VIReC Cyber Seminar Series 2006 VA Databases and Methods

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VIReC Cyber Seminar Series 2006 VA
Databases and Methods

• Using VA Pharmacy Data
• Presented by
• Todd A. Lee, PharmD, PhD
• Senior Investigator, MCHSPR COE
• VIReC, Senior Scientific Expert Pharmacy Data
• Research Assistant Professor, Northwestern
  University Feinberg School of Medicine

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Session Objectives

• Measurement Issues with Pharmacy Data
• Key Data Source Review PBM Data DSS Pharmacy
  Data
• Measurement Issues and Use of Pharmacy Data
• Where To Go For More Help

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Pharmacy Data Measurement Issues

• Comparability of data sources
• Do PBM and DSS contain the same data?
• Medication utilization
• Recent year? Longer historical view? Does policy
  change impact medication use?
• Exposure to specific medications or medication
  classes
• Are specific drugs associated with better/worse
  outcomes?
• Medication adherence
• How much of a prescribed medication are patients
  using?
• Combining outpatient and pharmacy data to
  identify events
• Can we identify acute exacerbations of COPD with
  outpatient and prescription data?
• Assessing comorbidity or case-mix with medication
  data
• Diagnoses-based measures vs. pharmacy-based
  measures

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Session Objectives

• Measurement Issues with Pharmacy Data
• Key Data Source Review PBM Data DSS Pharmacy
  Data
• Measurement Issues and Use of Pharmacy Data
• Where To Go For More Help

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Pharmacy Data Sources

• Local Databases
• VistA
• VISN Warehouses
• National Data Sources
• PBM
• DSS NDE Pharmacy SAS? Datasets
• FCDM

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VistA Pharmacy Data

• Veterans Health Information Systems and
  Technologies Architecture
• All Prescription Orders and Fills
• Inpatient and Outpatient
• CMOP (Consolidated Mail Outpatient Pharmacy)
• in VistA system for site where fill was
  requested
• Local Files
• At each VistA installation

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VistA Pharmacy Data

• Prescription Orders Dispensed
• Prescription File (FILE 52) - Outpatient
• Pharmacy Patient File (FILE 55) - Inpatient
• IV Orders (FILE 55.01)
• Unit Dose Orders (FILE 55.06)
• Local Drug File (FILE 50)
• Years covered
• 1997 forward
• Varies by site

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VistA Pharmacy Data

• Accessing
• FileMan hierarchical database management system
• MUMPS
• SQL
• VISN Warehouses
• Some contain prescription data
• Relational databases

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PBM Database

• Pharmacy Benefits Management Database
• FY1999 forward (October 1, 1998)
• Maintained by PBM/SHG at Hines VA Hospital
• Researchers must request extract

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National Extracts - PBM
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PBM Database

• Information in the Database
• Outpatient Prescriptions Dispensed
• Inpatient Prescriptions Dispensed (IV Unit
  Dose)
• Selected Labs
• Controlled Substance Use
• Automatic Replenishment/Ward Stock
• Procurement and Accounting
• Provider Information
• Patient Information

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PBM Database Variables

• Outpatient Prescription
• Dispensing Details
• Fill Date
• Drug Name
• Station Name
• Quantity
• NDC National Drug Code
• Dosing Instructions
• VA Drug Class
• Dispense Unit and Price per Dispense Unit

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PBM Database Variables

• Outpatient Prescription
• Provider Information
• Provider ID
• Provider Service
• Cardiology, Dental, Nursing, Surgery, etc.
• Provider Specialty Subspecialty
• Provider Type
• Staff, Fee, or Non-VA (TPB)
• Patient Information
• Patient Prescription Status

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DSS NDE Pharmacy SAS? Datasets

• Decision Support System National Data Extract
  Pharmacy SAS? Datasets.
• FY2002 forward
• Located on the host at the Austin Automation
  Center
• Directly accessible by Researchers

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National Extracts - DSS
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DSS NDE Pharmacy SAS?Datasets

• Information in the Datasets
• Outpatient Prescriptions Dispensed
• Inpatient Prescriptions Dispensed
• IV
• Unit Dose

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DSS NDE Pharmacy SAS? Datasets

• Files
• RMTPRD.MED.DSS.SAS.FYYY.VISNX.PHA
• YY year
• VISN V1TO5, V6TO10, V11TO16, V17TO22
• X I for inpatient, O for outpatient
• Based on patient status for encounter not type of
  prescription
• Safest to always use both files
• Inpatient
• RMTPRD.MED.DSS.SAS.FY03.V1TO5I.PHA
• Outpatient
• RMTPRD.MED.DSS.SAS.FY03.V1TO5O.PHA

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PBM vs. DSS
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Session Objectives

• Measurement Issues with Pharmacy Data
• Key Data Source Review PBM Data DSS Pharmacy
  Data
• Measurement Issues and Use of Pharmacy Data
• Where To Go For More Help

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Measurement Issues Pharmacy Data Comparison

• CSP 456 Hernia Study
• Population
• 1,591 Patients in the CSP 456 Study
• Prescriptions
• Outpatient
• FY2002
• Fills and refills
• 42,469 prescriptions

Report Available at http//www.virec.research.va.
gov/References/TechnicalReports/VIReCTechnicalRepo
rt1.pdf
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Measurement Issues Pharmacy Data Comparison

• Preliminary Results

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Measurement Issues Pharmacy Data Comparison

• Limitations
• Outpatient only
• Cohort not representative of whole population
• Conclusions
• DSS and PBM Pharmacy extracts capture same
  prescriptions
• DSS or PBM?
• Future Comparisons
• Inpatient data?
• Representative Cohort
• Anecdotal evidence of other examples where match
  is not as good

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Measurement Issues Medication Utilization

• Did change in prescription drug copayment impact
  medication utilization? (HSRD ECI 02-220, PI
  Kevin T. Stroupe, PhD)
• Examined 30-day equivalents of use of chronic
  medications in 3 groups of patients before and
  after copayment change
• Identified utilization in several categories
  essential vs. non-essential OTC vs.
  prescription high cost vs. low cost brand vs.
  generic
• Number of medications obtained from the VA
  decreased among those subject to copayments and
  biggest effects were in low cost and OTC
  medications

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Measurement Issues Exposure to specific
medications

• Determine if the use of ICS is associated with an
  increased risk of non-vertebral fractures in
  patients with COPD in the VA
• Conducted a nested case-control study in a cohort
  of VA patients with COPD
• Found increased risk of fractures in COPD
  patients using high dose ICS
• Needed to quantify amount of use of inhaled
  medications
• Pharmacy data not always easy to work with
  particularly true with regard to inhaled products
• More straightforward to calculate cumulative
  exposure when dealing with tablets/capsules than
  with inhalers

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Measurement Issues Exposure to specific
medications
ID
1
2
3
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Measurement Issues Exposure to specific
medications

• VA_PRODUCT
• Used to determine specific product
• Used to determine dose strength
• Used to determine number of actuations
• SIG
• Used to determine dosing frequency
• Used to determine number of doses per day

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Measurement Issues Exposure to specific
medications

• Calculation of cumulative ICS exposure
• Determine strength for each prescription
• Fluticasone 220?g
• Convert strength to beclomethasone equivalents
• BDP_Equiv gt 2200.5 110?g per dose
• Determine number of doses per prescription
• quantity dispensed doses per product
• 1 canister 120 actuations/canister 120 doses
• Calculate beclomethasone equivalents for each
  prescription and sum for cumulative exposure

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Measurement Issues Medication Adherence

• Examine factors associated with non-adherence in
  patients with COPD
• Measured adherence to respiratory medications
  using Medication Possession Ratio (MPR)
• MPRi
• Found use of CMOP and hospitalizations in prior
  period associated with higher adherence
• Cautions day supply variable accuracy (oral meds
  vs. inhaled meds) accounting for medications and
  days supply at beginning and end of period of
  interest

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Measurement Issues Combining Outpatient and
Pharmacy Data

• Identify acute exacerbations of COPD in the
  outpatient setting
• Use a combination of outpatient ICD-9 codes and
  Rx data
• Found many outpatient ICD-9 codes non-specific
  for identifying COPD exacerbation
• Most Rx for oral steroids or antibiotics
  dispensed within 5 days of ICD-9 code
• Used algorithm to disqualify ICD-9 codes and
  medication prescriptions
• SIGS with cellulitis, pharyngitis, sinusitis, etc.

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Measurement Issues Identifying Comorbidities
with Pharmacy Data

• Development of a VA-based version of RxRisk
  (Chronic Disease Score)
• Sloan KL, et al. Construction and characteristics
  of RxRisk-V a VA-adapted pharmacy-based case-mix
  instrument. Med Care 2003 41(6) 761-74
• Potential value in using pharmacy-based measures
  versus ICD-based measures
• RxRisk-V performed similarly to HCC and ADG
  case-mix adjusters when predicting costs
  prospectively
• Sales AE, et al. Predicting costs of care using a
  pharmacy-based measure risk adjustment in a
  veteran population. Med Care 2003 41(6) 753-60

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Session Objectives

• Measurement Issues with Pharmacy Data
• Key Data Source Review PBM Data DSS Pharmacy
  Data
• Measurement Issues and Use of Pharmacy Data
• Where To Go For More Help

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VIReC Help

• VIReC Webpage
• http//www.virec.research.va.gov
• Information on VA data sources and how to access
  data
• Documentation on some VA datasets, i.e., Medical
  SAS datasets
• http//www.virec.research.va.gov/DataSourcesName/M
  edical-SAS-Datasets/SASdocumentation.htm
• Includes lists of variables and their dataset
  locations
• Descriptions of each of the variables
• Values for selected variables

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VIReC Help (contd)

• HSRData Listserv
• Join at VIReC Web site
• Discussion among gt 200 data stewards, managers,
  and users
• Past messages in archive (on intranet)
• VIReC Help Desk
• VIReC staff will answer your question and/or
  direct you to available resources on topics
• VIReC_at_va.gov
• [phone]

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References

• Arnold N, Hynes DM, Stroupe KT. VIReC Technical
  Report 1 Comparison of VA Outpatient
  Prescriptions in the DSS Datasets and the PBM
  Database. Edward Hines, Jr. VA Hospital, Hines,
  IL VA Information Resource Center, January 15,
  2006.
• Lee TA, Weiss KB. Risk of non-vertebral fractures
  associated with inhaled corticosteroid use in
  obstructive lung disease. Am J Respir Crit Care
  Med. 2004 169(7) 855-859.
• Charbonneau A, Rosen AK, Ash AS, Owen RR, Kader
  B, Spiro A, III, et al. Measuring the quality of
  depression care in a large integrated health
  system. Med Care 2003 41(5)669-680.
• Sloan KL, et al. Construction and characteristics
  of RxRisk-V a VA-adapted pharmacy-based case-mix
  instrument. Med Care 2003 41(6) 761-74
• Sales AE, et al. Predicting costs of care using a
  pharmacy-based measure risk adjustment in a
  veteran population. Med Care 2003 41(6) 753-60