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
  

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