Comparing ambulatory commercial spending in Rhode Island and Massachusetts, 2016-2019.

OBJECTIVE: To evaluate trends and drivers of commercial ambulatory spending and price variation. DATA SOURCES AND STUDY SETTING: Commercial claims data from the Massachusetts and Rhode Island All-Payer Claims Databases from 2016 to 2019. STUDY DESIGN: Observational study of spending in major ambulatory care settings. We calculated per member per year spending, average price, and utilization rates to consider drivers of spending, and constructed site-specific price indices to evaluate price variation. DATA COLLECTION/EXTRACTION METHODS: We analyzed commercial claims data from All-Payer Claims Databases in the two states. PRINCIPAL FINDINGS: Ambulatory spending levels in Massachusetts were 38.0% higher than those in Rhode Island in 2019. Overall utilization rates were similar, but Massachusetts had a 6.2 percentage point higher share of visits occurring in hospital outpatient departments (HOPD). Average prices were 31.5% higher in Massachusetts in 2016 and 36.4% higher in 2019. We observed extensive price variation in both states across both office and HOPD settings. CONCLUSIONS: States seeking to address increases in health care spending, including those with cost growth benchmarks and rate review policies, should consider additional interventions that mitigate market failures in the establishment of commercial health care prices.

Assessment of a Price Index for Hospital Outpatient Department Services Using Commercial Claims Data in Massachusetts.

This cross-sectional study assesses a market basket price index to evaluate hospital outpatient department price levels and growth.

Using latent class analysis to inform the design of an EHR-based national chronic disease surveillance model.

The Multi-state EHR-based Network for Disease Surveillance (MENDS) developed a pilot electronic health record (EHR) surveillance system capable of providing national chronic disease estimates. To strategically engage partner sites, MENDS conducted a latent class analysis (LCA) and grouped states by similarities in socioeconomics, demographics, chronic disease and behavioral risk factor prevalence, health outcomes, and health insurance coverage. Three latent classes of states were identified, which inform the recruitment of additional partner sites in conjunction with additional factors (e.g. partner site capacity and data availability, information technology infrastructure). This methodology can be used to inform other public health surveillance modernization efforts that leverage timely EHR data to address gaps, use existing technology, and advance surveillance.

Using Electronic Referrals to Address Health Disparities and Improve Blood Pressure Control.

INTRODUCTION: Massachusetts developed and used bidirectional electronic referrals to connect clinical patients across the state to interventions run by community organizations. The objective of our study was to determine whether the use of Massachusetts's electronic referral system (MA e-Referral) reached racial/ethnic groups experiencing health disparities and whether it was associated with improved health outcomes. METHODS: We assembled encounter-level medical records from September 2013 through June 2017 for patients at Massachusetts clinics funded by the Clinical Community Partnerships for Prevention into 2 cohorts. First, all patients meeting program eligibility guidelines for an e-Referral (N = 21,701) were examined to assess the distribution of e-Referrals among populations facing health disparities; second, a subset of 3,817 people with hypertension were analyzed to detect changes in blood pressure after e-Referral to an evidence-based community intervention. RESULTS: Non-Hispanic black (OR, 1.4; 95% confidence interval [CI], 1.2-1.6) and Hispanic patients (OR, 1.3; 95% CI, 1.1-1.4) had higher odds than non-Hispanic white patients of being referred electronically. Patients completing their hypertension intervention had 74% (95% CI, 1.2-2.5) higher odds of having an in-control blood pressure reading than patients who were not electronically referred. CONCLUSION: Clinical to community linkage to interventions through MA e-Referral reached non-Hispanic black, Hispanic, and Spanish-speaking populations and was associated with improved blood pressure control.

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.

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.

Suicidality and sexual orientation: Characteristics of symptom severity, disclosure, and timing across the life course.

This investigation explored suicide-related characteristics and help-seeking behavior by sexual orientation. Population-based data are from the California Quality of Life Surveys, which included 1,478 sexual minority (lesbian, gay, bisexual, and homosexually experienced individuals) and 3,465 heterosexual individuals. Bisexual women had a nearly six-fold increased risk of lifetime suicide attempts than heterosexual women (RR = 5.88, 95%CI: 3.89-8.90), and homosexually experienced men had almost 7 times higher risk of lifetime suicide attempts than heterosexual men (RR = 6.93, 95%CI: 3.65-13.15). Sexual minority men and women were more likely than heterosexual men and women to have disclosed suicide attempts to a medical professional (RR = 1.48 and RR = 1.44, respectively). Among persons who ever attempted suicide, sexual minority women had a younger age of index attempt than heterosexual women (15.9 vs. 19.6 years of age, respectively). Healthcare professionals should be aware of suicidal risk heterogeneity among sexual minority individuals, including vulnerable points of risk and evidenced-based treatments.

Declining Trends and Widening Disparities in Overweight and Obesity Prevalence Among Massachusetts Public School Districts, 2009-2014.

OBJECTIVES: We evaluated the overall and sociodemographic disparities in trends in prevalence of childhood overweight and obesity in Massachusetts public school districts between 2009 and 2014. METHODS: In 2009, Massachusetts mandated annual screening of body mass index for students in grades 1, 4, 7, and 10. This was part of the statewide Mass in Motion prevention programs. We assessed trends in the prevalence of overweight and obesity between 2009 and 2014 by district, gender, grade, and district income. RESULTS: From 2009 to 2014, prevalence decreased 3.0 percentage points (from 34.3% to 31.3%) statewide. The 2014 district-level rates ranged from 13.9% to 54.5% (median = 31.2%). When stratified by grade, the decreasing trends were significant only for grades 1 and 4. Although rates of districts with a median household income greater than $37, 000 improved notably, rates of the poorest remain unchanged and were approximately 40%. CONCLUSIONS: Although overall prevalence began to decrease, the geographic and socioeconomic disparities in childhood obesity are widening and remain a public health challenge in Massachusetts. Special efforts should be made to address the needs of socioeconomically disadvantaged districts and to narrow the disparities in childhood obesity.

Effect of systems change and use of electronic health records on quit rates among tobacco users in a public hospital system.

OBJECTIVES: We examined electronic health records (EHRs) to assess the impact of systems change on tobacco use screening, treatment, and quit rates among low-income primary care patients in Louisiana. METHODS: We examined EHR data on 79,777 patients with more than 1.2 million adult primary care encounters from January 1, 2009, through January 31, 2012, for evidence of systems change. We adapted a definition of "systems change" to evaluate a tobacco screening and treatment protocol used by medical staff during primary care visits at 7 sites in a public hospital system. RESULTS: Six of 7 sites met the definition of systems change, with routine screening rates for tobacco use higher than 50%. Within the first year, a 99.7% screening rate was reached. Sites had a 9.5% relative decrease in prevalence over the study period. Patients were 1.03 times more likely to sustain quit with each additional intervention (95% confidence interval = 1.02, 1.04). CONCLUSIONS: EHRs can be used to demonstrate that routine clinical interventions with low-income primary care patients result in reductions in tobacco use and sustained quits.