The challenges of linking health insurer claims with electronic medical records.

This article explores the challenges inherent in linking data from disparate sources-electronic medical records (EMR) and health insurer claims-and the probable benefits of doing so to evaluate several quality measures associated with diabetes. Using the business associate agreement provision of the Health Insurance Portability and Accountability Act, we were able to link health insurer claims with EMR data; however, when restricting the linked data to patients with at least one medication and one diagnosis in the evaluation year, we lost 90 percent of our linked population. Whether this loss was due to difficulties in extracting the data from site EMRs, to changes in insurer coverage over time, or to both was not discernible. Because linking EMR data to health insurer claims can produce a clinically rich longitudinal data set, assessing the completeness and quality of the data is critical to health services research and health-care quality measurements.

The Dallas Heart Study: a population-based probability sample for the multidisciplinary study of ethnic differences in cardiovascular health.

The decrease in cardiovascular death rates in the United States has been slower in blacks than whites, especially in patients <65 years of age. The Dallas Heart Study was designed as a single-site, multiethnic, population-based probability sample to (1) produce unbiased population estimates of biologic and social variables that pinpoint ethnic differences in cardiovascular health at the community level and (2) support hypothesis-driven research on the mechanisms causing these differences using genetics, advanced imaging modalities, social sciences, and clinical research center methods. A probability-based sample of Dallas County residents aged 18 to 65 years was surveyed with an extensive household health interview. The subset of participants 30 to 65 years of age provided in-home fasting blood and urine samples and underwent multiple imaging studies, including cardiac magnetic resonance imaging and electron beam computed tomography. Completed interviews were obtained for 6,101 subjects (54% black), phlebotomy visits for 3,398 (52% black), and clinic visits for 2,971 (50% black). Participation rates were 80.4% for interviews, 75.1% for phlebotomy visits, and 87.4% for clinic visits. Weighted population estimates of many measured variables agreed closely with those of the United States census and were relatively stable from the interview sample to the phlebotomy and clinic subsamples. Thus, the Dallas Heart Study provides a phenotypically well-characterized probability sample for multidisciplinary research that will be used to improve the mechanistic understanding and prevention of cardiovascular disease, especially in black Americans.

Community recruitment process by race, gender, and SES gradient: lessons learned from the Community Health and Stress Evaluation (CHASE) Study experience.

Recruitment of community participants for clinical research studies is a challenging task. When possible, community-based recruitment efforts should involve members of the targeted community in the planning, community preparation, and actual recruitment process. It becomes even more difficult to recruit study participants from the community when the research involves an invasive procedure, or when diverse target groups require that a variety of recruitment methods be used. The Community Health and Stress Evaluation (CHASE) Study was designed to determine the role of psychosocial and biobehavioral factors in the etiology of coronary heart disease. It involved both an invasive medical procedure (a spinal tap) and the collection of survey and medical information from Black and White persons in different socioeconomic status (SES) groups. Interestingly, we experienced the greatest difficulty in recruiting lower SES white persons, while groups that typically are "difficult to find" (such as Blacks) were actually easiest to recruit for the study. This paper describes the background of the CHASE study, the community recruitment methods used, and the results of the recruitment efforts by race, gender and SES gradient. We present an evaluation of the community recruitment component, why we think differences occurred, and the lessons learned from the experiences that may be applied to similar studies.

Maternal drug use and the timing of prenatal care.

This paper explores the role of maternal drug use and the timing of prenatal care. The study data were collected from women delivering live births at eight participating hospitals in the Washington, D.C., Metropolitan Area Drug Study. An estimated 16.9 percent of the women in this sample initiated prenatal care in their third trimester or received no prenatal care. After adjusting for age, race/ethnicity, education, parity, and attitude toward pregnancy, cocaine use was strongly associated with the timing of prenatal care. Using multivariable ordinal logistic regression, the data suggest significant barriers to prenatal care for substance abusers, especially cocaine users. Increasing access to prenatal care continues to be an important public health policy objective, particularly in urban areas where substance abuse is prevalent. Health services research must test strategies that address the timing of prenatal care among drug-dependent, urban women.

The impact of smoking and other substance use by urban women on the birthweight of their infants.

The impact of maternal smoking and other substance use during pregnancy on infant birthweight is demonstrated in a sample of 766 urban women, using data collected in the Washington, D.C. Metropolitan Area Drug Study (DC*MADS). Women residing and giving birth in the District of Columbia were interviewed in 1992. A multivariable linear regression model was used to quantify the association between birthweight and the mother's use of cigarettes, alcohol, or illicit drugs during pregnancy, while controlling for possible confounding variables. The analysis focused on factors, including prenatal care and substance use during pregnancy that may contribute to low birthweight infants born to this sample of urban, predominantly black women. A woman's use of cigarettes, marijuana, and heroin during pregnancy was related to infant birthweight, but her use of alcohol and cocaine during pregnancy was not significantly related. Smoking during pregnancy was a strong predictor for low birthweight, suggesting that targeting more smoking cessation programs for pregnant women, particularly those who may also be illicit drug users, could help reduce adverse health consequences for low birthweight infants.

Project IMPACT: results from a pilot validity study of a new observational database.

OBJECTIVE: The objective of this study was to evaluate the accuracy of the information contained in the Project IMPACT database. Project IMPACT is a comprehensive database system developed to measure and describe the care of intensive care patients. This database is being used by a large group of hospitals to help clinicians improve the care of these patients. Data on patient demographics, diagnoses, treatment, and outcomes are entered into the Project IMPACT database by staff at participating hospitals. This pilot study was a first step in assessing the accuracy of these data to determine the usefulness of the Project IMPACT database for measuring intensive care unit (ICU) performance and patient outcomes. DESIGN: The design of the pilot study was the independent abstraction of selected data items from a random sample of ICU patient records from two hospitals participating in Project IMPACT. The abstracted data were compared with the data existing in the Project IMPACT database for agreement. SETTING: Abstraction was performed onsite at the two pilot hospitals by a trained abstractor who was not affiliated with either hospital. PATIENTS: Patients whose records were abstracted included 45 randomly selected ICU patients at each of the two pilot hospitals. MEASUREMENTS AND MAIN RESULTS: Comparison of the Project IMPACT data with the independently abstracted data indicated good agreement (80% or above) on discrete items, such as type of ICU patient. Poorer agreement (under 80%) was seen for continuous items (e.g., 24-hr urine output) and coded items requiring judgment (e.g., reason for ICU admission). CONCLUSIONS: The pilot study showed good internal validity for most of the abstracted variables. High agreement rates were observed, regardless of method of original data capture (electronic download or manual entry), although agreement was higher for some data items that had been electronically downloaded into the Project IMPACT database. The results suggest that Project IMPACT is a valuable resource for ICUs to collect and evaluate information about treatment and patient outcomes.