# Presentation: 739293

## Using Registries in Practice, Quality Improvement, Research, and EducationElizabeth O. Kern, MD, MS, Susan R. Kirsh, MD, and David C. Aron, MD, MS, Center for Quality Improvement Research, VA Medical Center, Cleveland, OH and QUERI-DM

- Objectives:
- To understand the link between Registry data structure and its functionality.
- To understand how a Registry can be created from the VISTA database.
- To understand how a disease Registry can be used to in quality improvement, education, and research.

## Outline
Context for registry use: Chronic Care Models and Systems Redesign based on such models
Development of the Cleveland VAMC Diabetes Registry from the VISTA Database
Using the Diabetes Registry in Practice
Identification of patients at high cardiovascular risk for targeted interventions
Identification of patients and provision of self-management assistance.
Using the Diabetes Registry in Quality Improvement and Research
Analyses for managers
Audit and feedback for staff providers 
Evaluation of quality improvement projects
Registry as a research data base
Using the Diabetes Registry in Education
Audit and feedback for trainees

- Context for registry use: Chronic Care Models and Systems Redesign based on such models
- Development of the Cleveland VAMC Diabetes Registry from the VISTA Database
- Using the Diabetes Registry in Practice
- Identification of patients at high cardiovascular risk for targeted interventions
- Identification of patients and provision of self-management assistance.
- Using the Diabetes Registry in Quality Improvement and Research
- Analyses for managers
- Audit and feedback for staff providers
- Evaluation of quality improvement projects
- Registry as a research data base
- Using the Diabetes Registry in Education
- Audit and feedback for trainees

## The Context for Registries

- The various models for management of chronic illness have one feature common: information Rx to care for both the sick patient and sick system

- WHO

- Improving Care for People with Long-Term Conditions: A Review of UK and International Frameworks. NHS Institute of Innovation, 2006

## Shared Medical Appointments (Group Visits) Based on the Wagner Chronic Care Model

## What are the components of Clinical Information Systems?

**Patient **_**registries**_** that are organized into a database to access important patient information easily, track individual patient outcome measures and prevention activities, and provide feedback to providers.**
**Clinical summaries **
**Clinical reminders **
**Register recall system **

## A ‘Flat File’ is a Roster + Information

| Name | ID | Date of Birth | Site ID | Primary Provider |
| --- | --- | --- | --- | --- |
| John Doe | 001 | 8/7/45 | 541 | Miller |
| Al Smith | 002 | 9/5/25 | 541 | Miller |
| John Jones | 003 | 1/4/52 | 541 | Kern |

- Each row represents a unique patient,
- plus extra information that can fit within the single row.

## A Table is Structured by its ‘Attributes’ and its ‘Primary Key’

- Patient Name
**Patient ID**
- Site ID
- Date of Birth
- Primary Care Provider

**Primary Key**

**‘****Attributes’**
**are the **
**column **
**headings**

## Tables are Linked to Other Tables by the Primary Key

| 

ID is the 
‘Primary Key’ linking this Pharmacy Table 
to the Demographic
Table. | ID | Medication | Fill Date | Prescribing Provider |
| --- | --- | --- | --- | --- |
|  | 001 | Metformin | 5/6/06 | Miller |
|  | 001 | NPH insulin | 5/6/06 | Miller |
|  | 001 | Metformin | 8/1/06 | Miller |

## Linked Tables in the Cleveland VAMC 

**Linked Tables in the Cleveland VAMC **
**Diabetes Registry**

## Data Flow from the Database to Web Page

**Diabetes **
**Registry**
** ****Database**

**Step 1:****Nightly Data Pull**
**                ****Step 2:**** SQL Stored Procedures**

**Data Warehouse**
**VISN 10 VISTA**

**Step 3:**** ASP.NET platform**
**Step 4:**** Standard Queries in C#**

**VA Intranet  **
**Web Page**
**‘****Live’ Data Reports **
**by User Request**

## Data Flow Software 

- VISTA data                         VISN 10 SQL Data Warehouse
- KB-SQL in a SSIS-SQL Package
- SQL Data Warehouse         Diabetes Registry
- SQL Relational Database
- SQL Stored Procedures (helps to run standard queries faster)
- Diabetes Registry                Web Page
- ASP.NET 2.0 platform
- C# programming language to create standard queries
- Design tool is Visual Studio 2005
- Web Page reports               Clinical User
- Excel Spreadsheets
- Microsoft ‘Mail Merge’  generates templated letters to patients

## Analytic Software

- To pull data from the Diabetes Registry for *ad hoc* analyses
- SQL ‘Query Analyzer’
- To place data in analytic format
- Notepad .txt tab delimited file
- Excel spreadsheet
- For data management and analysis
- SAS statistical analytic program
- SAS datasets
- For security and confidentiality
- All files (including SAS working files) remain behind the VA firewall, on a server drive, in folders limited to specific users

## Operational Definitions

- DEFINE patients with diabetes
- Had at least 3 ICD-9 codes indicating diabetes on 3 separate dates  (codes are 250.xx, 357.2, 362.0, 366.41)
- OR
- Had a diabetes-specific medication* dispensed from a VISN 10 pharmacy
- *Diabetes-specific medication list maintained as a ‘look-up’ table in the Diabetes Registry database

## Operational Definitions

- DEFINE Active versus Non-Active patients
**ACTIVE** =
- Date of Death = null
- 	AND
- 		(The patient had a primary care visit within the 	past 18 months
- 				OR
- 		The patient had diabetes-specific medications 	dispensed within the past 18 months)
**Non-ACTIVE** = conditions for ACTIVE not met

## Operational Definitions

- DEFINE the clinic most responsible for diabetes care for each ACTIVE patient
- Find the most recent_ primary care type visit_ within past 18 months.
- From this visit, assign each patient to the facility _site_ and _clinic or CBOC_ associated with that visit (i.e., ‘follow the patient trail’)
- A novel system was created, mapping each visit (also called ‘encounter’) to a specific site and clinic using the ‘Hospital_Location’ variable in VISTA.
- The 4,200 unique Hospital_Locations were pared down to 1,792 associated with encounters in a primary care clinic, and categorized as ‘definitely indicating primary care’ (Tier 1) or ‘possible indicating primary care (Tier2).

## Mapping 1,792 ‘Hospital Locations’ to 51 Different Clinics in VISN 10 (Hospital Location’ is a variable included in each visit or encounter)EXAMPLE:

| Hospital Location Variable | Site ID | Tier | Map To: |
| --- | --- | --- | --- |
|  A PCM/FERRIS/WHITE | 541 | 1 | Cleveland Akron |
|  A PCM/HONG/WHITE | 541 | 1 | Cleveland Akron |
| A PCM/WOMENS HEALTH/HONG | 541 | 1 | Cleveland Akron |
| A ABI/NURSING | 541 | 2 | Cleveland Akron |
| A ADMN PROCESSING | 541 | 2 | Cleveland Akron |
| A ANTICOAG | 541 | 2 | Cleveland Akron |
| A ANTICOAG/LAB | 541 | 2 | Cleveland Akron |

## Assigning the Primary Care Provider

- From the Primary Care Manager Module database (PCMM) most patients are assigned to a primary care provider in VISN 10.
- The PCMM database is up dated manually, by a person assigned to this task.
- The Diabetes Registry pulls the _Primary Care Provider_  (PCP) variable from the PCMM to match with each patient in the Registry.
- Approximately 10% of Diabetes Registry patients are not assigned to a primary care provider, because the PCMM table has not been updated yet, or the patient is truly not assigned (e.g., ESRD patients, HIV patients, Employee Health patients)
- Some PCP’s cover multiple clinic sites: therefore knowing who is PCP does not necessarily mean the clinic site is known

## Data Cleaning

- Problem:  Text values appear in what is supposed to be a numeric result field
- Example:  LDL-c =  ‘comment’
- Example:  HbA1c =  ‘not done’
- Problem: Multiple ‘names’ and ‘codes’ for the same lab test
- Example: 14 different ‘names’ for the A1c test in VISN 10
- Example: 13 different ‘Test-ID’s’ for the A1c test in VISN 10
- Example: 3 different ‘National VA Lab Codes’ for the A1c test in  		VISN 10, or a National VA Lab code is not assigned

## How Many Ways to Name an A1c Test?

| Site ID | Test ID | Name | National VA 
Lab Code |
| --- | --- | --- | --- |
| 538 | 1751 | ZZHGB A1C | 85052 |
| 538 | 1869 | ~AT-HBA1C | NULL |
| 538 | 5172 | HEMOGLOBIN A1C, MEASURED | 85052 |
| 538 | 5414 | ZZZHEMOGLOBIN A1C,MEASURED | NULL |
| 539 | 5141 | HEMOGLOBIN A1C,CALC(d/c,4/17/00) | NULL |
| 539 | 5164 | ~HEMOGLOBIN A1C,MEASURED | 85053 |
| 539 | 5490 | ZZHEMOGLOBIN A1C(NEW,8/06)DO NOT USE!!!! | 85053 |
| 539 | 5523 | HBA1c-POCT | 82117 |
| 541 | 97 | HEMOGLOBIN A1C | 85053 |
| 552 | 1859 | HBA1C | 85052 |
| 757 | 97 | ZZHgb A1c (no longer orderable) | 85052 |
| 757 | 5122 | HEMOGLOBIN A1C, MEASURED | 85053 |
| 757 | 5210 | HEMOGLOBIN A1C, IN-HOUSE | 85053 |
| 757 | 5588 | HEMOGLOBIN A1c | 85053 |

## Using the Diabetes Registry for Population-Based Disease Management

- Find the patients who are outliers in
- A1c
- LDL-c
- Blood pressure
- Foot exam
- Eye exam
- Group by clinic/provider with primary responsibility to these patients for diabetes management

## Using the Diabetes Registry for Population-Based Disease Management

- Create spreadsheets for patient calls for special interventions at clinic level or provider level
- Merge the spreadsheets into templated letters for special interventions at clinic level or provider level
- Create individualized ‘Diabetes Report Cards’ containing the five parameters used for EPRP to send to patients by mail, or to use in group classes
- Include the Diabetes Medication Profile in order to group patients needing insulin starts or titration
- Example: patients with A1c > 9%, on 2 oral meds, need to start HS NPH

## Requesting a Report 

**Requesting a Report **
**from The Diabetes Registry Web Page**

## Report Result (fragment) from the 

- Report Result (fragment) from the
- Diabetes Registry Web Page

## Templated Header to the ‘Birthday Letter’

- Dear _**JOHN DOE**_,
- Happy Birthday!  Your VA health care providers want you to have many more!
- We are sending you your latest diabetes test results because our VA records show that your _**blood test for cholesterol is either too high, or needs to be rechecked**_.
- Your LDL-cholesterol (the ‘bad’ kind of cholesterol) should be less than 100 to protect you from stroke or heart attack.  Even if your last test was good, you are due to have it checked again.
- Your primary provider at the VA Lorain clinic would like you to call _**L       W**__**      **_ to go over your results, set up a fasting blood test, or set up a visit.
- Please call _**(440) 244-3833 EXT 2247**_** **to** **schedule.  If you come for a clinic visit, please bring in all of your medication bottles, your blood glucose meter, and any glucose records if you have them. Thanks!

-  (From the Diabetes Registry web page: patients in Lorain CBOC with high or missing LDL-C, with a birthday in July  )
- Underlined text is dropped in according to links and expert logic.

## Individualized Diabetes Report Contained in the ‘Birthday Letter’The values, messages, and smiley faces are driven by expert logic.

## Quality Improvement

- How do we know a change is needed?
- How do we know a change is an improvement?
- How do we know where to put scarce resources?
**A Diabetes Registry can provide data to:**
- Describe the patient population
- Identify patient sub-groups having the most need
- Identify who is in the sub-groups
- Show the ‘reach’ of intervention programs
- Show the outcomes of intervention programs

## Growth in the Patient Population with Diabetes in VISN 10

**The net growth in live patients with diabetes was  ****73%**** over the 5 year period from 2002 to 2006.  **
**By the end of 2006, there were 42,499 patients with diabetes, representing approximately 21-25% of the VISN 10 patient population.**
_**Source:**_** VISN 10 Diabetes Registry**

## Almost Half of Patients Do Not 

**Almost Half of Patients Do Not **
**Receive Self-Management Education**
**from the **
**VA**

**	****     ****From 2002-2006 **
**looking back for **
**outpatient notes**
**Diabetes Education = **
**diabetes education class**
**glucometer class **
**diabetes specialty clinic **
**diabetes team program **
**Nutrition Education =**
**any nutrition visit.**
_**Source:**_**  **
**VISN 10 Diabetes Registry**

## Target Patients with Poor Glycemic Control

_**Prioritize by the **_
_**most recent HbA1c**_
**27,031 (64%) are < 7.5%**
**10,131 (24%) are between 7.5-8.9%**
**5,278 (12%) are 9% or greater**
_**Source:**_** VISN 10 Diabetes Registry**

## Glycemic Control Plus Medication Profiles Can Guide Interventions

- High A1c, on no diabetes meds from the VA, may need VA prescription.
- High HbA1c, _on orals only_, may need start of basal insulin and/or carb counting
- High HbA1c, _on insulin,_ needs insulin titration and carb counting
_**Source:**_** **
**VISN 10 Diabetes Registry**

## Drop in HbA1c After DSME classes in the Cleveland VAMC

**N= 436 patients**
- *Results were same for a subgroup already taking insulin.
_**Source:**_** **
**VISN 10 Diabetes Registry**

- -**0.1**

- -**0.3**

- -**0.8**

- -**2.4**

**Change **
**in **
**HbA1c%**

- P < .001 for all strata

## Growth of the Nurse Diabetes Case Manager Program in Cleveland VAMC

- From 2003 through 2006,  the Diabetes Case Manager program saw 3,886 unique patients.
- (~ 20% of Cleveland VA patient population with diabetes).
- The program grew from
- 3 to 10 by  2006.
- 7 achieved CDE _after _training for case management.

- _Source:_
- VISN 10 Diabetes Registry

## Diabetes Case Management Resulted in  Better A1c Outcomes than Usual Care 

- Case management resulted in greater drops in A1c for patients with starting A1c < 9%,
- and an equivalent drop in A1c for patients with starting A1c >= 9%

**0    -0.3**

**-0.5   -0.7**

**-1.3   -1.4**

*****

*****

***** p <.05

**Change**
** ****in**
**HbA1c**

_**Source:**_** **
**VISN 10 Diabetes Registry**

## Dataset (from the VISN 10 Diabetes Registry)

- 40,632 patients receiving diabetes-specific medications in VISN 10 since Jan 2005, and who are alive.
- ~ 9,000 patients in VISN 10 do not receive either glucose test strips or hypoglycemic agents from the VA, but have an ICD-9 code of diabetes.  These patients were excluded from this analysis

## Thiazolidenedione (TZD) and A1c Outcomes Within VISN 10, by Site

|  | Total Patients on Diabetes Medications  | A1c >=9%  | A1c Missing in past 24 months  | Patients on TZD, No Insulin  | Patients on TZD, With Insulin  |
| --- | --- | --- | --- | --- | --- |
| 1 | 3,992 | 10.8 | 2.5 | 14 | 7 |
| 2 | 6,609 | 11.3 | 5.4 | 21 | 9 |
| 3 | 5,901 | 11.7 | 2.9 | 12 | 8 |
| 4 | 18,171 | 11.7 | 3.5 | 5 | 3 |
| 5 | 5,959 | 13.2 | 6.2 | 9 | 4 |

## Using Registries in Practice, Quality Improvement, Research, and EducationElizabeth O. Kern, MD, MS, Susan R. Kirsh, MD, and David C. Aron, MD, MS, Center for Quality Improvement Research, VA Medical Center, Cleveland, OH and QUERI-DM

- Objectives:
- To understand the link between Registry data structure and its functionality.
- To understand how a Registry can be created from the VISTA database.
- To understand how a disease Registry can be used to in quality improvement, education, and research.

## Shared Medical Appointments (Group Visits) Based on the Wagner Chronic Care Model

## The Patient Encounter

- Personnel
- MD, NP/CDE, RN, Pharmacist, Psychologist
- 8-20 patients/session
- 90 minutes sessions
- Return visit interval: 4-8 weeks or until goals achieved
- Group activities
- Education
- Patient Centered Discussion
- Review of labs/medications
- Individual activities
- Medication management
- Referrals
- Individualized plan of care outlined and give to patient

**Notes:**
HIPPA and patient confidentiality

## Evaluation of the impact of SMAsKirsh et al. QSHC 2007; in press.

**Subjects**:
- Diabetic patients with _>_1 of:
- A1c >9%
- SBP blood pressure >160 mmHg
- LDL-c >130 mg/dl
- _Patients largely derived from registry data, few referred from pcp_
- participated in _>_1 SMA from 4/05 to 9/05.
**Study Design**:
- Quasi-experimental with concurrent, but non-randomized controls
- patients who participated in SMAs from 5/06 through 8/06. A retrospective period of observation prior to their SMA participation was used.

## Kirsh et al. 2007; in press. Findings

- Levels of A1c, LDL-c, and SBP all fell significantly post-intervention
- A1c decreased 1.4 (0.8, 2.1) (p<0.001)
- LDL-c decreased 14.8 (2.3, 27.4) (p=0.022)
- SBP decreased 16.0 (9.7, 22.3) (p<0.001).
- The reductions greater in the intervention group relative to the control group:
- A1c 1.44 vs -0.30 (p=0.002) for A1c
- SBP 14.83 vs 2.54 mmHg (p=0.04) for SBP.
- No diff. for LDL-c 16.0 vs 5.37 mg/dl (p=0.29).

## Registry use in continuing care

- Track additional patient data hard coded in note for future reference
- Monitor progress on patients and give report card to providers-pilot
- Birthday letters generated by registry data to engage patients in initiating SMA

## Trainee Participation in SMA

- Internal Medicine residents and  third year medical students on chronic disease block
- Uses of registry in general to manage population
- Clinical Information System module
- Audit and feedback of resident’s primary care panels and teams

## Questions?

## References

- Gliklich RE, Dreyer NA, eds. Registries for Evaluating Patient Outcomes: A User’s Guide. (Prepared by Outcome DEcIDE Center [Outcome Sciences, Inc. dba Outcome] under Contract No. HHSA29020050035I TO1.) AHRQ Publication No. 07- EHC001-1. Rockville, MD: Agency for Healthcare Research and Quality. April 2007.
**Bodenheimer T, Grumbach K. Electronic Technology A Spark to  Revitalize Primary Care? ***JAMA.* 2003;290:259-264