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.

Using electronic health records to identify candidates for human immunodeficiency virus pre-exposure prophylaxis: An application of super learning to risk prediction when the outcome is rare.

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) protects high risk patients from becoming infected with HIV. Clinicians need help to identify candidates for PrEP based on information routinely collected in electronic health records (EHRs). The greatest statistical challenge in developing a risk prediction model is that acquisition is extremely rare. METHODS: Data consisted of 180 covariates (demographic, diagnoses, treatments, prescriptions) extracted from records on 399 385 patient (150 cases) seen at Atrius Health (2007-2015), a clinical network in Massachusetts. Super learner is an ensemble machine learning algorithm that uses k-fold cross validation to evaluate and combine predictions from a collection of algorithms. We trained 42 variants of sophisticated algorithms, using different sampling schemes that more evenly balanced the ratio of cases to controls. We compared super learner's cross validated area under the receiver operating curve (cv-AUC) with that of each individual algorithm. RESULTS: The least absolute shrinkage and selection operator (lasso) using a 1:20 class ratio outperformed the super learner (cv-AUC = 0.86 vs 0.84). A traditional logistic regression model restricted to 23 clinician-selected main terms was slightly inferior (cv-AUC = 0.81). CONCLUSION: Machine learning was successful at developing a model to predict 1-year risk of acquiring HIV based on a physician-curated set of predictors extracted from EHRs.

Effects of daily treatment with acid suppressants for stress ulcer prophylaxis on risk of ventilator-associated events.

OBJECTIVE: To estimate the effects of continuous daily treatment with different acid suppressants on the risk of ventilator-associated events in critically ill patients. DESIGN: Retrospective cohort study. PATIENTS: Adult critically ill patients who underwent mechanical ventilation for ≥3 days during an inpatient admission between January 2006 and December 2014. METHODS: We estimated the 30-day cumulative risk ratios (RRs) for ventilator-associated events comparing daily proton pump inhibitor (PPI) versus daily histamine-2-receptor antagonist (H2RA) strategies while controlling for time-fixed and time-varying confounding and accounting for competing events. RESULTS: Of 6,133 patients, on ventilation day 3, 58.8% received H2RAs, 26.1% received PPIs, and 4.1% received sucralfate. Patients frequently changed treatment throughout follow-up. Among 4,595 patients receiving PPIs or H2RAs on day 3, we found no differences in risk estimates for ventilator mortality and extubation alive comparing daily PPI versus daily H2RA strategies: RR, mortality, 1.03 (95% CI, 0.89-1.22); extubation alive, 1.00 (95% CI, 0.96-1.03). We found similar results after accounting for PPI dose. For possible ventilator-associated pneumonia (PVAP) and infection-related ventilator-associated complication (IVAC), point estimates were larger, but the 95% CIs crossed 1.0: RR PVAP, 1.25 (95% CI, 0.80-1.94); IVAC, 0.89 (95% CI, 0.64-1.17). The magnitude of effect estimates depended on PPI dose. The RR for PVAP, high-dose PPI versus H2RA, was 1.53 (95% CI, 0.82-2.51), and for low-dose PPI versus H2RA, the RR was 0.97 (95% CI, 0.47-1.63). For IVAC, high-dose PPI versus H2RA, the RR was 1.01 (95% CI, 0.66-1.42), and for low-dose PPI versus H2RA, the RR was 0.78 (95% CI, 0.50-1.11). CONCLUSIONS: We estimated no effect of daily PPI versus daily H2RA on risk of mortality or extubation alive in critically ill patients. Further investigation with larger samples is warranted for PVAP and IVAC.

Development and validation of an automated HIV prediction algorithm to identify candidates for pre-exposure prophylaxis: a modelling study.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is effective but underused, in part because clinicians do not have the tools to identify PrEP candidates. We developed and validated an automated prediction algorithm that uses electronic health record (EHR) data to identify individuals at increased risk for HIV acquisition. METHODS: We used machine learning algorithms to predict incident HIV infections with 180 potential predictors of HIV risk drawn from EHR data from 2007-15 at Atrius Health, an ambulatory group practice in Massachusetts, USA. We included EHRs of all patients aged 15 years or older with at least one clinical encounter during 2007-15. We used ten-fold cross-validated area under the receiver operating characteristic curve (cv-AUC) with 95% CIs to assess the model's performance at identifying individuals with incident HIV and patients independently prescribed PrEP by clinicians. The best-performing model was validated prospectively with 2016 data from Atrius Health and externally with 2011-16 data from Fenway Health, a community health centre specialising in sexual health care in Boston (MA, USA). We calculated HIV risk scores (ie, probability of an incident HIV diagnosis) for every HIV-uninfected patient not on PrEP during 2007-15 at Atrius Health and assessed the distribution of scores for thresholds to determine possible candidates for PrEP in the three study cohorts. FINDINGS: We included 1 155 966 Atrius Health patients from 2007-15 (150 [<0·1%] patients with incident HIV) in our development cohort, 537 257 Atrius Health patients in 2016 (16 [<0·1%] with incident HIV) in our prospective validation cohort, and 33 404 Fenway Health patients from 2011-16 (423 [1·3%] with incident HIV) in our external validation cohort. The best-performing algorithm was obtained with least absolute shrinkage and selection operator (LASSO) and had a cv-AUC of 0·86 (95% CI 0·82-0·90) for identification of incident HIV infections in the development cohort, 0·91 (0·81-1·00) on prospective validation, and 0·77 (0·74-0·79) on external validation. The LASSO model successfully identified patients independently prescribed PrEP by clinicians at Atrius Health in 2016 (cv-AUC 0·93, 95% CI 0·90-0·96) or Fenway Health (0·79, 0·78-0·80). HIV risk scores increased steeply at the 98th percentile. Using this score as a threshold, we prospectively identified 9515 (1·8%) of 536 384 patients at Atrius Health in 2016 and 4385 (15·3%) of 28 702 Fenway Health patients as potential PrEP candidates. INTERPRETATION: Automated algorithms can efficiently identify patients at increased risk for HIV acquisition. Integrating these models into EHRs to alert providers about patients who might benefit from PrEP could improve prescribing and prevent new HIV infections. FUNDING: Harvard University Center for AIDS Research, Providence/Boston Center for AIDS Research, Rhode Island IDeA-CTR, the National Institute of Mental Health, and the US Centers for Disease Control and Prevention.

Oral vancomycin prophylaxis during systemic antibiotic exposure to prevent Clostridiodes difficile infection relapses.

OBJECTIVE: To determine whether oral vancomycin prophylaxis accompanying systemic antibiotics reduces the risk of relapse in patients with history of Clostridioides difficile infection (CDI). DESIGN: Retrospective cohort study. PATIENTS: Adult inpatients with a history of CDI who received systemic antibiotics in either of 2 hospitals between January 2009 and June 2015. METHODS: We compared relapse rates in patients who started oral vancomycin concurrently with systemic antibiotics (exposed group) versus those who did not. We assessed for CDI relapse by toxin or nucleic acid testing at 90 days. We used inverse probability weighting and machine learning to adjust for confounders, to estimate propensity for treatment, and to calculate odds ratios for CDI relapse. We performed secondary analyses limited to toxin-positive relapses, patients with 1 versus >1 prior CDI episodes, and patients who received oral vancomycin on each antibiotic day. RESULTS: CDI relapse occurred within 90 days in 19 of 193 exposed patients (9.8%) versus 53 of 567 unexposed patients (9.4%; unadjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.60-1.81; adjusted OR, 0.63; 95% CI, 0.35-1.14). CDI relapses at 90 days were less frequent in exposed patients with only 1 prior episode of CDI (OR, 0.42; 95% CI, 0.19-0.93) but not in those with >1 prior episode (OR, 1.19; 95% CI, 0.42-3.33). Our findings were consistent with a lack of benefit of oral vancomycin when restricting results to toxin-positive relapses and to patients who received vancomycin each antibiotic day. CONCLUSIONS: Prophylactic oral vancomycin was not consistently associated with reduced risk of CDI relapse among hospitalized patients receiving systemic antibiotics. However, patients with only 1 prior CDI episode may benefit.

Temporal Patterns in Chlamydia Repeat Testing in Massachusetts.

INTRODUCTION: National guidelines recommend test-of-cure for pregnant women and test-of-reinfection for all patients with chlamydia infections in order to interrupt transmission and prevent adverse sequelae for patients, partners, and newborns. Little is known about retesting and positivity rates, and whether they are changing over time, particularly in private sector practices. METHODS: Electronic health record data on patients with chlamydia tests were extracted from three independent clinical practice groups serving ≅20% of the Massachusetts population. Records were extracted using the Electronic medical record Support for Public Health platform (esphealth.org). These data were analyzed for temporal trends in annual repeat testing rates by using generalized estimating equations after index positive chlamydia tests between 2010 and 2015 and for differences in intervals to first repeat tests among pregnant females, non-pregnant females, and males. Data extraction and analysis were performed during calendar years 2017 and 2018. RESULTS: An index positive C. trachomatis result was identified for 972 pregnant female cases, 10,309 non-pregnant female cases, and 4,973 male cases. Test-of-cure 3-5 weeks after an index positive test occurred in 37% of pregnant females. Test-of-reinfection 8-16 weeks after an index positive test occurred in 39% of pregnant females, 18% of non-pregnant females, and 9% of males. There were no significant increases in test-of-cure or test-of-reinfection rates from 2010 to 2015. Among cases with repeat tests, 16% of pregnant females, 15% of non-pregnant females, and 16% of males had positive results. CONCLUSIONS: Chlamydia test-of-cure and test-of-reinfection rates are low, with no evidence of improvement over time. There are substantial opportunities to improve adherence to chlamydia repeat testing recommendations.

Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014.

Importance: Estimates from claims-based analyses suggest that the incidence of sepsis is increasing and mortality rates from sepsis are decreasing. However, estimates from claims data may lack clinical fidelity and can be affected by changing diagnosis and coding practices over time. Objective: To estimate the US national incidence of sepsis and trends using detailed clinical data from the electronic health record (EHR) systems of diverse hospitals. Design, Setting, and Population: Retrospective cohort study of adult patients admitted to 409 academic, community, and federal hospitals from 2009-2014. Exposures: Sepsis was identified using clinical indicators of presumed infection and concurrent acute organ dysfunction, adapting Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria for objective and consistent EHR-based surveillance. Main Outcomes and Measures: Sepsis incidence, outcomes, and trends from 2009-2014 were calculated using regression models and compared with claims-based estimates using International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe sepsis or septic shock. Case-finding criteria were validated against Sepsis-3 criteria using medical record reviews. Results: A total of 173 690 sepsis cases (mean age, 66.5 [SD, 15.5] y; 77 660 [42.4%] women) were identified using clinical criteria among 2 901 019 adults admitted to study hospitals in 2014 (6.0% incidence). Of these, 26 061 (15.0%) died in the hospital and 10 731 (6.2%) were discharged to hospice. From 2009-2014, sepsis incidence using clinical criteria was stable (+0.6% relative change/y [95% CI, -2.3% to 3.5%], P = .67) whereas incidence per claims increased (+10.3%/y [95% CI, 7.2% to 13.3%], P < .001). In-hospital mortality using clinical criteria declined (-3.3%/y [95% CI, -5.6% to -1.0%], P = .004), but there was no significant change in the combined outcome of death or discharge to hospice (-1.3%/y [95% CI, -3.2% to 0.6%], P = .19). In contrast, mortality using claims declined significantly (-7.0%/y [95% CI, -8.8% to -5.2%], P < .001), as did death or discharge to hospice (-4.5%/y [95% CI, -6.1% to -2.8%], P < .001). Clinical criteria were more sensitive in identifying sepsis than claims (69.7% [95% CI, 52.9% to 92.0%] vs 32.3% [95% CI, 24.4% to 43.0%], P < .001), with comparable positive predictive value (70.4% [95% CI, 64.0% to 76.8%] vs 75.2% [95% CI, 69.8% to 80.6%], P = .23). Conclusions and Relevance: In clinical data from 409 hospitals, sepsis was present in 6% of adult hospitalizations, and in contrast to claims-based analyses, neither the incidence of sepsis nor the combined outcome of death or discharge to hospice changed significantly between 2009-2014. The findings also suggest that EHR-based clinical data provide more objective estimates than claims-based data for sepsis surveillance.

State and Local Chronic Disease Surveillance Using Electronic Health Record Systems.

OBJECTIVES: To assess the feasibility of chronic disease surveillance using distributed analysis of electronic health records and to compare results with Behavioral Risk Factor Surveillance System (BRFSS) state and small-area estimates. METHODS: We queried the electronic health records of 3 independent Massachusetts-based practice groups using a distributed analysis tool called MDPHnet to measure the prevalence of diabetes, asthma, smoking, hypertension, and obesity in adults for the state and 13 cities. We adjusted observed rates for age, gender, and race/ethnicity relative to census data and compared them with BRFSS state and small-area estimates. RESULTS: The MDPHnet population under surveillance included 1 073 545 adults (21.8% of the state adult population). MDPHnet and BRFSS state-level estimates were similar: 9.4% versus 9.7% for diabetes, 10.0% versus 12.0% for asthma, 13.5% versus 14.7% for smoking, 26.3% versus 29.6% for hypertension, and 22.8% versus 23.8% for obesity. Correlation coefficients for MDPHnet versus BRFSS small-area estimates ranged from 0.890 for diabetes to 0.646 for obesity. CONCLUSIONS: Chronic disease surveillance using electronic health record data is feasible and generates estimates comparable with BRFSS state and small-area estimates.

Randomized Controlled Trial of DHA Supplementation during Pregnancy: Child Adiposity Outcomes.

Investigating safe and effective interventions in pregnancy that lower offspring adiposity is important given the burden of obesity and subsequent metabolic derangements. Our objective was to determine if docosahexaenoic acid (DHA) given during pregnancy to obese mothers results in lower offspring adiposity. This study was a long-term follow-up of a randomized trial of mothers with gestational diabetes or obesity who were randomized to receive DHA supplementation at 800 mg/day or placebo (corn/soy oil) starting at 25-29 weeks gestation. Anthropometric measures were collected at birth and maternal erythrocyte DHA and arachidonic (AA) levels were measured at 26 and 36 weeks gestation. At two- and four-year follow-up time points, offspring adiposity measures along with a diet recall were assessed. A significant increase in erythrocyte DHA levels was observed at 36 weeks gestation in the supplemented group (p < 0.001). While no significant differences by measures of adiposity were noted at birth, two or four years by randomization group, duration of breastfeeding (p < 0.001), and DHA level at 36 weeks (p = 0.002) were associated with body mass index z-score. Our data suggest that DHA supplementation during pregnancy in obese mothers may have long-lasting effects on offspring measures of adiposity.

Ultra-Short-Course Antibiotics for Patients With Suspected Ventilator-Associated Pneumonia but Minimal and Stable Ventilator Settings.

BACKGROUND: Many patients started on antibiotics for possible ventilator-associated pneumonia (VAP) do not have pneumonia. Patients with minimal and stable ventilator settings may be suitable candidates for early antibiotic discontinuation. We compared outcomes among patients with suspected VAP but minimal and stable ventilator settings treated with 1-3 days vs >3 days of antibiotics. METHODS: We identified consecutive adult patients started on antibiotics for possible VAP with daily minimum positive end-expiratory pressure of ≤5 cm H2O and fraction of inspired oxygen ≤40% for at least 3 days within a large tertiary care hospital between 2006 and 2014. We compared time to extubation alive vs ventilator death and time to hospital discharge alive vs hospital death using competing risks models among patients prescribed 1-3 days vs >3 days of antibiotics. All models were adjusted for patient demographics, comorbidities, severity of illness, clinical signs of infection, and pathogens. RESULTS: There were 1290 eligible patients, 259 treated for 1-3 days and 1031 treated for >3 days. The 2 groups had similar demographics, comorbidities, and clinical signs. There were no significant differences between groups in time to extubation alive (hazard ratio [HR], 1.16 for short- vs long-course treatment; 95% confidence interval [CI], .98-1.36), ventilator death (HR, 0.82 [95% CI, .55-1.22]), time to hospital discharge alive (HR, 1.07 [95% CI, .91-1.26]), or hospital death (HR, 0.99 [95% CI, .75-1.31]). CONCLUSIONS: Very short antibiotic courses (1-3 days) were associated with outcomes similar to longer courses (>3 days) in patients with suspected VAP but minimal and stable ventilator settings. Assessing serial ventilator settings may help clinicians identify candidates for early antibiotic discontinuation.

Abnormal glucose metabolism in Hispanic parents of children with acanthosis nigricans.

Objective. Assess the prevalence of abnormal glucose metabolism among Hispanic parents of children with acanthosis nigricans (AN). Methods. Hispanic families (n = 258) were evaluated for metabolic and anthropometric parameters including fasting glucose levels and AN status. Results. Mothers with AN+ children had IFG (17.3%) and 4% had glucose levels ≥126 mg/dL (P = 0.028) compared to 7.1% and 1.8% of mothers with AN- children, respectively. Mothers of AN+ children also had greater odds of having impaired fasting glucose levels (OR: 3.917, 95% CI: 1.475-10.404; P < 0.004) but this was not the case for fathers (OR: 1.125, 95% CI: 0.489-2.586; P = 0.781). Mothers of AN+ children were also more likely to be AN+ (OR: 5.76, 95% CI: 2.98-11.13, P < 0.001). Screening discovered glucose levels >126 mg/dL in 9% of fathers with AN+ children. Conclusions. Hispanic mothers of AN+ children are at higher risk of carbohydrate metabolism abnormalities. AN in children can be a marker for prevention and delay programs aimed at identifying adults at risk for diabetes.

High blood pressure in school children: prevalence and risk factors.

BACKGROUND: The purpose of this study was to determine the prevalence of high blood pressure (HBP) and associated risk factors in school children 8 to 13 years of age. METHODS: Elementary school children (n = 1,066) were examined. Associations between HBP, body mass index (BMI), gender, ethnicity, and acanthosis nigricans (AN) were investigated using a school based cross-sectional study. Blood pressure was measured and the 95th percentile was used to determine HBP. Comparisons between children with and without HBP were utilized. The crude and multiple logistic regression adjusted odds ratios were used as measures of association. RESULTS: Females, Hispanics, overweight children, and children with AN had an increased likelihood of HBP. Overweight children (BMI > or = 85th percentile) and those with AN were at least twice as likely to present with HBP after controlling for confounding factors. CONCLUSION: Twenty one percent of school children had HBP, especially the prevalence was higher among the overweight and Hispanic group. The association identified here can be used as independent markers for increased likelihood of HBP in children.

Prevalence of risk for type 2 diabetes in school children.

According to the Centers for Disease Control and Prevention, 1 in 3 children born in 2000 in the United States will become diabetic. The odds are higher for African American and Hispanic children as nearly 50% of them will develop diabetes. Random screening is not effective in identifying children at risk for type 2 diabetes mellitus (T2DM); therefore, there is a need to apply screening strategies that guide the development of appropriate primary prevention efforts. To assess the prevalence of risk factors for T2DM, 1066 fifth-grade children were screened using American Diabetes Association guidelines. Overall, 22.6% were found at risk; African American and Hispanic children were almost 8 times more likely to be at risk when compared to Caucasians (odds ratio = 7.41 and 7.87). Children who reported watching TV/playing video games 2 or more hours/day were 73% more likely to be at risk. Children identified to be at risk were referred to their primary care provider and were invited to participate in a counseling session. The environmental risk factors for T2DM identified in this study are modifiable and should be targeted in preventive interventions at the school and community level to reduce overweight and consequently prevent T2DM in children, especially among minority children.

Cardiovascular risk factors in Mexican-American children at risk for type 2 diabetes mellitus (T2DM).

PURPOSE: To assess risk factors for type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) with the hypothesis that risk for T2DM in children would be associated with an increase in risk factors for CVD. METHODS: Subjects from a group of Mexican-American school children (aged 10-12 years) identified to be at risk for T2DM, and their siblings, were selected for this study. There were 68 children with acanthosis nigricans (AN+), and 71 without AN (AN-). Both AN+ and AN- children were assessed for T2DM and CVD risk factors. Probands and siblings were evaluated by physical examination, family history, and fasting serum parameters: glucose, insulin, body mass index (BMI), serum lipoproteins, and oxidized lipids. Data were analyzed by descriptive, univariate, and multivariate procedures. RESULTS: BMI, waist/hip ratio, systolic and diastolic blood pressure were all significantly higher (p <.002) in AN+, whereas Tanner stages were similar in both groups. Fasting serum glucose was in the normal range, whereas insulin was elevated in AN+ compared with AN- (30.0 +/- 1.9 microU/mL vs. 14.8 +/- 1.0 p <.0001). Insulin resistance as assessed by the homeostasis assessment model (HOMA-IR) was elevated in both groups, although higher among AN+ (p <.0001). High-density lipoprotein-cholesterol (HDL-C) was lower (6.2 mg/dL) in the AN+ group (p <.003). The lower HDL-C in AN+ was associated with elevated triglycerides and a higher serum total cholesterol TC/HDL-C ratio when contrasted with the AN- values (145.9 +/- 7.6 mg/dL vs. 97.1 +/- 0.07, p <.0001; 4.1 +/- 0.2 vs. 3.4 +/- 0.1, p <.0001, respectively). In addition to the high prevalence of overweight/obesity (BMI > 85th percentile) in this population (76.3%, 106/139), elevated insulin (59.7% >15 microU/mL), low HDL-C (27.3% <40 mg/dL), and elevated low-density lipoprotein cholesterol (LDL-C) (41.0% >100 mg/dL) were also detected. CONCLUSIONS: The altered metabolic pattern observed in this group of Mexican-American children is characteristic of metabolic syndrome, a condition associated with obesity and increased risk for both T2DM and CVD in adults. This study points to the value of BMI and acanthosis nigricans as easily accessible markers for children and nuclear families at increased risk for developing T2DM and CVD.