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.

Effect of a multi-modal intervention on immunization rates in obstetrics and gynecology clinics.

BACKGROUND: There is increasing attention on immunizations by obstetrician-gynecologists and a need to improve vaccination rates for all women. OBJECTIVE: To evaluate the effect of a multimodal intervention on rates of immunization with tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); and influenza in outpatient obstetrics and gynecology clinics. STUDY DESIGN: Immunization rates at 2 clinics were compared pre- and post-implementation of multiple interventions at a public integrated health-care system. Study interventions began on June 6, 2012 and concluded on May 31, 2014; the preimplementation time period used was June 6, 2010 to June 5, 2012. Interventions included stocking of immunizations in clinics, revision and expansion of standing orders, creation of a reminder/recall program, identification of an immunization champion to give direct provider feedback, expansion of a payment assistance program, and staff education. All women aged 15 and older who made a clinic visit during influenza season were included in the influenza cohort; women who delivered an infant during the study time period and had at least 1 prenatal visit within 9 months preceding delivery were included in the Tdap cohort; each clinic visit by a nonpregnant woman aged 15-26 years was assessed and included in the HPV analysis as an eligible visit if the patient was lacking any of the 3 HPV vaccines in the series. The primary outcome was receipt of influenza and Tdap vaccine per current American College of Obstetricians and Gynecologists guidelines and receipt of HPV vaccine during eligible visits. Influenza and Tdap were assessed with overall coverage rates at the institutional level, and HPV was assessed at the visit level by captured opportunities. All analyses included generalized estimating equations and the primary outcome was assessed with time as a covariate in all models. RESULTS: A total of 19,409 observations were included in the influenza cohort (10,231 pre- and 9178 post-intervention), 2741 in the Tdap cohort (1248 pre- and 1493 post-intervention), and 12,443 in the HPV cohort (7966 pre- and 4477 post-intervention). Our population was largely Hispanic, English-speaking, and publicly insured. The rate of influenza vaccination increased from 35.4% pre-intervention to 46.0% post-intervention (P < .001). The overall rate for Tdap vaccination increased from 87.6% pre-intervention to 94.5% post-intervention until the recommendation to vaccinate during each pregnancy was implemented (z = 4.58, P < .0001). The average Tdap up-to-date rate after that recommendation was 75.0% (z = -5.77, P < .0001). The overall rate of HPV vaccination with an eligible visit increased from 7.1% before to 23.7% after the intervention. CONCLUSION: Using evidence-based practices largely established in other settings, our intervention was associated with increased rates of influenza, Tdap, and HPV vaccination in outpatient underserved obstetrics and gynecology clinics. Integrating such evidence-based practices into routine obstetrics and gynecology care could positively impact preventive health for many women.

The impact of tailored diabetes registry report cards on measures of disease control: a nested randomized trial.

BACKGROUND: Most studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback. METHODS: 5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews. RESULTS: Many providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources. CONCLUSIONS: Patient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00827710.