JE, Kilbourne AM (in press). Am J Public Health

  6. Is it scientifically valid to use data for purposes for which it was not originally collected? • Yes, because…. • No, because… • Maybe…please use caution

  7. Today and next week • Uses of secondary data • Common biases encountered with secondary data • Methods of adjustment • Sources of secondary data • Possible effects of HIPAA on this type of research

  8. Different Uses • Health Care Delivery • Quality assessment • Geographic variation; under-/over-utilization • Adverse events • Outcomes of a particular treatment • Cost • Natural history • incidence, prevalence • prognosis • Association not causation • Other • Regulatory

  9. Some Examples To show you the range of uses To show you the work is publishable

  10. Regulatory enforcement • TENET HEALTHCARE - 2002 • Medicare Report Jan-Oct 2004 included these findings: • – At Alvarado Hospital, prosecutors accused Tenet of running covert kickback arrangements • – Document requests were received from federal prosecutors in L.A. • – False claims were uncovered and the company agreed to pay $22.5M to settle allegations • – Redding Medical Center was determined to be performing unnecessary cardiac surgery • – Tenet sold some holdings to Hospital Partners of America to satisfy part of the 2003 settlement with federal officials • – Whistleblowers were to receive over $8M

  11. Whose data set is it anyway? Sharing raw data from randomized trials Andrew J Vickers Trials. 2006 May 16;7:15 http://www.trialsjournal.com/content/pdf/1745-6215-7-15.pdf

  12. Risk of death in elderly users of conventional vs. atypical antipsychotic medications Wang PS, Schneeweiss S, Avorn J, Fischer MA, Mogun H, Solomon DH, Brookhart MA. N Engl J Med. 2005 Dec 1;353(22):2335-41 http://content.nejm.org/cgi/reprint/353/22/2335.pdf

  13. Cancer incidence in Kentucky, Pennsylvania, and West Virginia: disparities in Appalachia Lengerich EJ, Tucker TC, Powell RK, Colsher P, Lehman E, Ward AJ, Siedlecki JC, Wyatt SW (2005). J Rural Health 21(1):39-47. http://www.blackwell-synergy.com/toc/jrh/21/1

  14. Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly? Shih YC, Zhao L, Elting LS (2006). Health Aff (Millwood). Jul-Aug; 25(4):1153-62.http://content.healthaffairs.org/cgi/content/full/25/4/1153

  15. Can you think of examples of secondary data analysis that you have read in the medical literature? • Any that have changed your practice or your research direction?

  16. Methods of Learning • Lecture • In class epidemiologic exercise • Journal article evaluation – readings are online (http://czresearch.com/dropbox/) • Optional brief proposal for your own secondary data analysis

  17. Exercise #1 Policy Decision on FundingOf Regional Trauma Center (handout)

  18. Secondary Data Exercise #1 A Regional Trauma Center (which encourages the surrounding hospitals to refer patients with serious injuries to it for expert care) is seeking additional funds from next year’s health budget for more equipment and staff. A local politician (who would rather spend such money on a new hospital named after his father) criticizes this request for additional resources by claming that Regional Trauma Centers do not, in fact, save lives, and he submits the following data to back up his claim. You are asked for your opinion on these data. How should you respond?

  19. Secondary Data Exercise #1 A Regional Trauma Center (which encourages the surrounding hospitals to refer patients with serious injuries to it for expert care) is seeking additional funds from next year’s health budget for more equipment and staff. A local politician (who would rather spend such money on a new hospital named after his father) criticizes this request for additional resources by claming that Regional Trauma Centers do not, in fact, save lives, and he submits the following data to back up his claim. By examining the data stratified by severity, the value of the regional trauma center becomes clear.

  20. Bias • Systematic error in measurement or a systematic difference (other than the one of interest) between groups • Selection • For cohorts, assembly, migration, contamination, and referral bias • Measurement • Confounding

  21. Bias: Anticipate and Control • Restriction (may lose generalizability) • Matching • Stratification • Standardization • Multivariate Adjustment • Assuming the worst (sensitivity analyses) • Discussing possible effects on your results

  22. Example: Hospital Mortality Report Cards • Originally unadjusted • Hospitals without trauma centers, doing primarily elective surgery, etc., looked really good • Made hospitals who took care of the sickest of the sick look bad

  23. Quality Assessment • Data Quality: Garbage in, garbage out • Risk Adjustment: To remove the confounding effect of different institutions providing care to patients with dissimilar severity of illness and case complexity

  24. Interpret data carefully

  25. Data Quality • If no reliable (accurate and adequate) data are available, questions about risk adjustment are moot • Inconsistent practices in assigning standard ICD9 codes & names to diseases exist—but this has improved over time (Do you know who assigns the codes?) http://www.eicd.com/ • Lack of specificity of ICD9 system in some diagnostic areas, especially with regard to severity

  26. Administrative Data Limitations • Need patient-specific identifiers to link episodes • Need multi-year data when outcomes are infrequent • Limited generalizability if restricted by type of institution or hospital, by type of payor, or by location/region • May lack important clinical variables known to be related to outcomes (especially clinical tests or qualitative evaluations of severity)

  27. Risk Adjustment • Controls for those patient characteristics that are related to the outcomes of interest • Removes the confounding effect of different institutions providing care to patients with dissimilar severity of illness and case complexity • Addresses regional variations • Inadequate case-mix adjustment can lead to misclassification of outlier status

  28. Risk Adjustment • Primary data collection vs. administrative data • Disease-specific vs. generic • Commercial vs. developed for your study • Predictors vary by outcomes being predicted

  29. Essential Elements of Risk Adjustment • Outcome-specific • Contains specification of the principal diagnosis • Contains demographics as proxies for preexisting physiological reserve • Measure count of comorbidities and all the most important comorbidities to assume their own empirically derived coefficients

  30. Classification of Disease States • ICD-9: too many specific codes (n~10,000) • Clinical Classifications for Health Policy Research (CCHPR): good for chronic illness and longitudinal care [http://www.ahrq.gov/data/hcup/his.htm] • Primary diagnosis: good for studies that focus on a single episode of care

  31. Risk Adjustment: Charlson • Advantages: • Commonly used case-mix classification system in the health care industry • System with which most clinicians and reviewers are familiar

  32. Risk Adjustment: Charlson • Disadvantages • Principal diagnosis not differentiated • Original work did not specify ICD-9 codes that went into the disease categories • Developed on inpatients predicting mortality; may not be well suited to outpatients at low risk of death • Not good for longitudinal care / chronic illness

  33. Demographic Factors to Consider in Risk Adjustment • Age (e.g., age-adjusted Charlson) • Proxies of Social Support • Marital status • Race • Gender • SES (occupation, employment status, education) • Proxies of Socioeconomic Status • Health insurance status • Home address zip code average income

  34. Race and Gender • Don’t adjust for automatically • Ideally adjust for variation in the patients’ physiological reserve and disease burden but not for variation in care rendered to patients

  35. Propensity Scores • Useful when dataset is small, to conserve power • Need a good proxy to develop a propensity score • Ask: propensity for what? • Include as many predictors as possible to get predicted probability of group membership (Rosenbaum & Rubin) • Published schema may include predictors you want to study separately • Best for non-randomized studies of treatment effect where you want to adjust for the factors that may have influenced the treatment choices

  36. Your Assignment • Read; think • If you want extra feedback, e-mail me a 1-page proposal (abstract) for a database analysis related to your area of interest any time in next few years copelandl@uthscsa.edu

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