NHLBI Workshop

Data Needs for Cardiovascular Events, Management, and Outcomes

HMO Populations and Clinical Databases as a Source for Monitoring Trends in CVD Morbidity & Mortality -
Dr. Joseph Selby

Key Points

• Integrated HMOs are an increasingly rich source of longitudinal data on CVD events, risk factors and quality of care
• Membership is quite stable
• Large registries of persons with CVD diagnoses are being created
• Many of these HMOs share the same electronic medical record, and data definitions are being harmonized across HMOs
  

HMO Research Network (HMORN) -- 13 million members

• Fallon Health Care, Worcester, MA
• Group Health Cooperative, Seattle, WA
• Harvard Pilgrim Health Care, Boston, MA
• HealthPartners Research Foundation, Minneapolis, MN
• Henry Ford Health System, Detroit, MI
• Kaiser Permanente Colorado, Denver, CO
• Kaiser Permanente Georgia, Atlanta, GA
• Kaiser Permanente Hawaii, Honolulu, HI
• Kaiser Permanente Northwest, Portland, OR
• Kaiser Permanente Northern CA, Oakland, CA
• Kaiser Permanente Southern CA, Pasadena, CA
• Lovelace Clinic Foundation, Albuquerque, NM
• Scott and White Health System, Temple, Texas
• United Healthcare, Minnetonka, MN
  

Major Collaborative Projects of the HMO Research Network (HMORN)

Data are Improving

• Membership (denominators & demographics)
• Complete hospital discharge data (endpoints, procedures, comorbidities)
• Outpatient diagnoses & procedures (comorbidities and endpoints)
• Pharmacy data (comorbidities, quality of care)
• Laboratory results (risk factors)
• Outpatient measurements (BP, smoking status, BMI)
  

Availability of CVD Risk Factor Data among 1.2 million persons, age 45 and above, 1/1/04; Kaiser Permanente Northern California

Examples of Studies Conducted in Kaiser Permanente, Northern California

• Joint Control of Three CVD Risk Factors in the KP Population, 2001 to 2003:
  The 3D Study -- Support: Pfizer, Inc.
• Troponin Measurement and Trends in Acute Coronary Syndrome Hospital Discharge Diagnosis
  
  • To determine the role of troponin measurement in the changing distribution of ACS hospitalization discharge diagnoses in Kaiser Permanente Northern California (KPNC)
  • All data, including cardiac biomarkers, were obtained from KPNC electronic databases.
  • All hospital discharges for ACS from KPNC hospitals between 1994-2003 were determined (primary discharge codes 410.x, 411.1, 414.x primary with 411.1 secondary)
    
• Kaiser Permanente Acute Coronary Syndrome Registry (KP-ACS)
  • Modeled after National Registry of Myocardial Infarction (NRMI)
  • Systematic chart review of all hospitalized acute myocardial infarction and troponin (+) unstable angina patients at 17 Kaiser facilities since 2002 (AMI) & 2004 (UA)
  • ~9,000-10,000 reviewed cases annually
    
• Kaiser Permanente Chronic Heart Failure Registry (KP-CHF)
  • Chronic heart failure (CHF) identified from hospitalizations and ambulatory visit (outpatient, ED) databases
  • 96% of primary hospital discharge diagnoses and 85-90% of cases identified from outpatient diagnoses are verified using Framingham criteria at chart review
  • 1996-2002: 59,772 adults > or = 20 years met registry criteria for CHF in Kaiser No. Cal.
  • Registry is updated annually and linked to treatment & clinical outcomes
    

Conclusions

• Data from integrated HMOs can provide a timely look at incidence, complications, mortality for a variety of CVD conditions
• Rich clinical data allows adjustment for population differences in comorbidities and disease severity
• Data definitions can be standardized across settings
• Data may allow exploration of possible artifactual differences in observed patterns

Limitations

• HMO patients do not represent the extremes of U.S. SES spectrum
• Time trends, geographic variation, subject to differences and changes in clinical and coding practices
• Data completeness is sometimes a question
• Potentially, time trends may be affected by differing enrollment/departure over time
  

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