Risk factor measurement quality in primary care routine data was variable but nondifferential between individuals

Prevalence of high blood pressure and high normal blood pressure among 7- to 17-year-old children and adolescents in developed regions, China from 2014 to 2017: using new national blood pressure reference for Chinese children and adolescents

As the first blood pressure (BP) reference considering influence of height in China, national blood pressure reference for Chinese han children and adolescents aged 7 to 17 years (CCBP) was issued in 2017. The current study aimed to observe the short-term trends in BP and prevalence of high blood pressure (HBP) and high normal blood pressure (HNBP) using this CCBP reference in Suzhou, China. Data of children and adolescents aged 7 to 17 years were collected from 2014 to 2017. Total population of 2014 to 2017 were 617,383, 684,453, 695,302, and 774,605, respectively, and proportions of males were 54.1%, 54.0%, 53.9%, and 53.8%, respectively. P-trend tests were conducted to examine the trends of BP among different age, region, body mass index, and socioeconomic status groups for each gender. Multivariate logistic regression analyses found secular decreases in prevalence of HBP and HNBP, after adjustment for potential confounders. Compared with that in 2014, the odds ratios (95% confidence intervals) for total study population were 0.936 (0.928, 0.944) in 2015, 0.879 (0.872, 0.887) in 2016, and 0.934 (0.926, 0.941) in 2017. In conclusion, prevalence of HBP and HNBP decreased among children and adolescents in developed regions of China from 2014 to 2017, and a slight rise were found in 2017.

Are self-reported telemonitored blood pressure readings affected by end-digit preference: a prospective cohort study in Scotland

OBJECTIVE

Simple forms of blood pressure (BP) telemonitoring require patients to text readings to central servers creating an opportunity for both entry error and manipulation. We wished to determine if there was an apparent preference for particular end digits and entries which were just below target BPs which might suggest evidence of data manipulation.

DESIGN

Prospective cohort study SETTING: 37 socioeconomically diverse primary care practices from South East Scotland.

PARTICIPANTS

Patients were recruited with hypertension to a telemonitoring service in which patients submitted home BP readings by manually transcribing the measurements into text messages for transmission ('patient-texted system'). These readings were compared with those from primary care patients with uncontrolled hypertension using a system in which readings were automatically transmitted, eliminating the possibility of manipulation of values ('automatic-transmission system').

METHODS

A generalised estimating equations method was used to compare BP readings between the patient-texted and automatic-transmission systems, while taking into account clustering of readings within patients.

RESULTS

A total of 44 150 BP readings were analysed on 1068 patients using the patient-texted system compared with 20 705 readings on 199 patients using the automatic-transmission system. Compared with the automatic-transmission data, the patient-texted data showed a significantly higher proportion of occurrences of both systolic and diastolic BP having a zero end digit (OR 2.1, 95% CI 1.7 to 2.6) although incidence was <2% of readings. Similarly, there was a preference for systolic 134 and diastolic 84 (the threshold for alerts was 135/85) (134 systolic BP OR 1.5, 95% CI 1.3 to 1.8; 84 diastolic BP OR 1.5, 95% CI 1.3 to 1.9).

CONCLUSION

End-digit preference for zero numbers and specific-value preference for readings just below the alert threshold exist among patients in self-reporting their BP using telemonitoring. However, the proportion of readings affected is small and unlikely to be clinically important.

TRIAL REGISTRATION NUMBER

ISRCTN72614272; Post-results.

Generalizability of Indicators from the New York City Macroscope Electronic Health Record Surveillance System to Systems Based on Other EHR Platforms

Introduction:

The New York City (NYC) Macroscope is an electronic health record (EHR) surveillance system based on a distributed network of primary care records from the Hub Population Health System. In a previous 3-part series published in eGEMS, we reported the validity of health indicators from the NYC Macroscope; however, questions remained regarding their generalizability to other EHR surveillance systems.

Methods:

We abstracted primary care chart data from more than 20 EHR software systems for 142 participants of the 2013–14 NYC Health and Nutrition Examination Survey who did not contribute data to the NYC Macroscope. We then computed the sensitivity and specificity for indicators, comparing data abstracted from EHRs with survey data.

Results:

Obesity and diabetes indicators had moderate to high sensitivity (0.81–0.96) and high specificity (0.94–0.98). Smoking status and hypertension indicators had moderate sensitivity (0.78–0.90) and moderate to high specificity (0.88–0.98); sensitivity improved when the sample was restricted to records from providers who attested to Stage 1 Meaningful Use. Hyperlipidemia indicators had moderate sensitivity (≥0.72) and low specificity (≤0.59), with minimal changes when restricting to Stage 1 Meaningful Use.

Discussion:

Indicators for obesity and diabetes used in the NYC Macroscope can be adapted to other EHR surveillance systems with minimal validation. However, additional validation of smoking status and hypertension indicators is recommended and further development of hyperlipidemia indicators is needed.

Conclusion:

Our findings suggest that many of the EHR-based surveillance indicators developed and validated for the NYC Macroscope are generalizable for use in other EHR surveillance systems.

Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review

BACKGROUND

To interpret blood pressure (BP) data appropriately, healthcare providers need to be knowledgeable of the factors that can potentially impact the accuracy of BP measurement and contribute to variability between measurements.

METHODS

A systematic review of studies quantifying BP measurement inaccuracy. Medline and CINAHL databases were searched for empirical articles and systematic reviews published up to June 2015. Empirical articles were included if they reported a study that was relevant to the measurement of adult patients' resting BP at the upper arm in a clinical setting (e.g. ward or office); identified a specific source of inaccuracy; and quantified its effect. Reference lists and reviews were searched for additional articles.

RESULTS

A total of 328 empirical studies were included. They investigated 29 potential sources of inaccuracy, categorized as relating to the patient, device, procedure or observer. Significant directional effects were found for 27; however, for some, the effects were inconsistent in direction. Compared with true resting BP, significant effects of individual sources ranged from -23.6 to +33 mmHg SBP and -14 to +23 mmHg DBP.

CONCLUSION

A single BP value outside the expected range should be interpreted with caution and not taken as a definitive indicator of clinical deterioration. Where a measurement is abnormally high or low, further measurements should be taken and averaged. Wherever possible, BP values should be recorded graphically within ranges. This may reduce the impact of sources of inaccuracy and reduce the scope for misinterpretations based on small, likely erroneous or misleading, changes.

A rigorous algorithm to detect and clean inaccurate adult height records within EHR systems

BACKGROUND

Height is a critical variable for many biomedical analyses because it is an important component of Body Mass Index (BMI). Transforming EHR height measures into meaningful research-ready values is challenging and there is limited information available on methods for "cleaning" these data.

OBJECTIVES

We sought to develop an algorithm to clean adult height data extracted from EHR using only height values and associated ages.

RESULTS

The algorithm we developed is sensitive to normal decreases in adult height associated with aging, is implemented using an open-source software tool and is thus easily modifiable, and is freely available. We checked the performance of our algorithm using data from the Northwestern biobank and a replication sample from the Marshfield Clinic biobank obtained through our participation in the eMERGE consortium. The algorithm identified 1262 erroneous values from a total of 33937 records in the Northwestern sample. Replacing erroneous height values with those identified as correct by the algorithm resulted in meaningful changes in height and BMI records; median change in recorded height after cleaning was 7.6 cm and median change in BMI was 2.9 kg/m(2). Comparison of cleaned EHR height values to observer measured values showed that 94.5% (95% C.I 93.8-% - 95.2%) of cleaned values were within 3.5 cm of observer measured values.

CONCLUSIONS

Our freely available height algorithm cleans EHR height data with only height and age inputs. Use of this algorithm will benefit groups trying to perform research with height and BMI data extracted from EHR.

Cardiovascular screening for men at high risk in Heart of Birmingham Teaching Primary Care Trust: the 'Deadly Trio' programme

BACKGROUND

The Deadly Trio programme offered cardiovascular health checks to men over 40 in inner-city Birmingham. The aim was to increase diagnosis of diabetes, cardiovascular and kidney disease among this deprived and ethnically diverse population. Either patients' own general practitioners (GPs) were paid to provide health checks or patients were invited to an alternative provider.

METHODS

Routine data were sought from 68 participating practices. Logistic regression analysis was undertaken to determine the patient and practice factors associated with being screened and with being added to a disease register.

RESULTS

Data were obtained from 58 practices; 5871 (24.3%) of 24 166 eligible men were screened. Screening uptake was higher in those with a recorded phone number, South Asians and Blacks but lower in smokers. Compared to the alternative provider, uptake was higher among men registered with single-handed (but not multi-partner) GPs paid to provide health checks. South Asian, older and screened men were more often added to disease registers. Men with missing information and GP-screened men were less likely to be added to registers.

CONCLUSIONS

The programme achieved higher screening uptake and diagnosis of disease among minority ethnic men. Single-handed GPs paid to provide screening (and their patients) were more responsive than multi-partner practices.

Population based time trends and socioeconomic variation in use of radiotherapy and radical surgery for prostate cancer in a UK region: continuous survey

OBJECTIVE

To examine variation in the management of prostate cancer in patients with different socioeconomic status.

DESIGN

Survey using UK regional cancer registry data.

SETTING

Regional population based cancer registry.

PARTICIPANTS

35 171 patients aged >or=51 with a diagnosis of prostate cancer, 1995-2006.

MAIN OUTCOME MEASURES

Use of radiotherapy and radical surgery. Socioeconomic status according to fifths of small area deprivation index.

RESULTS

Over the nine years of the study, information on stage at diagnosis was available for 15 916 of 27 970 patients (57%). During the study period, the proportion of patients treated with radiotherapy remained at about 25%, while use of radical surgery increased significantly (from 2.9% (212/7201) during 1995-7 to 8.4% (854/10 211) during 2004-6, P<0.001). Both treatments were more commonly used in least deprived compared with most deprived patients (28.5% v 21.0% for radiotherapy and 8.4% v 4.0% for surgery). In multivariable analysis, increasing deprivation remained strongly associated with lower odds of radiotherapy or surgery (odds ratio 0.92 (95% confidence interval 0.90 to 0.94), P<0.001, and 0.91 (0.87 to 0.94), P<0.001, respectively, per incremental deprivation group). There were consistently concordant findings with multilevel models for clustering of observations by hospital of diagnosis, with restriction of the analysis to patients with information on stage, and with sequential restriction of the analysis to different age, stage, diagnosis period, and morphology groups.

CONCLUSIONS

After a diagnosis of prostate cancer, men from lower socioeconomic groups were substantially less likely to be treated with radical surgery or radiotherapy. The causes and impact on survival of such differences remain uncertain.

Trends and variation in the management of oesophagogastric cancer patients: a population-based survey

Background

Previous evidence indicates potential variation in the quality of care of cancer patients. We aimed to examine whether recent changes in the treatment of oesophagogastric cancers have been distributed equally among different patient subgroups.

Methods

We analysed population-based cancer registry data about the treatment patterning of oesophagogastric cancer (other than oesophageal squamous cell carcinoma) during 1995-2006.

Results

There were 14,077 patients aged ≥40 years (69% men). There was only limited information on stage, and no information on co-morbidity status. During successive triennia, curative surgery use decreased from 28% to 20% (p < 0.001) whilst chemotherapy use increased from 9% to 30% (p < 0.001). Use of palliative surgery and of radiotherapy increased significantly but modestly (7% to 10%, and 9% to 11%, respectively). In multivariable logistic regression adjusting for age group, gender, diagnosis period and tumour type, curative surgery and chemotherapy were used less frequently in more deprived patients [per increasing deprivation group Odds Ratio (OR) = 0.96, 95% Confidence Interval (CI) 0.93-0.99, and OR = 0.90, 95%CI 0.87-0.93, respectively, p < 0.001 for both)]. Chemotherapy was also used less frequently in women (OR = 0.76, p < 0.001).

Conclusions

During the study period, curative surgery decreased by a third and chemotherapy use increased by more than three-fold, reflecting improvements in the appropriateness and quality of management, but chemotherapy use, in particular, was unequal, both by socioeconomic status and gender.

End-digits preference for self-reported height depends on language

Background

When individuals report figures, they often prefer to round to specific end-digits (e.g. zero). Such preference has been found in reports of body weight, cigarette consumption or blood pressure measurements. Very little is known about self-reported body height. End-digit preference can distort estimates of prevalence and other statistical parameters. This study examines end-digit preference for self-reported height and how it relates with sex, age, educational level or cultural affiliation.

Methods

We analysed reports of height of 47,192 individuals (aged 15 years or older) living in Switzerland and participating in one of the three population-based Swiss Health Surveys carried out in 1992/93, 1997 and 2002 respectively. Digit preferences were analysed by sex, age group, educational level, survey, smoking status, interview language (only for Swiss nationals) and nationality. Adjusted odds ratios (OR) with 95% confidence interval were calculated by using multivariate logistic regression.

Results

Italian and French nationals (44.1% and 40.6%) and Italian and French Swiss (39.6% and 35.3%) more strongly preferred zero and five than Germans and German Swiss (29.2% and 30.3%). Two, four, six and eight were more popular in Germans and German Swiss (both 44.4%). Compared to German Swiss (OR = 1), for the end-digits zero and five, the OR were 1.50 (1.38–1.63) for Italian Swiss and 1.24 (1.18–1.30) for French Swiss; 1.73 (1.58–1.89) for Italian nationals and 1.61 (1.33–1.95) for French nationals. The end-digits two, four, six and eight showed an opposite pattern.

Conclusion

Different preferences for end-digits depending on language and nationality could be observed consistently in all three national health surveys. The patterns were strikingly similar in Swiss and foreign nationals speaking the same language, suggesting that preferences were specific to language rather than to nationality. Taking into account rounding preferences could allow more valid comparisons in analyses of self-reported data originating from different cultures.