Small area estimation and childhood obesity surveillance using electronic health records.

There is an urgent need for childhood surveillance systems to design, implement, and evaluate interventions at the local level. We estimated obesity prevalence for individuals aged 5-17 years using a southcentral Wisconsin EHR data repository, Public Health Information Exchange (PHINEX, 2007-2012). The prevalence estimates were calculated by aggregating the estimated probability of each individual being obese, which was obtained via a generalized linear mixed model. We incorporated the random effects at the area level into our model. A weighted procedure was employed to account for missingness in EHR data. A non-parametric kernel smoothing method was used to obtain the prevalence estimates for locations with no or little data (<20 individuals) from the EHR. These estimates were compared to results from newly available obesity atlas (2015-2016) developed from various EHRs with greater statewide representation. The mean of the zip code level obesity prevalence estimates for males and females aged 5-17 years is 16.2% (SD 2.72%); 17.9% (SD 2.14%) for males and 14.4% (SD 2.00%) for females. The results were comparable to the Wisconsin Health Atlas (WHA) estimates, a much larger dataset of local community EHRs in Wisconsin. On average, prevalence estimates were 2.12% lower in this process than the WHA estimates, with lower estimation occurring more frequently for zip codes without data in PHINEX. Using this approach, we can obtain estimates for local areas that lack EHRs data. Generally, lower prevalence estimates were produced for those locations not represented in the PHINEX database when compared to WHA estimates. This underscores the need to ensure that the reference EHRs database can be made sufficiently similar to the geographic areas where synthetic estimates are being created.

Resource Utilization Among Portal Users Who Send Messages: A Retrospective Cohort Study.

PURPOSE: To examine the association between patients' use of online health portal-based secure messaging and the likelihood of traditional encounters (office visits and telephone calls) and to identify patient characteristics associated with use of the messaging feature of health portals. METHODS: This retrospective cohort study used EHR data from 80,801 patients aged 18 and older to determine traditional encounter rates among portal users who sent at least 1 message compared to those who sent none. Association between the number of messages sent and number of traditional encounters, while accounting for other covariates (including number of traditional encounters the year before account activation and other patient characteristics) was examined using a hurdle negative-binomial (NB) model. RESULTS: In the year after their portal account activation, 22,789 (28%) patients sent at least 1 message (median = 3, mean = 5.38). Patients who sent messages were more likely to be female (63.9% vs 58.0%, P <0.001), white (92.2% vs 90.0%, P <0.001), and have depression (27.0% vs 24.2%, P <0.001) than those who sent none. We observed a positive association between sending messages and number of traditional encounters. Patients who sent messages were more likely to have a traditional encounter and have more traditional encounters in the year after account activation than those who sent none (mean 17.6 vs 11.4, P <0.001); they also had more in-person office visits (7.6 vs 5.0, P <0.001) and telephone calls (9.9 vs 6.4, P <0.001)) when examined separately. CONCLUSIONS: Our study adds to the growing literature that EHR messaging is associated with increased traditional resource utilization. This has the potential to add to workload while diminishing productivity and increasing the risk of staff and physician burnout. Health systems should prepare for the increased visits and calls expected as more patients use secure messaging.

Effectiveness of a Best Practice Alerts at Improving Hypertension Control.

BACKGROUND: Inadequately treated hypertension (HTN) leads to considerable morbidity and mortality. Despite many treatment options, blood pressure (BP) control is suboptimal. Missed opportunities due to the growing complexity of primary care office visits contribute. Electronic health records (EHRs) offer best practice alerts (BPA) tools to support clinicians in identifying poor BP control. BPAs have demonstrated effectiveness for other health outcomes. METHODS: EHR data were collected for patients ≥18 years old seen for primary care office visits prior to, during, and after the BPA active period and used to identify patients for whom the BPA fired or would have fired during control periods. Logistic regression examined the association of BPA activation with follow-up BP check within 14-90 days and with BP control at follow-up, controlling for demographics and health conditions. RESULTS: The BPA active period was associated with reduced patient follow-up; however, a number of covariates were predictive of increased follow-up: Black non-Hispanics, Hispanics, patients on the chronic kidney disease, HTN, or diabetes registries, as well as the morbidly obese, insurance status, and seasonal factors. For those who did follow-up, BPA activation was associated with improved BP control. CONCLUSIONS: BPA activation was associated with worse patient follow-up but improved BP control. Some subgroups had significantly different rates of follow-up and BP control. This study did not have an experimental design as the BPA was a quality improvement initiative. These results highlight the critical importance of planning experimentally designed organizational initiatives to fully understand their impact.

Screening Pediatric Patients for Food Insecurity: A Retrospective Cross-Sectional Study of Comorbidities and Demographic Characteristics.

BACKGROUND: Food insecurity is a household-level economic and social condition of limited or uncertain access to adequate and nutritional food that is associated with diabetes, obesity, anxiety, depression, and behavioral disorders. The presence of these comorbidities motivated the UW Health Pediatrics Department to start screening for food insecurity. METHODS: Our study describes demographic characteristics of screened patients, comparing risk factors and health status between food insecure patients and food secure patients. We extracted variables on all screened patients: sex, age, race, ethnicity, insurance type, height, weight (to calculate body mass index [BMI] and BMI percentile), and any diagnosis of diabetes, hypertension, sleeping problems, restless leg syndrome, anemia, elevated blood lead levels, depression, anxiety, or attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD). RESULTS: Over the 8-month screening period, 1,330 patients were screened for food insecurity, and 30 screened positive. Insurance type was a significant predictor for food insecurity; patients on public or with no insurance had 6.39 times greater odds of being food insecure than those on private insurance (CI 3.81, 13.29). Also, diagnoses of anemia and ADD/ADHD were both significantly higher in the food insecure group. The odds of having anemia was 8.47 times greater for food insecure patients (CI 3.03, 23.63), and the odds for having ADD/ADHD was 5.89 times greater for food insecure patients than food secure patients (CI 1.48, 23.55). DISCUSSION: These results provide useful information to clinicians as the screening process moves toward widespread adoption. These results also provide a baseline for expanded research once screening is implemented throughout all pediatric clinics within our health care organization.

Linking childhood cancer with potential environmental exposure determinants.

Childhood chronic diseases, especially cancer, are of growing concern. Research has focused on 2 developmental periods, prenatal and postnatal. While it is hypothesized that chemical contaminants in the physical environment may play a role in the development and exacerbation of many chronic diseases, the role of environmental exposures in the etiology of these conditions remains uncertain. This can be somewhat attributed to the fact that it is very difficult to efficiently link chronic health effects with environmental exposures that are likely to have occurred temporally and spatially distant from diagnosis. This study explored the utility of linking childhood cancer cases with their birth certificate data as a method for increasing the number of geo-referenced data points available for linking health effect data with environmental monitoring data. This would begin to quantify the transiency of 1 subset of the population, and provide a basis for characterizing and estimating potentials for exposure to numerous environmental contaminants during prenatal and postnatal periods. A total of 441 unduplicated cancer diagnosis records of children who were both born and diagnosed with cancer in Wisconsin between 1995 and 2002 were linked with birth records to explore the variability between address at birth and diagnosis. The majority of records were matched to a birth record file (81.0%). Of these matched records, 86% moved <1 mile from birth to time of diagnosis. The results suggest that administrative and public health surveillance data can be used to quantify transiency. Data from the sample tested indicate that during the given time period children do not move far from their birth homes, suggesting minimal changes in exposure potential related to residence location from birth to diagnosis. This background is useful for future epidemiological investigations linking environmental factors with chronic health effects.