2011 VIReC Database and Met

Cyber Seminar Series

RESEARCHERS’ GUIDE TO VA DATA
2011 VIReC Database and Methods Cyber Seminar S

Assessing VA Health Care Us

Inpatient

Session 13

August 1, 2011

Presented by:

Denise M. Hynes, MPH, PhD, RN

Director, VA Information Resource Center (VIReC

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

How has healthcare utilization been measured in VA studies?Overview of Medical SAS inpatient d b ata

bases

Finding information in the Inpatient SAS databasesExamples of VA studies that have meVA healthcare utilizationWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

 How has healthcare utilization been 

measured in VA studies?Overview of Medical SAS inpatient d b ata

bases

Finding information in the Inpatient Medical SAS databasesExamples of VA studies that have meaVA healthcare utilizationWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
How has healthcare utilization bee

measured in VA studies?

Cully, J. A., Zimmer, M., Khan, M. M., & Petersen, L. A. (2008). Quality of depression care d i i and its impact onhealth service use and mortality among veterans veterans. Psychiatr Psychiatr Serv., 59, 1399-1405.

RESEARCHERS’ GUIDE TO VA DATA
How has healthcare utilization bee

measured in VA studies?

Frayne, S. M., YuYano, E. M., Yano, E. M., Ana

L., Iqbal, S., Thr

Thr

A. et al. (2007). 

G d d Gen

der and use

care: planning ftomorrow's VeteHealth AdministHealth AdministJ Womens Healt(Larchmt Larchmt.)., 16, .)., 16, 1199.

RESEARCHERS’ GUIDE TO VA DATA
How has healthcare utilization bee

measured in VA studies?

Romano, P. S., Mull, H. J., Rivard, P. E., Zhao, S., Henderson, W. G., Loveland, S. et al. 

(2009) V lidi f (2009). V

alidity

of 

selected AHRQ patient safety indicators based on VA National Surgical Quality Improvement Program data . Health Serv Res Health Serv Res.,44, 182-204.

RESEARCHERS’ GUIDE TO VA DATA
How has healthcare utilization bee

measured in VA studies?

Stineman, M. G., KP L K i hi J E P. L., Kurichi, J. E

Bettger, J. A., VogB., Maislin, G. et a(2008). The 

eff ti f i 

ffectiveness

of in

rehabilitation in tacute postoperatiphase of care afte

t tibi l transtibi

al or

transfemoral amputation: study integrated health d li t d

elivery sys

tem. A 

Phys Med Rehabil1863-1872.

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

How has healthcare utilization been measured in VA studies?

 Overview of Medical SAS inpatient 

d b ata

bases

Finding information in the Inpatient SAS databasesExamples of VA studies that have meVA healthcare utilizationWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
How has healthcare utilization been m

in VA studies?

Medical SAS (MedSAS) Inpatient and Outpatient Datasets

• Most comprehensive datasets for VA healt

utilization information

• National VHA health care delivery data• SAS datasets housed on mainframe compu

Austin Information Technology Center (AIT

– Divided to pat e t a d outpat e t d

 into inpatie

n

t

a

n

d outpatie

n

t d

– Datasets available on a quarterly basis– In general, researchers are advised to 

annual, closed-out datasets

– Common element: patient identifier 

(scrambled SSN)

RESEARCHERS’ GUIDE TO VA DATA
General Description

Services provided to inpatients are recorth M dSAS I ti t d t t d I th

e M

edSAS Inpatient d

a

tase

t

s and Inpa

Encounters Dataset.Also o as ( at e t eat e t e) kn

own as PTF 

(

Patie

n

t Treat

m

e

n

t File)

Common dataset structure, generally stable timeB k t b fi l f di h d t Bro

ken out b

y fiscal year

of disc

harge d

a

t

e

– Admission may have occurred in a previo

year

RESEARCHERS’ GUIDE TO VA DATA
Inpatient Data Flow

Data Progression from the VHA Medical Centers t

AITC to the Medical SAS® 

RESEARCHERS’ GUIDE TO VA DATA
Four datasets within each category of 

For each care setting, NDS generates and maintaset f “d il” SAS D h idi diff of “detail” SAS Datasets, each providing diffetypes of information on patient stays: 

– Main 

• Summary of entire stay (episode of care) and 

demographic information

– Bedsection

• Data on a segment of the inpatient stay defined b

specialty of the physician who managed the patie

– Procedures 

• Contains information on up to five procedures per

at a given time on a given day

– Surgery

• Information on up to five surgeries

RESEARCHERS’ GUIDE TO VA DATA
Four datasets within each category of 

File Reference Reference

(Acute Dataset)

Dates

Main PMyy 1970 - pre

pre

Bedsection PByy 1984 – pre

pre

Procedure PPyy 1988 – pre

pre

Surgery Surgery PSyy 1984 - pre

pre

Where yy= last 2-digits fiscal year

RESEARCHERS’ GUIDE TO VA DATA

yy g y
Data element Data element examples examples

Patient demographicsPrimary/secondary diagnosesLength of stayICD-9 procedure codesPatient identifier (SCRSSN) Facility & VISN identifiersAdmission & discharge date & timeDischarge Type (e.g., Regular, Death Discharge Type (e.g., Regular, Death-Autopsy, N

Autopsy, N

bed Care)

For a complete list:

– htt // i h /D t S N 

http://www.virec.research.va.gov/DataSourcesNamMedical-SAS-Datasets/MedSAS-Inpt-RUG/MedSASRUG-Inpt.htm

RESEARCHERS’ GUIDE TO VA DATA
Data Access Information

Data Steward: 

– National Data Systems (NDS) (John Quin

Director)

W b it /Wh t t fi d W

e

b

sit

e/Where t

o go t

o fi

nd more:

– http://vaww.va.gov/nds/

RESEARCHERS’ GUIDE TO VA DATA
Strengths of Medical SAS Datase

Centralized data sourceLarge number of patientsUnique identifier (SCRSSN: Scrambled Social Security Number) allows linkinrecords across files/yearsQuality assessments/audits are conducted on datasets

RESEARCHERS’ GUIDE TO VA DATA
Limitations of Medical SAS Data

They don’t capture all care paid for by 

– e.g., t t some con

tract care

Coding may be more complete and acfor some dia

g p noses or 

procedures tha

others, depending on VA needs and incentives

– Some conditions may be under/over

-report

VA data compared to other settings

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

How has healthcare utilization been measured in VA studies?Overview of Medical SAS in

patient 

databases

 Finding information in the Inpatient 

Medical SAS databasesExamples of VA studies that have mVA healthcare utilizationWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
Assessing Inpatient Healthcare Use:

Finding info in Inpatient Medical SAS Datasets

Where do I find information about ad i i d di h d

missions and disc

harges

?

All in

patient datasets include:

• admission date and time• station # (facility)• VISN• principal diagnosis code• discharge date and time• discharge status (in Main dataset only)• discharge type (e.g., Regular, Death-A

Non-bed Care)

RESEARCHERS’ GUIDE TO VA DATA
Assessing Inpatient Healthcare Use:

Finding info in Inpatient Medical SAS Datasets

Where can I find information on a patdiagnosis

?

– DXPRIME: Principal Diagnosis

• The condition which, after study, is determi

chiefly responsible for the admission of the the hospital.

• Codes assigned by professional coders (HIM

• Leads to the calculation of the DRG

– DXLSF: Primary diagnosis for Admission

• Diagnosis initially assigned at admission.

• This could be different than the DXPRIME as 

diagnosis could change after study/tests resback. 

• Not coded by HIM

RESEARCHERS’ GUIDE TO VA DATA
Assessing Inpatient Healthcare Use:

Finding info in Inpatient Medical SAS Datasets

Where can I find information on a patdiagnosis (cont )? (cont.)?– DXF2 – DXF13: Secondary ICD-9-CM diagn

cod f f ll h it l t des for f

ull hospit

al 

s

tay

• MAIN data set only

– Di l t d t th B d S ti St Diagnoses rela

t

ed t

o th

e B

ed Section Stay

• DXLSB, DXB2-DXB5

RESEARCHERS’ GUIDE TO VA DATA
Assessing Inpatient Healthcare Use:

Finding info in Inpatient Medical SAS Datasets

Where do I find information about in

patien

procedures

?

– Inpatient procedure datasets contain:

• Procedures not performed in an operating roo• Dialysis type & number of dialysis treatments

– Inpatient surgery datasets contain:

• Surgeries performed in operating room

– A 

“procedure

” in one facility may be conside

“su ge y r

r

y

” in 

a ot e ac ty C ec bot dat

not

h

er facility. 

C

heck both dat

RESEARCHERS’ GUIDE TO VA DATA
Assessing Inpatient Healthcare Use:

Finding info in Inpatient Medical SAS Datasets

How do I identify the specialty of the ph i i i th ti t hysician managing th

e patien

t’s 

car

– Use BEDSECN to identify physician speci

• Found in Bedsection and Procedure datase• Contains the treating specialty code• Most common acute bedsections 

– General (acute) medicine– High Intensity General Psychiatry– Medical ICU– General Surgery– Surgical ICU

RESEARCHERS’ GUIDE TO VA DATA
Assessing Inpatient Healthcare Use:

Finding info in Inpatient Medical SAS Datasets

How is Bedsection defined?– Bed section is the treating specialty of the 

who manages the patients care during the portion of the inpatient stay.

– One inpatient stay may have as many as 2

section stays

RESEARCHERS’ GUIDE TO VA DATA
Assessing Inpatient Healthcare Use:

Finding info in Inpatient Medical SAS Datasets

How do I identify care for a defined periotime

?

– Records are created at discharge for the fu

even if the admission was in a prior year

– Exception: Claims for Non-VA Care are inc

in the dataset for the fiscal year they were 

not the year for which care was provided

RESEARCHERS’ GUIDE TO VA DATA
Assessing Inpatient Healthcare Use:

Finding info in Inpatient Medical SAS Datasets

How do I compute acute length of sta– Inpatient Main dataset includes LS, which 

acute and non acute information, fo

r

the entire episode of care

• Since 2006, calculated as: 

LS=[(DISDAY – ADMITDAY) – (ABO + PASS

w/minimum value of 1. 

• Recalculate if any info missing

– For bed section LS, use bed section specifi

• Date & time of transfer into & out of be

(BSINDAY & BSOUTDAY) 

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

How has healthcare utilization been measured in VA studies?Overview of Medical SAS inpatient anoutpatient databasesFinding information in the Inpatient SAS databases

 Examples of VA studies that have me

VA healthcare utilizationWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
Research Example I:

Validity of Selected AHRQ Patient Safety Indicators Based on VA Nat

Quality Improvement Program Data

Patrick S Romano et al (2008 Sept) Patrick S Patrick S. Romano, et al. (2008 Sept) (2008 Sept) Health Services Research Health Services Research. 44(

Study Objectives. To examcriterion validity of the AHRQ Safety Indicators (PSIs) usinNational Surgical Quality ImpProgram (NSQIP).Study Design. Examined thsensitivities, specificities, pospredictive values (PPVs), and likelihood ratios of five surgiccorresponded to NSQIP adveData Sources. 55,752 match i li i f hospitalizations from 2001 V

2001 V

MedSAS datasets datasetsand NSQIP chart and NSQIP chart-abstracted 

abstracted 

major noncardiac surgeries.

RESEARCHERS’ GUIDE TO VA DATA
Research Example I:

Validity of Selected AHRQ Patient Safety Indicators Based on VA Nat

Quality Improvement Program Data 

Patrick S Patrick S Romano et al (2008 Sept) Patrick S. Romano, et al. (2008 Sept) (2008 Sept) Health Services Research Health Services Research. 44(

RESEARCHERS’ GUIDE TO VA DATA
Research Example II:

Diagnosis of pulmonary malignancy after hospitalization for pne

Mortensen EM, et al (2010 Jan) Am J Med, 123(1):66 , 123(1):66-71

Objective: To assess the frequency of diagpy nosis of pulmonarymalignancy, & identify risk factors for pulmonary malignancy following hospitalization for pneumonia.Study Design: Retrospective cohort study of VA inpatients during FY2002-7, age 65 years or older. age 65 years or older.Data Sources:

– VA Inpatient and Outpatient MedSAS

datasets (aka, National Patient Care Database)

– VA prescription data from the VA 

DSS-NDE & Pharmacy Benefits Management

– VA Vital Status file

RESEARCHERS’ GUIDE TO VA DATA
Research Example II:

Diagnosis of pulmonary malignancy after hospitalization for pne

Mortensen EM, et al (2010 Jan) Am J Med, 123(1):66 , 123(1):66-71

Inclusion/exclusion criteria

– Were age 65 years or older on the date o

admission

– H d t l t t ti t li i i it i t

Had at least one outpatient clinic visit in tyear preceding the index admission

– Received at least one active and filled 

outpatient medication within 90d of adm

– Hospitalized during FY 2002-7

– Had a previously validated discharge diag

of pneumonia/influenza (International Classification of Diseases, 9th Revision co480 0 483 99 or 485 487) 

RESEARCHERS’ GUIDE TO VA DATA

480.0-483.99 or 485-487) 
Research Example II:

Diagnosis of pulmonary malignancy after hospitalization for 

Mortensen EM Mortensen EM,( ) et al (2010 Jan 2010 Jan) Am J Med, () 123 1 :66

Variables Posthospitalization No Pulmon

w/Pulmonary Malignancy(N=3760)

Malignanc(N=36,984

Age (mean SD) Age (mean, SD) 76 5 (6 3) 76.5 (6.3) 77 8 (

77.8 (

Characteristics of Hospitalization-ICU 285 (8) 5471 (O t u comes

Mortality at 30d 48 (1) 5222 (Mortality at 90d 267 (7) 8184 (

Length of Stay 6.21 (7.4) 8.1 (1

RESEARCHERS’ GUIDE TO VA DATA
Research Example III

Mental illness Mental illness-related disparities in length of stay: Algorith

related disparities in length of stay: Algorith

influences results 

Frayne S et al (2010/Nov) JRRD 47 (8): 709 Frayne S, et al (2010/Nov) JRRD, 47 (8): 709-71

Objective: Examine

xamine

algorithm choice affeconclusions about mcondition (MHC) condition (MHC)-rela

rela

in LOS for VHA patiediabetes.

Study Design: Usincohort of diabetes patracked inpatient use Data Sources:

– Bedsection– Extended care – Observation– Census files for abo– Fee Basis

RESEARCHERS’ GUIDE TO VA DATA

– Non VHA
Session Objectives

How has healthcare utilization been measured in VA studies?Overview of Medical SAS in

patient an

outpatient databasesFinding information in the Inpatient SAS databasesExamples of VA studies that have meVA healthcare utilization

 Where to go for more help

RESEARCHERS’ GUIDE TO VA DATA
VIReC Help

VIReC Webpage

http://www http://www virec research va gov http://www.virec.research research.va.gov

– Information on VA data sources and how to a

data

– Documentation on some VA datasets i e Me

Documentation on some VA datasets, i.e., MeSAS datasets:

• http://www.virec.research.va.gov/DataSou

me/Medical-SAS-Datasets/SAS htm Datasets/SAS.htm

• Includes lists of variables and their datase

locations

• D i ti f h f th i bl Descriptions of each of the variables

• Values for selected variables

RESEARCHERS’ GUIDE TO VA DATA
VIReC Help (cont’d)

HSRData Listserv

– Join at VIReC Web site– Discussion among > 550 data stewa

managers, and users

– Past messages in archive (on intrane

VIReC Help Desk

– VIReC staff will answer your questio

direct you to available resources on 

– VIReC@va.gov– (708) 202-2413

RESEARCHERS’ GUIDE TO VA DATA
Suggested other resources: Medical SAS Dat

Data Quality Information

Quality assessments performed by the Office oInspector General, the Medical Care Cost Recovprogram, and special workgroupsData Quality, Information Assurance, Office of I f ti In

formation

– http://vaww.vhaco.va.gov/dataquality/defa

VHA Coding Council - VHA Coding Handbook 

– http://vaww1.va.gov/health/him/VHACC/VA

coding_council1.htm

RESEARCHERS’ GUIDE TO VA DATA
Sample Bibliography

Cully, J. A., Zimmer, M., Khan, M. M., & Petersen, L. A. (2008). Qua

depression care and its impact on health service use and morveterans. Psychiatr Serv., 59, 1399-1405.

Damush, T. M., Jia, H., Ried, L. D., Qin, H., Cameon, R., Plue, L. et 

Case-finding algorithm for post-stroke depression in the veteradministration. Int J Geriatr Psychiatry., 23, 517-522.

Fontana, A. & Rosenheck, R. (2008). Treatment-seeking veterans o

Afghanistan: comparison with veterans of previous wars. J Ne196, 513-521.

Frayne, S. M., Yu, W., Yano, E. M., Ananth, L., Iqbal, S., Thrailkill, A

(2007) Gender and use of care: planning for tomorrow (2007). Gender and use of care: planning for tomorrow s Vete

's Vete

Administration. J Womens Health (Larchmt.)., 16, 1188-1199

Frayne, S. M., Yano, E. M., Nguyen, V. Q., Yu, W., Ananth, L., Chiu, 

(2008). Gender disparities in Veterans Health Administration c

importance of accounting for veteran status importance of accounting for veteran status. Med Care 46 Med Care., 46, 5

Fuller MA, Shermock KM, Secic M, Laich JS, Durkin MB. 2002. Serv

costs among VA patients with schizophrenia taking risperidone olanzapine. Psychiatr Serv. 53(7):855-60.

RESEARCHERS’ GUIDE TO VA DATA
Sample Bibliography

K i hi ur

chi, J E . ., Stineman, M G . .,

Kwon

g, P L B t B E & R k D 

P. L., B

a

tes, B. E., & R

e

ker, D

Assessing and using comorbidity measures in elderly veterans witextremity amputations. Gerontology., 53, 255-259.

Kurichi, J. E., Small, D. S., Bates, B. E., Prvu-Bettger, J. A., Kwong, P

W. B. et al. (2009). Possible Incremental Benefits of Specialized R

Bed Units Among Vete ans Afte Lo e E t emit Amp tation Bed Units Among Vete

rans Afte

r Lo

we

r E

x

t

remit

y Amp

utation. Me

Me

%20..

Lee, T. A., Pickard, A. S., Au, D. H., Bartle, B., & Weiss, K. B. (2008)

death associated with medications for recently diagnosed chronic pulmonary disease. Ann Intern Med., 149, 380-390

L W C J Sl R L l K W G ld t i B & L

o

gan, W. C., Jr., Sloane, R., L

yles, K. W., G

old

s

t

ein, B., & H i oeng, H 

H

Incidence of fractures in a cohort of veterans with chronic multipltraumatic spinal cord injury. Arch Phys Med Rehabil., 89, 237-243

Miller, D. R., Gardner, J. A., Hendricks, A. M., Zhang, Q., & Fincke, B

Health care resource utilization and expenditures associated with 

i li l i insuli

n glargine. Cli Th 29 Cli

n Ther., 29, 478-487

Mortensen EM, et al (2010 Jan) Diagnosis of pulmonary malignancy a

hospitalization for pneumonia. Am J Med, 123(1):66 , 123(1):66-71 

Movahed, M. R., Hashemzadeh, M., & Jamal, M. (2007). Increased pr

ventricular fibrillation in patients with type 2 diabetes mellitus. He

22, 251-2 35

3

Movahed, M. R., Hashemzadeh, M., & Jamal, M. M. (2007). Significan

the prevalence of non-rheumatic aortic valve disease in patients wdiabetes mellitus. Exp Clin Endocrinol Diabetes., 115, 105-107.

RESEARCHERS’ GUIDE TO VA DATA
Sample Bibliography

Murphy PA, Cowper DC, Seppala G, Stroupe KT, Hynes DM. 2002. 

Health Administration inpatient and outpatient care data: a rich of research data. Effective Clinical Practice. 5:e4. 

Payne SM, Lee A, Clark JA, Rogers WH, Miller DR, Skinner KM, Ren 

LE 2005 Utilization of medical services by Veterans Health StuLE. 2005. Utilization of medical services by Veterans Health Sturespondents. J Ambul Care Manage. Apr-Jun;28(2):125-40.

Pugh, M. J., Rosen, A. K., Montez-Rath, M., Amuan, M. E., Fincke, 

Burk, M. et al. 2008. Potentially inappropriate prescribing for theffects of geriatric care at the patient and health care system l

Care 46 Care., 46, 167-173.

Romano, P. S., Mull, H. J., Rivard, P. E., Zhao, S., Henderson, W. 

Loveland, S. et al. 2009. Validity of selected AHRQ patient safeindicators based on VA National Surgical Quality Improvement data. Health Serv Res., 44, 182-204

Savas, L. S., del Junco, D. J., Bastian, L. A., & Vernon, S. W. 2009

ascertainment of women veterans: a comparison of sources of information, 1979-2002. Med Care., 47, 125-128

Singh, J. A. & Strand, V. 2009. Health care utilization in patients w

spondyloarthropathies spondyloarthropathies. Rheumatology (Oxford) 48 Rheumatology (Oxford)., 48, 272-276

Sonnenberg, A., Richardson, P. A., & Abraham, N. S. 2009. Hospit

for Inflammatory Bowel Disease Among US Military Veterans 1Dig.Dis Sci

RESEARCHERS’ GUIDE TO VA DATA
Sample Bibliography

Stineman, M. G., Kwong, P. L., Kurichi, J. E., Prvu-Bettger, J. A., 

B., Maislin, G. et al. (2008). The effectiveness of inpatient rehin the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care d

system. Arch Phys Med Rehabil., 89, 1863-1872

Stroupe KT, et al. 2006. Cost-Effectiveness of coronary artery byp

grafts versus percutaneous coronary intervention for revasculaof high-risk patients. Circulation. 114: 1251-57.

Weeks, W. B. & West, A. N. (2007). Where do veterans health 

administration patients obtain heart liver and kidney transplaadministration patients obtain heart, liver, and kidney transplaMed., 172, 1154-1159

Weeks, W. B., West, A. N., Wallace, A. E., Lee, R. E., Goodman, D

Dimick, J. B. et al. (2007). Reducing avoidable deaths among directing private-sector surgical care to high-performance hos

J Publ l h 9 blic Healt

h., 

97, 2 86 1 -2 92 1

Weeks, W. B., West, A. N., Wallace, A. E., & Fisher, E. S. (2008). 

Comparing the characteristics, utilization, efficiency, and outcoVA and non-VA inpatient care provided to VA enrollees: a case N

e o w Y

ork. 

Med Ca e , 6, Ca

r

e., 46, 863-871

West, A. N., Weeks, W. B., Wright, S. M., Wallace, A. E., & Fisher

(2008). When VA patients have non-VA hospitalizations, who what services, and what are the research implications? A New case study. Med Care., 46, 872-877

RESEARCHERS’ GUIDE TO VA DATA
Questions?

RESEARCHERS’ GUIDE TO VA DATA