Using CPCSSN Data for Primary Care Researchin Canada

Alan Kaplan MD CCFP(EM) FCFPChairperson, Family Physician Airways Group of Canada

Chairperson, Communities of Practice, Respiratory Medicine, College of Family Physicians of Canada

Outline

• Introduction to CPCSSN• CPCSSN Data Holdings• A Tour of CPCSSN Data Tables• Respiratory medicine in CPCSSN• Limitations in the use of CPCSSN for research• Who to contact

329 physicians in 8 provinces using 10 EMRs

10 PC-PBRNs• British Columbia - BCPCReN (Wolf ) • Alberta - SaPCReN, Calgary (Med Access, Wolf) - AFRPN, Edmonton (Med Access)

• Manitoba - MaPCReN, Winnipeg (Jonoke)

• Ontario - DELPHI, London (Healthscreen, Optimed, OSCAR - NorTReN, Toronto (Nightingale, xwave, Practice Solutions) - CSPC, Kingston (P&P, OSCAR, xwave)

• Quebec - Q-Net, Montréal (Da Vinci, Purkinje)

• Nova Scotia / New Brunswick - MarNet, Halifax (Nightingale, Purkinje)

• Newfoundland - APBRN, St. John’s (Wolf , Nightingale)

Data Holdings Q2 2012

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Data Cleaning/Recoding

• Currently clean and recode the following fields

• Billing, Encounter and Problem List Diagnoses (ICD9)• Medications (ATC)• Lab results (LOINC)• Referrals (SNOMED CT)• Physical signs (Wt, Ht, BP, unit conversion, calculate BMI)• Vaccines (ATC)• Risk factors (smoking, alcohol, diet --Text)

6Patient Demographics

} < 5%

} < 5%

368,000 Records

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Billing

6.8 Million Records

Dates of Encounter

Original diagnosis sent for billing

Text from Code Recoded by CPCSSN

Original Diagnosis Code sent for billing

Recoded by CPCSSN

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Research Discussion

• Useful for case finding• Useful for understanding deficiencies of using

billing information for clinical research

• There is some inconsistency in use of billing codes across the country

• CPCSSN attempts to recode all billing diagnosis codes to a standard version

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Encounters

5.1 Million Records

Dates of Encounter

Data inconsistent across the Country

CPCSSN Cleaning Not Started

Active area of CleaningE.g., Office Visit, Phone, E-mail etc

Problem List Diagnoses

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Original Diagnosis Written by UserE.g. DMT2

Recoded by CPCSSNE.g., Diabetes Mellitus, Type 2

} Not well populated

1.8 Million Records

Active = Problem ListInactive = Past Medical History

Problem List Diagnoses

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List of cleaned up diagnoses

Chronic airway obstruction, not elsewhere classified (496)Bronchitis, not specified as acute or chronic (490)Chronic bronchitis (491)Emphysema (492)Diabetes mellitus (250)Depressive disorder, not elsewhere classified (311)Suicide and self-inflicted poisoning by solid or liquid substances (E590)Suicidal ideation (V62.84) Adjustment reaction (309)Post traumatic stress disorder (309.81)Major depressive disorder, recurrent episode (296.3)Bipolar I disorder, most recent episode (or current) (296.7)Mental disorders complicating pregnancy, childbirth, or the puerperium (648.4)Essential hypertension (401)Osteoarthrosis and allied disorders (715)Spondylosis and allied disorders (721)Total knee replacement (81.54)Total hip replacement (81.51)Polycystic ovarian syndrome (256.4)Abnormal glucose tolerance of mother complicating pregnancy childbirth or the puerperium (648.8)Secondary diabetes mellitus (249)

MORE BEING ADDED SOON

Other abnormal glucose (790.29)Migraine (346)Heart failure (428)Acute myocardial infarction (410)Old myocardial infarction (412)Other forms of chronic ischemic heart disease (414)Cardiac dysrhythmias (427)Essential and other specified forms of tremor (333.1)Esophageal varices with bleeding (456.0)Esophageal varices without bleeding (456.1)Angina pectoris (413)Other acute and subacute forms of ischemic heart disease (411)Calculus of kidney and ureter (592)Portal hypertension (572.3)Asthma (493)Dementias (290)Alzheimer's disease (331.0)Dementia with lewy bodies (331.82)Parkinson's disease (332)Epilepsy and recurrent seizures (345)Epileptic convulsions, fits, or seizures nos (345.9)

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Research Discussion

• Sensitivity and specificity of problem list diagnoses not currently known, so cannot determine incidence and prevalence of disease from problem list alone

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Vital Signs

Name of exam (e.g., sBP)

Cleaned up result(e.g, lbs -> kg, inch -> cm)

5 Million Records

Cleaned up unit of measure(e.g., unit is kg, but result was lb)

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Research Discussion

• Currently have access to– sBP/dBP– Ht– Wt– BMI– Waist circumference

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Allergies

Name of allergen

Cleaned up name

155K Records

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Research Discussion

• Not yet cleaned, but will soon clean it• Focus of cleaning will be on medication

allergies– All other allergies will be retained as original text

• Useful when assessing why patients are not receiving medications for a particular disease

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Risk Factors

Name of Risk Factor (e.g., smoking)

Cleaned up version of Risk Factors.

588K Records

Working on cleaning up Current Exposures & Cumulative Exposures

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Laboratory Results

Original Lab Result Name(e.g., Hb A1c, HGbA1c, etc)

Recoded by CPCSSN 100% LOINC(e.g., HBA1C)

3 Million Records

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Research Discussion• Currently only capturing the following

• One site does not capture labs yet

HDLTRIGLYCERIDESLDLTOTAL CHOLESTEROLFASTING GLUCOSEHBA1CURINE ALBUMIN CREATININE RATIOMICROALBUMINGLUCOSE TOLERANCE

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Encounter Diagnoses

Original Diagnosis Recorded in Encounter(e.g., axniety)

83% Recoded by CPCSSN(Anxiety ICD-9 300)

6.3 Million Records

63% Originally coded by Doctor

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Research Discussion

• Not all EMRs capture Encounter Diagnoses in a structured manner

• This table is not ready for prime time across all sites, but may be useful for projects where data from just a few sites is acceptable

Medications

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What the doctor orderedE.g., HCTZ 25 mg bid

91% Recoded by CPCSSNE.g., Hydrochlorthiazide

56% Coded as DIN

Strength 56%Dose 70%

Unit of Measure 84%Frequency 95%Duration 52%

Dispensed 86%

72% Coded by doctor (DIN + other)

91% Coded by CPCSSN (ATC)

4.9 Million Records

}

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Research Discussion

• Medication name data is relatively clean• Medications coded as ATC

– Allows easy grouping by class

• Don’t have daily dose and months supply for many records –working on clean up

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Referrals

Original Text of Referral

80% Recoded by CPCSSNSNOMED-CT

600 K Records

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Procedures

Original Text of Procedure

Not Currently Coded by CPCSSN

1.3 Million Records

So…...NO spirometry!!!

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Vaccines

What the doctor typed

93% Recoded by CPCSSN (ATC)

960 K Records

46% Coded by Doctor (DIN)

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Limitations for Respiratory Disease

Currently studying 8 conditions:five chronic and mental health conditions

-hypertension, osteoarthritis,

diabetes, COPD and depression)

and three neurologic conditions

-Alzheimer’s and related dementias,

epilepsy and Parkinson’s disease.

Asthma –Text Diagnoses• Asthma 1996 1st time in life• Asthma 1999 ASTHMA 3 years• Asthma age 10• asthma and allergies• asthma and bronchitis • asthma attack postoperatively (493.) • Asthma- class IV work related • Asthma Condition • asthma diabetes • asthma diagnosed in 1999 and treated with rhinocort, ventolin and beclovent. off

all meds since a short course of treatment. • ?asthma equivalent cough

Asthma –Challenges • 2. ? Asthma as teenager • Exercise induced asthma as child. • Asthma since childhood• Asthma age 10• asthma Dx age 7-hospitalized few

times/gluten free diet then-but came off after 1 yr-better during teen yrs

• Asthma since age 17• Asthma-age 15 • Bronchial asthma age 18.

Smoking D/C • asthma, ? GERD

• Asthma since 2005• asthma prior to 1980 • Asthma since teen• Asthma?? Hx SOB 1997• - asthma as a child; • 1980: childhood asthma • Asthma in childhood• Asthma in childood• Asthma since childhood • Childhood Asthma • asthma until age 13 • Asthme (MPOC), contr?l??????

Smoking

• Smoking data in EMRs is particularly challenging• Most EMRs capture smoking data as text• There are a lot of ways to say ‘the patient does not

smoke’– Quit, ex-, non-, smoking =0, x-– Makes separating ex-/non- from smokers difficult using an

algorithmic approach• Dates are poorly captured• Cumulative exposure is poorly captured

Smoking VariabilitySite A Site B Site C

NON-SMOKER TOBACCO NON-SMOKER NON SMOKER

T TOBACCO NEVER SMOKER

EX-SMOKER TOBACCO EX SMOKER QUIT > 1 YEAR

SMOKER: QUITTING TOBACCO NON-SMOKER QUIT < 1 YEAR

SMOKER: NO PLAN TO QUIT TOBACCO SMOKER

SMOKER: ACTIVELY QUITING NEVER SMOKED

TOBACCO USE (305.1) TOBACCO NON SMOKER

SMOKER: ACTIVELY QUITTING

SMOKING

NON SMOKER

NICOTINE ADDICTION

NONSMOKER

EX SMOKER

Smokers vs Ex-Smokers

• Smoker: no plan to quit • smoker: actively quiting • SMOKER. TO STOP• Trying to quit smoking• smoker- 20 pyh, quit

1997

• SMOKER-NON• smoking - quit 1997• Stopped smoking • ex-smoker-30 pck/year,

quit 2002 • Second hand smoke • smoker- 30 pyh, trying

to quit

Improving Smoking Data

• Smoking data is uniformly poor across the country and across EMRs

• EMRs don’t have structured data entry templates for smoking status

• EMRs need to be able to capture– Status: Smoker –Current, Former, Never– Current exposure: cig/day– Cumulative exposure: Pack-year history

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Other groups working on this:

They have the concept

But, as of yet, no liasons…

Metropolitan Toronto database

Metropolitan Toronto database

Research Opportunities• Population Health and Epidemiological Studies

– Incidence/Prevalence of disease– Impact of SES on health– Rates of treatment for diseases– Rates of disease control– Burden of illness and multi-morbidity

• Clinical –database studies– Comparative effectiveness– Case-Control– Exposure-Outcome– Quality Improvement– Associations– Intervention-Outcome– Guideline effectiveness

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Research Using CPCSSN Data

ResearcherLetter of

Intent

CPCSSN Research

Committee

Writes

Letter of Intent

Reviews

1 page, includes: Researchers, Organization, Research Title,

Objective, Methodology, Data Required

Approved

1. Resubmit2. Not Feasible

3. Outside Mandate

No

Researcher

1. Protocol2. Data Access Request Form

3. Data Sharing Agreement

Letter of Acceptance Yes

Writes

CPCSSN Research

Committee

CPCSSN Data

ResearcherInvoice

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Letter of intent

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Letter of intent (2)

CPCSSN ContactTyler Williamson, Senior Epidemiologist Canadian Primary Care Sentinel Surveillance Network

Centre for Studies in Primary CareQueen’s UniversityKingston ON K7L 5E9

Tel: (613) 533-9300, Ext. 73838Fax: (613) 533-9302e-mail: tylerw@cpcssn.org

Mine: for4kids@gmail.com45

So, I have an opportunity to do a study with COPD, at least in Toronto group

• With what I have shown you, what would you suggest I do?

• Is there an opportunity to work with any of your existing projects?

• And then…funding…..