Clinical Case Registries (CCR): Local and National Registries to Improve HIV Care

1. 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. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Clinical Case Registry Components Internet VA Intranet CCR Data clean-up EMR CCR Nightly data sweep National Reports EMR National CCR Local registry functions/reports VISNs CCR VACO EMR CCR Population Health Palo Alto VA Medical Center Patients EMR Conferences 130 local registries built on local electronic medical record (EMR) at all VA facilities Clinicians

11. 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

12. HIV Population in VA Care

13. 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

14. 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

15. NQF Measures over Time

16. NQF Measures over Time

17. NQF Measures over Time

18. NQF Measures: 2011

19. HIV Patients with Diabetes over Time

20. 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

21. HEDIS Diabetes Care Measures Over Time

22. HEDIS Diabetes Care Measures: 2011 * For this measure only, lower rates are better 1FY2011 VA Data from Office of Analytics and Business Intelligence, vaww.oqp.med.va.gov

23. 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 • .

24. 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