NHLBI Workshop

Data Needs for Cardiovascular Events, Management, and Outcomes

Small Working Group: In hospital Surveillance - Dr. Veronique Roger, Group Leader


Gaps in knowledge

  • Nation-wide incidence data
    • Myocardial infarction (MI)
    • Stroke, including stroke subtypes
  • Track procedures: Percutaneous coronary interventions (PCI) and coronary artery by-pass grafting (CABG)
  • To track unstable angina (UA): need validation procedures
  • Heart failure (HF) and atrial fibrillation (AF): definitional and ascertainment challenges
  • Data should reflect national demographics (age, sex, ethnic/racial distributions)

Possible approaches

  • Capitalize on electronic medical records (EMR) attractive but problematic given incomplete penetration of the use of EMR, which may introduce an unknown degree of bias
  • Data sources
    • JCAHO
    • National hospital discharge survey
    • NHANES
  • Need for systematic reporting of MI/stroke

Cases identification

  • MI: lab-based using biomarkers
    • Problematic given false positive rates particularly with Troponin, but reliance on MD diagnosis unsatisfactory (~adoption of criteria, under-ascertainment of post proc MI…)
  • Stroke: imaging
  • Need to develop use of other data sources
    • JCAHO
    • National hospital discharge survey
    • NHANES

Validation

  • Sampling
  • Relying on uniform standardized criteria
  • As part of validation procedures, include a limited number of standardized core measures (risk factors, AF, others...)

Outcomes

  • Mortality
    • Need to rely on mortality at fixed point in time (not in-hospital mortality given temporal declines in duration of hospital stay and likely inter site variations)
  • Recurrent MI or stroke
    • Need for linkage with individual identifiers to measure true incidence
  • Other non-fatal outcomes
    • Presently not feasible as part of nation-wide system

Optimize existing systems

  • Important intermediate step while progress towards nationwide mandatory reporting
  • Adding sites to existing surveillance programs that increase ethnic diversity leading to the establishment of appropriately diverse surveillance networks
  • Use of same standardized criteria essential
  • Veterans Health Administration (VA) system attractive for enhancement of diversity of surveillance data

Other disease targets

  • HF: need in- and out-patient data
    • Challenge - standardized definition for HF
    • Option of tracking HF with low ejection fraction
    • Could be the focus of center-specific efforts (VA, Kaiser)
    • Use CMS/JCAHO
  • AF: collect while validating stroke, otherwise outpatient entity
  • UA: will need to validate, cannot rely on codes

Three-tier approach recommended:

  • Tier 1: Systematic nation-wide reporting of MI and stroke
  • Tier 2: Validation and collection of a limited number of standardized core measures
  • Tier 3: Detailed hypothesis-driven studies of these patients in specific centers
Heart disease centers, modeled from cancer registries

Back to Workshop Agenda

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