more information © 2015 denver public health tobacco metrics: the power of electronic health...

© 2015 Denver Public Health

Tobacco Metrics: the Power of Electronic Health Records

Theresa Mickiewicz, MSPH

Public Health in the RockiesSeptember 16, 2015


Dr. Bill Burman, MD: Director of Denver Public Health

Dr. Arthur Davidson, MD: Director of Public Health Informatics,

Epidemiology and Preparedness

Emily McCormick, MPH: Epidemiologist

Tracey Richers-Maruyama: Tobacco Program Manager

Denver Public Health Colleagues


“The truth is rarely pure and never simple.”Oscar Wilde

The Truth


Objective

Describe how electronic health record (EHR) data can be a powerful complement to traditional surveillance sources in program evaluation.


Background

Tobacco control and prevention are critical public health functions• Many interventions are applied at the local level• Need timely, specific data for evaluation• More data today than yesterday and data are more

readily available• Meaningful use through the HITECH Act (2009)


Methods

Compare three datasets:• Trends• Timeliness• Representativeness• Granularity• Reliability


Behavioral Risk Factor Surveillance System (BRFSS)

• Used to monitor health behaviors among adults• A primary data source• A survey administered via telephone• Anonymous• Self-report• Weighted to represent Colorado, some regional areas• A way to compare estimates and trends in health

behaviors across states and the US


Colorado Health Observation Regional Data Service (CHORDS) • A collaborative regional pilot project that uses EHR

data to monitor public health trends• A secondary data source• Clinical data from multiple partners transformed into

standardized metrics• De-identified but not necessarily de-duplicated• Representative of residents who seek health care• A way to compare health behaviors and outcomes

across and within regional areas in Colorado


Cigarette Consumption

• Cigarette taxes paid (at the wholesale level)• Colorado-level data• Very sensitive to events• Short lag time for availability of monthly

estimates


Trends

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

10

20

30

0

10

20

30

40

50

60

70

2119.7

20.3

17.7

20.8 20.7 20.6

17.2

15.814.9

13.912.7

Smoking Rates among Denver Adults (by Data Source) and Cigarette Consumption in Colorado

BRFSS landlineBRFSS: Cell AddedCHORDSPacks/capita

Year

% S

mok

ing

Rate

Num

ber o

f Cig

arett

e Pa

cks S

old/

Capi

ta

2006: Colorado Clean Indoor Air Act

2004: Cigarette tax increases $0.60

Amendment 35 Funds Available


TimelinessFrequency of available estimates:• BRFSS: Annually or every other year if sample sizes

are too small for annual• CHORDS: Monthly with the potential for more • Consumption: Monthly, semi-annual, annual

Lag-time for estimates• BRFSS: 6 months after the end of the year (June)• CHORDS: Monthly with potential for near real-time• Consumption: about 2 months


Representativeness• BRFSS is designed to represent the population of interest

but is limited in cases of small geographies/sub-strata analyses

• CHORDS represents those who seek health care but may over-count individuals

• CHORDS includes all ages whereas BRFSS includes adults.• In most cases, CHORDS metrics are derived from clinical

data and BRFSS are self-report• Consumption data represents those who smoke cigarettes

but excludes other types of tobacco and does not capture cigarettes procured over the internet, on the black market or in another state


Representativeness

Demographic Distributions Among Denver Adults, 2014: Comparing CHORDS and BRFSS to the US Census

US Census BRFSS CHORDS*

N % n % n %

Overall Adults (18+) 514,308 100% 1,291 100% 232,214 100%

Gender

Females 257,788 50% 697 48% 147,912 64%

Males 256,520 50% 594 52% 84,302 36%

*includes unique individuals with a 2014 primary care visit where tobacco screening occurred


Granularity

At a geographic level:• BRFSS:– State/US– Health Statistic Region– Large County level

• CHORDS:– Regional or County level– Council District– Neighborhood or census tract

• Consumption:– State level


Granularity


Granularity

Prevalence of Smoking by Demographic Strata Among Denver Adults: 2014

BRFSS CHORDS*

n % 95% CI n % 95% CIOverall Adults (18 +) 1142 17.2% 14.5%-19.9% 232,214 12.7% 12.5%-12.8%Race/Ethnicity

Black 108 29.3% 13.8%-33.3% 17,311 23.0% 22.4%-23.6%Hispanic 258 16.2% 13.8%-24.8% 46,942 14.4% 14.1%-14.8%

Other 48 * * 25,483 11.1% 10.7%-11.4%White 699 22.0% 11.0%-17.5% 142,478 11.1% 11.0%-11.3%


Reliability

non-Hispanic Black Hispanic non-Hispanic Black HispanicBRFSS CHORDS

0%

5%

10%

15%

20%

25%

30%

35%

Smoking Prevalence Among Hispanic and non-Hispanic Denver Adults, by Data Source: 2014


Conclusions

• For evaluation of local level programming, EHR data:– Are more sensitive to programmatic activities– Are more timely– Allow for sub-strata analyses – Are less representative of the entire population

• In the era of the HITECH Act and meaningful use, the time is right to pursue public health/clinical partnerships


Discussion

How could EHR data advance and enhance your programmatic activities?


CHORDS AppendixRegistry Topic area Example health questions that CHORDS can track Example of relevant data fields

Obesity •What percent of adults are at a healthy weight? •What percent of children are at a healthy weight?

•Height•Weight•Body Mass Index (BMI)

Tobacco Use and Exposure

•What percent of adults are screened for tobacco use?•What percent of adults use tobacco?•What percent of children are screened for exposure to secondhand tobacco smoke?•What percent of children are exposed to secondhand tobacco smoke?

•Tobacco use•Secondhand tobacco smoke exposure

Cardiovascular Disease

•What percent of adults are screened for high blood pressure (known as hypertension)?•What percent of adults have been diagnosed with high blood pressure (known as hypertension)?•What percent of adults are screened for high cholesterol?•What percent of adults have been diagnosed with high cholesterol?

•Blood pressure levels•Diagnosis of hypertension•Cholesterol test results•Diagnosis of high cholesterol

Future: Mental Health•What percent of adults have been diagnosed with depression?•What percent of adolescents have been diagnosed with depression?

•Diagnosis of depression

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