Improving Antibiotic Prescribing for Children with Community-acquired Pneumonia in Outpatient Settings.

OBJECTIVE: To assess whether a two-phase intervention was associated with improvements in antibiotic prescribing among non-hospitalized children with community-acquired pneumonia. STUDY DESIGN: In a large health care organization, a phase one intervention was implemented in September 2020 directed at antibiotic choice and duration for children 2 months through 17 years of age with pneumonia. Activities included clinician education and implementation of a pneumonia-specific order set in the electronic health record (EHR). In October 2021, a second phase comprised additional education and order set revisions. A narrow spectrum antibiotic (eg, amoxicillin) was recommended in most circumstances. EHR data were used to identify pneumonia cases and antibiotics ordered. Using interrupted time series analyses, antibiotic choice and duration after phase one (September 2020 to September 2021) and after phase two (October 2021 to October 2022) were compared with a pre-intervention pre-pandemic period (January 2016 to early March 2020). RESULTS: Overall, 3570 cases of community-acquired pneumonia were identified: 3246 cases pre-intervention, 98 post-phase-one, and 226 post-phase-two. The proportion receiving narrow spectrum monotherapy increased from 40.6% pre-intervention to 68.4% post-phase-one to 69.0% post-phase-two (p<0.001). For children with an initial narrow spectrum antibiotic, duration decreased from pre-intervention (mean duration 9.9 days, standard deviation [SD] 0.5 days) to post-phase-one (mean 8.2, SD 1.9) to post-phase-two (mean 6.8, SD 2.3) periods (p<0.001). CONCLUSIONS: A two-phase intervention with educational sessions combined with clinical decision support was associated with sustained improvements in antibiotic choice and duration among children with community-acquired pneumonia.

Associations between Missed Colonoscopy Appointments and Multiple Prior Adherence Behaviors in an Integrated Healthcare System: An Observational Study.

BACKGROUND: Missed colonoscopy appointments delay screening and treatment for gastrointestinal disorders. Prior nonadherence with other care components may be associated with missed colonoscopy appointments. OBJECTIVE: To assess variability in prior adherence behaviors and their association with missed colonoscopy appointments. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients scheduled for colonoscopy in an integrated healthcare system between January 2016 and December 2018. MAIN MEASURES: Prior adherence behaviors included: any missed outpatient appointment in the previous year; any missed gastroenterology clinic or colonoscopy appointment in the previous 2 years; and not obtaining a bowel preparation kit pre-colonoscopy. Other sociodemographic, clinical, and system characteristics were included in a multivariable model to identify independent associations between prior adherence behaviors and missed colonoscopy appointments. KEY RESULTS: The median age of the 57,590 participants was 61 years; 52.8% were female and 73.4% were white. Of 77,684 colonoscopy appointments, 3,237 (4.2%) were missed. Individuals who missed colonoscopy appointments were more likely to have missed a previous primary care appointment (62.5% vs. 38.4%), a prior gastroenterology appointment (18.4% vs. 4.7%) or not to have picked up a bowel preparation kit (42.4% vs. 17.2%), all p < 0.001. Correlations between the three adherence measures were weak (phi < 0.26). The rate of missed colonoscopy appointments increased from 1.8/100 among individuals who were adherent with all three prior care components to 24.6/100 among those who were nonadherent with all three care components. All adherence variables remained independently associated with nonadherence with colonoscopy in a multivariable model that included other covariates; adjusted odds ratios (with 95% confidence intervals) were 1.6 (1.5-1.8) for outpatient appointments, 1.9 (1.7-2.1) for gastroenterology appointments, and 3.1 (2.9-3.4) for adherence with bowel preparation kits, respectively. CONCLUSIONS: Three prior adherence behaviors were independently associated with missed colonoscopy appointments. Studies to predict adherence should use multiple, complementary measures of prior adherence when available.

Sources of Clinician Burnout in Providing Care for Underserved Patients in a Safety-Net Healthcare System.

BACKGROUND: Burnout among clinicians is common and can undermine quality of care, patient outcomes, and workforce preservation, but sources of burnout or protective factors unique to clinicians working in safety-net settings are less well understood. Understanding these clinician experiences may inform interventions to reduce burnout. OBJECTIVE: To describe clinician perspectives on sources of burnout in a safety-net healthcare system. DESIGN: Semi-structured interviews were conducted with clinicians from multiple disciplines who provided care at a safety-net healthcare system from October 2018 to January 2019. Transcripts were analyzed using thematic analysis. PARTICIPANTS: Forty clinicians (25 female and 15 male; mean [SD] age, 41 [9.1]) participated, including physicians, social workers, advanced practice providers, nurses, psychologists, physical and occupational therapists, and other healthcare professionals. MAIN OUTCOMES AND MEASURES: Themes and subthemes that reflected clinician experiences, burnout, and workload expectations. KEY RESULTS: Five themes emerged: limited resources (entrenched social injustices, brokenness of the US healthcare system, precarious discharge options, and "revolving door" readmissions), barriers to building trust with patients (chasm of communication, addressing fear and mistrust, and being exposed to threats), administrative requirements (criticism hampering meaningful care, assuming extra workloads, bureaucratic burden), compassion fatigue (confronting traumatic situations, persistent worry about patient safety and welfare, witnessing mistreatment and stigmatization, overextending and overinvesting, withdrawing and shutting down, blaming self and career crisis), and advocacy as a counterbalance to burnout (solidarity when helping underserved communities, fervent advocacy, and patient gratitude). CONCLUSIONS: Among clinicians who provide care in a safety-net healthcare system, sources of burnout included limited resources, barriers to building trust with patients, administrative requirements, and compassion fatigue, but clinicians remained driven by their desire to advocate for patients. Policy-level interventions which increase funding to safety-net healthcare systems to bolster existing resources and staffing, create peer-support and wellness programs, and support advocacy efforts may mitigate burnout.

Participant perspectives on the impact of receiving medically tailored meals on post-hospitalization.

OBJECTIVE: The objective of this program evaluation was to measure the impact of a medically tailored meals (MTM) intervention on participants' self-reported recovery and satisfaction while recovering from a recent hospitalization. DESIGN: A qualitative design was employed using a brief survey among all participants at the end of the intervention and phone interviews with a subset of participants. SAMPLE: Participants in this study were recently discharged from the hospital and were members of (redacted for review) who had received 2-4 weeks of MTM. MEASUREMENTS: The survey assessed overall satisfaction with the meals and perceived impact on their recovery after hospitalization (81% response rate). Interview questions asked how they felt the meals may have helped while recovering (e.g., helped them financially or with their ability to remain independent). RESULTS: Among survey participants, 65% were extremely or very satisfied with their meals. Reasons that MTM were helpful while they were recovering included having sufficient food to eat, having healthy food to eat, the convenience of the meals, and ease of preparing the meals. CONCLUSIONS: Participants receiving MTM were generally very satisfied with the program. Including nutrition education and more flexibility in quantity and frequency of food may improve satisfaction and consumption of food.

Social Risk Factors and Desire for Assistance Among Patients Receiving Subsidized Health Care Insurance in a US-Based Integrated Delivery System.

PURPOSE: Because social conditions such as food insecurity and housing instability shape health outcomes, health systems are increasingly screening for and addressing patients' social risks. This study documented the prevalence of social risks and examined the desire for assistance in addressing those risks in a US-based integrated delivery system. METHODS: A survey was administered to Kaiser Permanente members on subsidized exchange health insurance plans (2018-2019). The survey included questions about 4 domains of social risks, desire for help, and attitudes. We conducted a descriptive analysis and estimated multivariate modified Poisson regression models. RESULTS: Of 438 participants, 212 (48%) reported at least 1 social risk factor. Housing instability was the most common (70%) factor reported. Members with social risks reported more discomfort being screened for social risks (14.2% vs 5.4%; P = .002) than those without risks, although 90% of participants believed that health systems should assist in addressing social risks. Among those with 1-2 social risks, however, only 27% desired assistance. Non-Hispanic Black participants who reported a social risk were more than twice as likely to desire assistance compared with non-Hispanic White participants (adjusted relative risk [RR] 2.2; 95% CI, 1.3-3.8). CONCLUSIONS: Athough most survey participants believed health systems have a role in addressing social risks, a minority of those reporting a risk wanted assistance and reported more discomfort being screened for risk factors than those without risks. Health systems should work to increase the comfort of patients in reporting risks, explore how to successfully assist them when desired, and offer resources to address these risks outside the health care sector.VISUAL ABSTRACT.

Social determinants of obesity in American Indian and Alaska Native peoples aged ≥ 50 years.

OBJECTIVE: American Indian and Alaska Native peoples (AI/ANs) have a disproportionately high rate of obesity, but little is known about the social determinants of obesity among older AI/ANs. Thus, our study assessed social determinants of obesity in AI/ANs aged ≥ 50 years. DESIGN: We conducted a cross-sectional analysis using multivariate generalized linear mixed models to identify social determinants associated with the risk of being classified as obese (BMI ≥ 30.0 kg/m2). Analyses were conducted for the total study population and stratified by median county poverty level. SETTING: Indian Health Service (IHS) data for AI/ANs who used IHS services in FY2013. PARTICIPANTS: 27,696 AI/ANs aged ≥ 50 years without diabetes. RESULTS: Mean BMI was 29.8 ± 6.6 with 43% classified as obese. Women were more likely to be obese than men, and younger ages were associated with higher obesity risk. While having Medicaid coverage was associated with lower odds of obesity, private health insurance was associated with higher odds. Living in areas with lower rates of educational attainment and longer drive times to primary care services were associated with higher odds of obesity. Those who lived in a county where a larger percentage of people had low access to a grocery store were significantly less likely to be obese. CONCLUSIONS: Our findings contribute to the understanding of social determinants of obesity among older AI/ANs and highlight the need to investigate AI/AN obesity, including longitudinal studies with a life course perspective to further examine social determinants of obesity in older AI/ANs.

Social risks and social needs in a health insurance exchange sample: a longitudinal evaluation of utilization.

BACKGROUND: Health systems are increasingly attempting to intervene on social adversity as a strategy to improve health care outcomes. To inform health system efforts to screen for social adversity, we sought to explore the stability of social risk and interest in assistance over time and to evaluate whether the social risk was associated with subsequent healthcare utilization. METHODS: We surveyed Kaiser Permanente members receiving subsidies from the healthcare exchange in Southern California to assess their social risk and desire for assistance using the Accountable Health Communities instrument. A subset of initial respondents was randomized to be re-surveyed at either three or six months later. RESULTS: A total of 228 participants completed the survey at both time points. Social risks were moderate to strongly stable across three and six months (Kappa range = .59-.89); however, social adversity profiles that included participants' desire for assistance were more labile (3-month Kappa = .52; 95% CI = .41-.64 & 6-month Kappa = .48; 95% CI = .36-.6). Only housing-related social risks were associated with an increase in acute care (emergency, urgent care) six months after initial screening; no other associations between social risk and utilization were observed. CONCLUSIONS: This study suggests that screening for social risk may be appropriate at intervals of six months, or perhaps longer, but that assessing desire for assistance may need to occur more frequently. Housing risks were associated with increases in acute care. Health systems may need to engage in screening and referral to resources to improve overall care and ultimately patient total health.

Associations Between Rurality, pre-pregnancy Health Status, and Macrosomia in American Indian/Alaska Native Populations.

OBJECTIVES: To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care. METHODS: The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health. RESULTS: Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia.

Identifying Relative Changes in Social Risk Factors: An Analytic Approach.

BACKGROUND: Individuals often report concurrent social risk factors such as food insecurity, unstable housing, and transportation barriers. Comparing relative changes between pairs of social risk factors may identify those that are more resistant to change. OBJECTIVE: The objective of this study was to develop a method to describe relative changes in pairs of social risk factors. RESEARCH DESIGN: This was a prospective cohort study. SUBJECTS: Participants in a randomized controlled trial of hypertension care in an Urban Indian Health Organization. MEASURES: We measured 7 social risk factors (housing, transportation, food, clothing, health care, utilities, and debts) at enrollment, 6, and 12 months among 295 participants in the trial. We hypothesized that pairwise comparisons could identify social risk factors that were less likely to change over time. We used conditional odds ratios (ORs) with 95% confidence intervals (CIs) to rank each pair. RESULTS: Food, clothing, health care, utilities, and debts had more changes between 0 and 6 months relative to housing (OR=2.3, 3.4, 4.7, 3.5, and 3.4, respectively; all 95% CI excluded 1.0). These same social risk factors also had more changes between baseline and 6 months relative to transportation (OR=2.8, 3.4, 4.9, 4.7, and 4.1, respectively; all 95% CI excluded 1.0). Changes in housing and transportation risk factors were comparable (OR=0.7, 95% CI: 0.4-1.4). Relative changes between 6 and 12 months were similar. CONCLUSIONS: Housing and transportation exhibited fewer relative changes than other social risk factors and might be more resistant to change. Awareness of the relationships between social risk factors can help define priorities for intervention.

Association of Financial Worry and Material Financial Risk with Short-Term Ambulatory Healthcare Utilization in a Sample of Subsidized Exchange Patients.

BACKGROUND: Financial burden can affect healthcare utilization. Few studies have assessed the short-term associations between material (debt, trouble paying rent) and psychological (worry or distress about affording future healthcare) financial risks, and subsequent outpatient and emergency healthcare use. Worry was defined as concerns about affording future healthcare. OBJECTIVE: Examine whether worry about affording healthcare is associated with healthcare utilization when controlling for material risk and general anxiety DESIGN: Longitudinal observational study PARTICIPANTS: Kaiser Permanente members with exchange-based federally subsidized health insurance (n = 450, 45% response rate) MAIN MEASURES: Survey measures of financial risks (material difficulty paying for medical care and worry about affording healthcare) and general anxiety. Healthcare use (primary care, urgent care, emergency department, and outpatient specialty visits) in the 6 months following survey completion. KEY RESULTS: Emergency department and primary care visits were not associated with material risk, worry about affording care, or general anxiety in individual and pooled analyses (all 95% confidence intervals (CI) for relative risk (RR) included 1). Although no individual predictor was associated with urgent care use (all 95% CIs for RR included 1), worry about affording prescriptions (relative risk (RR) = 2.01; 95% CI 1.14, 3.55) and general anxiety (RR = 0.38; 95% CI 0.15, 0.95) were significant when included in the same model, suggesting the two confounded each other. Worry about affording healthcare services was associated with fewer specialty care visits (RR = 0.40; 95% CI 0.25, 0.64) even when controlling for material risk and general anxiety, although general anxiety was also associated with more specialty care visits (RR = 1.98; 95% CI, 1.23, 3.18). CONCLUSIONS: Screening for both general anxiety and financial worry may assist with specialty care utilization. Identifying these concerns may provide more opportunities to assist patients. Future research should examine interventions to reduce worry about cost of care.

Patient Navigation: Addressing Social Challenges in Dialysis Patients.

Members of racial and ethnic minority groups make up nearly 50% of US patients with end-stage kidney disease and face a disproportionate burden of socioeconomic challenges (ie, low income, job insecurity, low educational attainment, housing instability, and communication challenges) compared with non-Hispanic whites. Patients with end-stage kidney disease who face social challenges often have poor patient-centered and clinical outcomes. These challenges may have a negative impact on quality-of-care performance measures for dialysis facilities caring for primarily minority and low-income patients. One path toward improving outcomes for this group is to develop culturally tailored interventions that provide individualized support, potentially improving patient-centered, clinical, and health system outcomes by addressing social challenges. One such approach is using community-based culturally and linguistically concordant patient navigators, who can serve as a bridge between the patient and the health care system. Evidence points to the effectiveness of patient navigators in the provision of cancer care and, to a lesser extent, caring for people with chronic kidney disease and those who have undergone kidney transplantation. However, little is known about the effectiveness of patient navigators in the care of patients with kidney failure receiving dialysis, who experience a number of remediable social challenges.

Impact of Transportation Interventions on Health Care Outcomes: A Systematic Review.

INTRODUCTION: Lack of reliable transportation can be a barrier to keeping appointments or accessing other health care services. Increasingly, insurers and health care delivery systems subsidize transportation services for patients. This systematic review synthesizes existing research on nonemergency medical transportation interventions. METHODS: We searched 3 databases (Embase, PubMed, Google) for studies of health care sector-sponsored programs that provided patients assistance with nonemergency transportation and directly assessed the impact of transportation assistance on health and health care utilization outcomes. Studies meeting inclusion criteria were graded for quality using standard grading criteria. FINDINGS: Eight studies met all inclusion criteria. Most were rated as low quality. All studies included examined process or health care utilization outcomes, such as uptake of transportation services, return for follow-up, or missed appointment rates; only 1 included health outcomes, such as illness severity and blood pressure. Results were mixed. More rigorous studies showed low patient uptake of transportation services and inconsistent impacts on health and utilization outcomes. CONCLUSIONS: Despite considerable interest in subsidizing transportation services to improve health for patients facing transportation barriers, little rigorously conducted research has demonstrated the impact of transportation services on health or health care utilization. Some extant literature suggests that transportation assistance is more likely to be effective when offered with other interventions to reduce social and economic barriers to health.

Predictors of Hyperkalemia and Hypokalemia in Individuals with Diabetes: a Classification and Regression Tree Analysis.

BACKGROUND: Both hyperkalemia and hypokalemia can lead to cardiac arrhythmias and are associated with increased mortality. Information on the predictors of potassium in individuals with diabetes in routine clinical practice is lacking. OBJECTIVE: To identify predictors of hyperkalemia and hypokalemia in adults with diabetes. DESIGN: Retrospective cohort study, with classification and regression tree (CART) analysis. PARTICIPANTS: 321,856 individuals with diabetes enrolled in four large integrated health care systems from 2012 to 2013. MAIN MEASURES: We used a single serum potassium result collected in 2012 or 2013. Hyperkalemia was defined as a serum potassium ≥ 5.5 mEq/L and hypokalemia as < 3.5 mEq/L. Predictors included demographic factors, laboratory measurements, comorbidities, medication use, and health care utilization. KEY RESULTS: There were 2556 hypokalemia events (0.8%) and 1517 hyperkalemia events (0.5%). In univariate analyses, we identified concordant predictors (associated with increased probability of both hyperkalemia and hypokalemia), discordant predictors, and predictors of only hyperkalemia or hypokalemia. In CART models, the hyperkalemia "tree" had 5 nodes and a c-statistic of 0.76. The nodes were defined by prior potassium results and eGFRs, and the 5 terminal "leaves" had hyperkalemia probabilities of 0.2 to 7.2%. The hypokalemia tree had 4 nodes and a c-statistic of 0.76. The hypokalemia tree included nodes defined by prior potassium results, and the 4 terminal leaves had hypokalemia probabilities of 0.3 to 17.6%. Individuals with a recent potassium between 4.0 and 5.0 mEq/L, eGFR ≥ 45 mL/min/1.73m2, and no hypokalemia in the previous year had a < 1% rate of either hypokalemia or hyperkalemia. CONCLUSIONS: The yield of routine serum potassium testing may be low in individuals with a recent serum potassium between 4.0 and 5.0 mEq/L, eGFR ≥ 45 mL/min/1.73m2, and no recent history of hypokalemia. We did not examine the effect of recent changes in clinical condition or medications on acute potassium changes.

The Experience of Primary Caregivers of Undocumented Immigrants with End-Stage Kidney Disease that Rely on Emergency-Only Hemodialysis.

BACKGROUND: Undocumented immigrants with end-stage kidney disease (ESKD) who rely on emergency-only hemodialysis (dialysis only after an emergency department evaluation) face psychosocial distress. Emergency-only hemodialysis (EOHD) is likely burdensome for primary caregivers as well. OBJECTIVE: To understand the experience of primary caregivers of undocumented immigrants with ESKD who rely on emergency-only hemodialysis. DESIGN, SETTING, AND PARTICIPANTS: A qualitative, semi-structured interview study to assess the experiences of primary caregivers of undocumented immigrants with ESKD at a safety-net hospital in Denver, Colorado from June 28 to November 15, 2018. Applied thematic analysis was used to analyze interviews. MAIN OUTCOMES AND MEASURES: Themes and subthemes. RESULTS: Twenty primary caregiver participants had a mean (SD) age of 46 (17), 13 (65%) were female, 7 (35%) were in an adult child caregiver role, and 13 (65%) were spouses. Five themes and 17 subthemes (in parentheses) were identified: (1) Caregiver role (providing emotional, physical, and economic support, advocacy and care navigation), (2) Caregiver burden (anxiety related to patient and personal death, emotional exhaustion and personal illness, struggle with finances, self-care and redefining relationship), (3) Unpredictable EOHD (acute episodes of illness that trigger emergency, stress when patient is denied dialysis, impact on work and sleep, and emotional relief after a session of EOHD), (4) Effect on children (dropping out or missing school, psychosocial distress, children assuming caregiver responsibilities, and juggling multi-generational caregiving of children), (5) Faith and appreciation (comfort in God and appreciation of healthcare). CONCLUSIONS AND RELEVANCE: Caregivers of undocumented immigrants with ESKD who rely upon EOHD experience caregiver burden and distress. The impact of EOHD on caregivers should be considered when assessing the consequences of excluding undocumented immigrants from public insurance programs.

Randomized Clinical Trial of a Clinical Decision Support Tool for Improving the Appropriateness Scores for Ordering Imaging Studies in Primary and Specialty Care Ambulatory Clinics.

OBJECTIVE. The objective of our study was to evaluate whether the use of a clinical decision support (CDS) tool improved the appropriateness scores of orders for advanced imaging in clinical practice. MATERIALS AND METHODS. We used a stepped-wedge, cluster randomized clinical trial to evaluate the effectiveness of a CDS tool in an integrated health care system. Clinicians entered structured indications for each CT and MRI order, and the indications were electronically scored against appropriateness criteria to assign an appropriateness score. We compared the proportion of orders with adjusted appropriateness scores of 7 or greater (on a 1-9 scale) before and after activation of best practice alerts (BPAs) triggered for orders with low or marginal appropriateness scores. Secondary outcomes included the rate per month of orders for advanced imaging and the proportion of orders for which the radiology department requested changes. RESULTS. Between October 2015 and February 2016, 941 clinicians ordered 22,279 CT or MRI studies that met eligibility criteria. Before activation of the BPA, the mean proportion of appropriate orders (adjusted for time and clinic effect) was 77.0% (95% CI, 75.5-78.4%), which increased to 80.1% (95% CI, 78.7-81.5%) after activation (p = 0.001). There was no significant change in the rate of orders per month for advanced imaging. The proportion of order changes requested by the radiology department decreased from 5.7% (95% CI, 5.6-5.9%) before CDS implementation to 5.3% (95% CI, 5.1-5.5%) after CDS implementation (p < 0.001). CONCLUSION. Using an evidence-based CDS tool in clinical practice was associated with a modest but significant improvement in the appropriateness scores of advanced imaging orders.

Developing a Regional Distributed Data Network for Surveillance of Chronic Health Conditions: The Colorado Health Observation Regional Data Service.

Electronic health records (EHRs) provide an alternative to traditional public health surveillance surveys and administrative data for measuring the prevalence and impact of chronic health conditions in populations. As the infrastructure for secondary use of EHR data improves, many stakeholders are poised to benefit from data partnerships for regional access to information. Electronic health records can be transformed into a common data model that facilitates data sharing across multiple organizations and allows data to be used for surveillance. The Colorado Health Observation Regional Data Service, a regional distributed data network, has assembled diverse data partnerships, flexible infrastructure, and transparent governance practices to better understand the health of communities through EHR-based, public health surveillance. This article describes attributes of regional distributed data networks using EHR data and the history and design of Colorado Health Observation Regional Data Service as an emerging public health surveillance tool for chronic health conditions. Colorado Health Observation Regional Data Service and our experience may serve as a model for other regions interested in similar surveillance efforts. While benefits from EHR-based surveillance are described, a number of technology, partnership, and value proposition challenges remain.

Monitoring Depression Rates in an Urban Community: Use of Electronic Health Records.

OBJECTIVES: Depression is the most common mental health disorder and mediates outcomes for many chronic diseases. Ability to accurately identify and monitor this condition, at the local level, is often limited to estimates from national surveys. This study sought to compare and validate electronic health record (EHR)-based depression surveillance with multiple data sources for more granular demographic subgroup and subcounty measurements. DESIGN/SETTING: A survey compared data sources for the ability to provide subcounty (eg, census tract [CT]) depression prevalence estimates. Using 2011-2012 EHR data from 2 large health care providers, and American Community Survey data, depression rates were estimated by CT for Denver County, Colorado. Sociodemographic and geographic (residence) attributes were analyzed and described. Spatial analysis assessed for clusters of higher or lower depression prevalence. MAIN OUTCOME MEASURE(S): Depression prevalence estimates by CT. RESULTS: National and local survey-based depression prevalence estimates ranged from 7% to 17% but were limited to county level. Electronic health record data provided subcounty depression prevalence estimates by sociodemographic and geographic groups (CT range: 5%-20%). Overall depression prevalence was 13%; rates were higher for women (16% vs men 9%), whites (16%), and increased with age and homeless patients (18%). Areas of higher and lower EHR-based, depression prevalence were identified. CONCLUSIONS: Electronic health record-based depression prevalence varied by CT, gender, race/ethnicity, age, and living status. Electronic health record-based surveillance complements traditional methods with greater timeliness and granularity. Validation through subcounty-level qualitative or survey approaches should assess accuracy and address concerns about EHR selection bias. Public health agencies should consider the opportunity and evaluate EHR system data as a surveillance tool to estimate subcounty chronic disease prevalence.

A Multilevel Analysis of Individual, Health System, and Neighborhood Factors Associated with Depression within a Large Metropolitan Area.

Depression prevalence is known to vary by individual factors (gender, age, race, medical comorbidities) and by neighborhood factors (neighborhood deprivation). However, the combination of individual- and neighborhood-level data is rarely available to assess their relative contribution to variation in depression across neighborhoods. We geocoded depression diagnosis and demographic data from electronic health records for 165,600 patients seen in two large health systems serving the Denver population (Kaiser Permanente and Denver Health) to Denver's 144 census tracts, and combined these data with indices of neighborhood deprivation obtained from the American Community Survey. Non-linear mixed models examined the relationships between depression rates and individual and census tract variables, stratified by health system. We found higher depression rates associated with greater age, female gender, white race, medical comorbidities, and with lower rates of home owner occupancy, residential stability, and higher educational attainment, but not with economic disadvantage. Among the Denver Health cohort, higher depression rates were associated with higher crime rates and a lower percent of foreign born residents and single mother households. Our findings suggest that individual factors had the strongest associations with depression. Neighborhood risk factors associated with depression point to low community cohesion, while the role of education is more complex. Among the Denver Health cohort, language and cultural barriers and competing priorities may attenuate the recognition and treatment of depression.