Diagnostic code agreement for electronic health records and claims data for tuberculosis.

OBJECTIVE: To measure the frequency of diseases related to latent tuberculosis infection (LTBI) and tuberculosis (TB), we assessed the agreement between diagnosis codes for TB or LTBI in electronic health records (EHRs) and insurance claims for the same person.METHODS: In a US population-based, retrospective cohort study, we matched TB-related Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) EHR codes and International Statistical Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) claims codes. Furthermore, LTBI was identified using a published ICD-based algorithm and all LTBI- and TB-related SNOMED CT codes.RESULTS: Of people with the 10 most frequent TB-related claim codes, 50% did not have an exact-matched EHR code. Positive tuberculin skin test was the most frequent unmatched EHR code and people with the 10 most frequent TB EHR codes, 40% did not have an exact-matched claim code. The most frequent unmatched claim code was TB screening encounter. EHR codes for LTBI matched to claims codes for TB testing; pulmonary TB; and nonspecific, positive or adverse tuberculin reaction.CONCLUSION: TB-related EHR codes and claims diagnostic codes often disagree, and people with claims codes for LTBI have unexpected EHR codes, indicating the need to reconcile these coding systems.

Civil rights as determinants of public health and racial and ethnic health equity: Health care, education, employment, and housing in the United States.

This essay examines how civil rights and their implementation have affected and continue to affect the health of racial and ethnic minority populations in the United States. Civil rights are characterized as social determinants of health. A brief review of US history indicates that, particularly for Blacks, Hispanics, and American Indians, the longstanding lack of civil rights is linked with persistent health inequities. Civil rights history since 1950 is explored in four domains-health care, education, employment, and housing. The first three domains show substantial benefits when civil rights are enforced. Discrimination and segregation in housing persist because anti-discrimination civil rights laws have not been well enforced. Enforcement is an essential component for the success of civil rights law. Civil rights and their enforcement may be considered a powerful arena for public health theorizing, research, policy, and action.

Developing the Guide to Community Preventive Services--overview and rationale. The Task Force on Community Preventive Services.

When the GUIDE TO COMMUNITY PREVENTIVE SERVICES: Systematic Reviews and Evidence-Based Recommendations (the Guide) is published in 2001, it will represent a significant national effort in encouraging evidence-based public health practice in defined populations (e.g., communities or members of specific managed care plans). The Guide will make recommendations regarding public health interventions to reduce illness, disability, premature death, and environmental hazards that impair community health and quality of life. The Guide is being developed under the guidance of the Task Force on Community Preventive Services (the Task Force)-a 15-member, nonfederal, independent panel of experts. Subject matter experts, methodologists, and scientific staff are supporting the Task Force in using explicit rules to conduct systematic literature reviews of evidence of effectiveness, economic efficiency, and feasibility on which to base recommendations for community action. Contributors to the Guide are building on the experience of others to confront methodologic challenges unique to the assessment of complex multicomponent intervention studies with nonexperimental or nonrandomized designs and diverse measures of outcome and effectiveness. Persons who plan, fund, and implement population-based services and policies to improve health at the state and local levels are invited to scrutinize the work in progress and to communicate with contributors. When the Guide is complete, readers are encouraged to consider critically the value and relevance of its contents, the implementation of interventions the Task Force recommends, the abandonment of interventions the Task Force does not recommend, and the need for rigorous evaluation of the benefits and harms of promising interventions of unknown effectiveness.

Developing an evidence-based Guide to Community Preventive Services--methods. The Task Force on Community Preventive Services.

Systematic reviews and evidence-based recommendations are increasingly important for decision making in health and medicine. Over the past 20 years, information on the science of synthesizing research results has exploded. However, some approaches to systematic reviews of the effectiveness of clinical preventive services and medical care may be less appropriate for evaluating population-based interventions. Furthermore, methods for linking evidence to recommendations are less well developed than methods for synthesizing evidence. The Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) will evaluate and make recommendations on population-based and public health interventions. This paper provides an overview of the Guide's process to systematically review evidence and translate that evidence into recommendations. The Guide reviews evidence on effectiveness, the applicability of effectiveness data, (i.e., the extent to which available effectiveness data is thought to apply to additional populations and settings), the intervention's other effects (i.e., important side effects), economic impact, and barriers to implementation of interventions. The steps for obtaining and evaluating evidence into recommendations involve: (1) forming multidisciplinary chapter development teams, (2) developing a conceptual approach to organizing, grouping, selecting and evaluating the interventions in each chapter; (3) selecting interventions to be evaluated; (4) searching for and retrieving evidence; (5) assessing the quality of and summarizing the body of evidence of effectiveness; (6) translating the body of evidence of effectiveness into recommendations; (7) considering information on evidence other than effectiveness; and (8) identifying and summarizing research gaps. Systematic reviews of and evidence-based recommendations for population-health interventions are challenging and methods will continue to evolve. However, using an evidence-based approach to identify and recommend effective interventions directed at specific public health goals may reduce errors in how information is collected and interpreted, identify important gaps in current knowledge thus guiding further research, and enhance the Guide users' ability to assess whether recommendations are valid and prudent from their own perspectives. Over time, all of these advantages could help to increase agreement regarding appropriate community health strategies and help to increase their implementation.

Data collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services. Task Force on Community Preventive Services.

INTRODUCTION: A standardized abstraction form and procedure was developed to provide consistency, reduce bias, and improve validity and reliability in the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide). DATA COLLECTION INSTRUMENT: The content of the abstraction form was based on methodologies used in other systematic reviews; reporting standards established by major health and social science journals; the evaluation, statistical and meta-analytic literature; expert opinion and review; and pilot-testing. The form is used to classify and describe key characteristics of the intervention and evaluation (26 questions) and assess the quality of the study's execution (23 questions). Study procedures and results are collected and specific threats to the validity of the study are assessed across six categories (intervention and study descriptions, sampling, measurement, analysis, interpretation of results and other execution issues). DATA COLLECTION PROCEDURES: Each study is abstracted by two independent reviewers and reconciled by the chapter development team. Reviewers are trained and provided with feedback. DISCUSSION: What to abstract and how to summarize the data are discretionary choices that influence conclusions drawn on the quality of execution of the study and its effectiveness. The form balances flexibility for the evaluation of papers with different study designs and intervention types with the need to ask specific questions to maximize validity and reliability. It provides a structured format that researchers and others can use to review the content and quality of papers, conduct systematic reviews, or develop manuscripts. A systematic approach to developing and evaluating manuscripts will help to promote overall improvement of the scientific literature.

Methods for systematic reviews of economic evaluations for the Guide to Community Preventive Services. Task Force on Community Preventive Services.

OBJECTIVES: This paper describes the methods used in the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) for conducting systematic reviews of economic evaluations across community health-promotion and disease-prevention interventions. The lack of standardized methods to improve the comparability of results from economic evaluations has hampered the use of data on costs and financial benefits in evidence-based reviews of effectiveness. The methods and instruments developed for the Guide provide an explicit and systematic approach for abstracting economic evaluation data and increase the usefulness of economic information for policy making in health care and public health. METHODS: The following steps were taken for systematic reviews of economic evaluations: (1) systematic searches were conducted; (2) studies using economic analytic methods, such as cost analysis or cost-effectiveness, cost-benefit or cost-utility analysis, were selected according to explicit inclusion criteria; (3) economic data were abstracted and adjusted using a standardized abstraction form; and (4) adjusted summary measures were listed in summary tables. RESULTS: These methods were used in a review of 10 interventions designed to improve vaccination coverage in children, adolescents and adults. Ten average costs and 14 cost-effectiveness ratios were abstracted or calculated from data reported in 24 studies and expressed in 1997 USD. The types of costs included in the analysis and intervention definitions varied extensively. Gaps in data were found for many interventions.

Identifying ancestry: The reliability of ancestral identification in the United States by self, proxy, interviewer, and funeral director.

We examined consistency in the classification of ancestry by self, proxy, interviewer, and funeral director (on a death certificate) in a sample of the U.S. population--the First National Health and Nutrition Examination Survey and Epidemiologic Follow-up. Among study subjects for whom comparable ethnic identity options were available at both interviews, 58% of subjects specified the same identity at two times. Persons who specified four different ethnic backgrounds were 3.4 times as likely to change their identity over time as persons specifying only one background. Self-classification of ancestry at initial interview was consistent with proxy reports at follow-up for 55% of subjects for whom proxy information was available. Comparison of the self-classification of ancestry with the classification of race by interviewers and by funeral directors indicates high consistency for Whites and Blacks and low consistency for American Indians. The "measurement" of ancestry (that is, race or ethnicity) is critical to the understanding and elimination of differences in health status among racial/ethnic populations, but the low reliability of these measures over time and across observers complicates the analysis and interpretation of health statistics by ancestry, particularly for populations other than White or Black.

Substance use and HIV-related sexual behaviors among US high school students: are they related?

OBJECTIVES: This study was undertaken to examine whether use of alcohol, cigarettes, marijuana, cocaine, and other illicit drugs is related to the likelihood of sexual behaviors that increase risk for human immunodeficiency virus (HIV) infection among youth. METHODS: The 1990 national Youth Risk Behavior Survey was used to collect self-reported information about a broad range of health risk behaviors from a representative sample of 11,631 high school students in the United States. RESULTS: Students who reported no substance use were least likely to report having had sexual intercourse, having had four or more sex partners, and not having used a condom at last sexual intercourse. Adjusted for age, sex, and race/ethnicity, odds ratios for each of these sexual risk behaviors were greatest among students who had used marijuana, cocaine, or other illicit drugs. Students who had used only alcohol or cigarettes had smaller but still significant increases in the likelihood of having had sexual intercourse and of having had four or more sex partners. CONCLUSIONS: HIV prevention programs for youth should recognize that substance use may be an important indicator of risk for HIV infection and acquired immunodeficiency syndrome through its association with unsafe sexual behaviors.

HIV instruction, HIV knowledge, and drug injection among high school students in the United States.

BACKGROUND: The prevalence of HIV-related behaviors and determinants of these behaviors among adolescents in the United States have not been well studied. METHODS: To determine the prevalence of HIV-related drug behaviors and to assess the effects of HIV-related school-based instruction and HIV knowledge on these behaviors, data were analyzed from a 39-item, self-administered questionnaire completed by a probability sample of all students in grades 9 through 12 in the United States. RESULTS: Usable responses were obtained from 8098 students. Of these, 2.7% (95% confidence interval [CI] = 2.3-3.2) and 1.7% (95% CI = 1.3-2.1) reported injecting illicit drugs ever and during the past year, respectively. Corresponding prevalences of needle sharing were 0.8% (95% CI = 0.5-1.1) and 0.5% (95% CI = 0.3-0.7). Regression analysis revealed that students with higher knowledge scores were less likely and males more likely to have ever injected drugs. HIV knowledge was similarly associated with other outcome measures of drug-injection behavior. Although HIV instruction did not directly influence drug-injection behavior independently of demographic characteristics, it was positively associated with HIV knowledge. CONCLUSIONS: While these results do not establish a causal relationship, they suggest that HIV knowledge and school-based instruction may play a role in maintaining low levels of drug-injection behavior among high school students.

HIV-related knowledge, beliefs, and behaviors among high school students in the United States: results from a national survey.

The Secondary School Student Health Risk Survey measured the prevalence of sexual intercourse and illegal drug injection among a national probability sample of U.S. high school students and assessed their HIV-related knowledge and beliefs. Ninety-nine (81%) of the 122 selected schools and 8,098 (83%) of the eligible students participated. Nearly all high school students knew the major modes of HIV transmission. Three percent reported injecting illegal drugs, and 1% reported sharing needles used to inject drugs. In addition, 59% of students reported having sexual intercourse and, of students who reported having sexual intercourse, 40% reported having four or more sexual partners. HIV-related knowledge, beliefs, and behaviors among high school students suggest the need for school-based HIV education programs that help young people acquire the knowledge and skills to adopt and maintain behaviors that reduce risk of HIV infection and other related health problems.

Progress in efforts to prevent the spread of HIV infection among youth.

The Human Immunodeficiency Virus (HIV) that causes AIDS will continue to threaten public health for years to come. Despite some popular misperceptions, adolescents are at risk of infection. Twenty percent of persons reported with AIDS have been ages 20 through 29. Given the long incubation period between HIV infection and AIDS, some of these young adults probably were infected while they were teenagers. Young people must develop the skills they will need to avoid HIV infection and other related health problems. In 1987, the Centers for Disease Control (CDC) launched a national program to help schools and other agencies that serve youth across the nation provide effective health education to prevent the spread of HIV. CDC supports and works closely with national health and education organizations, State and local education agencies, colleges and universities, and local health departments to establish HIV prevention policies and programs, training and demonstration centers, information development and dissemination activities. The impact of these efforts are assessed through applied surveillance and evaluation research. Through this system, CDC is attempting to institutionalize the means for continuously providing educational programs that will be effective in preventing HIV infection and other important health problems.

HIV infection among women entering the New York State correctional system.

Human immunodeficiency virus infection is the leading medical problem among prison inmates in several states. In 1988 a blinded seroprevalence study was conducted on 480 New York female prison entrants to determine the prevalence of and risk factors for HIV infection in this population. Ninety (18.8 percent) women were HIV-seropositive. Seroprevalence was highest among women ages 30-39 (25.0 percent) and varied by ethnicity (Hispanics, 29.4 percent; Blacks, 14.4 percent; Whites, 7.1 percent) and residence (New York City, 23.8 percent; Upstate, 5.1 percent). Nearly half (44.9 percent) of the 136 acknowledged intravenous drug users and one-third (33.8 percent) of the 71 women with a positive syphilis serology were HIV-seropositive. There was no difference in fertility histories between seropositive and seronegative women, and two of 21 pregnant women were seropositive. This study led to increased clinical and prevention services for this high-risk population.

AIDS behind bars. Epidemiology of New York State prison inmate cases, 1980-1988.

During the last five years, AIDS has become the preeminent health care problem in New York State correctional facilities. Through December 31, 1988, 915 cases of AIDS had been diagnosed among inmates. This represented approximately 1% of the cumulative AIDS cases in the United States, 4% of those in New York State, and 40% of those reported in state correctional systems nationwide. An analysis of epidemiologic data on these cases showed an annual increase in cases from 3 in 1981 to 227 in 1988, with an incidence greater than 400 per 100,000 inmates per year over the past four years. While most cases occurred in males (96%), females had the same high incidence rates (compared to the general population, in which female rates are one-eight of males). Forty-seven percent of infected inmates were Hispanic, 38% black, and 13% white. Pneumocystis carinii pneumonia was the most common diagnosis (65%), while Kaposi's sarcoma was rare (3%). Previous intravenous drug use has been the major risk factor, seen in 95% of cases. A comparison of 54 inmate AIDS cases with 107 matched and 196 unmatched controls showed that inmates in whom AIDS developed had significantly lower white blood cell counts on entry into prison, lower hematocrits and serum albumin levels, and higher serum glutamic oxaloacetic transaminase and globulin counts. Through July 1989, 643 (70%) of these 915 inmates had died of AIDS, and HIV infection and AIDS account for 68% of recent inmate deaths.

Increasing incidence of tuberculosis in a prison inmate population. Association with HIV infection.

The incidence of tuberculosis (TB) among inmates of the New York State prison system increased from 15.4 per 100,000 in 1976 through 1978 to 105.5 per 100,000 in 1986. Matching of TB and acquired immunodeficiency syndrome registries indicated that the majority (56%) of inmates with TB reported in 1985 and 1986 had acquired immunodeficiency syndrome or human immunodeficiency virus infection; none were known to be human immunodeficiency virus seronegative. A case-control study examined 59 inmates with TB reported from 1984 through 1986 and 59 matched control inmates without TB. Inmates who reported street drug use were more likely to develop TB: odds ratio, 9.7; 95% confidence interval, 2.8 to 33.6 and odds ratio, 7.3; 95% confidence interval, 0.9 to 59.3 by unconditional and conditional logistic regression analyses, respectively. Although the majority of cases are thought to be due to reactivation of latent infection, phage typing of 16 Mycobacterium tuberculosis cultures suggested the possibility of inmate-to-inmate transmission in at least one cluster of three cases. It is of crucial importance that TB control measures be reinforced in the prison setting to counter the increased risk created by human immunodeficiency virus infection.

Snow Mountain agent gastroenteritis from clams.

A 1983 investigation of two clambake-related gastroenteritis outbreaks in Rochester, New York, showed that 84 (43%) of 196 persons interviewed had an acute illness characterized by watery diarrhea, vomiting, and abdominal cramps. None of the ill persons were hospitalized or had complications. Illness was associated with eating raw (p = 0.002) or baked (p less than 0.01) hard-shell clams, with the risk of illness increasing with the total number of clams consumed (p less than 0.01). The median incubation period and duration of illness were 36 and 44 hours, respectively. Stool samples obtained 2-4 days after onset of illness were negative for commonly recognized bacterial and viral pathogens. However, of 31 persons whose stools were tested, the stool of only one ill person was positive by enzyme-linked immunosorbent assay for the Snow Mountain agent, one of the Norwalk-like viruses. Paired serum specimens from six (67%) of nine ill and two (29%) of seven well persons showed a fourfold or greater rise in antibody titer to Snow Mountain agent. Persons who ate clams were more likely to seroconvert to Snow Mountain agent (eight of 12) than were those who did not eat clams (zero of four) (p = 0.04). The clams were harvested off the coast of southern Massachusetts in late October, when harvest waters were documented to be contaminated by untreated municipal sewage. This report describes the first documented outbreak of shellfish-associated gastroenteritis attributed to Snow Mountain agent of which we are aware.