Application for NHIRD Researches
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1 Application for NHIRD Researches Investigating the Long Term Interaction among Pulmonary Tuberculosis & Chronic non Communicable Diseases with the Taiwan National Health Insurance Research Database Chih Hsin Lee Taipei Tzu Chi Hospital 25 Sep, 2013 National Health Research Institute 2 Taiwan Gold Rush Published Papers in Peer Reviewed Journals using NHIRD > Adated from Tsung Hsueh Lu 3 Taiwan National Health Insurance Research Database (NHIRD) Taiwan launched a single payer National Health Insurance program on March 1, Large computerized databases derived from this system are maintained by the National Health Research Institutes for research purposes. The NHIRD contains registration files and original claim data for reimbursement. 4
2 Registration Files Registry for contracted beds (BED) Original Claim Data Registry for contracted specialty services (DETA) Registry for contracted medical facilities (HOSB) Supplementary registry for contracted medical facilities (HOSX) Registry for board certified specialists (DOC) Registry for medical personnel (PER) Registry for catastrophic illness patients (HV) Registry for medical services (HOX) Registry for drug prescriptions (DRUG) Registry for beneficiaries (ID) 5 Monthly claim summary for inpatient claims (DT) Monthly claim summary for ambulatory care claims (CT) Inpatient expenditures by admissions (DD) Details of inpatient orders (DO) Ambulatory care expenditures by visits (CD) Details of ambulatory care orders (OO) Expenditures for prescriptions dispensed at contracted pharmacies (GD) Details of prescriptions dispensed at contracted pharmacies (GO) 6 Advantage of NHIRD The privacy information is encrypted to the researchers and thus less ethical issues. Nationwide population (98% coverage rate), huge cohort (27 million beneficiaries). Comprehensive coverage for nearly all territories of medical care. Follow up period up to 16 years Registry for catastrophic illness patients is very reliable. 7 Disadvantage of NHIRD Only claim data (billing receipt). Laboratory, radiology findings, and clinical presentations are UNAVAILABLE. No validation data. Contains 0.3 1% erroneous entries. Package claim of inpatient prescriptions and thus temporal information was wiped during admission. 8
3 Outpatient Prescription file gb/y The Data NHIRD Screening is Extremely and Aggregation HUGE to the Clinical Investigations Catastrophic data file 142 mb/y Inpatient file 1.36 gb/y Inpatient Prescription file 1.55 gb/y Outpatient File 5.67 gb/y Adated from Tsung Hsueh Lu 9 The LHID 2005 released on 2007 contains original claim data about 135GB. Single outpatient prescription file occupies for more than 400 MB. Essentially 150 million outpatient prescriptions joining to 620 million order details A total of 1 billion records. 10 The Clinical Information is VAGUE to the Information Technology Specialists Datamining Tools Diagnostic codes are extremely unreliable. Tests, diagnoses, procedures, medications and insurance distribution rules are constantly altered. Simple association study is dangerous. Diuretics are important risk factors for chronic renal failure. Spirometry increases the risk of post operative ventilation dependency. Sputum cultures increase the risk of pulmonary TB. Confounded by Indication 11 Graphical database Interface Access, Excel Programming language C, java, R, Perl High level database programing language Dbase, FoxPro, SAS, SQL
4 Test Platform FEE_YM APPL_TYPE HOSP_ID APPL_DATE ID Workstation: i7 920, 12G RAM, 300GB HDDs x 8 on Raid 10 MySQL 5.1 Dbvisualizer Java 40,000 beneficiaries from LHID 資料定義白皮書 Transcription of Raw Data of NHIRD Purposely developed Java program Stream the text file row by row. Exam the data record for length and encodings according to the code book. Slice the data fields. Check the data for unreasonable values. Load to the relational database through JDBC gateway
5 A Prescription Record in NHIRD A prescription record is identified by combination of six data fields (FEE_YM, APPL_TYPE, HOSP_ID, APPL_DATE, CASE_TYPE, SEQ_NO) The detail orders consisting the very prescription are dispersed in the OO table Index with Relational Database Data Reduction without Loss in Information: Normalization FEE_YM 4 byte APPL_TYPE 1 byte HOSP_ID 34 byte APPL_DATE 4 byte CASE_TYPE 2 byte SEQ_NO 6 byte (total 51 byte) IPD_VISIT 3 byte 19 20
6 Sliced the Data to Benefit from Multicore Processors Teamwork The NHIRD was sliced into smaller subsets. The subsets are independent to each other and can be processed in parallel. Research Ideas Research Output Time Dependent Information Peerless Zone for NHIRD Studies The NHIRD has a very long duration of follow up (up to 17 years) with comprehensive temporal information. Taking corticosteroids 1 week ago, 1 month ago, 1 year ago or 10 years ago should have different clinical impact. NHIRD Time dependent analysis Weak association Multifactorial 24
7 Risk of developing TB among Patients with COPD Background COPD are associated with chronic bronchial inflammation with impaired airway mucus clearance. Inhaled and systemic corticosteroids are the treatment of choice for COPD. Inhaled corticosteroids reduce the risk of acute exacerbations and thus systemic corticosteroids consumption and nosocomial exposure of TB. 25 Material and Methods Results and Interpretation Conclusion Future Remarks 26 Pulmonary Tuberculosis (TB) Chronic infection causes persistent inflammation and tissue destruction for years. Mycobacterium tuberculosis complex. Delay 6 12 months in diagnosis is common. Scaring and fibrosis of lung parenchyma & bronchial tree. 27 TB Prevalence (WHO 2010) 28
8 Chronic Obstructive Pulmonary Disease (COPD) Pulmonary TB in Taiwan Chronic inflammation of bronchial tree causes major mortalities and disabilities. Persistent decline of lung function. Taiwan CDC, High Dose ICS is Associated with Risk of Developing Pulmonary TB Background Shu CC, et al. Medicine 2010, 89:53 61 Use of Medication (ICS, oral corticosteroids) were not treated as time dependent variables. Control of COPD severity based only on lung function. Acute exacerbation may increase the nosocomial exposure of TB. 31 Material and Methods Results and Interpretation Conclusion Future Remarks 32
9 Identifying Variables in NHIRD Cohort: COPD Exposure: COPD associated medication (ICS, OCS) Confounding Factors: Systemic comorbidities: diabetes mellitus, malignancy, HIV, pneumoconiosis, auto immune disease Event: Pulmonary tuberculosis Clinical Diagnosis for TB Symptoms/Signs Radiology Microbiology Identifying TB in NHIRD Data Processing for Prescriptions of anti TB Medications Radiology Microbiology Clinical Presentations The prescriptions are categorized according to the main constitutes. Anti TB Drugs TB Diagnostic Codes The doses were converted to the defined daily dose (DDD) and aggregated
10 Processing the anti TB prescriptions Definitions for TB 2 OPD or 1 admission with compatible ICD. 2 anti TB drugs for 28 days within 90 days. Day 0 Day OPD or 1 admission with compatible ICD. At least one prescription consisting 3 anti TB drugs. 2 anti TB drugs for 120 days within 180 days. TB diagnosis during last two months of anti TB treatment No NTM diagnosis during last two months of anti TB treatment 38 Identifying Specific Disease in NHIRD A set of criteria (loose ~ strict). Trends of TB Notification Rate compared to local epidemiology reports One fits all (global). Better to have local epidemiology data
11 Clinical Diagnosis for COPD Identifying COPD in NHIRD Radiology Lung function Symptoms Spirometry Radiology Clinical Presentations COPD Drugs COPD Diagnostic Codes Combined Assessment Air flow limitation Acute exacerbations Symptoms Diagnosis Duration Medication Frequency Age of Onset 43 44
12 Background Material and Methods Results and Interpretation Diagnosis Duration Medication Conclusion Frequency Future Remarks Age of Onset COPD is an independent Risk Factor for TB Confounding by Tobacco Smoking Variables p value Hazard 95% C.I. Ratio lower upper Age (10 years) < Male < COPD < DM ESRD Liver cirrhosis Lee C.H. BMC Infectious Disease 2013, 13: Study population p value Hazard Ratio 95% confidence interval lower upper All < Men < Women < Lee CH, et al. BMC Infectious Disease 2013, 13:194 48
13 Time Dependent Cox Regression for Risk Factors of TB Among Patients with COPD Sensitivity Analysis The risk factors included age, male, oral corticosteroids, DM, oral β agonists, and low income status. The hazard ratios agreed well among different selection scenarios for COPD. Lee CH, et al. BMC Infectious Disease 2013, 13: Lee CH, et al. BMC Infectious Disease 2013, 13: COPD Medication Background The association of increased use of bronchodilators to active TB suggests that the deterioration in pulmonary symptoms requiring increased medication. Lee CH, et al. BMC Infectious Disease 2013, 13: Material and Methods Results and Interpretation Conclusion Future Remarks 52
14 COPD patients are at high risk of developing TB, especially those frequently receiving oral corticosteroids and β agonists. Although ICS therapy has been shown to predispose COPD patients to pneumonia, it does not increase the risk of TB in real world practice. 53 Conclusion The present study platform provides Physician Investigators and IT specialists an efficient workflow and communication. The usefulness of the study platform was demonstrated by probing the association between TB, COPD and DM. With time dependent analysis, the impacts of Treatment Associated Variables for Chronic Diseases can be readily evaluated. The selection criteria for various diseases defined in the present study can be applied in future claim database studies. 54 Background Future Remarks Material and Methods Results and Interpretation Conclusion Research Ideas Research Output Future Remarks 55 56
15 Association of Urinary TB and Urinary Cancer Thank you for your attention 57
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