Session #4. AscertainingVeterans'VitalStatus: VA Data Sources for

Database & Methods Cyberseminar Series

Session #4. Ascertaining Veterans’ Vital Status:

VA Data Sources for Mortality Ascertainment and

Cause of Death

The objectives of this cyberseminar are to:

• Identify data sources for Veteran vital status ascertainment

• Understand the contents and structure of the VA Vital Status Files and their

appropriate use for mortality ascertainment

• Describe the respective strengths and limitations of available VA data sources

for mortality ascertainment

• Identify other relevant sources of death data including the National Death Index

and state death certificates

• Demonstrate how these data resources can be used in research studies

01/2019

Session roadmap

• Data sources for Veteran vital status

ascertainment

• VHA Vital Status Files

• Data sources for Veteran & Non-Veteran mortality

• Date of Death Workgroup

• Other resources for mortality data

• Examples of using mortality data for research

01/2019

Poll Question #1

What is your role in research and/or quality

improvement?

• Investigator, PI, Co-I

• Data manager, analyst, or programmer

• Project coordinator

• Other – please describe via the Q&A function

01/2019

Poll Question #2

How would you rate your knowledge of methods to

ascertain death dates for Veterans in the VA?

1 (No knowledge)

5 (Expert)

01/2019

Session roadmap

• Data sources for Veteran vital status

ascertainment

• Sources in VHA Vital Status Files

• Sources not in VHA Vital Status Files

• VHA Vital Status Files

• Data sources for Veteran & Non-Veteran mortality

• Date of Death Workgroup

• Other resources for mortality data

• Examples of using mortality data for research

01/2019

Available in the VSF

BIRLS Death File

Received from

Veterans Benefits Administration (VBA) Beneficiary

Identification and Records Locator System (BIRLS) database

extract

Information Sources

Family,

VHA hospitals, VA National Cemetery Administration,

Social Security Administration (SSA)

Coverage

Veterans known to VA

Update Schedule

Monthly (complete overlay)

Location

Austin Information Technology Center (AITC) and on VINCI

01/2019

Available in the VSF

VA/CMS Medicare Vital Status File

Received from

Centers for Medicare & Medicaid Services (CMS) annually

Information Sources

SSA, Medicare claims, Other (e.g., family)

Coverage

Veterans enrolled in Medicare (>=65 years old or disabled)

Update Schedule

Annual (deaths through October 2017)

Location

Available from VIReC

01/2019

Available in the VSF

SSA Death Master File

Received from

Social Security Administration (SSA)

Information Sources

Family, funeral directors, post offices, financial institutions,

other federal agencies, state vital records agencies

Coverage

Individuals with SSN (first issued 1936)

Includes deaths occurring outside United States

More complete for over 65 population and for beneficiaries

Update Schedule

Weekly (and VA receives annual overlay)

Location

AITC

01/2019

Available in the VSF

Medical SAS Inpatient File

Received from

Austin Information Technology Center (AITC)

Information Sources

VistA PTF File (#45), Date of Disposition (DISDAY), and Type of

Disposition (DISTYPE) fields

Coverage

Inpatient deaths in VA facilities

Inpatient deaths in non

-VA hospitals

Update Schedule

Weekly

Location

AITC (MedSAS) and Corporate

Data Warehouse (CDW)

01/2019

Not Available in the VSF

Corporate Data Warehouse (CDW)

Received from

Corporate Data Warehouse (CDW)

Information Sources

VISTA

Coverage

Deaths verified by official source including VHA facilities, death

certificates, and National Cemetery Administration (NCA)

Update Schedule

Daily

Location

[CDW Patient 3.0 ]

01/2019

CDW

SPatient.SPatient Table

Columns were updated in 2017 Patient release

Columns

DeathDateTime

DeathVistaErrorDate and DeathDateTransformSID

Death date may contain defaulted month and day

DeceasedFlag (created by CDW)

Flag set to ‘Y’ if there is information in the DeathDateTime column

that can be converted to a date and ‘N’ otherwise. There are a

small number of records with invalid values in the death date time

that have an ‘N’ in this column, previously the Deceased column

contained a ‘Y’ for these records.

01/2019

CDW

New Fields

Fields

DeathDocumentationType

DeathEnteredByStaffSID

DeathLastUpdatedByStaffSID

DeathModifiedDateTime

DeathModifiedDateTimeTransformSID

DeathModifiedVistaErrorDate

DeathNotificationSource

01/2019

CDW Limitations

Current policy: Information to be entered from “official

sources” only

• VHA Directive 1906

− VHA facility (if patient died in the VHA facility or while under VA

auspices)

− Death certificate

− National Cemetery Administration

• 38 CFR 3.211 – Death

• EVVE Certification

CDW Date of Death Analysis and Vital Status File

Comparison

01/2019

Session roadmap

• Data sources for Veteran vital status

ascertainment

• VHA Vital Status Files

• Structure and contents

• Challenges in using the VHA VSF

• Data sources for Veteran & Non-Veteran mortality

• Date of Death Workgroup

• Other resources for mortality data

• Examples of using mortality data for research

01/2019

Poll Question #3

Have you ever used the VHA VSF?

a. Yes, both the Master File and Mini File

b. Yes, only the Mini File

c. Yes, only the Master File

d. No

01/2019

VHA VSF Background

• Single sources are incomplete

• Using the National Death Index as the gold standard:

DOD Source Sensitivity

BIRLS 64-80%

VA/CMS Medicare

83%

SSA 89-95%

PTF 5-12%

• Combined sources provide 97.5%-98.3% sensitivity

• VIReC VA-NDI Mortality Data Merge Project

01/2019

VHA VSF Creation

Owner

Built by National Data Systems (NDS)

First available in October 2006

Data Access

See VHA Data Portal website:

http://vaww.vhadataportal.med.va.gov/Home.aspx

(Intranet only)

Coverage

Veterans known to VA

VHA activity FY 1992 or later

VBA compensation and pension

Update Schedule

Updated quarterly

Files

Two files + conversion file:

Master, Mini, scrambled/real SSN

01/2019

VBA Data

VHA Data

· One record per SSN/DOB/SEX

· Last Activity Dates by Source

· Inpatient Deaths

MVI Data

· Add MVI DOB and Sex

BIRLS

CMS

SSA

Deaths

· Add Death Data

· DOB, SEX, &DOD

VSF

MASTER

File

· Select veterans

· Select ‘best’ DOB, SEX, DOD for each SSN

· Obtain Date of Last Activity for an SSN

VSF MINI

File

Merge on

SSN, DOB & SEX

Merge on

SSN

Merge on

SSN

One Record Per SSNOne Record Per SSN, DOB, Sex

· Medical SAS Inpatient Datasets and Census (PTF)

· Inpatient and Outpatient Encounter (ENC)

· Non-VA care or Fee Files (FEE)

· DSS Pharmacy Files (DSS)

· Enrollment (ENR)

· Veterans Service Network Corporate Mini Master File (VETSNET)

Construction of VHA VSF

01/2019

More detail on VHA VSF Construction

Ascertaining Veterans’ Vital Status: VA Data Sources

for Mortality Ascertainment & Cause of Death

Noreen Arnold, MS & Claire Hoffmire, PhD

5/4/2015

http://www.hsrd.research.va.gov/for_researchers/cyber_seminars

/archives/video_archive.cfm?SessionID=982

Ascertaining Veterans' Vital Status and Dates of

Death: The VHA Vital Status File and Other Data

Sources for Mortality Ascertainment in VA

Elizabeth Tarlov, PhD

7/14/2014

http://www.hsrd.research.va.gov/for_researchers/cyber_seminars

/archives/video_archive.cfm?SessionID=857

01/2019

Vital Status Files

January 8, 2019

Master

Mini

Combined data from multiple Master records

Veterans & Non-Veterans Veterans only

1 record per SSN/DOB/Sex

combination

1 record per SSN

125 variables 16 variables

31,265,546 records 19,168,889 records

21,696,734 SSNs 19,168,889 SSNs

39% of SSNs have >1 record

(8,514,506)

01/2019

Variable Label

Vital Status Mini Contents

1/8/2019

n = 19,168,889

ACT_LAST_DT LAST HEALTHCARE OR BENEFIT ACTIVITY DATE

ACT_LAST_DT_IND LAST HEALTHCARE OR BENEFIT ACTIVITY DATE INDICATOR

ACT_LAST_DT_SRC LAST HEALTHCARE OR BENEFIT ACTIVITY DATE SOURCE

DOB BEST DATE OF BIRTH

DOB_IND BEST DATE OF BIRTH INDICATOR

DOB_SRC DATA SOURCE BEST DATE OF BIRTH

DOD BEST DATE OF DEATH

DOD_IND BEST DATE OF DEATH INDICATOR

DOD_SRC DATA SOURCE BEST DATE OF DEATH

LIVING_IND PRESUMED LIVING INDICATOR

SCRSSN SCRAMBLED SOCIAL SECURITY NUMBER

SEX BEST GENDER

USE_AFTER_DTH_FLG UTL_LAST_DT IS GT DOD +31 DAYS (0=NO 1=YES)

UTL_LAST_DT LAST HEALTHCARE UTILIZATION DATE

UTL_LAST_DT_IND LAST HEALTHCARE UTILIZATION DATE INDICATOR

UTL_LAST_DT_SRC LAST HEALTHCARE UTILIZATION DATE SOURCE

01/2019

Best DOB and DOD Sources on VSF Mini

VHA VSF Mini on January 8, 2019

Best Birth Date Data Source Best Death Date Data Source

BIRLS DEATH FILE

1,194

MEDICARE DATA

500,294

DECISION SUPPORT SYSTEM

10,906

OUTPT/INPAT ENCOUNTER

1,742,011

ENROLLMENT SYSTEM

99,263

FEE BASIS

6,780

MVI

16,413,512

PATIENT TREATMENT FILE

130,297

SOCIAL SECURITY DEATH FILE

22,431

VBA

242,201

Total

19,168,889

No Death Date

11,694,950

BIRLS DEATH FILE

174,115

MEDICARE DATA

4,513,388

FEE BASIS

103,842

PATIENT TREATMENT FILE

822,105

SOCIAL SECURITY DEATH FILE

1,860,489

Total

19,168,889

01/2019

Potential Challenges when using VHA VSF

• Demographics do not match

• Multiple dates of death

• Activity after date of death

• Erroneously recorded dates of death in sources

Note: VHA VSF should not be used for business operations

regarding individual veterans

01/2019

Possible Strategies for Matching Cohorts

Use the Mini File for the

initial search for deaths

Match on SSN

Use the Master File to

investigate unusual cases

For example:

•

Cohort DOB/Sex do not match Mini DOB/Sex

• May be records on the Master File with

matching demographics

Activity after death

• Check DOB/Sex for DOD sources on Master

File

• Are all DOD on Master File the same?

Consider additional

supplementary data

sources

Use the NDI or State Vital Statistics Offices for

cases lost to follow up, i.e.,

• No death date

• No VHA or VBA activity after end of follow

Consider using

CDW

Use for individuals without activity after 1991

or very recent deaths

01/2019

Session roadmap

• Data sources for Veteran vital status

ascertainment

• VHA Vital Status Files

• Data sources for Veteran & Non-Veteran

mortality

• Date of Death Workgroup

• Other resources for mortality data

• Examples of using mortality data for research

01/2019

National Death Index

• Gold standard for death ascertainment

• Available from the National Center for Health Statistics

• Source of data: State Vital Statistics Offices

• Records from 1979 through 2018 early release (~12 month lag)

• Contains cause of death from death certificates

• Information about fees & access:

• http://www.cdc.gov/nchs/ndi.htm

• Suicide Data Repository

01/2019

1979

2016

2000

VHA Users

Service members separating after January 1, 1974

National Death Index for Veterans

CDC’s National Death Index Plus contains ~3.0 million records (1979-

2016)

• Date and cause of death (ICD-10 codes)

• Veteran decedents only, all causes of death

• Current mortality archive:

• Service members who separated from active duty service (including

deactivation NG & Reserve) between 1979-2011

• All users of VHA services, FY2000-2016

• Please see http://vaww.virec.research.va.gov/Mortality/Overview.htm

National Death Index for Veterans

Availability

Suicide Data Repository (SDR), which is administered jointly

between VA Office of Mental Health and DoD

Data Access

All applications for access to NDI data available from SDR

Reviewed by a joint VA

-DoD Board of Governance (meets

quarterly

– January, April, July, October)

Contact

Information

Contact

VHACANSDRDataRequests@va.gov for more

information about accessing NDI data from the SDR.

Data through 2016 will be available soon.

01/2019

SSA Epidemiological Search

• Provides date of death

• Validates SSN

• Provides ‘presumed living’ status

• Based on SSA administrative data including:

• Payroll deductions, railroad retirement or disability payments, death

claims filed by beneficiaries

• Advantage: Reduces loss to follow up

• Deaths occurring outside the US

• Fees & Access

• http://www.ssa.gov/policy/about/epidemiology.html

01/2019

State Death Certificates

• States’ policies regarding the release of death certificates

vary considerably, as deceased individuals are not human

subjects.

• An informal review of state vital statistics offices websites

revealed that 24 mentioned a process for obtaining death

records.

01/2019

State Death Certificates

Advantages and Disadvantages

• Veteran status is reported on the death certificate.

• The whole death record, including contributing causes

and not just underlying cause, is available.

• With identifiers can be linked to VA data.

• Limited in scope-not all states allow release of records for

research.

• Death record is the official record but concerns about

accuracy of information remain.

01/2019

Defense Manpower Data Center (DMDC)

• Contains files that report casualties in past and ongoing

conflicts.

• These publicly available files contain the actual names,

rank, pay grade, unit, and place of death.

• This reporting is part of the Defense Casualty Analysis

System (DCAS).

• For more information:

https://dcas.dmdc.osd.mil/dcas/pages/casualties.xhtml

• These files have been used for research purposes, e.g.

The association of state per capita income and military

service deaths in the Vietnam and Iraq wars. Population

Health Metrics 2009; 9:2.

01/2019

Session roadmap

• Data sources for Veteran vital status

ascertainment

• VHA Vital Status Files

• Data sources for Veteran & Non-Veteran mortality

• Date of Death Workgroup

• Other resources for mortality data

• Examples of using mortality data for research

01/2019

Date of Death Project

• VHA Date of Death Workgroup evolved into the Date of Death Project

that now includes leadership and participation from VHA, VBA, and

NCA

• Purpose: improve VA ascertainment and documentation of death of

individuals known to the VA

• Develop processes and procedures to improve accuracy and

completeness of date of death

• Master Veteran Index (MVI) is the authoritative service for date of

death

• Electronic Verification of Vital Events is now in use at the VA

01/2019

Date of Death Project (cont.)

EVVE – Electronic Verification of Vital Events

• NAPHSIS

• National Association for Public Health Statistics and Information

Systems

• Online query system of state vital statistics data bases

• Death Certificates

• Birth Certificates

01/2019

Date of Death Project (cont.)

Status

• MVI became the authoritative source for date of death in

August 2017.

• In the fall of 2017, MVI was seeded with dates of death

originating from VistA.

• In November 2017, MVI began accepting dates of death

from the weekly SSA DMF file after internal verification of

the deaths.

• The MVI in 2019 includes deaths from the SSA DMF.

• Dates of death in the MVI are being pushed out to the

VistA records, thus more death dates will be found in the

CDW.

Session roadmap

• Data sources for Veteran vital status

ascertainment

• VHA Vital Status Files

• Data sources for Veteran & Non-Veteran mortality

• Date of Death Workgroup

• Other resources for mortality data

• Examples of using mortality data for research

01/2019

CDC National Center for Health Statistics

• The Centers for Disease Control (CDC) also has a

number of death search tools as well as limited individual

death files.

• Examples include CDC Wonder underlying cause of

death search tool

• http://wonder.cdc.gov

• Individual level multiple cause of death files are also

available

• http://www.cdc.gov/nchs/data_access/VitalStatsOnline.htm#

Mortality_Multiple

01/2019

CDC Injury Prevention & Control

Data & Statistics

• Web-based Injury Statistics Query and Reporting System

(WISQARS)

• http://www.cdc.gov/injury/wisqars/index.html

• These databases have limited information due to privacy

concerns, but have research applications.

• Essentially these files are de-identified.

01/2019

Benefits of Additional Mortality Information

• Findings derived from information on VHA Veterans alone are

unlikely to be broadly generalizable to all Veterans

• 70% of the 22 million living U.S. Veterans in 2012 not

enrolled/using VHA service

• Relative to the Vital Status File, additional data sources allow

VA researchers to:

• Study the whole/general Veteran population

• Compare Veterans who use VHA services prior to death to

those who do not

• Compare Veteran and non-Veteran by cause of death

01/2019

Session roadmap

• Data sources for Veteran vital status

ascertainment

• VHA Vital Status Files

• Data sources for Veteran & Non-Veteran mortality

• Date of Death Workgroup

• Other resources for mortality data

• Examples of using mortality data for research

01/2019

Research Example #1

Service Connected Disability (Veteran National

Death Index)

• Maynard et al. Cause of death in Veterans with service

connected conditions, Military Medicine 2018;183:e371-

e376.

• Veterans were categorized by 3 age groups,

corresponding to period of service.

• In the group born after 1957, cardiovascular disease and

cancer accounted for about 1/3 of deaths, whereas

deaths due to accidents, suicide, or assault accounted for

nearly 35% of deaths.

01/2019

Research Example #2

Service Connected Disability and One Year

Survival

• Maynard et al. Disability rating and one-year mortality in

Veterans with service connected conditions. Public Health

Reports 2018;133:692-699.

• Linked VETNSET file with VS Mini file.

• Veterans with a 100% rating had poorer 1 year survival

than did those with lower ratings.

01/2019

Research Example #3

State Death Certificates

• Washington State offers death records for purchase.

• Files of decedent names and the death records

themselves are available from 1968 to current with each

file costing $20 per year.

• For more information:

http://www.doh.wa.gov/DataandStatisticalReports/VitalSta

tisticsData/OrderDataFiles.

01/2019

Studies using Washington State Death Records

• Dominitz, et al. Assessment of vital status in Department of Veterans Affairs

National Databases: Comparison with state death certificates. Annals of

Epidemiology 2001;11:281-86.

• Maynard, et al. Differences in cause of death between Washington State

veterans who did and did not use VA health care services. Journal of

Rehabilitation Research and Development 2006;43:825-830.

• Maynard, et al. Suicide rates in the Washington State veteran population.

Psychiatric Services 2008;6:3.

• Maynard, et al. Cause of death in Washington state veterans hospitalized

with acute coronary syndromes in the Veterans Health Administration.

Population Health Metrics 2008;6:3.

• Maynard. Accidental deaths in Veterans and non-veterans in Washington

State. Internet Journal of Epidemiology 2010;8:2.

• Maynard. Cause of death in middle age white non-Hispanic Washington State

veterans, 2000-2003. Internet Journal of Epidemiology 2015;13:1.

Additional Resources

Mortality Data Sources Cheat Sheet

Data

Source

Coverage

Update schedule

Included in

VHA VSF?

BIRLS Death File

Veterans known to VA

Monthly

(complete overlay)

YES

VA/CMS Medicare Vital

Status File

Veterans enrolled in Medicare

(>=65 years old or disabled)

Annual

YES

SSA Death Master File

Individuals with SSN (first issued

1936); Includes deaths occurring

outside United States; More

complete for over 65 population

and for beneficiaries

Weekly

(and VA receives annual

overlay)

YES

Patient Treatment File

Inpatient deaths

(VA hospitals, Non

-VA when

covered by VA

Weekly

YES

Corporate Data

Warehouse

Veterans

Daily

National Death Index

Veterans

and non-veterans Search engine, lags 1 year

SSA Epidemiological

Social Security

recipients and

applicants

Search engine

State death records

Veterans

and non-veterans Annually

Resources

VHA Data Quality

http://vaww.virec.research.va.gov/DataQuality/Overview.htm

National Data Systems

Dorothea Garrett ([email protected])

VIReC Website Resources

http://vaww.virec.research.va.gov (VA Intranet only)

Information on VA data sources and how to access data

Documentation on VA data sources like VHA VSF

(http://vaww.virec.research.va.gov/VSF/Overview.htm)

VHA Data Portal

Integrates information from multiple sources into a single

location to promote a comprehensive knowledge base

http://vaww.vhadataportal.med.va.gov/Home.aspx (Intranet only)

01/2019

HelpDesk HSRData Listserv

VIReC Options for Specific Questions

• Community knowledge

sharing

• ~1,400 VA data users

• Researchers, operations,

data stewards, managers

• Subscribe by visiting

http://vaww.virec.research.va.gov/Support/H

SRData-L.htm (VA Intranet)

• Individualized support

[email protected]

(708) 202-2413

Quick Guide: Resources for Using VA Data

http://vaww.virec.research.va.gov/Toolkit/QG-Resources-for-Using-VA-Data.pdf (VA Intranet)

VIReC: http://vaww.virec.research.va.gov/Index.htm (VA Intranet)

VIReC Cyberseminars: http://www.virec.research.va.gov/Resources/Cyberseminars.asp

VHA Data Portal: http://vaww.vhadataportal.med.va.gov/Home.aspx (VA Intranet)

VINCI: http://vaww.vinci.med.va.gov/vincicentral/ (VA Intranet)

Health Economics Resource Center (HERC): http://vaww.herc.research.va.gov (VA Intranet)

CDW: https://vaww.cdw.va.gov/Pages/CDWHome.aspx (VA Intranet)

Archived cyberseminar: What can the HSR&D Resource Centers do for you?

https://www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm

Quick links for VA data resources

01/2019

References

• Da Graca B, Filardo G, Nicewander D. Consequences for healthcare quality and research of

the exclusion of records from the death master file. Circ Cardiovasc Qual Outcomes

2013;6:124-128.

• U.S. Department of Veterans Affairs. VHA Directive 1906 Data Quality Requirements for

Healthcare Identity Management and Master Veteran Index Functions. April 29, 2013.

• Doody MM, Chimes K. The Social Security Administration "presumed living" search. Am J

Public Health 2000;90:1948-1949.

• Savas LS, del Junco DJ, Bastian LA, Vernon SW. Mortality ascertainment of women

veterans: a comparison of sources of vital status information, 1979-2002. Med Care

2009;47:125-128.

• Sohn MW, Arnold N, Maynard C, Hynes DM. Accuracy and completeness of mortality data in

the Department of Veterans Affairs. Popul Health Metr 2006;4:2.

• Arnold N, Sohn M, Maynard C, Hynes DM. VIReC Technical Report 2: VA NDI Mortality Data

Merge Project. April 9, 2006. VA Information Resource Center. Available:

http://vaww.virec.research.va.gov/Reports/TR/TR-VA-NDI-Mortality-CY06-ER.pdf

• Hoffmire C, Kemp J, Bossarte R. Changes in Suicide Mortality for Veterans Relative to Non

Veterans by Gender and History of VHA Service Utilization, 2000-2010. Psychiatric Services

2015; 00:1–7; doi: 10.1176/appi.ps.201400031

• Maynard C. Databases. The Encyclopedia of Death and the Human Experience. Thousand

Oaks CA: Sage Publications, 2009:258-261.

01/2019

Contact information

VA Information Resource Center

Hines VA Hospital

[email protected]

708-202-2413

Chuck Maynard

cmaynard@uw.edu

Measuring Veterans' Medicare Health

Services Use

Database & Methods Cyberseminar Series

Kristin de Groot, MPH

VA Information Resource Center