Use of Sequential Hot-Deck Imputation for Missing Health Care Systems Data for Population Health Research.

Electronic medical record (EMR) data present many opportunities for population health research. The use of EMR data for population risk models can be impeded by the high proportion of missingness in key patient variables. Common approaches like complete case analysis and multiple imputation may not be appropriate for some population health initiatives that require a single, complete analytic data set. In this study, we demonstrate a sequential hot-deck imputation (HDI) procedure to address missingness in a set of cardiometabolic measures in an EMR data set. We assessed the performance of sequential HDI within the individual variables and a commonly used composite risk score. A data set of cardiometabolic measures based on EMR data from 2 large urban hospitals was used to create a benchmark data set with simulated missingness. Sequential HDI was applied, and the resulting data were used to calculate atherosclerotic cardiovascular disease risk scores. The performance of the imputation approach was assessed using a set of metrics to evaluate the distribution and validity of the imputed data. Of the 567,841 patients, 65% had at least 1 missing cardiometabolic measure. Sequential HDI resulted in the distribution of variables and risk scores that reflected those in the simulated data while retaining correlation. When stratified by age and sex, risk scores were plausible and captured patterns expected in the general population. The use of sequential HDI was shown to be a suitable approach to multivariate missingness in EMR data. Sequential HDI could benefit population health research by providing a straightforward, computationally nonintensive approach to missing EMR data that results in a single analytic data set.

Identifying Racial and Ethnic Disparities in Acute Inpatient Rehabilitation.

OBJECTIVE: To investigate whether racial, ethnic, and linguistic disparities exist at discharge from an acute inpatient rehabilitation facility (IRF) by examining change in Functional Independence Measure (FIM) scores and discharge destination. DESIGN: This is a retrospective study using our IRF's data from the Uniform Data System for Medical Rehabilitation from 2013-2019. FIM scores and discharge destination were compared between race, language, and ethnic groups, with adjustment for patient characteristics. SETTING: An urban hospital with a level 1 trauma center, comprehensive stroke center, and IRF with Commission on Accreditation of Rehabilitation Facilities (CARF) certification. PARTICIPANTS: 2518 patients admitted to the IRF from 2013-2019 (N=2518). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in FIM score and discharge destination. RESULTS: After adjusting for covariates, non-White patients and patients with limited English proficiency had significantly lower functional recovery, as measured by smaller changes in FIM scores from IRF admission to discharge. Additionally, both groups were more likely to be discharged home with home health care than to a skilled nursing facility, compared with White and English-speaking patients. Disparities in discharge destination persisted within patients with noncommercial insurance (Medicaid or Medicare) and a stroke diagnosis but not within those who had commercial insurance or a nonstroke diagnosis. CONCLUSIONS: Racial and linguistic disparities were identified within our CARF certified IRF; however, the organization is committed to reducing health care disparities. Next steps will include investigating interventions to reduce disparities.

Improving Access to Yoga for Chronic Pain in a Spanish-Speaking Community: A Quality Improvement Initiative.

BACKGROUND: The recent increase in opioid misuse and overdose among the Hispanic population signifies the need for an initiative to increase efforts in pain management in the Hispanic population. Yoga is an evidence-based therapeutic intervention that is effective for several pain-associated disorders. However, in the United States, it is primarily taught in English and not always accessible. This quality improvement (QI) project aimed to assess the outcome of implementing a yoga program on pain and quality of life in the Hispanic population. METHODS: Twenty Spanish-speaking community center members participated in a linguistically-tailored yoga program over the course of 10 weeks that included educational, demonstration, and practice videos. Outcome measures of the QI program included changes in pain interference, physical function, opioid medication use, the overall impression of change in pain, satisfaction with the program, and the likelihood of continuation of yoga practice. RESULTS: Data collected from participants (n = 16) after the 10-week period indicated that nearly 60% experienced an improvement in their overall impression of change in pain; their reported likelihood of continuation of yoga practice at home or another location were 6.8 and 7.4, respectively, on a 10-point scale. While pain interference was unaffected, there was an improvement in markers of physical function, including a two-fold improvement in general activity without limitations. The mean average intensity of pain decreased by 33%. CONCLUSION: The use of a linguistically-tailored yoga program improved self-reported overall pain, physical function, average intensity of pain, and initiated an interest in participants in utilizing yoga practice for self-management of pain. This QI project provides results that can be used for further implementation initiatives at other sites and consideration of use in diverse populations.

An Electronic Teen Questionnaire, the eTeenQ, for Risk Behavior Screening During Adolescent Well Visits in an Integrated Health System: Development and Pilot Implementation.

Background: Screening for risk behaviors is a routine and essential component of adolescent preventive health visits. Early identification of risks can inform targeted counseling and care. If stored in discrete fields in the electronic health record (EHR), adolescent screening data can also be used to understand risk behaviors across a clinic or health system or to support quality improvement projects. Objective: Goals of this pilot study were to adapt and implement an existing paper adolescent risk behavior screening tool for use as an electronic data capture tool (the eTeenQ), to evaluate acceptance of the eTeenQ, and to describe the prevalence of the selected risk behaviors reported through the eTeenQ. Methods: The multidisciplinary project team applied an iterative process to develop the 29-item eTeenQ. Two unique data entry forms were created with attention to (1) user interface and user experience, (2) the need to maintain patient privacy, and (3) the potential to transmit and store data for future use in clinical care and research. Three primary care clinics within a large health system piloted the eTeenQ from August 17, 2020, to August 27, 2021. During preventive health visits for adolescents aged 12 to 18 years, the eTeenQ was completed on tablets and responses were converted to a provider display for teens and providers to review together. Responses to the eTeenQ were stored in a REDCap (Research Electronic Data Capture; Vanderbilt University) database, and for patients who agreed, responses were transferred to an EHR flowsheet. Responses to selected eTeenQ questions are reported for those consenting to research. At the conclusion of the pilot, the study team conducted semistructured interviews with providers and staff regarding their experience using the eTeenQ. Results: Among 2816 adolescents with well visits, 2098 (74.5%) completed the eTeenQ. Of these, 1811 (86.3%) agreed to store responses in the EHR. Of 1632 adolescents (77.8% of those completing the eTeenQ) who consented for research and remained eligible, 1472 (90.2%) reported having an adult they can really talk to and 1510 (92.5%) reported feeling safe in their community, yet 401 (24.6%) reported someone they lived with had a gun and 172 (10.5%) reported having had a stressful or scary event that still bothered them. In addition, 157 (9.6%) adolescents reported they were or wondered if they were gay, lesbian, bisexual, pansexual, asexual, or other, and 43 (2.6%) reported they were or wondered if they were transgender or gender diverse. Of 11 staff and 7 providers completing interviews, all felt that the eTeenQ improved confidentiality and willingness among adolescents to answer sensitive questions. All 7 providers preferred the eTeenQ over the paper screening tool. Conclusions: Electronic capture of adolescent risk behaviors is feasible in a busy clinic setting and well accepted among staff and clinicians. Most adolescents agreed for their responses to risk behavior screening to be stored in the EHR.

Colchicine and/or Naltrexone for Hospitalized COVID-19 Patients Not Requiring High Levels of Ventilatory Support (COLTREXONE): A Prospective, Randomized, Open-Label Trial.

We assessed the efficacy and safety of colchicine and low-dose naltrexone (LDN), alone and in combination, in preventing progression to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this prospective, randomized, open-label trial, colchicine and LDN were compared to standard of care (SOC) in patients hospitalized with SARS-CoV-2 not requiring high levels of ventilatory support. Patients were randomly assigned to colchicine alone, LDN alone, colchicine/LDN in combination, or SOC. The primary outcome was time to disease recovery. Secondary outcomes included total time hospitalized, study enrollment, level of care, oxygen support, and adverse events.  One-hundred and thirty-seven patients were randomized (Nc = 34, Nc+ldn = 33, Nldn = 35, Nsoc = 35). Eighty-four patients (61%) achieved disease recovery by day 5. There was no significant difference in the proportion of patients who experienced the primary efficacy outcome among those who received colchicine, LDN, or between the four study arms.Patients receiving colchicine had a shorter length of enrollment but not a significant reduction in the length of stay. Diarrhea was the most common adverse reaction. In adults hospitalized with SARS-CoV-2 not requiring high-level ventilatory support, colchicine and LDN, alone and in combination, were not associated with significant reductions in progression to severe disease.

Factors Associated With Increased Health Care Utilization for Patients With Dementia With Lewy Bodies: A Narrative Review.

Numerous studies have demonstrated that dementia is associated with increased utilization of health care services, which in turn results in increased costs of care. Dementia with Lewy bodies (DLB) is associated with greater costs of care relative to other forms of dementia due to higher rates of hospitalization and nursing home placement directly related to neuropsychiatric symptoms, parkinsonism, increased susceptibility to delirium, and elevated rates of caregiver burden. There is a critical need for researchers to identify potentially modifiable factors contributing to increased costs of care and poor clinical outcomes for patients with DLB, which may include comorbidities, polypharmacy/contraindicated medications, and access to specialty care. Previous research has utilized Medicare claims data, limiting the ability to study patients with early-onset (ie, prior to age 65) DLB. Integrated health systems offer the ability to combine electronic medical record data with Medicare, Medicaid, and commercial claims data and may therefore be ideal for utilization research in this population. The goals of this narrative review are to 1) synthesize and describe the current literature on health care utilization studies for patients with DLB, 2) highlight the current gaps in the literature, and 3) provide recommendations for stakeholders, including researchers, health systems, and policymakers. It is important to improve current understanding of potentially modifiable factors associated with increased costs of care among patients with DLB to inform public health policies and clinical decision-making, as this will ultimately improve the quality of patient care.

COVID-19 vaccine uptake among non-US-born populations in the United States, 2020-2022.

BACKGROUND: In the United States (US), COVID-19 vaccination rates among non-US-born individuals (i.e., refugees, immigrants, and migrants [RIM]) are variable. Understanding baseline COVID-19 vaccine coverage among these populations and determining if disparities exist is essential for quality improvement initiatives and public health interventions. METHODS: Baseline COVID-19 vaccination rates for both primary series and booster doses were calculated at four health systems located in Minnesota, Colorado, and Pennsylvania participating in the Minnesota Department of Health's Center of Excellence in Newcomer Health. Patients aged ≥5 years as of 1/1/22, seen for ≥1 primary care visit during 7/1/2019-6/30/22 were included. Descriptive statistics were calculated for three measures of COVID-19 vaccine coverage during 12/14/2020-6/30/2022: 1) initiation of primary series; 2) completion of primary series; 3) completion of first booster. We calculated vaccine coverage rates for the entire population and stratified by subgroup including country of origin, refugee status, and primary language preference. RESULTS: We included 1,624,573 patients eligible for COVID-19 primary series vaccine and 907,749 eligible for COVID-19 booster vaccination. The percent of eligible patients who completed a COVID-19 primary series (63.4 %) and booster dose (66.2 %) were similar. Completion of the primary series was higher for non-US-born persons (72.7 %) compared with US born persons (65.4 %), similar among refugees (63.5 %) and non-refugees (63.4 %), and lower in patients with language preference other than English (62.7 %) compared with English preferring patients (63.6 %). Booster completion was lower for non-US-born persons (61.8 %), refugees (46.7 %), and patients with language preference other than English (55.3 %) compared with US-born (70 %), non-refugees (66.3 %), and English preferring patients (67.3 %) respectively. CONCLUSIONS: This evaluation identified disparities in COVID-19 vaccination rates among non-US-born persons and persons with a language preference other than English living in the US. Targeted outreach efforts may be beneficial in reaching these populations.