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.

Erratum: "A Biomonitoring Study of Lead, Cadmium, and Mercury in the Blood of New York City Adults".

[This corrects the article DOI: 10.1289/ehp.10056.].

Prevalence, diagnosis, and treatment of depression and generalized anxiety disorder in a diverse urban community.

OBJECTIVE: This study assessed the prevalence, diagnosis, and treatment of major depressive disorder and generalized anxiety disorder among New York City adults. METHODS: As part of the first community-specific Health and Nutrition Examination Survey in the United States, depression and anxiety were assessed in a representative sample of 1,817 noninstitutionalized adults in 2004. RESULTS: A total of 8% had major depressive disorder and 4% had generalized anxiety disorder. Respondents with depression were more likely to be formerly married, publicly insured, younger, and U.S. born. Only 55% of adults with depression were diagnosed, and 38% of those with depression or anxiety were in treatment; individuals with a diagnosis of depression were more likely to receive treatment than those without a diagnosis (61% versus 7%; p<.001). Immigrants with depression were 60% less likely to be diagnosed than their U.S.-born counterparts; immigrants arriving in this country ten or more years ago had slightly more anxiety than immigrants arriving less than ten years ago (3% versus 2%, not significant). Among respondents with anxiety, 23% reported disability compared with 15% of those with depression. Compared with adults with neither diagnosis, adults with depression or anxiety were twice as likely to smoke tobacco (p<.05), adults with depression were twice as likely to have diabetes (p<.01), and those with anxiety were twice as likely to have asthma (p<.01). CONCLUSIONS: Mental disorders are often disabling and inadequately diagnosed and treated. Foreign-born adults experience barriers to diagnosis and treatment despite having less depression; anxiety may increase with time since immigration. Increased awareness of and linkage to mental health services are needed, especially in larger, more diverse urban communities.

Population prevalence of reported and unreported HIV and related behaviors among the household adult population in New York City, 2004.

BACKGROUND: Surveillance for HIV likely underestimates infection among the general population: 25% of US residents are estimated to be unaware of their HIV infection. OBJECTIVE: To determine the prevalence of HIV infection and risk behaviors among New York City (NYC) adults and compare these with surveillance findings. METHODS: The NYC Health and Nutrition Examination Survey (HANES) provided the first opportunity to estimate population-based HIV prevalence among NYC adults. It was conducted in 2004 among a representative sample of adults > 20 years. Previously reported HIV infection was identified from the NYC HIV/AIDS Surveillance Registry. A blinded HIV serosurvey was conducted on archived blood samples of 1626 NYC HANES participants. Data were used to estimate prevalence for HIV infection, unreported infections, high-risk activities, and self-perceived risk. RESULTS: Overall, 18.1% engaged in one or more risky sexual/needle-use behaviors, of which 92.2% considered themselves at low or no risk of HIV or another sexually transmitted disease. HIV occurred in 21 individuals (prevalence 1.4%; 95% confidence interval (CI), 0.8-2.5]; one infection (5%; 95% CI, 0.7-29.9) was not reported previously and possibly undiagnosed. HIV infection was significantly elevated in those with herpes simplex virus 2 (4%), men who have sex with men (14%), and needle-users (21%) (P < 0.01). CONCLUSIONS: Among NYC adults, HIV prevalence was consistent with surveillance findings overall. The proportion of unreported HIV was less than estimated nationally, but findings were limited by sample size. Most adults with risky behaviors perceived themselves to be at minimal risk, highlighting the need for risk reduction and routine HIV screening.

A biomonitoring study of lead, cadmium, and mercury in the blood of New York city adults.

OBJECTIVES: We assessed the extent of exposure to lead, cadmium, and mercury in the New York City (NYC) adult population. METHODS: We measured blood metal concentrations in a representative sample of 1,811 NYC residents as part of the NYC Health and Nutrition Examination Survey, 2004. RESULTS: The geometric mean blood mercury concentration was 2.73 microg/L [95% confidence interval (CI), 2.58-2.89]; blood lead concentration was 1.79 microg/dL (95% CI, 1.73-1.86); and blood cadmium concentration was 0.77 microg/L (95% CI, 0.75-0.80). Mercury levels were more than three times that of national levels. An estimated 24.8% (95% CI, 22.2-27.7%) of the NYC adult population had blood mercury concentration at or above the 5 microg/L New York State reportable level. Across racial/ethnic groups, the NYC Asian population, and the foreign-born Chinese in particular, had the highest concentrations of all three metals. Mercury levels were elevated 39% in the highest relative to the lowest income group (95% CI, 21-58%). Blood mercury concentrations in adults who reported consuming fish or shellfish 20 times or more in the last 30 days were 3.7 times the levels in those who reported no consumption (95% CI, 3.0-4.6); frequency of consumption explained some of the elevation in Asians and other subgroups. CONCLUSIONS: Higher than national blood mercury exposure in NYC adults indicates a need to educate New Yorkers about how to choose fish and seafood to maximize health benefits while minimizing potential risks from exposure to mercury. Local biomonitoring can provide valuable information about environmental exposures.

Risk factors for asthma in US adults: results from the 2000 Behavioral Risk Factor Surveillance System.

BACKGROUND: Identifying populations at risk for having asthma is an essential step toward appropriately allocating resources and reducing the burden of this disease. To date, the impact of demographic and social factors on asthma prevalence has not been assessed in a nationally representative sample of U.S. adults. METHODS: We conducted weighted analyses using data from a random digit-dialed telephone survey of non-institutionalized persons > or = 18 years of age in 50 states, Puerto Rico, and the District of Columbia to assess risk factors for asthma prevalence. RESULTS: We found that women were more likely than men to report current asthma [odds/ratio (OR): 1.91, 95% confidence interval (CI): 1.77-2.06]; adults aged 35-64 and >65 were less likely than adults aged 18-34 to report current asthma (OR: 0.79, 95% CI: 0.73-0.85 and OR: 0.65, 95% CI: 0.58-0.72, respectively); persons from the lower socioeconomic status (SES) were more likely to report current asthma than those in other SES (OR: 1.36, 95% CI: 1.25-1.49); overweight and obese people were more likely to report current asthma than were those of normal weight (OR: 1.10, 95% CI: 1.02-1.20 and OR: 1.65, 95% CI: 1.51-1.80, respectively); and current and former smokers were more likely than never smokers to report current asthma (OR: 1.28, 95% CI: 1.18-1.39 and OR: 1.36, 95% CI: 1.24-1.48, respectively). CONCLUSIONS: While several important sociodemographic risk factors were associated with increased asthma prevalence in U.S. adults, the impact of generally modifiable risk factors such as elevated body mass index and cigarette smoking is of specific concern. These findings further underscore the need to target and diminish these risk factors among U.S. adults.