Electronic Health Records Versus Survey Small Area Estimates for Public Health Surveillance.

INTRODUCTION: Electronic health records (EHRs) are increasingly being leveraged for public health surveillance. EHR-based small area estimates (SAEs) are often validated by comparison to survey data such as the Behavioral Risk Factor Surveillance System (BRFSS). However, survey and EHR-based SAEs are expected to differ. In this cross-sectional study, SAEs were generated using MDPHnet, a distributed EHR-based surveillance network, for all Massachusetts municipalities and zip code tabulation areas (ZCTAs), compared to BRFSS PLACES SAEs, and reasons for differences explored. METHODS: This study delineated reasons a priori for how SAEs derived using EHRs may differ from surveys by comparing each strategy's case classification criteria and reviewing the literature. Hypertension, diabetes, obesity, asthma, and smoking EHR-based SAEs for 2021 in all ZCTAs and municipalities in Massachusetts were estimated with Bayesian mixed effects modeling and poststratification in the summer/fall of 2023. These SAEs were compared to BRFSS PLACES SAEs published by the U.S. Centers for Disease Control and Prevention. RESULTS: Mean prevalence was higher in EHR data versus BRFSS in both municipalities and ZCTAs for all outcomes except asthma. ZCTA and municipal symmetric mean absolute percentages ranged from 12.0 to 38.2% and 13.1 to 39.8%, respectively. There was greater variability in EHR-based SAEs versus BRFSS PLACES in both municipalities and ZCTAs. CONCLUSIONS: EHR-based SAEs tended to be higher than BRFSS and more variable. Possible explanations include detection of undiagnosed cases and over-classification using EHR data, and under-reporting within BRFSS. Both EHR and survey-based surveillance have strengths and limitations that should inform their preferred uses in public health surveillance.

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care.

Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Emergency Medical Services Prenotification is Associated with Reduced Odds of In-Hospital Mortality in Stroke Patients.

OBJECTIVE: Arrival by emergency medical services (EMS) and prenotification among ischemic stroke patients are well-established to improve the timeliness and quality of stroke care, yet the association of prenotification with in-hospital mortality has not been previously described. Our cross-sectional study aimed to assess the association between EMS prenotification and in-hospital mortality for patients with acute ischemic stroke or transient ischemic attack. METHODS: We analyzed data from the Massachusetts Paul Coverdell National Acute Stroke Program registry. Our study population included adult patients presenting by EMS with transient ischemic attack or acute ischemic stroke from non-health care settings between 2016 and 2020. We excluded patients who were comfort measures only on arrival or day after arrival. We used generalized estimating equations to assess the association between prenotification and in-hospital stroke mortality. RESULTS: In the adjusted model, prenotification was associated with lower odds of in-hospital mortality (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.76-0.98). Other variables associated with in-hospital mortality were longer door-to-imaging interval (OR 1.03, 95% CI 1.03-1.04) and year of presentation (OR 0.91 for each year, 95% CI 0.88-0.93). Odds of in-hospital mortality also varied by insurance, race, and ethnicity. CONCLUSIONS: Prenotification by EMS was associated with reduced in-hospital mortality for patients with ischemic stroke and transient ischemic attack. These findings add to the large body of literature demonstrating the key role of EMS in the stroke systems of care. Our study underscores the importance of standardizing prehospital screening and triage, increasing rates of prenotification via feedback and education, and encouraging active collaborations between prehospital personnel and stroke-capable hospitals to increase in-hospital survival among patients with stroke and transient ischemic attack.

Influence of Hospital Characteristics on Hospital Transfer Destinations for Patients With Stroke.

BACKGROUND: Patients with stroke are frequently transferred between hospitals. This may have implications on the quality of care received by patients; however, it is not well understood how the characteristics of sending and receiving hospitals affect the likelihood of a transfer event. Our objective was to identify hospital characteristics associated with sending and receiving patients with stroke. METHODS: Using a comprehensive statewide administrative dataset, including all 78 Massachusetts hospitals, we identified all transfers of patients with ischemic stroke between October 2007 and September 2015 for this observational study. Hospital variables included reputation (US News and World Report ranking), capability (stroke center status, annual stroke volume, and trauma center designation), and institutional affiliation. We included network variables to control for the structure of hospital-to-hospital transfers. We used relational event modeling to account for complex temporal and relational dependencies associated with transfers. This method decomposes a series of patient transfers into a sequence of decisions characterized by transfer initiations and destinations, modeling them using a discrete-choice framework. RESULTS: Among 73 114 ischemic stroke admissions there were 7189 (9.8%) transfers during the study period. After accounting for travel time between hospitals and structural network characteristics, factors associated with increased likelihood of being a receiving hospital (in descending order of relative effect size) included shared hospital affiliation (5.8× higher), teaching hospital status (4.2× higher), stroke center status (4.3× and 3.8× higher when of the same or higher status), and hospitals of the same or higher reputational ranking (1.5× higher). CONCLUSIONS: After accounting for distance and structural network characteristics, in descending order of importance, shared hospital affiliation, hospital capabilities, and hospital reputation were important factor in determining transfer destination of patients with stroke. This study provides a starting point for future research exploring how relational coordination between hospitals may ensure optimized allocation of patients with stroke for maximal patient benefit.

The COVID-19 Pandemic and Access to Selected Ambulatory Care Services Among Populations With Severely Uncontrolled Diabetes and Hypertension in Massachusetts.

OBJECTIVES: The outbreak of COVID-19 in Massachusetts may have reduced ambulatory care access. Our study aimed to quantify this impact among populations with severely uncontrolled diabetes and hypertension; these populations are at greatest risk for adverse outcomes caused by disruptions in care. METHODS: We analyzed multidisciplinary ambulatory electronic health record data from MDPHnet. We established 3 cohorts of patients with severely uncontrolled diabetes and 3 cohorts of patients with severely uncontrolled hypertension using 2017, 2018, and 2019 data, then followed each cohort through the subsequent 15 months. For the diabetes cohorts, we generated quarterly counts of glycated hemoglobin A1c (HbA1c) tests. For the hypertension cohorts, we generated monthly counts of blood pressure measurements. Finally, we assessed telehealth use among the 2019 diabetes and hypertension cohorts from January 2020 through March 2021. RESULTS: HbA1c testing and blood pressure monitoring dropped considerably during the pandemic compared with previous years. In the 2019 diabetes cohort, HbA1c measurements declined from 44.0% in January-March 2020 (baseline) to 15.9% in April-June 2020 and was 11.8 percentage points below baseline in January-March 2021. In the 2019 hypertension cohort, blood pressure measurements declined from 40.0% in January 2020 to 4.5% in April 2020 and was 23.5 percentage points below baseline in March 2021. Telehealth use increased precipitously during the pandemic but was not uniform across subpopulations. CONCLUSIONS: Access to selected diabetes and hypertension services declined sharply during the pandemic among populations with severely uncontrolled disease. Although telehealth is an important strategy, ensuring equity in access is essential. Telehealth hybrid models can also minimize disruptions in care.

Integration of Regional Hospitalizations, Registry and Vital Statistics Data for Development of a Single Statewide Ischemic Stroke Database.

OBJECTIVE: Administrative databases seldom include detailed clinical variables and vital status, limiting the scope of population-based studies. We demonstrate a comprehensive process for integrating 3 databases (all-payor inpatient hospitalizations, clinical acute stroke registry and vital statistics) into a single statewide ischemic stroke database. MATERIALS AND METHODS: The 3 Massachusetts databases spanned 2007-2017. Our integration process was composed of 3 phases: 1) hospitalizations-registry linkage, 2) hospitalizations-vital linkage, and 3) final integration of all 3 databases. Following data uniqueness assessment, rule-based deterministic linkage on indirect identifiers were applied in the first two phases. We validated the linkages by comparing additional patient variables not used in the linkage process in the absence of a gold standard database crosswalk. RESULTS: During the overlapping period from 1/1/2008 to 9/30/2015, there were 47,713 stroke admissions in the hospitalizations database and 43,487 admissions in the registry. We linked 38,493 (80.7%) of cases, 95% of which were validated. There were 391,176 deaths reported in Massachusetts between 1/1/2010 and 3/6/2017 in the vital database. Of the 38,493 encounters in the hospitalizations-registry linked data, 10,660 (27.7%) were linked to deaths, reflecting the cumulative mortality over the 7-year period among all registry-linked ischemic stroke hospitalization records. CONCLUSION: We demonstrate that a high-quality integration of the statewide hospitalizations, clinical registry, and vital statistics databases is achievable leveraging indirect identifiers. This data integration framework takes advantage of rich clinical data in registries and long term outcomes from hospitalizations and vital records and may have value for larger scale outcomes research.

Evaluating the impact of community health worker certification in Massachusetts: Design, methods, and anticipated results of the Massachusetts community health worker workforce survey.

Background: Professional certification of community health workers (CHWs) is a debated topic. Although intended to promote CHWs, certification may have unintended impacts given the grassroots nature of the workforce. As such, both intended effects and unintended adverse effects should be carefully evaluated. However, there is a lack of published literature describing such effective evaluations with a robust methodology. In this methods paper, we describe a key component of evaluating CHW certification in Massachusetts-the Massachusetts CHW Workforce Survey. Methods: Design of the surveys was informed by a program theory framework that delineated both positive and negative potential impacts of Massachusetts CHW certification on CHWs and CHW employers. Using this framework, we developed measures of interest and preliminary CHW and CHW employer surveys. To validate and refine the surveys, we conducted cognitive interviews with CHWs and CHW employers. We then finalized survey tools with input from state and national stakeholders, CHWs, and CHW employers. Our sample consisted of three frames based on where CHWs are most likely to be employed in Massachusetts: acute care hospitals, community-based organizations, and ambulatory care health centers, primarily community health centers and federally qualified health centers. We then undertook extensive outreach efforts to determine whether each organization employed CHWs and to obtain CHW and CHW employer contact information. Our statistical analysis of the data utilized inverse probability score weighting accounting for organizational, site, and individual response. Anticipated results: Wave one of the survey was administered in 2016 prior to launch of Massachusetts CHW certification and wave two in 2021. We report descriptive statistics of the three sample frames and response rates of each survey for each wave. Further, we describe select anticipated results related to certification, including outcomes of the program theory framework. Conclusions: The Massachusetts CHW Workforce Survey is the culmination of 5 years of effort to evaluate the impact of CHW certification in Massachusetts. Our comprehensive description of our methodology addresses an important gap in CHW research literature. The rigorous design, administration, and analysis of our surveys ensure our findings are robust, valid, and replicable, which can be leveraged by others evaluating the CHW workforce.

Waiting list eradication in secondary care psychology: Addressing a National Health Service blind spot.

OBJECTIVES: Waiting times for secondary care psychological therapy remain a 'blind spot' in serious mental illness (SMI) provision, and their reduction is a priority within the National Health Service (NHS) Five Year Forward View. The paper describes the eradication of waiting times within a community-based NHS service and the effectiveness of strategies whilst examining help-seeking behaviour, compliance and therapeutic need. METHODS: Analyses are reported for treatment compliance and therapeutic outcomes for 208 waiting-list cohort individuals seen by the SMI psychology service over an 18-month period between October 2014 and March 2016. RESULTS: No significant clinical or demographic differentiation between individuals who successfully completed therapy compared to those who disengaged was observed. Despite an average 2.20-year waiting time, this alone did not significantly impact engagement with psychological treatment and all psychological therapies provided led to a significant clinical improvement and no individuals who completed therapy required re-referral at 12-month follow-up. CONCLUSIONS: If imposed appropriately over a suitable time frame evidence-based practice coupled with effective operationalization can result in efficient needs-led psychological provision within SMI and secondary care. Potentially debilitating waiting times for service users and other referring professionals can be avoided, whilst psychology provision retains a flexible, formulation-based and person-centred approach.

RiskScape: A Data Visualization and Aggregation Platform for Public Health Surveillance Using Routine Electronic Health Record Data.

Automated analysis of electronic health record (EHR) data is a complementary tool for public health surveillance. Analyzing and presenting these data, however, demands new methods of data communication optimized to the detail, flexibility, and timeliness of EHR data.RiskScape is an open-source, interactive, Web-based, user-friendly data aggregation and visualization platform for public health surveillance using EHR data. RiskScape displays near-real-time surveillance data and enables clinical practices and health departments to review, analyze, map, and trend aggregate data on chronic conditions and infectious diseases. Data presentations include heat maps of prevalence by zip code, time series with statistics for trends, and care cascades for conditions such as HIV and HCV. The platform's flexibility enables it to be modified to incorporate new conditions quickly-such as COVID-19.The Massachusetts Department of Public Health (MDPH) uses RiskScape to monitor conditions of interest using data that are updated monthly from clinical practice groups that cover approximately 20% of the state population. RiskScape serves an essential role in demonstrating need and burden for MDPH's applications for funding, particularly through the identification of inequitably burdened populations.

The Association between Presentation by EMS and EMS Prenotification with Receipt of Intravenous Tissue-Type Plasminogen Activator in a State Implementing Stroke Systems of Care.

Introduction: Collaboration between emergency medical services (EMS) and hospitals receiving stroke patients is critical to ensure prompt, effective treatment, and is a key component of the stroke systems of care (SSoC). The goal of our study was to evaluate the association between presentation by EMS and EMS prenotification with odds of receiving Tissue-type Plasminogen Activator (IV-tPA) in a state implementing SSoC while rigorously accounting for missing data. Methods: We utilized data from the Massachusetts Paul Coverdell Stroke Registry for this study, and analyzed adult patients presenting with ischemic stroke to Massachusetts Coverdell hospitals between 2016 and 2018. Patients with contraindications to IV-tPA were excluded. We used generalized estimating equations to assess associations between presentation by EMS, EMS prenotification, and receipt of IV-tPA. We also performed a sensitivity analysis using multiple imputation to assess the sensitivity of our findings to missing data. Results: We identified 9,230 eligible patients with ischemic stroke during the study period. In multivariate complete case regressions, presentation by EMS and EMS prenotification were associated with statistically significant increased odds of receiving IV-tPA (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.28-1.80, p-value < 0.01; OR 1.75, 95% CI 1.36-2.24, p-value < 0.01, respectively). Analysis of imputed data indicated level or stronger associations. Conlcusion: Our analysis indicates that presentation by EMS and EMS prenotification are associated with increased odds of receiving IV-tPA in a state implementing the SSoC. Our results lend importance to the critical role of EMS in the SSoC. Future interventions should work to increase rates of prenotification by EMS and assess inequities in receipt of IV-tPA.

Concordance Between Common Hypertension Control Algorithms in Electronic Medical Record Data.

Because quality improvement metrics and treatment guidelines are used to conduct research, evaluate care quality, and assess population health, they should, ideally, align. We used electronic medical record data to analyze variation between blood pressure control estimates calculated by using thresholds derived from National Quality Forum 0018 (NQF 0018) and Joint National Committee (JNC) treatment guidelines in a cohort of patients with hypertension. Percentage of patients with controlled blood pressure derived from each quality improvement or treatment guideline cutoff varied up to 16.1 percentage points. This variance demonstrates that discrepancies in blood pressure thresholds produce considerable variation in estimates; thus, treatment guidance and metrics should be selected carefully.

Lactate clearance as a predictor of mortality in trauma patients.

BACKGROUND: Initial serum lactate has been associated with mortality in trauma patients. It is not known if lactate clearance is predictive of death in a broad cohort of trauma patients. METHODS: We enrolled 4,742 trauma patients who had an initial lactate measured during a 10-year period. Patients were identified via the trauma registry. Lactate clearance was calculated at 6 hours. Multivariable logistic regression was used to identify the independent contribution of both initial lactate and lactate clearance with mortality, after adjustment for severity of injury. RESULTS: Initial lactate level was strongly correlated with mortality: when lactate was less than 2.5 mg/dL, 5.4% (95% confidence interval [CI], 4.5-6.2%) of patients died; with lactate 2.5 mg/dL to 4.0 mg/dL, mortality was 6.4% (95% CI, 5.1-7.8%); with lactate 4.0 mg/dL or greater, mortality was 18.8% (95% CI, 15.7-21.9%). After adjustment for age, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, heart rate, and blood pressure, initial lactate remained independently associated with increased mortality, with adjusted odds ratios of 1.0, 1.5 (95% CI, 1.1-2.0) and 3.8 (95% CI, 2.8-5.3), for lactate less than 2.5 mg/dL, 2.5 mg/dL to 4.0 mg/dL, and 4.0 mg/dL or greater, respectively. Among patients with an initially elevated lactate (≥4.0 mg/dL), lower lactate clearance at 6 hours strongly and independently predicted an increased risk of death. For lactate clearances of 60% or greater, 30% to 59%, and less than 30%, the adjusted odds ratio for death were 1.0, 3.5 (95% CI 1.2-10.4), and 4.3 (95% CI, 1.5-12.6), respectively. CONCLUSION: Both initial lactate and lactate clearance at 6 hours independently predict death in trauma patients. LEVEL OF EVIDENCE: Prognostic study, level III.