The Healthcare Cost and Utilization Project (HCUP)

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Slide 1

The Healthcare Cost and Utilization Project (HCUP)

HCUP Data Resources to Inform Research & Policy

P. Hannah Davis, MS
Claudia Steiner, MD, MPH
Agency for Healthcare Research and Quality
AHRQ Annual Conference 9-10-2012

Slide 2

Today's Objectives

• Project Overview.
• The HCUP Partnership.
• The HCUP Databases.
• Obtaining HCUP Databases.
• The HCUP Tools and Products.
• Additional HCUP Resources.

Slide 3

What is HCUP?

• HCUP is the largest collection of multi-year, all-payer data that includes inpatient and selected outpatient data that is based on the hospital billing record.

Image: A photograph shows a patient in a hospital bed.

Slide 4

What is HCUP?

Image: The HCUP logo is at the top of a chart "tree" with four branches:

• HCUP Databases (The databases are represented by data-bin icons labeled SID, SEDD, SASD, NEDS, NIS, and KID).
• Research Tools (Represented by a pile of computer discs).
• Research Publications (Represented by covers of sample publications).
• User Support (A photograph of a woman at a computer is shown).

Slide 5

Why Do We Need Another Hospital Data Source?

Slide 6

What can you get from HCUP?

Slide 7

HCUP Supports High Impact Health Services, Policy & Clinical Research

Image: A number of images of logos from news publications are shown.

Slide 8

Today's Objectives

• Project Overview.
• The HCUP Partnership.
• The HCUP Databases.
• Obtaining HCUP Databases.
• The HCUP Tools and Products.
• Additional HCUP Resources.

Slide 9

The HCUP Partnership

Image: The three partners—State, Federal, and Industry—are connected in a circle by double-headed arrows, indicating their mutual interaction.

Slide 10

What is the Agency for Healthcare Research and Quality (AHRQ)?

• The Agency for Healthcare Research and Quality (AHRQ) is a federal agency under the Department of Health and Human Services.

Image: A "family tree" of the Dept. of Health & Human Services shows AHRQ's place among its sister agencies, with HCUP as its child.

Slide 11

Current HCUP State Partners

Alaska State Hospital and Nursing Home Association.
Arizona Department of Health Services.
Arkansas Department of Health.
California Office of Statewide Health Planning & Development.
Colorado Hospital Association.
Connecticut Hospital Association.
Florida Agency for Health Care Administration.
Georgia Hospital Association.
Hawaii Health Information Corporation.
Illinois Department of Public Health.
Indiana Hospital Association.
Iowa Hospital Association.

Slide 12

Current HCUP State Partners

Kansas Hospital Association.
Kentucky Cabinet for Health and Family Services.
Louisiana Department of Health and Hospitals.
Maine Health Data Organization.
Maryland Health Services Cost Review Commission.
Massachusetts Division of Health Care Finance and Policy.
Michigan Health & Hospital Association.
Minnesota Hospital Association.
Mississippi Department of Health.
Missouri Hospital Industry Data Institute.
Montana MHA – An Association of Montana Health Care Providers.
Nebraska Hospital Association.

Slide 13

Current HCUP State Partners

Nevada Department of Health and Human Services.
New Hampshire Department of Health & Human Services.
New Jersey Department of Health.
New Mexico Department of Health.
New York State Department of Health.
North Carolina Department of Health and Human Services.
Ohio Hospital Association.
Oklahoma State Department of Health.
Oregon Association of Hospitals and Health Systems.
Oregon Office for Oregon Health Policy & Research.
Pennsylvania Health Care Cost Containment Council.
Rhode Island Department of Health.
South Carolina State Budget & Control Board.

Slide 14

Current HCUP State Partners

South Dakota Association of Health Care Organizations.
Tennessee Hospital Association.
Texas Department of State Health Services.
Utah Department of Health.
Vermont Association of Hospitals and Health Systems.
Virginia Health Information.
Washington State Department of Health.
West Virginia Health Care Authority.
Wisconsin Department of Health Services.
Wyoming Hospital Association.

46 States and continuing to recruit additional States to the HCUP Partnership

Slide 15

HCUP Partners Providing 2010 Inpatient Data

Image: A map of the United States is shown with the HCUP participating States highlighted. The non-participating States are Alabama, Delaware, Idaho, and North Dakota.

Slide 16

HCUP Partners Providing 2010 Emergency Department Data

Image: A map of the United States is shown with the participating HCUP partner States providing 2010 ambulatory surgery data highlighted. The non-participating States are Alaska, Oregon, Washington, Nevada, Idaho, Montana, Wyoming, Colorado, New Mexico, Texas, Oklahoma, North Dakota, Arkansas, Louisiana, Mississippi, Illinois, Michigan, Alabama, West Virginia, Virginia, Pennsylvania, and Delaware.

Slide 17

HCUP Partners Providing 2010 Ambulatory Surgery Data

Image: A map of the United States is shown with the HCUP partner States providing 2010 emergency department data highlighted. The non-participating states are Alaska, Washington, Nevada, Idaho, Montana, Wyoming, Arizona, New Mexico, Texas, North Dakota, Arkansas, Louisiana, Mississippi, Alabama, West Virginia, Virginia, Pennsylvania, Massachusetts, and Delaware.

Slide 18

Partnership: HCUP Database Participation By State

Image: A map of the United States is shown with each State color-coded to show how it participates in HCUP.

Non-participating:

• ID.
• ND.
• AL.
• DE.

Partners Providing Inpatient Data Only:

• WA.
• NV.
• MT.
• WY.
• NM.
• TX.
• AR.
• LA.
• MS.
• WV.
• VA.
• PA.

Partners Providing Inpatient & Ambulatory Surgery Data:

• CO.
• OR.
• OK.
• MI.

Partners Providing Inpatient & Emergency Department Data:

• AZ.
• MA.
• RI.

Partners Providing Inpatient, Ambulatory Surgery, & Emergency Department Data:

• CA.
• UT.
• SD.
• NE.
• KS.
• MN.
• IA.
• MO.
• WI.
• IL.
• IN.
• KY.
• TN.
• OH.
• GA.
• FL.
• NC.
• SC.
• MD.
• NJ.
• NY.
• CT.
• VT.
• NH.
• ME.

Slide 19

Today's Objectives

• Project Overview.
• The HCUP Partnership.
• The HCUP Databases:
  • Where does data come from?
  • HCUP State Databases.
  • HCUP Nationwide Databases.
• Obtaining HCUP Databases.
• The HCUP Tools and Products.
• Additional HCUP Resources.

Slide 20

HCUP Has Six Types of Databases

• Three State-level databases:
  • State Inpatient Databases (SID).
  • State Ambulatory Surgery Databases (SASD).
  • State Emergency Department Databases (SEDD).

Images: Each database listed above is accompanied by a representative photograph. SID, a doctor is examining a patient. SASD, a medical team is performing surgery. SEDD, an ambulance.

Slide 21

HCUP Has Six Types of Databases

• Three nationwide databases:
  • Nationwide Emergency Department Sample (NEDS).
  • Nationwide Inpatient Sample (NIS).
  • Kids' Inpatient Database (KID).

Images: Each database listed above is accompanied by a representative photograph. NIS, a medical technician is working with a blood sample. NEDS, an ambulance. KID, a nurse cradles a baby.

Slide 22

Today's Objectives

• Project Overview.
• The HCUP Partnership.
• The HCUP Databases:
  • Where do the data come from?
  • HCUP State Databases.
  • HCUP Nationwide Databases.
• Obtaining HCUP Databases.
• The HCUP Tools and Products.
• Additional HCUP Resources.

Slide 23

The Foundation of HCUP Data is Hospital Billing Data

Image: Billing records are shown. Sections labeled "Demographic Data" and "Diagnoses, Procedures, Charges" are indicated by brackets.

Slide 24

The Making of HCUP Data

Image: A series of images connected by a long, curving arrow depicts the following process:

• Patient enters hospital [Image: A patient with a doctor].
• Billing record created [Image: Billing records].
• Hospital sends billing data and any additional data elements to data organizations [Image: A man working at a computer].
• States store data in varying formats [Image: columns of data].
• AHRQ standardizes data to create uniform HCUP databases [Image: HCUP logo].

Slide 25

The HCUP Process

• Standardized file formats and variable values.
• Value-added variables:
  • Hospital characteristics:
    • Region, Urban/rural, Teaching status, Ownership/control, Bed size.
  • Severity Measures:
    • APR-DRGs, APS-DRGs, Disease Staging, Comorbidity Measures.
• Basic quality checks.

Slide 26

Where Do We Get HCUP Data?

HCUP data is mostly from community hospitals.

Image: A pie chart displays the following data:

Typically not included in HCUP data:

• Federal/Other/LTC 14% (N=769).

Included in HCUP data:

• Community: 86% (N=4,985).

Source: American Hospital Association (AHA), 2010.

Slide 27

What Are Community Hospitals?

American Hospital Association Definition:
Non-Federal, short-term, general, and other specialty hospitals, excluding hospital units of other institutions (e.g., prisons).

Slide 28

Today's Objectives

• Project Overview.
• The HCUP Partnership.
• The HCUP Databases:
  • Where does data come from?
  • HCUP State Databases.
  • HCUP Nationwide Databases.
• Obtaining HCUP Databases.
• The HCUP Tools and Products.
• Additional HCUP Resources.

Slide 29

HCUP State Databases

Slide 30

What Data Elements are included in the HCUP databases?

Data Elements:

• Patient demographics (age, sex).
• Diagnoses & procedures.
• Expected payer.
• Length of stay.
• Patient disposition.
• Admission source & type.
• Admission month.
• Weekend admission.

Image: A photograph shows a computer with the HCUP Web site on the screen.

Slide 31

Some Data Elements Vary by State

• Race/Ethnicity.
• Patient county.
• Patient ZIP Code.
• Severity of illness.
• Birthweight.
• Procedure date (days from admission).
• Primary payer details.
• Secondary payer.
• Detailed charges.
• Patient identifiers encrypted.
• Physician identifiers encrypted.
• Physician specialty.
• Hospital identifier unencrypted.

Image: A map of the United States is shown.

Slide 32

Example: Payer Detail Varies by State

Slide 33

Example: Race Detail Varies by State

Slide 34

Partner State Files vs. HCUP State Files

• HCUP State Files vs. Data Files received directly from the State.

Slide 35

States Releasing Databases through HCUP Central Distributor

• Arizona.
• Arkansas.
• California.
• Colorado.
• Florida.
• Hawaii.
• Iowa.
• Kentucky.
• Maine.
• Maryland.
• Massachusetts.
• Michigan.
• Nebraska.
• Nevada.
• New Jersey.
• New Mexico.
• New York.
• North Carolina.
• Oregon.
• Rhode Island.
• South Carolina.
• South Dakota.
• Utah.
• Vermont.
• Washington.
• West Virginia.
• Wisconsin.

Remember: Not all States participate in all years and for all databases.

Slide 36

Today's Objectives

• Project Overview.
• The HCUP Partnership.
• The HCUP Databases:
  • Where does data come from?
  • HCUP State Databases.
  • HCUP Nationwide Databases.
• Obtaining HCUP Databases.
• The HCUP Tools and Products.
• Additional HCUP Resources.

Slide 37

HCUP National Databases

Slide 38

NIS is a Stratified Sample of Hospitals from the SID

State Inpatient Databases (SID)

N = ~ 5K hospitals, ~ 36M records.

5 NIS Strata:

1. U.S. Region.
2. Urban/Rural.
3. Teaching Status.
4. Ownership/Control.
5. Bed Size.

Stratified Sample of HOSPITALS (State is NOT included as a stratum) →

Nationwide Impatient Sample (NIS)

N = ~ 1K hospitals, ~ 8M records.

100% of all discharges from each hospital.

Slide 39

KID is a Stratified Sample of Discharges from the SID

State Inpatient Databases (SID)

N = ~ 4K hospitals, ~ 32M records.

3 NIS Strata:

1. Uncomplicated Births.
2. Complicated Births.
3. Pediatric Non-Births.

10% stratified sample of uncomplicated BIRTHS (State is NOT included as a stratum) →

80% stratified sample of other pediatric DISCHARGES →

Kids' Inpatient Database (KID)

N = ~ 4K hospitals, ~ 3M records.

Slide 40

NEDS is a Stratified Sample of Hospitals from the SEDD and SID

State Inpatient Databases (SID)

State Emergency Department Databases (SEDD)

5 NIS Strata:

1. U.S. Region.
2. Urban/Rural.
3. Teaching Status.
4. Ownership/Control.
5. Trauma.

Stratified Sample of HOSPITALS (State is NOT included as a stratum) →

Nationwide Emergency Department Sample (NEDS)

N = ~ 1K hospitals ~ 28M records.

Slide 41

What Types of Care Are and Are Not Captured by HCUP?

Image: A photograph shows a woman working at a computer.

Slide 42

What is HCUP and What Is It Not?

Slide 43

Hospital Billing Data Have Benefits and Limitations

Benefits

Large number of visit records.

Uniformity of coding.

Routine, regular collection.

Ease of access.

All-payer.

Available at local, state, regional and national level.

Supplemental files available to facilitate research.

Limitations

Differences in coding across hospitals.

Limited clinical details.

Lack revenue information.

May not include all hospitals.

May not show complete experience of care.

No data on individuals outside of hospital system.

Slide 44

Some Limitations Can be Addressed by Linking to Other Databases

Image: Six green data bin icons are labeled SID, SEDD, NEDS, SASD, NIS, and KID. From these bins, a series of double-headed arrows are arrayed.

• The first arrow is labeled "AHAID" and points to "American Hospital Association (AHA) Annual Survey."
• The second arrow is labeled "County" and points to "Health Resources and Services Administration's (HRSA) Area Resource File (ARF)."
• The third arrow is labeled "ZIP Code" and points to "ZIP Code files from Census or Vendor."
• The fourth arrow is labeled "Medicare ID" and points to "Medicare Cost Reports."
• The fifth arrow is labeled "AHAID" and points to "Trauma Information Exchange Program (TIEP)."

Slide 45

Summary

• Six types of HCUP databases.
• Databases are based on administrative hospital data.
• Available for multiple years:
  • NIS (1988-2010).
  • NEDS (2006, 2007, 2008, 2009).
  • KID (1997, 2000, 2003, 2006, 2009).
  • SID (1990- 2011).
  • SASD (1997- 2011).
  • SEDD (1999-2011).
• Can look at breadth of health care issues.
• Can be linked to external files.

Slide 46

Today's Objectives

• Project Overview.
• The HCUP Partnership.
• The HCUP Databases:
  • Where does data come from?
  • HCUP State Databases.
  • HCUP Nationwide Databases.
• Obtaining HCUP Databases.
• The HCUP Tools and Products.
• Additional HCUP Resources.

Slide 47

The HCUP Database Process

• Processed data sent to HCUP Partners.
• State databases may become available to public through:
  • State Data Organization.

    OR

  • HCUP Central Distributor.

Slide 48

Purchase Data through HCUP Central Distributor

• Step 1: Download and complete application kit:
  http://www.hcup-us.ahrq.gov/tech_assist/centdist.jsp.
• Step 2: Obtain more information (if needed):
  Phone: 866-556-HCUP (4287) toll free
  Email: HCUPDistributor@ahrq.gov.
• Step 3: Take Data Use Agreement (DUA) on-line training and sign DUA.
• Step 4: Send order form, signed DUA, and payment to HCUP Central Distributor.

Slide 49

Pricing Information per Data Year

Nationwide Databases (NIS, KID, NEDS)

• NIS: $350 (CY 2010; student price $50)
  $160-200 (earlier years; student price $20).
• KID: $350 (CY 2009; student price $50)
  $200 (earlier years; student price $20).
• NEDS: $500 (student price $75).

State Databases (SID, SASD, SEDD)

• Varies by state, database, year, and type of applicant.
• $35 - $3,185

Slide 50

Software Requirements of Working with the Full HCUP Files

MS Excel® and Access® are NOT GOOD Options!

Image: A table compares capacities for software packages SAS, STAT, SPSS, and SUDAAN; all but the last are compatible with HCUP Tools Programs.

Slide 51

Today's Objectives

• Project Overview.
• The HCUP Partnership.
• The HCUP Databases.
• Obtaining HCUP Databases.
• The HCUP Tools and Products:
  • Software Tools.
  • Supplemental Files.
  • Online Tools.
  • Methods Reports.
• Additional HCUP Resources.

Slide 52

ICD and CPT: The Clinical Backbone of Claims Data

• ICD-9-CM Diagnosis and Procedures Codes:
  • Included in both inpatient and outpatient databases.
• Common Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS):
  • Procedure coding for outpatient data.

Images: The covers of the ICD-9-CM Manual, the 2011 CPT manual, and the HCPCH Manual are shown.

Slide 53

Clinical Classifications Software (CCS)

• Clusters diagnosis and procedure codes into categories:
  • >12,000 diagnosis codes → ~260 categories.
  • > 4,000 procedure codes → ~230 categories.
• Useful for presenting descriptive statistics, understanding patterns.

Image: A box labeled "CCS for ICD-9-CM" has an arrow pointing from it to the following text:

ICD-9-CM Codes:

• 0031 0202 0223 0362 0380 0381 03810 03811 03819 0382 0383 03840 03841 03842 03843 03844 03849 0388 0389 0545 449 7907.
• 0700 0701 0702 07020 07021 07022 07023 0703 07030 07031 07032 07033 0704 07041 07042 07043 07044 07049 0705 07051 07052 07053 07054 07059 0706 07070 07071 0709 57140 57141 57149 5731 5732 5733.

Brackets follow the two listed sets of codes above and point respectively toward two listed items:

CCS Codes:

• CCS 2: Septicemia.
• CCS 6: Hepatitis.

Slide 54

Procedure Classes

• Groups ICD-9-CM procedure codes into one of four categories.
• Major procedures defined as OR procedures (DRGs).

Image: A box labeled "ICD-9-CM Procedure Codes" has an arrow pointing from it to the following list:

1. Minor Diagnostic:
   1. Ex: Electrocardiogram.
2. Major Diagnostic:
   1. Ex: Pericardial Biopsy.
3. Minor Therapeutic:
   1. Ex: Pacemaker.
4. Major Therapeutic:
   1. Ex: CABG.

Slide 55

Chronic Condition Indicator (CCI)

• Groups ICD-9-CM diagnosis codes in Chronic or Non-Chronic Categories.

Image: A box labeled "ICD-9-CM Diagnosis Codes" has an arrow pointing from it to the following list:

1. Chronic:
   1. Ex: Diabetes.
2. Non-Chronic:
   1. Ex: Food Poisoning.

Slide 56

Comorbidity Software

• Creates and appends indicator flags to each record for 29 major comorbidities.

Image: A box labeled "ICD-9-CM Codes, DRGs on Administrative Data" has an arrow pointing from it to a pile of computer discs captioned "Comorbidity Software." Another arrow points from the discs to the following list:

29 Comorbidity Groups:

• CHF.
• Valvular disease.
• Pulm circ disorders.
• Peripheral vascular dx.
• Hypertension.
• Paralysis.
• Other neuro disorders.
• Chronic pulmonary dx.
• DM w/o complications.
• DM w/ complications.
• Hypothyroidism.
• Renal failure.
• Liver disease...

Slide 57

Supplemental Files

• Supplemental Variables for Revisit Analyses.
• Cost-to-Charge Ratio Files.
• Hospital Market Structure Files.
• Trends Files (NIS & KID).
• NIS Hospital Ownership File.
• AHA Linkage Files.

http://www.hcup-us.ahrq.gov/tools_software.jsp

Image: A photograph shows a man working at a computer.

Slide 58

Online Tools

• MONAHRQ
  • A desktop software tool that enables organizations to input their own hospital administrative data and/or the CMS Hospital Compare data to generate a data-driven Web site.
  • http://monahrq.ahrq.gov.
• HCUPnet
  • Free, interactive online query system.
  • http://hcup.ahrq.gov/hcupnet.

Image: The HCUP and MONAHRQ logos are shown.

Slide 59

Welcome to HCUPnet

http://hcup.ahrq.gov/hcupnet

Image: A screen shot of the HCUPnet Web site is shown.

Slide 60

HCUP Methods Reports

• Methodological information on the HCUP databases and software tools.

Image: A screen shot shows the HCUP Methods Series list on the HCUP Web site.

Slide 61

HCUP Publications

• Statistical Briefs.
• Annual Reports.
• Special Analysis Reports.
• Fact Books.

Images: The covers of HCUP publications are shown.

Slide 62

Today's Objectives

• Project Overview.
• The HCUP Partnership.
• The HCUP Databases.
• Obtaining HCUP Databases.
• The HCUP Tools and Products:
  • Software Tools.
  • Supplemental Files.
  • Online Tools.
  • Methods Reports.
• Additional HCUP Resources.

Slide 63

HCUP User Support Web site

• Find detailed information on HCUP databases, tools, and products.
• Access HCUPnet.
• Find comprehensive list of HCUP-related publications, database reports, and fact books.
• Access technical assistance.

http://www.hcup-us.ahrq.gov

Image: A screen shot shows the HCUP Web site.

Slide 64

Interactive On-line HCUP Tutorial Series

• Overview Course:
  • Provides information about HCUP data, software tools, and products.
• Technical Tutorials:
  • HCUP Sample Design.
  • Load and Check HCUP Data.
  • Producing National HCUP Estimates.
  • Calculating Standard Errors.

http://www.hcup-us.ahrq.gov/tech_assist/tutorials.jsp

Image: A screen shot of the HCUP Tutorials page is shown.

Slide 65

Using HCUP Technical Assistance

Active Technical Assistance.

• Responds to inquiries about HCUP data, products, and tools.
• Collects user feedback and suggestions for improvement.

Email: hcup@ahrq.gov

Image: A photograph shows a computer with the HCUP Web site on the screen.

Slide 66

Join the HCUP Email List

• HCUP Newsletter, published quarterly:
  • User Tech Tips.
  • Upcoming Events.
• New Data Releases.
• New Reports.

http://www.ahrq.gov/data/hcup/hcuplist.htm

Image: A screen shot shows the HCUP Email Updates page.

Slide 67

Healthcare Cost and Utilization Project (HCUP)

Images: The HCUP logo is shown. Beneath it is a strip of slightly blurred photo images: A hand holding a pen, a emergency room team rushing away with a patient on a cart, a patient lying in a hospital bed, four medical staff walking down a hallway, a doctor's face wearing a surgical mask.

Slide 68

Questions/Comments?

Time for Questions and/or Comments.

Image: A multitude of question marks appear on pieces of paper.