Neighborhood-Level Chronic Disease Surveillance: Utility of Primary Care Electronic Health Records and Emergency Department Claims Data.

CONTEXT: Disease burden may vary substantively across neighborhoods in an urban setting. Yet, data available for monitoring chronic conditions at the neighborhood level are scarce. Large health care data sets have potential to complement population health surveillance. Few studies have examined the utility of health care data for neighborhood-level surveillance. OBJECTIVE: We examined the use of primary care electronic health records (EHRs) and emergency department (ED) claims for identifying neighborhoods with higher chronic disease burden and neighborhood-level prevalence estimation. DESIGN: Comparison of hypertension and diabetes estimates from EHRs and ED claims with survey-based estimates. SETTING: Forty-two United Hospital Fund neighborhoods in New York City. PARTICIPANTS: The EHR sample comprised 708 452 patients from the Hub Population Health System (the Hub) in 2015, and the ED claim sample comprised 1 567 870 patients from the Statewide Planning and Research Cooperative System in 2015. We derived survey-based estimates from 2012 to 2016 Community Health Survey (n = 44 189). MAIN OUTCOME MEASURE: We calculated hypertension and diabetes prevalence estimates by neighborhood from each data source. We obtained Pearson correlation and absolute difference between EHR-based or claims-based estimates and survey-based estimates. RESULTS: Both EHR-based and claims-based estimates correlated strongly with survey-based estimates for hypertension (0.91 and 0.72, respectively) and diabetes (0.83 and 0.82, respectively) and identified similar neighborhoods of higher burden. For hypertension, 10 and 17 neighborhoods from the EHRs and ED claims, respectively, had an absolute difference of more than 5 percentage points from the survey-based estimate. For diabetes, 15 and 4 neighborhoods from the EHRs and ED claims, respectively, differed from the survey-based estimate by more than 5 percentage points. CONCLUSIONS: Both EHRs and ED claims data are useful for identifying neighborhoods with greater disease burden and have potential for monitoring chronic conditions at the neighborhood level.

Population-Based Estimates of Coronavirus Disease 2019 (COVID-19)-like Illness, COVID-19 Illness, and Rates of Case Ascertainment, Hospitalizations, and Deaths-Noninstitutionalized New York City Residents, March-April 2020.

Using a population-based, representative telephone survey, ~930 000 New York City residents had COVID-19 illness beginning 20 March-30 April 2020, a period with limited testing. For every 1000 persons estimated with COVID-19 illness, 141.8 were tested and reported as cases, 36.8 were hospitalized, and 12.8 died, varying by demographic characteristics.

Adapting Survey Data Collection to Respond to the COVID-19 Pandemic: Experiences From a Local Health Department.

The New York City (NYC) Department of Health and Mental Hygiene ("Health Department") conducts routine surveys to describe the health of NYC residents. During the COVID-19 pandemic, the Health Department adjusted existing surveys and developed new ones to improve our understanding of the impact of the pandemic on physical health, mental health, and social determinants of health and to incorporate more explicit measures of racial inequities. The longstanding Community Health Survey was adapted in 2020 to ask questions about COVID-19 and recruit respondents for a population-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serosurvey. A new survey panel, Healthy NYC, was launched in June 2020 and is being used to collect data on COVID-19, mental health, and social determinants of health. In addition, 7 Health Opinion Polls were conducted from March 2020 through March 2021 to learn about COVID-19-related knowledge, attitudes, and opinions, including vaccine intentions. We describe the contributions that survey data have made to the emergency response in NYC in ways that address COVID-19 and the profound inequities of the pandemic. (Am J Public Health. 2021;111(12):2176-2185. https://doi.org/10.2105/AJPH.2021.306515).

The Burden of Depression in New York City Adults: Results from the 2013-14 NYC Health and Nutrition Examination Survey.

Depression is responsible for a large burden of disability in the USA. We estimated the prevalence of depression in the New York City (NYC) adult population in 2013-14 and examined associations with demographics, health behaviors, and employment status. Data from the 2013-14 New York City Health and Nutrition Examination Survey, a population-based examination study, were analyzed, and 1459 participants met the inclusion criteria for this analysis. We defined current symptomatic depression by a Patient Health Questionnaire (PHQ-9) score ≥ 10. Overall, 8.3% of NYC adults had current symptomatic depression. New Yorkers with current symptomatic depression were significantly more likely to be female, Latino, and unemployed yet not looking for work; they were also significantly more likely to have less than a high school education and to live in a high-poverty neighborhood. Socioeconomic inequalities in mental health persist in NYC and highlight the need for better diagnosis and treatment.

Tracking Declines in Mercury Exposure in the New York City Adult Population, 2004-2014.

Mercury is a toxic metal that can be measured in human blood and urine. Population-based biomonitoring from 2004 guided New York City (NYC) Department of Health and Mental Hygiene (DOHMH) efforts to reduce exposures by educating the public about risks and benefits of fish consumption-a predominant source of exposure in the general population-and removing mercury-containing skin-lightening creams and other consumer products from the marketplace. We describe changes in exposures over the past decade in relation to these local public health actions and in the context of national changes by comparing mercury concentrations measured in blood (1201 specimens) and urine (1408 specimens) from the NYC Health and Nutrition Examination Survey (NYC HANES) 2013-2014 with measurements from NYC HANES 2004 and National Health and Nutrition Examination Surveys (NHANES) 2003-2004 and 2013-2014. We found that NYC adult blood and urine geometric mean mercury concentrations decreased 46% and 45%, respectively. Adult New Yorkers with blood mercury concentration ≥ 5 µg/L (the New York State reportable level) declined from 24.8% (95% CL = 22.2%, 27.7%) to 12.0% (95% CL = 10.1%, 14.3%). The decline in blood mercury in NYC was greater than the national decline, while the decline in urine mercury was similar. As in 2004, Asian New Yorkers had higher blood mercury concentrations than other racial/ethnic groups. Foreign-born adults of East or Southeast Asian origin had the highest prevalence of reportable levels (29.7%; 95% CL = 21.0%, 40.1%) across sociodemographic groups, and Asians generally were the most frequent fish consumers, eating on average 11 fish meals in the past month compared with 7 among other groups (p < 0.001). Fish consumption patterns were similar over time, and fish continues to be consumed more frequently in NYC than nationwide (24.7% of NYC adults ate fish ten or more times in the past 30 days vs. 14.7% nationally, p < 0.001). The findings are consistent with the hypothesis that blood mercury levels have declined in part because of local and national efforts to promote consumption of lower mercury fish. Local NYC efforts may have accelerated the reduction in exposure. Having "silver-colored fillings" on five or more teeth was associated with the highest 95th percentile for urine mercury (4.06 µg/L; 95% CL = 3.1, 5.9). An estimated 5.5% of the adult population (95% CL = 4.3%, 7.0%) reported using a skin-lightening cream in the past 30 days, but there was little evidence that use was associated with elevated urine mercury in 2013-14.

Change in Diabetes Prevalence and Control among New York City Adults: NYC Health and Nutrition Examination Surveys 2004-2014.

National examination surveys provide trend information on diabetes prevalence, diagnoses, and control. Few localities have access to such information. Using a similar design as the National Health and Nutrition Examination Survey (NHANES), two NYC Health and Nutrition Examination Surveys (NYC HANES) were conducted over a decade, recruiting adults ≥ 20 years using household probability samples (n = 1808 in 2004; n = 1246 in 2013-2014) and physical exam survey methods benchmarked against NHANES. Participants had diagnosed diabetes if told by a health provider they had diabetes, and undiagnosed diabetes if they had no diagnosis but a fasting plasma glucose ≥ 126 mg/dl or A1C ≥ 6.5%. We found that between 2004 and 2014, total diabetes prevalence (diagnosed and undiagnosed) in NYC increased from 13.4 to 16.0% (P = 0.089). In 2013-2014, racial/ethnic disparities in diabetes burden had widened; diabetes was highest among Asians (24.6%), and prevalence was significantly lower among non-Hispanic white adults (7.7%) compared to that among other racial/ethnic groups (P < 0.001). Among adults with diabetes, the proportion of cases diagnosed increased from 68.3 to 77.3% (P = 0.234), and diagnosed cases with very poor control (A1C > 9%), decreased from 26.9 to 18.0% (P = 0.269), though both were non-significant. While local racial/ethnic disparities in diabetes prevalence persist, findings suggest modest improvements in diabetes diagnosis and management.

Gender and Race Disparities in Cardiovascular Disease Risk Factors among New York City Adults: New York City Health and Nutrition Examination Survey (NYC HANES) 2013-2014.

While gender and racial/ethnic disparities in cardiovascular disease (CVD) risk factors have each been well characterized, few studies have comprehensively examined how patterns of major CVD risk factors vary and intersect across gender and major racial/ethnic groups, considered together. Using data from New York City Health and Nutrition Examination Survey 2013-2014-a population-based, cross-sectional survey of NYC residents ages 20 years and older-we measured prevalence of obesity, hypertension, hypercholesterolemia, smoking, and diabetes across gender and race/ethnicity groups for 1527 individuals. We used logistic regression with predicted marginal to estimate age-adjusted prevalence ratio by gender and race/ethnicity groups and assess for potential additive and multiplicative interaction. Overall, women had lower prevalence of CVD risk factors than men, with less hypertension (p = 0.040), lower triglycerides (p < 0.001), higher HDL (p < 0.001), and a greater likelihood of a heart healthy lifestyle, more likely not to smoke and to follow a healthy diet (p < 0.05). When further stratified by race/ethnicity, however, the female advantage was largely restricted to non-Latino white women. Non-Latino black women had significantly higher risk of being overweight or obese, having hypertension, and having diabetes than non-Latino white men or women, or than non-Latino black men (p < 0.05). Non-Latino black women also had higher total cholesterol compared to non-Latino black men (184.4 vs 170.5 mg/dL, p = 0.010). Despite efforts to improve cardiovascular health and narrow disparities, non-Latino black women continue to have a higher burden of CVD risk factors than other gender and racial/ethnic groups. This study highlights the importance of assessing for intersectionality between gender and race/ethnicity groups when examining CVD risk factors.

Using Calibration to Reduce Measurement Error in Prevalence Estimates Based on Electronic Health Records.

INTRODUCTION: Increasing adoption of electronic health record (EHR) systems by health care providers presents an opportunity for EHR-based population health surveillance. EHR data, however, may be subject to measurement error because of factors such as data entry errors and lack of documentation by physicians. We investigated the use of a calibration model to reduce bias of prevalence estimates from the New York City (NYC) Macroscope, an EHR-based surveillance system. METHODS: We calibrated 6 health indicators to the 2013-2014 NYC Health and Nutrition Examination Survey (NYC HANES) data: hypertension, diabetes, smoking, obesity, influenza vaccination, and depression. We classified indicators into having low measurement error or high measurement error on the basis of whether the proportion of misclassification (ie, false-negative or false-positive cases) was greater than 15% in 190 reviewed charts. We compared bias (ie, absolute difference between NYC Macroscope estimates and NYC HANES estimates) before and after calibration. RESULTS: The health indicators with low measurement error had the same bias after calibration as before calibration (diabetes, 2.5 percentage points; smoking, 2.5 percentage points; obesity, 3.5 percentage points; hypertension, 1.1 percentage points). For indicators with high measurement error, bias decreased from 10.8 to 2.5 percentage points for depression, and from 26.7 to 8.4 percentage points for influenza vaccination. CONCLUSION: The calibration model has the potential to reduce bias of prevalence estimates from EHR-based surveillance systems for indicators with high measurement errors. Further research is warranted to assess the utility of the current calibration model for other EHR data and additional indicators.

Innovations in Population Health Surveillance: Using Electronic Health Records for Chronic Disease Surveillance.

With 87% of providers using electronic health records (EHRs) in the United States, EHRs have the potential to contribute to population health surveillance efforts. However, little is known about using EHR data outside syndromic surveillance and quality improvement. We created an EHR-based population health surveillance system called the New York City (NYC) Macroscope and assessed the validity of diabetes, hyperlipidemia, hypertension, smoking, obesity, depression, and influenza vaccination indicators. The NYC Macroscope uses aggregate data from a network of outpatient practices. We compared 2013 NYC Macroscope prevalence estimates with those from a population-based, in-person examination survey, the 2013-2014 NYC Health and Nutrition Examination Survey. NYC Macroscope diabetes, hypertension, smoking, and obesity prevalence indicators performed well, but depression and influenza vaccination estimates were substantially lower than were survey estimates. Ongoing validation will be important to monitor changes in validity over time as EHR networks mature and to assess new indicators. We discuss NYC's experience and how this project fits into the national context. Sharing lessons learned can help achieve the full potential of EHRs for population health surveillance.

Racial and Ethnic Subgroup Disparities in Hypertension Prevalence, New York City Health and Nutrition Examination Survey, 2013-2014.

INTRODUCTION: Racial/ethnic minority adults have higher rates of hypertension than non-Hispanic white adults. We examined the prevalence of hypertension among Hispanic and Asian subgroups in New York City. METHODS: Data from the 2013-2014 New York City Health and Nutrition Examination Survey were used to assess hypertension prevalence among adults (aged ≥20) in New York City (n = 1,476). Hypertension was measured (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or self-reported hypertension and use of blood pressure medication). Participants self-reported race/ethnicity and country of origin. Multivariable logistic regression models assessed differences in prevalence by race/ethnicity and sociodemographic and health-related characteristics. RESULTS: Overall hypertension prevalence among adults in New York City was 33.9% (43.5% for non-Hispanic blacks, 38.0% for Asians, 33.0% for Hispanics, and 27.5% for non-Hispanic whites). Among Hispanic adults, prevalence was 39.4% for Dominican, 34.2% for Puerto Rican, and 27.5% for Central/South American adults. Among Asian adults, prevalence was 43.0% for South Asian and 39.9% for East/Southeast Asian adults. Adjusting for age, sex, education, and body mass index, 2 major racial/ethnic minority groups had higher odds of hypertension than non-Hispanic whites: non-Hispanic black (AOR [adjusted odds ratio], 2.6; 95% confidence interval [CI], 1.7-3.9) and Asian (AOR, 2.0; 95% CI, 1.2-3.4) adults. Two subgroups had greater odds of hypertension than the non-Hispanic white group: East/Southeast Asian adults (AOR, 2.8; 95% CI, 1.6-4.9) and Dominican adults (AOR, 1.9; 95% CI, 1.1-3.5). CONCLUSION: Racial/ethnic minority subgroups vary in hypertension prevalence, suggesting the need for targeted interventions.

Comparing Prevalence Estimates From Population-Based Surveys to Inform Surveillance Using Electronic Health Records.

INTRODUCTION: Electronic health record (EHR) systems provide an opportunity to use a novel data source for population health surveillance. Validation studies that compare prevalence estimates from EHRs and surveys most often use difference testing, which can, because of large sample sizes, lead to detection of significant differences that are not meaningful. We explored a novel application of the two one-sided t test (TOST) to assess the equivalence of prevalence estimates in 2 population-based surveys to inform margin selection for validating EHR-based surveillance prevalence estimates derived from large samples. METHODS: We compared prevalence estimates of health indicators in the 2013 Community Health Survey (CHS) and the 2013-2014 New York City Health and Nutrition Examination Survey (NYC HANES) by using TOST, a 2-tailed t test, and other goodness-of-fit measures. RESULTS: A ±5 percentage-point equivalence margin for a TOST performed well for most health indicators. For health indicators with a prevalence estimate of less than 10% (extreme obesity [CHS, 3.5%; NYC HANES, 5.1%] and serious psychological distress [CHS, 5.2%; NYC HANES, 4.8%]), a ±2.5 percentage-point margin was more consistent with other goodness-of-fit measures than the larger percentage-point margins. CONCLUSION: A TOST with a ±5 percentage-point margin was useful in establishing equivalence, but a ±2.5 percentage-point margin may be appropriate for health indicators with a prevalence estimate of less than 10%. Equivalence testing can guide future efforts to validate EHR data.

Exposure to Secondhand Smoke Among Nonsmokers in New York City in the Context of Recent Tobacco Control Policies: Current Status, Changes Over the Past Decade, and National Comparisons.

INTRODUCTION: Exposure to secondhand smoke is hazardous and can cause cancer, coronary heart disease, and birth defects. New York City (NYC) and other jurisdictions have established smoke-free air laws in the past 10-15 years. METHODS: NYC Health and Nutrition Examination Survey (HANES) 2013-2014 was a population-based survey of NYC residents, aged 20 years and older, in which biospecimens were collected and cotinine levels were measured. Secondhand smoke exposure was assessed by demographics and risk factors and compared with that from NYC HANES 2004 and national HANES. RESULTS: More than a third (37.1%, 95% confidence interval [CI] = 33.3%-41.2%) of nonsmoking adult New Yorkers were exposed to secondhand smoke, defined as a cotinine level of 0.05-10ng/mL. This was significantly lower than in 2004 NYC HANES, when 56.7% (95% CI = 53.6%-59.7%) of nonsmokers were exposed to secondhand smoke, but was greater than the proportion of adults exposed nationwide, as measured by national HANES (24.4%, 95% CI = 22.0%-26.9% in 2011-2012). Men, non-Hispanic blacks, adults aged 20-39, those with less education, and those living in high-poverty neighborhoods were more likely to be exposed. CONCLUSIONS: There has been a large decrease in secondhand smoke exposure in NYC, although disparities persist. The decrease may be the result of successful policies to limit exposure to secondhand smoke in public places and of smokers smoking fewer cigarettes per day. Yet NYC residents still experience more secondhand smoke exposure than US residents overall. Possible explanations include multiunit housing, greater population density, and pedestrian exposure. IMPLICATIONS: Measuring exposure to secondhand smoke can be difficult, and few studies have monitored changes over time. This study uses serum cotinine, a nicotine metabolite, from a local population-based examination survey, the NYC HANES 2013-2014, to examine exposure to secondhand smoke in an urban area that has implemented stringent antismoking laws. Comparison with NYC HANES conducted 10 years ago allows for an assessment of changes in the last decade in the context of municipal tobacco control policies. Results may be helpful to jurisdictions considering implementing similar tobacco control policies.

Characterizing Adults Receiving Primary Medical Care in New York City: Implications for Using Electronic Health Records for Chronic Disease Surveillance.

INTRODUCTION: Electronic health records (EHRs) from primary care providers can be used for chronic disease surveillance; however, EHR-based prevalence estimates may be biased toward people who seek care. This study sought to describe the characteristics of an in-care population and compare them with those of a not-in-care population to inform interpretation of EHR data. METHODS: We used data from the 2013-2014 New York City Health and Nutrition Examination Survey (NYC HANES), considered the gold standard for estimating disease prevalence, and the 2013 Community Health Survey, and classified participants as in care or not in care, on the basis of their report of seeing a health care provider in the previous year. We used χ(2) tests to compare the distribution of demographic characteristics, health care coverage and access, and chronic conditions between the 2 populations. RESULTS: According to the Community Health Survey, approximately 4.1 million (71.7%) adults aged 20 or older had seen a health care provider in the previous year; according to NYC HANES, approximately 4.7 million (75.1%) had. In both surveys, the in-care population was more likely to be older, female, non-Hispanic, and insured compared with the not-in-care population. The in-care population from the NYC HANES also had a higher prevalence of diabetes (16.7% vs 6.9%; P < .001), hypercholesterolemia (35.7% vs 22.3%; P < .001), and hypertension (35.5% vs 26.4%; P < .001) than the not-in-care population. CONCLUSION: Systematic differences between in-care and not-in-care populations warrant caution in using primary care data to generalize to the population at large. Future efforts to use primary care data for chronic disease surveillance need to consider the intended purpose of data collected in these systems as well as the characteristics of the population using primary care.

Assessing targeted invitation and response modes to improve survey participation in a diverse New York City panel: Healthy NYC.

BACKGROUND: Healthy NYC is an innovative survey panel created by the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) that offers a cost-effective mechanism for collecting priority and timely health information. Between November 2020 and June 2021, invitations for six different surveys were sent to Healthy NYC panelists by postal mail, email, and text messages. Panelists had the option to complete surveys online or via paper survey. METHODS: We analyzed whether panelists varied by sociodemographic characteristics based on the contact mode they provided and the type of invitation that led to their response using logistic regression models. Poisson regression models were used to determine whether the number of invitations received before participating in a survey was associated with sociodemographic characteristics. RESULTS: Younger age and higher education were positively associated with providing an email or text contact. Furthermore, age, race, and income were significant predictors for invitation modes that led to a survey response. Black panelists had 72% greater odds (OR 1.72 95% CI: 1.11-2.68) of responding to a mail invite and 33% lesser odds (OR 0.67, 95% CI: 0.54-0.83) of responding to an email invite compared with White panelists. Additionally, in five of the six surveys, more than half of the respondents completed surveys after two invites. Email invitations garnered the highest participation rates. CONCLUSIONS: We recommend using targeted invitation modes as an additional strategy to improve participation in panels. For lower-income panelists who do not provide an email address, it may be reasonable to offer additional response options that do not require internet access. Our study's findings provide insight into how panels can tailor outreach to panelists, especially among underrepresented groups, in the most economical and efficient ways.

Short-term and medium-term health effects of 9/11.

The New York City terrorist attacks on Sept 11, 2001 (9/11), killed nearly 2800 people and thousands more had subsequent health problems. In this Review of health effects in the short and medium terms, strong evidence is provided for associations between experiencing or witnessing events related to 9/11 and post-traumatic stress disorder and respiratory illness, with a correlation between prolonged, intense exposure and increased overall illness and disability. Rescue and recovery workers, especially those who arrived early at the World Trade Center site or worked for longer periods, were more likely to develop respiratory illness than were other exposed groups. Risk factors for post-traumatic stress disorder included proximity to the site on 9/11, living or working in lower Manhattan, rescue or recovery work at the World Trade Center site, event-related loss of spouse, and low social support. Investigators note associations between 9/11 exposures and additional disorders, such as depression and substance use; however, for some health problems association with exposures related to 9/11 is unclear.

Putting public health into practice: a model for assessing the relationship between local health departments and practicing physicians.

The New York City (NYC) Department of Health and Mental Hygiene (Health Department) surveyed practicing NYC physicians to quantify Health Department resource use. Although the Health Department successfully reaches most physicians, and information is valued in practice, knowledge of several key resources was low. Findings suggested 3 recommendations for all local health departments seeking to enhance engagement with practicing physicians: (1) capitalize on physician interest, (2) engage physicians early and often, and (3) make interaction with the health department easy. Also, older physicians may require targeted outreach.

Housing type and secondhand tobacco smoke exposure among non-smoking New York City adults, 2004 and 2013-14.

Secondhand tobacco smoke (SHS) exposure has declined due to smoking reductions, expanding workplace and public smoke-free air laws, and smoke-free housing policy promotion. Population-based studies examining objective SHS exposure biomarkers have documented reductions over time, however non-smoking urban adults are more likely to have elevated cotinine (a metabolite of nicotine) compared with national averages. Evidence suggests residential housing type may impact urban SHS exposure risk. Direct associations between multiunit housing (MUH) and elevated cotinine have been identified among children but not yet examined among adults. We used data from the cross-sectional 2004 and 2013/14 New York City Health and Nutrition Examination Surveys to investigate associations between MUH (single-family versus 2; 3-99; and 100 + units) and likelihood of elevated serum cotinine among nonsmoking adults (2004: n = 1324; 2013/14: n = 946), adjusting for socio-demographics (sex, age, race/ethnicity, education, income) and self-reported SHS exposure variables. Combined and single-year adjusted multivariable regressions were conducted. Elevated cotinine was defined as a serum level of ≥ 0.05 ng/ml. Combined year adjusted multivariable regression analyses found no difference in elevated cotinine by housing type among non-smoking adults. By survey year, elevated cotinine did not vary by housing type in 2004, while non-smoking adults in 3-99 unit buildings were twice as likely to have elevated cotinine compared with single family residents in 2013/14 (adjusted Odds Ratio = 2.55 (1.13, 5.79)). While SHS exposure has declined, relative burden may be increasing among MUH residents. In urban settings with extensive MUH, attention to housing-based policies and programmatic interventions is critical to reducing SHS exposure.