Electronic Health Records for Population Health Management: Comparison of Electronic Health Record-Derived Hypertension Prevalence Measures Against Established Survey Data.

BACKGROUND: Hypertension is the most prevalent risk factor for mortality globally. Uncontrolled hypertension is associated with excess morbidity and mortality, and nearly one-half of individuals with hypertension do not have the condition under control. Data from electronic health record (EHR) systems may be useful for community hypertension surveillance, filling a gap in local public health departments' community health assessments and supporting the public health data modernization initiatives currently underway. To identify patients with hypertension, computable phenotypes are required. These phenotypes leverage available data elements-such as vitals measurements and medications-to identify patients diagnosed with hypertension. However, there are multiple methodologies for creating a phenotype, and the identification of which method most accurately reflects real-world prevalence rates is needed to support data modernization initiatives. OBJECTIVE: This study sought to assess the comparability of 6 different EHR-based hypertension prevalence estimates with estimates from a national survey. Each of the prevalence estimates was created using a different computable phenotype. The overarching goal is to identify which phenotypes most closely align with nationally accepted estimations. METHODS: Using the 6 different EHR-based computable phenotypes, we calculated hypertension prevalence estimates for Marion County, Indiana, for the period from 2014 to 2015. We extracted hypertension rates from the Behavioral Risk Factor Surveillance System (BRFSS) for the same period. We used the two 1-sided t test (TOST) to test equivalence between BRFSS- and EHR-based prevalence estimates. The TOST was performed at the overall level as well as stratified by age, gender, and race. RESULTS: Using both 80% and 90% CIs, the TOST analysis resulted in 2 computable phenotypes demonstrating rough equivalence to BRFSS estimates. Variation in performance was noted across phenotypes as well as demographics. TOST with 80% CIs demonstrated that the phenotypes had less variance compared to BRFSS estimates within subpopulations, particularly those related to racial categories. Overall, less variance occurred on phenotypes that included vitals measurements. CONCLUSIONS: This study demonstrates that certain EHR-derived prevalence estimates may serve as rough substitutes for population-based survey estimates. These outcomes demonstrate the importance of critically assessing which data elements to include in EHR-based computer phenotypes. Using comprehensive data sources, containing complete clinical data as well as data representative of the population, are crucial to producing robust estimates of chronic disease. As public health departments look toward data modernization activities, the EHR may serve to assist in more timely, locally representative estimates for chronic disease prevalence.

Supporting Health Equity Through Data-Driven Decision-Making: A Local Health Department Response to COVID-19.

COVID-19 highlights preexisting inequities that affect health outcomes and access to care for Black and Brown Americans. The Marion County Public Health Department in Indiana sought to address inequities in COVID-19 testing by using surveillance data to place community testing sites in areas with the highest incidence of disease. Testing site demographic data indicated that targeted testing reached populations with the highest disease burden, suggesting that local health departments can effectively use surveillance data as a tool to address inequities. (Am J Public Health. 2021;111(S3):S197-S200. https://doi.org/10.2105/AJPH.2021.306421).

Hospital Partnerships for Population Health: A Systematic Review of the Literature.

EXECUTIVE SUMMARY: The U.S. healthcare system continues to experience high costs and suboptimal health outcomes that are largely influenced by social determinants of health. National policies such as the Affordable Care Act and value-based payment reforms incentivize healthcare systems to engage in strategies to improve population health. Healthcare systems are increasingly expanding or developing new partnerships with community-based organizations to support these efforts. We conducted a systematic review of peer-reviewed literature in the United States to identify examples of hospital-community partnerships; the main purposes or goals of partnerships; study designs used to assess partnerships; and potential outcomes (e.g., process- or health-related) associated with partnerships. Using robust keyword searches and a thorough reference review, we identified 37 articles published between January 2008 and December 2019 for inclusion. Most studies employed descriptive study designs (n = 21); health needs assessments were the most common partnership focus (n = 15); and community/social service (n = 21) and public health organizations (n = 15) were the most common partner types. Qualitative findings suggest hospital-community partnerships hold promise for breaking down silos, improving communication across sectors, and ensuring appropriate interventions for specific populations. Few studies in this review reported quantitative findings. In those that did, results were mixed, with the strongest support for improvements in measures of hospitalizations. This review provides an initial synthesis of hospital partnerships to address population health and presents valuable insights to hospital administrators, particularly those leading population health efforts.

Public Health Informatics in Local and State Health Agencies: An Update From the Public Health Workforce Interests and Needs Survey.

OBJECTIVE: To characterize public health informatics (PHI) specialists and identify the informatics needs of the public health workforce. DESIGN: Cross-sectional study. SETTING: US local and state health agencies. PARTICIPANTS: Employees from state health agencies central office (SHA-COs) and local health departments (LHDs) participating in the 2017 Public Health Workforce Interests and Needs Survey (PH WINS). We characterized and compared the job roles for self-reported PHI, "information technology specialist or information system manager" (IT/IS), "public health science" (PHS), and "clinical and laboratory" workers. MAIN OUTCOME MEASURE: Descriptive statistics for demographics, income, education, public health experience, program area, job satisfaction, and workplace environment, as well as data and informatics skills and needs. RESULTS: A total of 17 136 SHA-CO and 26 533 LHD employees participated in the survey. PHI specialist was self-reported as a job role among 1.1% and 0.3% of SHA-CO and LHD employees. The PHI segment most closely resembled PHS employees but had less public health experience and had lower salaries. Overall, fewer than one-third of PHI specialists reported working in an informatics program area, often supporting epidemiology and surveillance, vital records, and communicable disease. Compared with PH WINS 2014, current PHI respondents' satisfaction with their job and workplace environment moved toward more neutral and negative responses, while the IT/IS, PHS, and clinical and laboratory subgroups shifted toward more positive responses. The PHI specialists were less likely than those in IT/IS, PHS, or clinical and laboratory roles to report gaps in needed data and informatics skills. CONCLUSIONS: The informatics specialists' role continues to be rare in public health agencies, and those filling that role tend to have less public health experience and be less well compensated than staff in other technically focused positions. Significant data and informatics skills gaps persist among the broader public health workforce.

Electronic Health Record (EHR)-Based Community Health Measures: An Exploratory Assessment of Perceived Usefulness by Local Health Departments.

BACKGROUND: Given the widespread adoption of electronic health record (EHR) systems in health care organizations, public health agencies are interested in accessing EHR data to improve health assessment and surveillance. Yet there exist few examples in the U.S. of governmental health agencies using EHR data routinely to examine disease prevalence and other measures of community health. The objective of this study was to explore local health department (LHD) professionals' perceptions of the usefulness of EHR-based community health measures, and to examine these perceptions in the context of LHDs' current access and use of sub-county data, data aggregated at geographic levels smaller than county. METHODS: To explore perceived usefulness, we conducted an online survey of LHD professionals in Indiana. One hundred and thirty-three (133) individuals from thirty-one (31) LHDs participated. The survey asked about usefulness of specific community health measures as well as current access to and uses of sub-county population health data. Descriptive statistics were calculated to examine respondents' perceptions, access, and use. A one-way ANOVA (with pairwise comparisons) test was used to compare average scores by LHD size. RESULTS: Respondents overall indicated moderate agreement on which community health measures might be useful. Perceived usefulness of specific EHR-based community health measures varied by size of respondent's LHD [F(3, 88) = 3.56, p = 0.017]. Over 70% of survey respondents reported using community health data, but of those < 30% indicated they had access to sub-county level data. CONCLUSION: Respondents generally preferred familiar community health measures versus novel, EHR-based measures that are not in widespread use within health departments. Access to sub-county data is limited but strongly desired. Future research and development is needed as LHD staff gain access to EHR data and apply these data to support the core function of health assessment.

Characterizing Informatics Roles and Needs of Public Health Workers: Results From the Public Health Workforce Interests and Needs Survey.

OBJECTIVE: To characterize public health workers who specialize in informatics and to assess informatics-related aspects of the work performed by the public health workforce. METHODS (DESIGN, SETTING, PARTICIPANTS): Using the nationally representative Public Health Workforce Interests and Needs Survey (PH WINS), we characterized and compared responses from informatics, information technology (IT), clinical and laboratory, and other public health science specialists working in state health agencies. MAIN OUTCOME MEASURES: Demographics, income, education, and agency size were analyzed using descriptive statistics. Weighted medians and interquartile ranges were calculated for responses pertaining to job satisfaction, workplace environment, training needs, and informatics-related competencies. RESULTS: Of 10,246 state health workers, we identified 137 (1.3%) informatics specialists and 419 (4.1%) IT specialists. Overall, informatics specialists are younger, but share many common traits with other public health science roles, including positive attitudes toward their contributions to the mission of public health as well as job satisfaction. Informatics specialists differ demographically from IT specialists, and the 2 groups also differ with respect to salary as well as their distribution across agencies of varying size. All groups identified unmet public health and informatics competency needs, particularly limited training necessary to fully utilize technology for their work. Moreover, all groups indicated a need for greater future emphasis on leveraging electronic health information for public health functions. CONCLUSIONS: Findings from the PH WINS establish a framework and baseline measurements that can be leveraged to routinely monitor and evaluate the ineludible expansion and maturation of the public health informatics workforce and can also support assessment of the growth and evolution of informatics training needs for the broader field. Ultimately, such routine evaluations have the potential to guide local and national informatics workforce development policy.

Effectiveness and cost of risperidone and olanzapine for schizophrenia: a systematic review.

Risperidone and olanzapine are novel antipsychotic medications that compete as first-line agents in treating patients with schizophrenia. The objective of this paper is to review the available evidence regarding the effectiveness and cost of risperidone versus olanzapine. We reviewed both randomised and peer-reviewed non-randomised head-to-head (olanzapine versus risperidone) studies in populations with schizophrenia. The studies were selected through a MEDLINE search. Risperidone and olanzapine provide control of positive, negative and global symptoms of schizophrenia. Each drug has a distinct adverse effect profile. Five randomised trials comparing risperidone with olanzapine suggested grossly similar efficacy in the first 2 months of treatment, with some results indicating advantages for olanzapine over the longer term. Only two of the trials included measures of service utilisation. One had 28-week follow-up, and the other followed patients for 12 months but had small sample sizes. Both experimental and naturalistic studies indicated that the acquisition cost of olanzapine is about 50% greater than for risperidone at dose levels commonly used for the treatment of schizophrenia. The only experiment with 12-month total treatment cost data found essentially equivalent costs for patients assigned to olanzapine or risperidone, showing that there are circumstances where total cost is similar in spite of the higher drug acquisition cost of olanzapine. Most retrospective studies also reported comparable total cost. Few studies gave enough information to evaluate cost effectiveness. The clear difference in acquisition cost of these two medications was rarely reflected in overall treatment cost in the studies we reviewed. Overall, our review of the literature highlights that there is inadequate evidence to distinguish the relative total cost of care associated with risperidone versus olanzapine, although accumulating evidence suggests the difference is small. This population-based conclusion does not indicate which medication is more costly or more cost effective for a particular patient; this depends on each patient's response to each medication.

Open access to innovative drugs: treatment substitutions or treatment expansion?

Granting open access to new antipsychotic medications by the California Medicaid Program fostered the desired substitution of second-generation medications for conventional antipsychotics. However, open access also generated an immediate but temporary influx of previously treated patients, many with a recent institutionalization, who restarted drug therapy using the new antipsychotics. Persistence with initial therapy declined, but cost outcomes improved due primarily to reduced nursing home use. Racial disparities were also reversed. Program administrators must use caution when evaluating the impact of unrestricted access on drug therapy outcomes and treatment costs given the changes in the characteristics of patients seeking treatment.

The impact of olanzapine, risperidone, or haloperidol on the cost of schizophrenia care in a medicaid population.

OBJECTIVE: The objective of this study was to assess the impact of medication treatment on Medicaid costs for persons with schizophrenia. METHODS: Michigan Medicaid claims from January 1995 through September 1998 were analyzed for persons with schizophrenia diagnoses who initiated olanzapine (n = 458), risperidone (n = 481), or haloperidol (n = 252) treatment between January 1996 and September 1997. Total and component Medicaid payments were compared for the year after treatment initiation, with simultaneous adjustment for patient demographics, comorbid conditions, prior medication use, prior service use, and prior year costs. RESULTS: Significant baseline differences existed between the groups in prior medication and service use. Adherence to index medication varied between the groups (O = 60%; R = 54%; H = 37%; P < =.01 for each pairwise comparison). Average postperiod costs were US dollars 14512 per subject. After baseline adjustment, there were no significant differences in mean total cost. Excluding index medication costs, the olanzapine group's average cost was significantly lower than risperidone (-US dollars 1791, P =.002) and haloperidol (-US dollars 2080, P =.003), whereas the risperidone and haloperidol groups were not significantly different. The differences were driven by significantly lower cost for inpatient services for other medications among the olanzapine group. CONCLUSION: Total costs of schizophrenia care associated with olanzapine, risperidone, or haloperidol were similar, but component costs differed. Relative to risperidone or haloperidol, olanzapine may have a higher acquisition cost, but may decrease inpatient costs and be associated with more optimal medication use patterns. Use of risperidone may also increase pharmacy costs and be associated with greater persistence, relative to haloperidol.

Ethnic differences in use of antipsychotic medication among Texas medicaid clients with schizophrenia.

BACKGROUND: Culture and ethnicity have been suggested to influence the presentation of patients with schizophrenia. These factors are thought to affect the diagnoses, courses of treatment, and medical utilization patterns of patients with schizophrenia. Specifically, the differences between whites, African Americans, and Mexican Americans are of particular importance, as these groups comprise the majority of the population in the United States today. The traditional course of treatment for many patients with schizophrenia is the drug haloperidol. However, research has shown that some ethnic groups (African Americans and Mexican Americans) may respond better to atypical drugs, such as olanzapine, but may be less likely to receive these drugs. A better response to the course of treatment results in improved medical utilization patterns. The purpose of this study was to examine if ethnicity helped predict whether Texas Medicaid patients were prescribed haloperidol versus olanzapine when other factors were controlled for. METHOD: The study population consisted of 726 patients whose index drug was haloperidol and 1875 patients whose index drug was olanzapine. Patients had an ICD-9-CM diagnosis of schizophrenia or schizoaffective disorder. Texas medical and prescription claims data were used in a logistic regression analysis to determine significant predictors of the type of antipsychotic (haloperidol vs. olanzapine) patients were prescribed. Variables included in the analysis were ethnicity, gender, age, region, other mental illness comorbidities, and previous utilization of medications and resources. Data were collected from Jan. 1, 1996, to Aug. 31, 1998. RESULTS: The results show that when other demographic and utilization factors were controlled for, African Americans were less likely than whites to receive olanzapine rather than haloperidol. CONCLUSION: Ethnicity is a significant predictor of the type of antipsychotic that is prescribed.

Estimating the costs and benefits of new drug therapies: atypical antipsychotic drugs for schizophrenia.

This article presents an analytic tool populated with data from published studies to illustrate the likely impacts of a switch from typical to atypical antipsychotic drugs over a 3-year period on individual, family, and societal outcomes for a U.S. schizophrenia population. Data taken from clinical trials and observational data studies are used. Changes in annual health care costs, schizophrenia symptom days, extrapyramidal symptom (EPS) days, suicide rates, and employment days are estimated. For each 1,000 people treated with typical drugs, the base case scenario gives estimates of annual medical care costs of dollar 28.9 million with 80,253 moderate/severe schizophrenia symptom days and 92,006 EPS days. In the base case scenario, after switching to atypical drugs, schizophrenia symptom days are estimated to decrease up to 33 percent, EPS days up to 50 percent, and total medical care costs up to 19 percent over the 3-year period. Suicide rates fall and employment rates increase. The direction of the impacts remain the same for a wide range of input parameter values used in sensitivity analyses. Thus, switching to atypical drugs will likely reduce total medical care costs and decrease other disease burdens for people with schizophrenia, their families, and society.