# Presentation: 717065

##   VIReC CyberSeminar Series 2006 VA Databases and Methods

**Assessing VA Outpatient **
**Healthcare Use**
- Presented by
- Denise M. Hynes, Ph.D., R.N.
- Director, VIReCResearch Health Scientist, MCHSPR COE

## Session Objectives

- Why Measuring Outpatient Use is Not Always as Simple as it Seems
- Key Data Source Review: Medical SAS Outpatient Databases & DSS Outpatient
- Measurement Strategies for Evaluating Outpatient Care Use
- Where To Go For More Help

## Session Objectives

**Why Measuring Outpatient Use is Not Always as Simple as it Seems**
- Key Data Source Review: Medical SAS Outpatient Databases
- Measurement Strategies for Evaluating Outpatient Use
- Where To Go For More Help

## Outpatient Use Measurement Issues

- Frequency of outpatient visits
*Recent year? Longer historical view?*
- Specific types of outpatient visits by provider type
*Separate nurse visits from physician visits*
- Specific types of clinical settings or clinics
*Dialysis care? CBOCs versus VAMC Outpatient?*
- Outpatient procedures
*Can a CABG really be done in an outpatient setting?*
- When outpatient care overlaps with inpatient care
*Which is it?*
- Assessing comorbidity with outpatient care data
*Inpatient diagnoses versus outpatient diagnoses*

## Session Objectives

- Why Measuring Outpatient Use is Not Always as Simple as it Seems
**Key Data Source Review: Medical SAS Outpatient Databases** **& DSS Outpatient**** **
- Measurement Strategies for Evaluating Outpatient Use
- Where To Go For More Help

## VA Outpatient Medical SAS Datasets

- AKA as OPC (Outpatient Clinic File) or National Patient Care Database (NPCD) Outpatient SAS files
- Records generated for each ambulatory care encounter recorded in VISTA
- Outpatient events coded by CPT code, whereas Inpatient Datasets coded by ICD9

## VA Outpatient Data Flow to the MedSAS Datasets

## VA Medical SAS Outpatient Datasets

| File | Reference | Dates |
| --- | --- | --- |
| Visit | SF | 1980 - present |
| Event | SE | 1998 – present |
| Diagnosis | SG | 1997 – 2001 |
| Procedure | SC | 1990 - 2001 |

## Data Elements Common In Outpatient Med SAS Datasets

- Patient identifier (SCRSSN)
- Patient demographics (Age, date of birth, race, marital status)
- Patient Zip Code, County, & State of Residence
- Date of encounter

## Common Data Elements

- Means Test Indicator (MEANS)
- Patient eligibility code (ELIG)
- ELIG < 11 identifies a veteran
- Agent Orange exposure claimed (AOIND/AGOLOC)
- Radiation exposure claimed (RAD)
- Visit: 4 categories
- Event: exposed vs. not exposed

## Outpatient Visit Dataset (SF)

- Record = One day’s encounters for a patient at a clinic

## Outpatient Visit (SF) DatasetSelected Data Elements

- One record per visit
- Up to 15 clinic stops per visit
- No diagnosis or procedure information
- Race:
- RACE
- RACE1 – RACE7 from FY2004
- Insurance and religious preference only in Visit file

## Outpatient Event (SE) Dataset

- Record = Ambulatory encounter
- Coded as Primary Clinic Stop, which is officially referred to as DSS Identifier
- No limit on number of encounters per day

## Outpatient Event (SE) DatasetSelected Data Elements

- Record = Ambulatory encounter or clinic stop
- No limit on number of clinic stops per day
- Up to 10 diagnoses in ICD-9 codes (DXLSF, DXF2 – DXF10) per record
- Until FY2003: Up to 15 procedures in CPT4 codes (CPT1 – CPT15), no repeats allowed
- Since FY2004: Up to 20 CPT4 codes with repetition allowed
- Encounter ID to link the Event dataset with HERC Outpatient Average Cost Dataset since FY2003
- Appointment type only in Event Dataset

## VA Outpatient Med SAS Datasets

- Datasets in AAC are named  **MDPPRD.MDP.SAS.(XXyy) **where XX = the two letter code below and yy = two digit FY
**Outpatient Care**
**SE** – Outpatient Event File
- Information about each encounter (clinic stop) during a day’s outpatient care
- Combines diagnostic and procedural info in one dataset
**SF **– Outpatient Visit File (expanded in FY97 to include demographics previously in SC)
- Information about a day’s outpatient care encounters
**Outpatient Care – discontinued datasets**
**SC **– Outpatient Procedure File (not generated after FY2001)
- Contains CPT-4 outpatient procedure information
- Now folded into SE
**SG** – Outpatient Diagnosis File (not generated after FY2001)
- Contains outpatient ICD-9-CM diagnosis information
- Now folded into SE

## Strengths of VA Outpatient Med SAS Datasets

- Centralized data source
- Large groups of patients
- Unique identifier (SCRSSN: Scrambled Social Security Number) allows linking records across files/years
- Given good coding, datasets are reflective of general clinical status
- Historical data available back to 1970’s

## Limitations of VA Outpatient Med SAS Datasets

- Does not include all outpatient care dimensions
- Does not include VA home care or telehealth events
- Fee basis care, contract care, and Medicare outpatient use available in separate national datasets
- Non-VA non-Medicare outpatient care use not included

## Another Data Source:  DSS National Data Extract (NDE) Outpatient (OPAT) File 

- Available since FY99
- Has one record for each unique clinic stop visit
- Seven indicator variables (flags) to identify different types of data sources in outpatient clinic records
- Linkable with other VA data
- Due to large file size, data are grouped by VISNs and divided into Clinic Stop 160 (Pharmacy) and all other stops

## DSS NDE OPAT Dataset

- Includes costs fields
- Some discrepancies with NPCD/OPC exist
- HERC Report #9 on *Reconciliation of DSS Encounter-level National Data Extracts with the VA National Patient Care Database, FY2001-FY 2002*

## Session Objectives

- Why Measuring Outpatient Use is Not Always as Simple as it Seems
- Key Data Source Review: Medical SAS Outpatient Databases & DSS Outpatient
**Measurement Strategies for Evaluating Outpatient Use**
- Where To Go For More Help

## Measurement Strategies in Evaluating Outpatient Use: Outpatient Procedures

- Outpatient Outpatient Event (SE) File has information about each encounter
- Appointment type only in Outpatient Event File
- Encounter = “clinic stop”
- Primary Clinic Stop (CL): The first three characters of the 6-character Decision Support System (DSS) Identifier used to identify the production units or the revenue centers for outpatient care.
- Secondary Clinic Stop (CLC): The last three characters of the DSS Identifier
- No limit on number of encounters/clinic stops per day; no priority order
- Since FY2004: Up to 20 CPT4 codes with repetition allowed; before, up to 15 procedures with no repeats allowed; no priority order
- Note: You may want to exclude emergency room visits (CL = 101, 102)
- Outpatient Visit (SF) File has information about a _day’s_ encounters
- One record per visit
- Up to 15 clinic stops per visit
***No procedure information***

## Measurement Strategies in Evaluating Outpatient Use: Outpatient Surgeries

- Look by CPT code in Outpatient Event (SE) File
- Look by Clinic Stop (variables: CL, CLC) in Outpatient Event (SE) File
- Sampling of clinic stop codes: General Surgery (CL = 401), Cardiac Surgery (CL = 402), Neurosurgery (CL = 406). For complete list of clinic stop codes, refer to: _[http://www.virec.research.va.gov/References/RUG/RUG-_x000b_Outpatient04.pdf](http://www.virec.research.va.gov/References/RUG/RUG-%0BOutpatient04.pdf)_
- Outpatient Surgeries could be included in Inpatient Workload
- If interested in a particular type of surgery, also refer to Inpatient MedSAS Surgery and Procedure files – different facilities record procedures differently depending upon whether the procedure was done as an outpatient/inpatient or in the OR suite/outpatient surgery.
- Check the VA’s Fee Basis files for information on surgeries that are typically done on a fee basis: _[http://](http://www.herc.research.med.va.gov/data/fb.asp)__[www.herc.research.med.va.gov/data/fb.asp](http://www.herc.research.med.va.gov/data/fb.asp)_

## Measurement Strategies in Evaluating Outpatient Care: Including Outpatient SurgeriesExample from Morrison, et al CSP#385

- Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) trial CSP #385, PI: Douglass Morrison MD, PhD)
- This RCT compared Percutaneous Coronary Interventions (PCI, previously known as angioplasty) to Coronary Artery Bypass Grafts (CABG) for the urgent revascularization of medically refractory, high-risk myocardial ischemia patients
- Compared survival and survival free of angina for men with medically refractory myocardial ischemia at high-risk for adverse outcomes
- Also conducted a cost-effectiveness analysis of PCI vs. CABG in these patients – cost-effectiveness analysis funded by NIH R03 HL70287, PI: Kevin Stroupe, PhD
- Concluded that the PCI-assigned patients had lower medical costs and better survival, suggesting that PCI is the “economically dominant strategy” in high-risk patients

## Measurement Strategies in Evaluating Outpatient Use: Including Outpatient SurgeriesExample from Morrison, et al CSP#385

- The original AWESOME trial ran from Feb. 1995 – Feb. 2000. Using data from administrative databases we extended follow-up through Sep. 2003
- Data on hospital stays and outpatient visits in VA were from the VA National Patient Care Database Medical SAS Datasets
- Outpatient files: Outpatient Visit File; Outpatient Event File; Outpatient Procedure File
- Inpatient files: Acute Inpatient Files (PM, PB, PP, PS); Extended Care Files (XM, XB, XP, XS); Observation Files (PMO, PBO, PPO)
- To identify PCI or CABG procedures, used procedure codes in inpatient _***and***_ outpatient procedure (SC) files,
*	*_***and***_** **surgery ICD9CM codes in surgery files
*	*_***and***_*** ***used CPT codes in outpatient event (SE) file.
- Non-VA care paid for by VA was from the Fee Basis Files
- Medicare claims data for the 296 (67%) Medicare-eligible patients (i.e., 65 years of age or older) at enrollment

## 
Outpatient Event (SE) Dataset includes up to 10 diagnoses in ICD-9 codes (DXLSF, DXF2 – DXF10) per record
DXLSF = Primary Diagnosis for this encounter
DXF2 – DXF10 = Patient problems beyond the principal reason for the encounter--only 15% of records in FY99 contained a DXF2
Not available prior to FY97 
Agent orange and radiation exposure claimed is a common data element in all outpatient datasets

Outpatient Visit (SF) Dataset does *not* contain any diagnosis information

What if you were interested in diagnosis linked outpatient care prior to FY97??

- Outpatient Event (SE) Dataset includes up to 10 diagnoses in ICD-9 codes (DXLSF, DXF2 – DXF10) per record
- DXLSF = Primary Diagnosis for this encounter
- DXF2 – DXF10 = Patient problems beyond the principal reason for the encounter--only 15% of records in FY99 contained a DXF2
- Not available prior to FY97
- Agent orange and radiation exposure claimed is a common data element in all outpatient datasets
- Outpatient Visit (SF) Dataset does ****not**** contain any diagnosis information
***What if you were interested in diagnosis linked outpatient care prior to FY97??***

**Measurement Strategies in Evaluating Outpatient Use: Outpatient Diagnoses**

## No outpatient data element with physician specialty
Proxy: Area of care associated with the visit.
Outpatient Event dataset includes CMS category of provider (variable: PROV1–PROV10)
http://www.virec.research.va.gov/References/RUG/RUG-Outpatient04.pdf
Appendix A:
1100XX series physicians/osteopath
Eg. 110400 anesthesiology; 110600 cardiology; 110700 dermatology, etc.

- Proxy: Area of care associated with the visit.
- Outpatient Event dataset includes CMS category of provider (variable: PROV1–PROV10)
- _[http://www.virec.research.va.gov/References/RUG/RUG-Outpatient04.pdf](http://www.virec.research.va.gov/References/RUG/RUG-Outpatient04.pdf)_
- Appendix A:
- 1100XX series physicians/osteopath
- Eg. 110400 anesthesiology; 110600 cardiology; 110700 dermatology, etc.

**Measurement Strategies in Evaluating Outpatient Use: Outpatient Provider Specialty**

## Can link Inpatient and Outpatient databases via SCRSSN (Scrambled Social Security Number; patient unique identifier)
Identify inpatient event and dates of stay
All inpatient datasets include data on admission and discharge date and time
Use inpatient bedsection datasets to determine acute length of stay
Identify all outpatient procedures conducted during LOS
All outpatient datasets include date of encounter as a common data element (VIZDAY)
Outpatient Event File has information about each encounter’s procedures
To see if a patient has been discharged to outpatient treatment, refer to the “OPT” variable (outpatient treatment) in the Inpatient Main dataset (1 = Yes, 2 = Due to service-connected disability, patient is automatically eligible for outpatient care)

- Identify inpatient event and dates of stay
- All inpatient datasets include data on admission and discharge date and time
- Use inpatient bedsection datasets to determine acute length of stay
- Identify all outpatient procedures conducted during LOS
- All outpatient datasets include date of encounter as a common data element (VIZDAY)
- Outpatient Event File has information about each encounter’s procedures
- To see if a patient has been discharged to outpatient treatment, refer to the “OPT” variable (outpatient treatment) in the Inpatient Main dataset (1 = Yes, 2 = Due to service-connected disability, patient is automatically eligible for outpatient care)

**Measurement Strategies in Evaluating Outpatient Use: Outpatient Care Concomitant w/Inpatient Care**

## Measurement Strategies in Evaluating Outpatient Use: Intensity of Outpatient Care Example from Ashton et al., Am J Managed Care 2003

- Retrospective cohort study conducted by secondary analysis of Medical SAS Inpatient and Outpatient datasets
- Describe comorbid conditions and patterns of inpatient and outpatient service use by veterans with diabetes mellitus (DM)
- Utilization rates computed for 1997
- Measured intensity of care using Inpatient and Outpatient datasets
- Inpatient: bed-day rates (cumulative # of days in hospital)
- Outpatient: Rates of primary care visits, including ancillary services, consults, urgent care visits
- Results: In VA, beneficiaries with DM have a heavy burden of comorbidities, face a significant risk of dying, and are heavy users of inpatient and outpatient services.

**Notes:**
Other databases used:
BIRLS Death File to obtain vital status
OQP’s External Peer Review Program (EPRP) data to obtain information on adherence to clinical guidelines.
Limitations
Inclusion criteria (initial VA hospitalization for DM 1992 – 1997) excludes people with mild diabetes mellitus treated solely in the ambulatory care sector

## Measurement Strategies in Evaluating Outpatient Use: Outpatient Care Over Time Example from Maciejewski and Maynard, Diabetes Care 2004

- Retrospective cohort study conducted by secondary analysis of Medical SAS Inpatient and Outpatient datasets
- Describe patterns of inpatient and outpatient care by veterans with diabetes mellitus (DM), stratified by age and racial group
- Inpatient utilization for years 1994-1998; outpatient utilization for years 1997-1998
- Used VA Medical SAS Inpatient to measure:
- Length of stay
- Number of hospital discharges
- Rate of hospital discharge
- Used VA Medical SAS Outpatient Datasets to measure:
- Number of outpatient visits
- Results: Between 1994-1998, hospitalization rates decreased and outpatient visits increased

## OPC-SE 

- From: Maciejewski ML and Maynard CM. Diabetes-Related Utilization and Costs for Inpatient and Outpatient Services in the Veterans Administration. _Diabetes_. 2004: 27(suppl 2):B69-B73.

- OPC-SE

- OPC SC since FY90

- OPC DX started in 1997

- OPC-SF-back to 1980
- But no DX field to identify the DM cases

**Outpatient Care Over Time****Example from Maciejewski and Maynard, 2004**

## Session Objectives

- Why Measuring Outpatient Use is Not Always as Simple as it Seems
- Key Data Source Review: Medical SAS Outpatient Databases
- Measurement Strategies for Evaluating Outpatient Care Use
**Where To Go For More Help **

## VIReC Help

- VIReC Webpage
-     _[http://www.virec.research.va.gov](http://www.virec.research.va.gov/)_
- Information on VA data sources and how to access data
- Documentation on some VA datasets, i.e., Medical SAS datasets:
- _[http://www.virec.research.va.gov/DataSourcesName/Medical-SAS-Datasets/SASdocumentation.htm](http://www.virec.research.va.gov/DataSourcesName/Medical-SAS-Datasets/SASdocumentation.htm)_
- Includes lists of variables and their dataset locations
- Descriptions of each of the variables
- Values for selected variables

## VIReC Help (cont’d)

- HSRData Listserv
- Join at VIReC Web site
- Discussion among > 200 data stewards, managers, and users
- Past messages in archive (on intranet)
- VIReC Help Desk
- VIReC staff will answer your question and/or direct you to available resources on topics
- _[VIReC@va.gov](mailto:VIReC@va.gov)_
- (708) 202-2413

## Selected Recent References on Measurement of VA Outpatient Use

- Murphy PA, Cowper DC, Seppala G, Stroupe KT, Hynes DM. Veterans Health Administration inpatient and outpatient care data: a rich resource of research data. _Effective Clinical Practice_. 2002: 5:e4. Available at _[http://](http://www.acponline.org/journals/ecp)__[www.acponline.org/journals/ecp](http://www.acponline.org/journals/ecp)_.
- Fortney JC, Borowsky SJ, Hedeen AN, Maciejewski ML, Chapko MK. VA community-based outpatient clinics: access and utilization performance measures. Medical Care. 2002: Jul;40(7): 561-9.
- Fuller MA, Shermock KM, Secic M, Laich JS, Durkin MB. Service use and costs among VA patients with schizophrenia taking risperidone or olanzapine. Psychiatr Serv. 2002: 53(7):855-60.
- Ashton CM, Septimus J, Petersen NJ, Souchek J, Menke TJ, Collings TC, Wray NP.  Healthcare use by veterans treated for diabetes mellitus in the Veterans Affairs medical care system. _American Journal of Managed Care_. 2003: 9(2):145-150.
- Maciejewski ML and Maynard CM. Diabetes-Related Utilization and Costs for Inpatient and Outpatient Services in the Veterans Administration. _Diabetes_. 2004: 27(suppl 2):B69-B73.
- Weaver FM, Hatzakis M, Evans CT, Smith B, LaVela SL, Wallace C, Legro MW, Goldstein B. A comparison of multiple data sources to identify vaccinations for veterans with spinal cord injuries and disorders. J Am Med Inform Assoc. 2004: 11(5):377-9. Epub 2004 Jun 7.
- Washington DL, Villa V, Brown A, Damron-Rodriguez J, Harada N. Racial/ethnic variations in veterans' ambulatory care use. Am J Public Health. 2005: 95(12):2231-7. Epub 2005 Oct 27.
- Payne SM, Lee A, Clark JA, Rogers WH, Miller DR, Skinner KM, Ren XS, Kazis LE. Utilization of medical services by Veterans Health Study (VHS) respondents. J Ambul Care Manage. 2005: Apr-Jun;28(2):125-40.
- Weeks WB, Bott DM, Lamkin RP, Wright SM. 2005. Veterans Health Administration and Medicare outpatient health care utilization by older rural and urban New England veterans. J Rural Health. 2005 Spring;21(2):167-71.
- Luther SL, French DD, Powell-Cope G, Rubenstein LZ, Campbell R. 2005. Using administrative data to track fall-related ambulatory care services in the Veterans Administration Healthcare system. Aging Clin Exp Res. 2005 Oct;17(5):412-8.
- Fortney JC, Steffick DE, Burgess JF Jr, Maciejewski ML, Petersen LA. Are primary care services a substitute or complement for specialty and inpatient services? Health Serv Res. 2005: Oct;40(5 Pt 1):1422-42.

## Suggested other resources Medical SAS Datasets:Data Quality Information

- Quality assessments performed by the Office of Inspector General, the Medical Care Cost Recovery program, and special workgroups
- Data Quality, Information Assurance, Office of Information  (http://vaww.vhaco.va.gov/dataquality/  default.htm).
- VHA Coding Council (http://vaww1.va.gov/health/him/VHACC/VA_HIM_P/coding_council1.htm) - VHA Coding Handbook
- HSRData e-mail listserv