More Screening or More Disease? Gonorrhea Testing and Positivity Patterns Among Men in 3 Large Clinical Practices in Massachusetts, 2010-2017.

BACKGROUND: Gonorrhea diagnosis rates in the United States increased by 75% during 2009-2017, predominantly in men. It is unclear whether the increase among men is being driven by more screening, an increase in the prevalence of disease, or both. We sought to evaluate changes in gonorrhea testing patterns and positivity among men in Massachusetts. METHODS: The analysis included men (aged ≥15 years) who received care during 2010-2017 in 3 clinical practice groups. We calculated annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive result, among men tested. Log-binomial regression models were used to examine trends in these outcomes. We adjusted for clinical and demographic characteristics that may influence the predilection to test and probability of gonorrhea disease. RESULTS: On average, 306 348 men had clinical encounters each year. There was a significant increase in men with ≥1 gonorrhea test from 2010 (3.1%) to 2017 (6.4%; adjusted annual risk ratio, 1.12; 95% confidence interval, 1.12-1.13). There was a significant, albeit lesser, increase in the percentage of tested men with ≥1 positive result (1.0% in 2010 to 1.5% in 2017; adjusted annual risk ratio, 1.07; 95% confidence interval, 1.04-1.09). CONCLUSIONS: We estimated significant increases in the annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive gonorrhea test result between 2010 and 2017. These results suggest that observed increases in gonorrhea rates could be explained by both increases in screening and the prevalence of gonorrhea.

Denominators Matter: Understanding Medical Encounter Frequency and Its Impact on Surveillance Estimates Using EHR Data.

BACKGROUND: There is scant guidance for defining what denominator to use when estimating disease prevalence via electronic health record (EHR) data. OBJECTIVES: Describe the intervals between medical encounters to inform the selection of denominators for population-level disease rates, and evaluate the impact of different denominators on the prevalence of chronic conditions. METHODS: We analyzed the EHRs of three practices in Massachusetts using the Electronic medical record Support for Public Health (ESP) system. We identified adult patients' first medical encounter per year (2011-2016) and counted days to next encounter. We estimated the prevalence of asthma, hypertension, obesity, and smoking using different denominators in 2016: ≥1 encounter in the past one year or two years and ≥2 encounters in the past one year or two years. RESULTS: In 2011-2016, 1,824,011 patients had 28,181,334 medical encounters. The median interval between encounters was 46, 56, and 66 days, depending on practice. Among patients with one visit in 2014, 82-84 percent had their next encounter within 1 year; 87-91 percent had their next encounter within two years. Increasing the encounter interval from one to two years increased the denominator by 23 percent. The prevalence of asthma, hypertension, and obesity increased with successively stricter denominators - e.g., the prevalence of obesity was 24.1 percent among those with ≥1 encounter in the past two years, 26.3 percent among those with ≥1 encounter in the last one year, and 28.5 percent among those with ≥2 encounters in the past one year. CONCLUSIONS: Prevalence estimates for chronic conditions can vary by >20 percent depending upon denominator. Understanding such differences will inform which denominator definition is best to be used for the need at hand.

State and Local Chronic Disease Surveillance Using Electronic Health Record Systems.

OBJECTIVES: To assess the feasibility of chronic disease surveillance using distributed analysis of electronic health records and to compare results with Behavioral Risk Factor Surveillance System (BRFSS) state and small-area estimates. METHODS: We queried the electronic health records of 3 independent Massachusetts-based practice groups using a distributed analysis tool called MDPHnet to measure the prevalence of diabetes, asthma, smoking, hypertension, and obesity in adults for the state and 13 cities. We adjusted observed rates for age, gender, and race/ethnicity relative to census data and compared them with BRFSS state and small-area estimates. RESULTS: The MDPHnet population under surveillance included 1 073 545 adults (21.8% of the state adult population). MDPHnet and BRFSS state-level estimates were similar: 9.4% versus 9.7% for diabetes, 10.0% versus 12.0% for asthma, 13.5% versus 14.7% for smoking, 26.3% versus 29.6% for hypertension, and 22.8% versus 23.8% for obesity. Correlation coefficients for MDPHnet versus BRFSS small-area estimates ranged from 0.890 for diabetes to 0.646 for obesity. CONCLUSIONS: Chronic disease surveillance using electronic health record data is feasible and generates estimates comparable with BRFSS state and small-area estimates.