Disease Registry

A disease (condition) registry is a primary-data-collection observational study: investigators define a population by a disease or clinical condition (e.g., pulmonary arterial hypertension, idiopathic pulmonary fibrosis, a specific cancer) and prospectively enroll those patients at participating sites, capturing a predefined minimum dataset on a fixed schedule. This is the defining contrast with secondary-data RWD: claims and EHR are repurposed byproducts of billing and care, whereas a registry collects fit-for-purpose variables — disease severity, adjudicated events, patient-reported outcomes — that claims simply do not contain. Scope note: this entry covers disease registries. Product/exposure registries (anchored on a drug or device, the typical EU PASS or pregnancy-exposure registry) and health-services registries (anchored on an encounter or procedure) are close cousins with the same machinery but a different enrollment anchor; treat them as separate concepts.

Core conceptual distinction

. The registry is defined by its enrollment anchor and data provenance, not by an analytic contrast. Three things distinguish it from a claims/EHR cohort.

1. Anchor: entry is the date a patient is enrolled at a participating site after meeting clinical inclusion criteria — typically incident (newly diagnosed) or a mix of incident and prevalent patients, which must be declared because prevalent enrollment reintroduces left-truncation and survivor bias.
2. Provenance: variables are collected for the study, so severity, stage, ejection fraction, and adjudicated endpoints are available, but completeness depends on site staff and patient retention rather than a claim being filed.
3. Sampling frame: patients come from participating sites, which are rarely a probability sample of all care settings — academic and specialty centers are over-represented. The registry does not, by itself, deliver a causal estimand; it is a data platform on which natural-history description, quality benchmarking, or a comparative analysis (often an active-comparator new-user contrast nested within the registry, frequently with claims linkage for complete exposure and outcomes) is built.

Pros, cons, and trade-offs

.

• vs claims/EHR secondary-data cohorts: the registry captures clinical depth claims cannot — disease severity, functional class, adjudicated outcomes, PROs — and applies uniform definitions across sites. Cost: it is expensive and slow, enrolls a non-random slice of patients seen at participating sites, and suffers active loss to follow-up that passive claims do not (claims keep accruing as long as the person is enrolled in the plan). Prefer the registry when the scientific question hinges on variables absent from administrative data.
• vs a randomized trial: the registry reflects routine practice, includes patients trials exclude (elderly, comorbid, pregnant), and supports long-term and rare-disease follow-up at scale. Cost: no randomization, so confounding by indication and channeling remain; it answers what happens in practice, not the internally valid average treatment effect. Prefer the registry for external validity, natural history, and rare diseases where a trial is infeasible.
• vs a registry-claims linked study: linkage to claims and a death index buys complete exposure (every fill, every hospitalization, reliable mortality) on top of registry clinical depth. Cost: only the linkable subset is analyzable (a new selection layer), and registry, claims, and vital-records dates must be reconciled. Prefer linkage whenever exposure or outcome completeness is the binding constraint and consent/linkage is feasible.

When NOT to use — and when it is actively misleading or dangerous

.

• When you need a representative population estimate but enrollment is by convenience. Site-level and patient consent selection make the registry a poor frame for incidence/prevalence or population-attributable burden; presenting registry proportions as population rates is misleading.
• When sites cherry-pick patients. Differential enrollment of healthier (or sicker) patients, or enrolling only those who survive to a referral visit, inflates apparent benefit and biases survival — a covert immortal-time/left-truncation problem if enrollment lags diagnosis.
• When the comparison is across registries or across calendar time without harmonization. Secular drift in capture, evolving diagnostic criteria, and site mix changes confound time trends; registry-to-registry contrasts without common data definitions are unreliable.
• When loss to follow-up is differential by exposure or prognosis. Patients who deteriorate may stop attending the enrolling center; naive complete-case analysis then overstates benefit. Treat dropout as potentially informative and quantify it.
• When the registry is used as a single-arm external control without a defensible comparator. Comparing a new drug's registry arm to historical registry patients invites confounding by indication and period effects unless eligibility, time zero, and covariates are explicitly emulated.

Data-source operational depth

.

• Registry (primary): Strongest for indication, disease severity/stage, adjudicated endpoints, and PROs; enrollment date is the natural index. Failure modes: voluntary site participation and patient consent (selection on both); differential loss to follow-up; secular drift as criteria and site mix change; gaps between the registry data cutoff and current practice that make recent patients look incomplete. Workarounds: predefine a minimum dataset and adjudication charter; restrict to consecutive (not convenience) enrollment where possible; model site as a random effect; censor at last documented contact and conduct loss-to-follow-up sensitivity analyses; restrict to overlapping enrollment calendar time for trend or cross-cohort work.
• Claims: Used for linkage to a disease registry to complete exposure (NDC + `fill_date` + `days_supply`) and outcomes (hospitalization, procedures, death). Failure modes specific to claims under linkage: Medicare Advantage-only person-time lacks fee-for-service claims, so a registry enrollee who is MA-only appears to have no fills/events — exclude MA-only person-time and require continuous Parts A/B (and D for drug exposure). Differential competing risks by exposure in elderly registry cohorts: deaths captured by the registry but not the claims feed (or vice versa) distort cause-specific event rates — link to a death index and use a competing-risk framework, not naive Kaplan-Meier. Immortal time in procedure-anchored sub-studies: time between enrollment and a later procedure must be classified, not silently attributed to the post-procedure arm.
• EHR: A registry can be partly auto-populated from a site's EHR, gaining labs and notes cheaply, but visit-driven capture means patients who leave the system are differentially missing; provenance of each variable (entered by abstractor vs pulled from EHR) should be tracked because the two have different error structures.
• Linked registry-claims-vital records: The ideal substrate (clinical depth + exposure/outcome completeness + reliable mortality), but only the linkable, consented subset is analyzable, and registry enrollment dates, claims service dates, and vital-records death dates must be reconciled before time-zero and censoring assignment.

Worked claims-linked example

Question: 3-year all-cause mortality and heart-failure hospitalization among newly diagnosed pulmonary arterial hypertension (PAH) patients, using a PAH disease registry (REVEAL-style) linked to Medicare.

1. Eligibility: registry-confirmed incident PAH (right-heart-catheterization-adjudicated, enrolled within 90 days of diagnosis to limit left-truncation), age ≥65, and successful registry→Medicare linkage.
2. Continuous-enrollment / observability window: require continuous Medicare Parts A and B (plus Part D if PAH-drug exposure is studied) for the 12 months before and throughout follow-up after the registry enrollment date, and exclude any MA-only person-time because fee-for-service claims — and therefore HF hospitalizations and fills — are not observable then.
3. Index date (time zero): registry enrollment date; baseline covariates (WHO functional class, 6-minute walk, hemodynamics) come from the registry visit, comorbidities from the 12-month claims lookback.
4. Outcome ascertainment from both sources: HF hospitalization from a claims inpatient stay with a qualifying primary diagnosis, and the registry-adjudicated clinical-worsening event; flag and tabulate disagreement (registry event with no claim, or claim with no registry capture) rather than silently trusting one.
5. Death: take the earliest of registry-recorded death and the linked death-index date; treat death as a competing risk for HF hospitalization (Fine-Gray / cumulative incidence), not as censoring.
6. Censor at the minimum of last documented registry contact, Medicare disenrollment (or MA switch), death, and study end; run a loss-to-follow-up sensitivity analysis comparing those lost vs retained, because PAH patients who deteriorate may stop attending the enrolling center.

Decision diagram

flowchart TD
  Sites[Participating sites<br/>academic / specialty centers] --> Consent[Patient consent + inclusion criteria met]
  Consent --> Enroll[Registry enrollment = index/time zero<br/>minimum dataset captured]
  Enroll --> Adj[Adjudication of endpoints<br/>uniform definitions across sites]
  Adj --> Link[Linkage to claims + death index<br/>consented, linkable subset only]
  Link --> Recon[Reconcile registry / claims / vital-records dates<br/>exclude MA-only person-time]
  Recon --> Analysis[Analysis-ready cohort<br/>outcome from registry AND claims, disagreement flagged]
  Analysis --> Sens[Sensitivity: loss-to-follow-up, site random effect,<br/>competing-risk death, calendar overlap]

flowchart LR
  Site[Site participation] --> Enroll((Enrolled in registry))
  Consent[Patient consent / linkage] --> Enroll
  Severity[Disease severity] --> Enroll
  Severity --> Outcome[Outcome]
  Site --> Ascert[Outcome ascertainment]
  Enroll --> Ascert
  Ascert --> Outcome
  classDef collider fill:#ffe0e0,stroke:#c00;
  class Enroll collider;

Worked example

Scenario

We have three newly diagnosed pulmonary arterial hypertension (PAH) patients enrolled in a PAH disease registry. We want to see what a registry record actually looks like and why it captures clinical detail that an insurance claims table never would. Each registry row carries the patient's diagnosis date, disease stage, a biomarker, which treatment arm they are on, and a reviewer-confirmed outcome.

Dataset

A few rows from a disease-registry table: clinical fields collected on purpose for the study, the same way at every site.

Steps

Result

The registry rows tell you that of three incident PAH patients, the two sicker ones at enrollment (WHO FC III and IV, with high NT-proBNP of 1450 and 3100) went on to worsen or die, while the milder patient (WHO FC II, NT-proBNP 320) stayed stable. That severity-to-outcome story is visible only because the registry deliberately captured stage and biomarker, detail claims data lacks, and it applies only to patients enrolled at the participating sites.

Trade-offs

Runnable example

import pandas as pd
import numpy as np

BASELINE_DAYS = 365            # claims lookback for comorbidities / incident confirmation
INCIDENT_WINDOW = 90           # max days from diagnosis to enrollment (limit left-truncation)
STUDY_END = pd.Timestamp("2020-12-31")

def build_registry_cohort(reg, enroll, events, death):
    # 1) Inception restriction: incident patients enrolled close to diagnosis.
    reg = reg.copy()
    reg["dx_to_enroll"] = (reg["enroll_date"] - reg["dx_date"]).dt.days
    coh = reg[reg["incident_flag"] & (reg["dx_to_enroll"].between(0, INCIDENT_WINDOW))].copy()
    coh["t0"] = coh["enroll_date"]
    coh["baseline_start"] = coh["t0"] - pd.Timedelta(days=BASELINE_DAYS)

    # 2) Observability: continuous, FFS-observable claims (no MA-only) across baseline through t0.
    e = enroll.merge(coh[["person_id", "t0", "baseline_start"]], on="person_id")
    e["covers"] = ((e["enroll_start"] <= e["baseline_start"]) &
                   (e["enroll_end"]   >= e["t0"]) &
                   (~e["ma_only"]))                     # MA-only person-time lacks FFS claims
    linkable = e.loc[e["covers"], "person_id"].unique()
    coh = coh[coh["person_id"].isin(linkable)].copy()   # consented + linkable subset only

    # 3) Death from the earliest of registry death and death-index date (reconcile sources).
    d = death.groupby("person_id")["death_date"].min().rename("dx_death")
    coh = coh.merge(d, on="person_id", how="left")

    # 4) Censoring = min(last registry contact, claims disenroll/MA switch, death, study end).
    disenroll = (enroll[~enroll["ma_only"]].groupby("person_id")["enroll_end"].max()
                                           .rename("ffs_end"))
    coh = coh.merge(disenroll, on="person_id", how="left")
    coh["censor_date"] = coh[["last_contact_date", "ffs_end", "dx_death"]].min(axis=1)
    coh["censor_date"] = coh["censor_date"].clip(upper=STUDY_END)

    # 5) Outcome from BOTH sources within follow-up; flag disagreement rather than trusting one.
    ev = events[events["event_flag"]].merge(coh[["person_id", "t0", "censor_date"]], on="person_id")
    ev = ev[(ev["service_date"] >= ev["t0"]) & (ev["service_date"] <= ev["censor_date"])]
    claims_evt = ev.groupby("person_id")["service_date"].min().rename("claims_event_date")
    coh = coh.merge(claims_evt, on="person_id", how="left")
    coh["registry_event"] = coh["reg_event_date"].between(coh["t0"], coh["censor_date"])
    coh["claims_event"]   = coh["claims_event_date"].notna()
    coh["event_disagree"] = coh["registry_event"] ^ coh["claims_event"]   # source disagreement to tabulate
    return coh[["person_id", "site_id", "t0", "baseline_start", "censor_date",
                "registry_event", "claims_event", "event_disagree", "dx_death"]]

library(data.table)
BASELINE_DAYS   <- 365L
INCIDENT_WINDOW <- 90L
STUDY_END       <- as.Date("2020-12-31")

build_registry_cohort <- function(reg, enroll, events, death) {
  setDT(reg); setDT(enroll); setDT(events); setDT(death)

  # 1) Inception restriction: incident, enrolled close to diagnosis.
  coh <- reg[incident_flag &
             as.integer(enroll_date - dx_date) %between% c(0L, INCIDENT_WINDOW)]
  coh[, t0 := enroll_date]
  coh[, baseline_start := t0 - BASELINE_DAYS]

  # 2) Observability: continuous FFS-observable claims (no MA-only) across baseline through t0.
  e <- merge(enroll, coh[, .(person_id, t0, baseline_start)], by = "person_id")
  linkable <- e[enroll_start <= baseline_start & enroll_end >= t0 & !ma_only,
                unique(person_id)]
  coh <- coh[person_id %chin% linkable]

  # 3) Death = earliest of registry/death-index; 4) censor = min(last contact, FFS end, death, study end).
  d  <- death[, .(dx_death = min(death_date)), by = person_id]
  ff <- enroll[!ma_only, .(ffs_end = max(enroll_end)), by = person_id]
  coh <- merge(coh, d,  by = "person_id", all.x = TRUE)
  coh <- merge(coh, ff, by = "person_id", all.x = TRUE)
  coh[, censor_date := pmin(last_contact_date, ffs_end, dx_death, STUDY_END, na.rm = TRUE)]

  # 5) Outcome from BOTH sources; flag disagreement.
  ev <- merge(events[event_flag == TRUE], coh[, .(person_id, t0, censor_date)], by = "person_id")
  ev <- ev[service_date >= t0 & service_date <= censor_date,
           .(claims_event_date = min(service_date)), by = person_id]
  coh <- merge(coh, ev, by = "person_id", all.x = TRUE)
  coh[, registry_event := reg_event_date >= t0 & reg_event_date <= censor_date]
  coh[, claims_event   := !is.na(claims_event_date)]
  coh[, event_disagree := xor(registry_event %in% TRUE, claims_event)]
  coh[, .(person_id, site_id, t0, baseline_start, censor_date,
          registry_event, claims_event, event_disagree, dx_death)]
}

%let baseline = 365;   /* claims lookback (days)                         */
%let incwin   = 90;    /* max diagnosis->enrollment gap (days)           */
%let studyend = '31DEC2020'd;

/* 1) Inception restriction: incident patients enrolled near diagnosis. */
proc sql;
  create table coh0 as
  select person_id, site_id, last_contact_date, reg_event_date,
         enroll_date as t0 format=date9.,
         enroll_date - &baseline as baseline_start format=date9.
  from work.reg
  where incident_flag = 1
    and (enroll_date - dx_date) between 0 and &incwin;
quit;

/* 2) Observability: continuous FFS-observable claims (no MA-only) across baseline through t0. */
proc sql;
  create table coh1 as
  select c.*
  from coh0 c
  where exists (
    select 1 from work.enroll e
    where e.person_id = c.person_id
      and e.ma_only = 0                       /* MA-only person-time lacks FFS claims */
      and e.enroll_start <= c.baseline_start
      and e.enroll_end   >= c.t0
  );
quit;

/* 3) Death = earliest registry/death-index date; FFS end = latest non-MA span end. */
proc sql;
  create table coh2 as
  select c.*,
         (select min(d.death_date)  from work.death  d where d.person_id = c.person_id) as dx_death format=date9.,
         (select max(e.enroll_end)  from work.enroll e
            where e.person_id = c.person_id and e.ma_only = 0)                          as ffs_end  format=date9.
  from coh1 c;
quit;

/* 4) Censor = min(last contact, FFS end, death, study end). */
data coh3;
  set coh2;
  censor_date = min(last_contact_date, ffs_end, dx_death, &studyend);
  format censor_date date9.;
run;

/* 5) First claims outcome within follow-up; flag registry/claims disagreement. */
proc sql;
  create table claims_evt as
  select v.person_id, min(v.service_date) as claims_event_date format=date9.
  from work.events v
    inner join coh3 c on v.person_id = c.person_id
  where v.event_flag = 1
    and v.service_date between c.t0 and c.censor_date
  group by v.person_id;
quit;

proc sql;
  create table work.cohort as
  select c.person_id, c.site_id, c.t0, c.baseline_start, c.censor_date, c.dx_death,
         (c.reg_event_date between c.t0 and c.censor_date)            as registry_event,
         (e.claims_event_date is not null)                           as claims_event,
         ((c.reg_event_date between c.t0 and c.censor_date) ne
          (e.claims_event_date is not null))                         as event_disagree
  from coh3 c left join claims_evt e on c.person_id = e.person_id;
quit;

Citations

1. [1]Larsson S, Lawyer P, Garellick G, Lindahl B, Lundström M. Use of 13 disease registries in 5 countries demonstrates the potential to use outcome data to improve health care's value. Health Affairs. 2012;31(1):220-227.
2. [2]Hoque DME, Kumari V, Hoque M, Ruseckaite R, Romero L, Evans SM. Impact of clinical registries on quality of patient care and clinical outcomes: a systematic review. PLOS ONE. 2017;12(9):e0183667.

1. [3]Benza RL, Miller DP, Gomberg-Maitland M, et al. Predicting survival in pulmonary arterial hypertension: insights from the Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL). Circulation. 2010;122(2):164-172.

1. [4]Gliklich RE, Leavy MB, Dreyer NA, editors. Registries for Evaluating Patient Outcomes: A User's Guide. 4th ed. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020.