Is a Patient's Current Address of Record a Reasonable Measure of Neighborhood Deprivation Exposure? A Case for the Use of Point in Time Measures of Residence in Clinical Care

Neighborhood deprivation is not associated with abortion consideration or completion in patients with fetal myelomeningocele

OBJECTIVE

The objective of this study was to evaluate whether patient-level neighborhood deprivation index (NDI) was associated with termination of pregnancy consideration and completion in patients presenting with fetal myelomeningocele.

METHODS

This was a retrospective cohort analysis of patients with fetal myelomeningocele presenting to a fetal treatment center (FTC) in Illinois between 2018 and 2024. The exposure was NDI calculated from patient zip codes. The NDI was analyzed as both a dichotomous and ordinal exposure. The co-primary outcomes were abortion consideration prior to FTC consultation, ascertained by nurse intake, and abortion completion after consultation. Bivariate and log-binomial regression analyses were performed. Covariates were selected based on p < 0.10 on bivariate analyses. Otherwise, p < 0.05 indicated statistical significance.

RESULTS

A total of 157 participants were included. Evaluation of neighborhood deprivation as a dichotomous exposure revealed no association with abortion consideration or completion. AdditionallLy, no association was found on log binomial modeling after controlling for gestational age at presentation to the FTC and maternal race or ethnicity for abortion consideration (aRR 0.87, 95% CI 0.59-1.28) or completion (aRR 0.86, 95% CI 0.59-1.28). These results were similar when treating the NDI as an ordinal exposure.

CONCLUSIONS

Contrary to our hypothesis, NDI is not associated with abortion consideration or completion in patients with fetal myelomeningocele.

Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease

BACKGROUND

Pregnancy is an educable and actionable life stage to address social determinants of health (SDOH) and lifelong cardiovascular disease (CVD) prevention. However, the link between a risk score that combines multiple neighborhood-level social determinants in pregnancy and the risk of long-term CVD remains to be evaluated.

OBJECTIVE

To examine whether neighborhood-level socioeconomic disadvantage measured by the Area Deprivation Index (ADI) in early pregnancy is associated with a higher 30-year predicted risk of CVD postpartum, as measured by the Framingham Risk Score.

STUDY DESIGN

An analysis of data from the prospective Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be Heart Health Study longitudinal cohort. Participant home addresses during early pregnancy were geocoded at the Census-block level. The exposure was neighborhood-level socioeconomic disadvantage using the 2015 ADI by tertile (least deprived [T1], reference; most deprived [T3]) measured in the first trimester. Outcomes were the predicted 30-year risks of atherosclerotic cardiovascular disease (ASCVD, composite of fatal and nonfatal coronary heart disease and stroke) and total CVD (composite of ASCVD plus coronary insufficiency, angina pectoris, transient ischemic attack, intermittent claudication, and heart failure) using the Framingham Risk Score measured 2 to 7 years after delivery. These outcomes were assessed as continuous measures of absolute estimated risk in increments of 1%, and, secondarily, as categorical measures with high-risk defined as an estimated probability of CVD ≥10%. Multivariable linear regression and modified Poisson regression models adjusted for baseline age and individual-level social determinants, including health insurance, educational attainment, and household poverty.

RESULTS

Among 4309 nulliparous individuals at baseline, the median age was 27 years (interquartile range [IQR]: 23-31) and the median ADI was 43 (IQR: 22-74). At 2 to 7 years postpartum (median: 3.1 years, IQR: 2.5, 3.7), the median 30-year risk of ASCVD was 2.3% (IQR: 1.5, 3.5) and of total CVD was 5.5% (IQR: 3.7, 7.9); 2.2% and 14.3% of individuals had predicted 30-year risk ≥10%, respectively. Individuals living in the highest ADI tertile had a higher predicted risk of 30-year ASCVD % (adjusted ß: 0.41; 95% confidence interval [CI]: 0.19, 0.63) compared with those in the lowest tertile; and those living in the top 2 ADI tertiles had higher absolute risks of 30-year total CVD % (T2: adj. ß: 0.37; 95% CI: 0.03, 0.72; T3: adj. ß: 0.74; 95% CI: 0.36, 1.13). Similarly, individuals living in neighborhoods in the highest ADI tertile were more likely to have a high 30-year predicted risk of ASCVD (adjusted risk ratio [aRR]: 2.21; 95% CI: 1.21, 4.02) and total CVD ≥10% (aRR: 1.35; 95% CI: 1.08, 1.69).

CONCLUSION

Neighborhood-level socioeconomic disadvantage in early pregnancy was associated with a higher estimated long-term risk of CVD postpartum. Incorporating aggregated SDOH into existing clinical workflows and future research in pregnancy could reduce disparities in maternal cardiovascular health across the lifespan, and requires further study.

Neighborhood Disadvantage and Risk of Heart Failure: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

Heart failure (HF) affects >6 million US adults, with recent increases in HF hospitalizations. We aimed to investigate the association between neighborhood disadvantage and incident HF events and potential differences by diabetes status.

METHODS

We included 23 645 participants from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), a prospective cohort of Black and White adults aged ≥45 years living in the continental United States (baseline 2005-2007). Neighborhood disadvantage was assessed using a Z score of 6 census tract variables (2000 US Census) and categorized as quartiles. Incident HF hospitalizations or HF-related deaths through 2017 were adjudicated. Multivariable-adjusted Cox regression was used to examine the association between neighborhood disadvantage and incident HF. Heterogeneity by diabetes was assessed using an interaction term.

RESULTS

The mean age was 64.4 years, 39.5% were Black adults, 54.9% females, and 18.8% had diabetes. During a median follow-up of 10.7 years, there were 1125 incident HF events with an incidence rate of 3.3 (quartile 1), 4.7 (quartile 2), 5.2 (quartile 3), and 6.0 (quartile 4) per 1000 person-years. Compared to adults living in the most advantaged neighborhoods (quartile 1), those living in neighborhoods in quartiles 2, 3, and 4 (most disadvantaged) had 1.30 (95% CI, 1.06-1.60), 1.36 (95% CI, 1.11-1.66), and 1.45 (95% CI, 1.18-1.79) times greater hazard of incident HF even after accounting for known confounders. This association did not significantly differ by diabetes status (interaction P=0.59). For adults with diabetes, the adjusted incident HF hazards comparing those in quartile 4 versus quartile 1 was 1.34 (95% CI, 0.92-1.96), and it was 1.50 (95% CI, 1.16-1.94) for adults without diabetes.

CONCLUSIONS

In this large contemporaneous prospective cohort, neighborhood disadvantage was associated with an increased risk of incident HF events. This increase in HF risk did not differ by diabetes status. Addressing social, economic, and structural factors at the neighborhood level may impact HF prevention.

Community-level social determinants of health and pregestational and gestational diabetes

BACKGROUND

Individual adverse social determinants of health are associated with increased risk of diabetes in pregnancy, but the relative influence of neighborhood or community-level social determinants of health is unknown.

OBJECTIVE

This study aimed to determine whether living in neighborhoods with greater socioeconomic disadvantage, food deserts, or less walkability was associated with having pregestational diabetes and developing gestational diabetes.

STUDY DESIGN

We conducted a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be. Home addresses in the first trimester were geocoded at the census tract level. The exposures (modeled separately) were the following 3 neighborhood-level measures of adverse social determinants of health: (1) socioeconomic disadvantage, defined by the Area Deprivation Index and measured in tertiles from the lowest tertile (ie, least disadvantage [T1]) to the highest (ie, most disadvantage [T3]); (2) food desert, defined by the United States Department of Agriculture Food Access Research Atlas (yes/no by low income and low access criteria); and (3) less walkability, defined by the Environmental Protection Agency National Walkability Index (most walkable score [15.26-20.0] vs less walkable score [<15.26]). Multinomial logistic regression was used to model the odds of gestational diabetes or pregestational diabetes relative to no diabetes as the reference, adjusted for age at delivery, chronic hypertension, Medicaid insurance status, and low household income (<130% of the US poverty level).

RESULTS

Among the 9155 assessed individuals, the mean Area Deprivation Index score was 39.0 (interquartile range, 19.0-71.0), 37.0% lived in a food desert, and 41.0% lived in a less walkable neighborhood. The frequency of pregestational and gestational diabetes diagnosis was 1.5% and 4.2%, respectively. Individuals living in a community in the highest tertile of socioeconomic disadvantage had increased odds of entering pregnancy with pregestational diabetes compared with those in the lowest tertile (T3 vs T1: 2.6% vs 0.8%; adjusted odds ratio, 2.52; 95% confidence interval, 1.41-4.48). Individuals living in a food desert (4.8% vs 4.0%; adjusted odds ratio, 1.37; 95% confidence interval, 1.06-1.77) and in a less walkable neighborhood (4.4% vs 3.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.04-1.71) had increased odds of gestational diabetes. There was no significant association between living in a food desert or a less walkable neighborhood and pregestational diabetes, or between socioeconomic disadvantage and gestational diabetes.

CONCLUSION

Nulliparous individuals living in a neighborhood with higher socioeconomic disadvantage were at increased odds of entering pregnancy with pregestational diabetes, and those living in a food desert or a less walkable neighborhood were at increased odds of developing gestational diabetes, after controlling for known covariates.

Neighborhood Socioeconomic Disadvantage and Abnormal Birth Weight

OBJECTIVE

To examine whether exposure to community or neighborhood socioeconomic disadvantage as measured by the ADI (Area Deprivation Index) is associated with risk of abnormal birth weight among nulliparous individuals with singleton gestations.

METHODS

This was a secondary analysis from the prospective cohort NuMoM2b study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be). Participant addresses at cohort enrollment between 6 and 13 weeks of gestation were geocoded at the Census tract level and linked to the 2015 ADI. The ADI, which incorporates the domains of income, education, employment, and housing quality into a composite national ranking of neighborhood socioeconomic disadvantage, was categorized by quartiles (quartile 1, least disadvantaged, reference; quartile 4, most disadvantaged). Outcomes were large for gestational age (LGA; birth weight at or above the 90th percentile) and small for gestational age (SGA; birth weight below the 10th percentile) compared with appropriate for gestational age (AGA; birth weight 10th-90th percentile) as determined with the 2017 U.S. natality reference data, standardized for fetal sex. Multinomial logistic regression models were adjusted for potential confounding variables.

RESULTS

Of 8,983 assessed deliveries in the analytic population, 12.7% (n=1,143) were SGA, 8.2% (n=738) were LGA, and 79.1% (n=7,102) were AGA. Pregnant individuals living in the highest ADI quartile (quartile 4, 17.8%) had an increased odds of delivering an SGA neonate compared with those in the lowest referent quartile (quartile 1, 12.4%) (adjusted odds ratio [aOR] 1.32, 95% CI 1.09-1.55). Pregnant individuals living in higher ADI quartiles (quartile 2, 10.3%; quartile 3, 10.7%; quartile 4, 9.2%) had an increased odds of delivering an LGA neonate compared with those in the lowest referent quartile (quartile 1, 8.2%) (aOR: quartile 2, 1.40, 95% CI 1.19-1.61; quartile 3, 1.35, 95% CI 1.09-1.61; quartile 4, 1.47, 95% CI 1.20-1.74).

CONCLUSION

Neonates of nulliparous pregnant individuals living in U.S. neighborhoods with higher area deprivation were more likely to have abnormal birth weights at both extremes.

Association of Race and Area Deprivation With Breast Cancer Survival Among Black and White Women in the State of Georgia

Importance

Increasing evidence suggests that low socioeconomic status and geographic residence in disadvantaged neighborhoods contribute to disparities in breast cancer outcomes. However, little epidemiological research has sought to better understand these disparities within the context of location.

Objective

To examine the association between neighborhood deprivation and racial disparities in mortality among Black and White patients with breast cancer in the state of Georgia.

Design, Setting, and Participants

This population-based cohort study collected demographic and geographic data from patients diagnosed with breast cancer between January 1, 2004, and February 11, 2020, in 3 large health care systems in Georgia. A total of 19 580 patients with breast cancer were included: 12 976 from Piedmont Healthcare, 2285 from Grady Health System, and 4319 from Emory Healthcare. Data were analyzed from October 2, 2020, to August 11, 2022.

Exposures

Area deprivation index (ADI) scores were assigned to each patient based on their residential census block group. The ADI was categorized into quartile groups, and associations between ADI and race and ADI × race interaction were examined.

Main Outcomes and Measures

Cox proportional hazards regression models were used to compute hazard ratios (HRs) and 95% CIs associating ADI with overall mortality by race. Kaplan-Meier curves were used to visualize mortality stratified across racial and ADI groups.

Results

Of the 19 580 patients included in the analysis (mean [SD] age at diagnosis, 58.8 [13.2] years), 3777 (19.3%) died during the course of the study. Area deprivation index contributed differently to breast cancer outcomes for Black and White women. In multivariable-adjusted models, living in a neighborhood with a greater ADI (more deprivation) was associated with increased mortality for White patients with breast cancer; compared with the ADI quartile of less than 25 (least deprived), increased mortality HRs were found in quartiles of 25 to 49 (1.22 [95% CI, 1.07-1.39]), 50 to 74 (1.32 [95% CI, 1.13-1.53]), and 75 or greater (1.33 [95% CI, 1.07-1.65]). However, an increase in the ADI quartile group was not associated with changes in mortality for Black patients with breast cancer (quartile 25 to 49: HR, 0.81 [95% CI, 0.61-1.07]; quartile 50 to 74: HR, 0.91 [95% CI, 0.70-1.18]; and quartile ≥75: HR, 1.05 [95% CI, 0.70-1.36]). In neighborhoods with an ADI of 75 or greater, no racial disparity was observed in mortality (HR, 1.11 [95% CI, 0.92-1.36]).

Conclusions and Relevance

Black women with breast cancer had higher mortality than White women in Georgia, but this disparity was not explained by ADI: among Black patients, low ADI was not associated with lower mortality. This lack of association warrants further investigation to inform community-level approaches that may mitigate the existing disparities in breast cancer outcomes in Georgia.

Associations Between Different Self-reported Social Risks and Neighborhood-level Resources in Medicaid Patients

BACKGROUND

Adverse social conditions are a key contributor to health disparities. Improved understanding of how social risk factors interact with each other and with neighborhood characteristics may inform efforts to reduce health disparities.

DATA

A questionnaire of 29,281 patients was collected through the enrollment of Medicaid beneficiaries in a large Northern California integrated health care delivery system between May 2016 and February 2020.

EXPOSURES

Living in the least resourced quartile of neighborhoods as measured by a census-tract level Neighborhood Deprivation Index score.

MAIN OUTCOMES

Five self-reported social risk factors: financial need, food insecurity, housing barriers, transportation barriers, and functional limitations.

RESULTS

Nearly half (42.0%) of patients reported at least 1 social risk factor; 22.4% reported 2 or more. Mean correlation coefficient between social risk factors was ρ=0.30. Multivariable logistic models controlling for age, race/ethnicity, sex, count of chronic conditions, and insurance source estimated that living in the least resourced neighborhoods was associated with greater odds of food insecurity (adjusted odds ratio=1.07, 95% confidence interval: 1.00-1.13) and transportation barriers (adjusted odds ratio=1.20, 95% confidence interval: 1.11-1.30), but not financial stress, housing barriers, or functional limitations.

CONCLUSIONS AND RELEVANCE

We found that among 5 commonly associated social risk factors, Medicaid patients in a large Northern California health system typically reported only a single factor and that these factors did not correlate strongly with each other. We found only modestly greater social risk reported by patients in the least resourced neighborhoods. These results suggest that individual-level interventions should be targeted to specific needs whereas community-level interventions may be similarly important across diverse neighborhoods.

Relationships Between Socioeconomic Deprivation and Pediatric Firearm-Related Injury at the Neighborhood Level

BACKGROUND

Disparities in pediatric injury are widely documented and partly driven by differential exposures to social determinants of health (SDH). Here, we examine associations between neighborhood-level SDH and pediatric firearm-related injury admissions as a step to defining specific targets for interventions to prevent injury.

METHODS

We conducted a retrospective review of patients ≤16 years old admitted to our level 1 pediatric trauma center (2010-2019) after a firearm-related injury. We extracted patients' demographic characteristics and intent of injury. We geocoded home addresses to enable quantification of injury-related admissions at the neighborhood (census tract) level. Our population-level exposure variable was a socioeconomic deprivation index for each census tract.

RESULTS

Out of 15,686 injury-related admissions, 140 were for firearm-related injuries (median age 14 years [IQR 11,15]). Patients with firearm-related injuries were 75% male and 64% Black; 66% had public insurance. Nearly half (47%) of firearm-related injuries were a result of assault, 32% were unintentional, and 6% were self-inflicted; 9% died. At the neighborhood level, the distribution of firearm-related injuries significantly differed by deprivation quintile (p < .05). Children from the highest deprivation quintile experienced 25% of injuries of all types, 57% of firearm-related injuries, and 70% of all firearm-related injuries from assault. They had an overall risk of firearm-related injury 30-times that of children from the lowest deprivation quintile.

CONCLUSIONS

Increased neighborhood socioeconomic deprivation is associated with more firearm-related injuries requiring hospitalization, at rates far higher than injury-related admissions overall. Addressing neighborhood-level social determinants of health may help prevent pediatric firearm-related injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological - Level III.

Quantifying the population burden of musculoskeletal disorders, including impact on sickness absence: analysis of national Scottish data

Objectives

Musculoskeletal disorders (MSDs) account for the greatest burden of years lived with disability globally. To prevent disability, good-quality services need to be commissioned, appropriate for local need. We analysed data collected systematically from a new musculoskeletal service serving 70% of the population of Scotland to evaluate: age- and sex-specific occurrence; anatomical distribution; and impact and effect on work ability.

Methods

A new centralized telephone-based triage for people with musculoskeletal disorders was set up in Scotland in 2015. Available to most of the population aged >16 years (>3 million people), data were collected systematically into a database detailing: anatomical site, nature of onset, duration, impact/risk (modified STarT score), deprivation level and, for those in employment, sickness absence.

Results

Data were available from 219 314 new callers, 2015–18. Calls were more frequently from women (60%), increased with age until the eighth decade, and 66% reported symptoms that had been present for >6 weeks. Callers were more likely to be living in more deprived areas in each age band between 20 and 64 years and tended to have higher-impact symptoms. The majority (53%) of callers were in employment, and 19% of these were off sick because of their symptoms. Sickness absence was more common among those with highest impact/risk scores from deprived areas with more acute symptoms.

Discussion

Large-scale systematic data collection for MSDs emphasizes the size and impact of the burden among adults aged >16 years. A socio-economic gradient is evident in terms of prevalence and impact of MSDs, particularly for sickness absence.

Resilience to COVID-19: Socioeconomic Disadvantage Associated With Positive Caregiver-Youth Communication and Youth Preventative Actions

Socioeconomic disadvantage is associated with larger COVID-19 disease burdens and pandemic-related economic impacts. We utilized the longitudinal Adolescent Brain Cognitive Development Study to understand how family- and neighborhood-level socioeconomic disadvantage relate to disease burden, family communication, and preventative responses to the pandemic in over 6,000 youth-caregiver dyads. Data were collected at three timepoints (May-August 2020). Here, we show that both family- and neighborhood-level disadvantage were associated with caregivers' reports of greater family COVID-19 disease burden, less perceived exposure risk, more frequent caregiver-youth conversations about COVID-19 risk/prevention and reassurance, and greater youth preventative behaviors. Families with more socioeconomic disadvantage may be adaptively incorporating more protective strategies to reduce emotional distress and likelihood of COVID-19 infection. The results highlight the importance of caregiver-youth communication and disease-preventative practices for buffering the economic and disease burdens of COVID-19, along with policies and programs that reduce these burdens for families with socioeconomic disadvantage.

Mobility and social deprivation on primary care utilisation among paediatric patients with asthma

OBJECTIVE

Asthma care is negatively impacted by neighbourhood social and environmental factors, and moving is associated with undesirable asthma outcomes. However, little is known about how movement into and living in areas of high deprivation relate to primary care use. We examined associations between neighbourhood characteristics, mobility and primary care utilisation of children with asthma to explore the relevance of these social factors in a primary care setting.

DESIGN

In this cohort study, we conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates.

SETTING

We used data from community health centres in 15 OCHIN states.

PARTICIPANTS

The sample included 23 773 children with asthma aged 3-17 across neighbourhoods with different levels of social deprivation from 2012 to 2017. We conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates.

RESULTS

Clinic visit rates were higher among children living in or moving to areas with higher deprivation than those living in areas with low deprivation (rate ratio (RR) 1.09, 95% CI 1.02 to 1.17; RR 1.05, 95% CI 1.00 to 1.11). Children moving across neighbourhoods with similarly high levels of deprivation had increased RRs of influenza vaccination (RR 1.13, 95% CI 1.03 to 1.23) than those who moved but stayed in neighbourhoods of low deprivation.

CONCLUSIONS

Movement into and living within areas of high deprivation is associated with more primary care use, and presumably greater opportunity to reduce undesirable asthma outcomes. These results highlight the need to attend to patient movement in primary care visits, and increase neighbourhood-targeted population management to improve equity and care for children with asthma.

The Quality of End-of-Life Care for Women Deceased From Metastatic Breast Cancer

Metastatic breast cancer (MBC) carries unique disease burdens with potential for poor-quality end-of-life (EOL) care. It is the purpose of this article to explore the association of poor-quality EOL care indicators according to key tumor, demographic, social, and clinical factors. End-of-life quality indicators were based on Emanuel and Emanuel's good death model in conjunction with Earle et al (2003). A single-institution retrospective chart review of women deceased from MBC between November 2016 and November 2019 with double-verification chart review was completed. Data were analyzed with descriptive, correlative, and comparative statistics. Total sample was N = 167 women, with 14.4% (n = 24) Black and 85.6% (n = 143) White. Mean (SD) age was 55.3 (11.73) years. Overall, MBC survival was 3.12 years (SD, 3.31): White women, 41.2 months (3.4 years), and Black women, 19 months (1.6 years). A total of 64.1% (n = 107) experienced 1 or more indicators of poor-quality EOL care. Patients more likely to experience poor-quality EOL care were older (P = .03), estrogen negative (P = .08), human epidermal growth factor receptor 2 negative (P = .07), from more deprived neighborhoods (P = .02), married (P = .05), and with physical (P = .001) and mental (P = .002) comorbidities. Understanding sociodemographic and clinical factors associated with poor EOL MBC care may be useful for proactive patient navigation.

Resilience to COVID-19: Socioeconomic Disadvantage Associated With Higher Positive Parent-youth Communication and Youth Disease-prevention Behavior

Socioeconomic disadvantage is associated with larger COVID-19 disease burdens and pandemic-related economic impacts. We utilized the longitudinal Adolescent Brain Cognitive Development Study to understand how family- and neighborhood-level socioeconomic disadvantage relate to disease burden, family communication, and preventative responses to the pandemic in over 6,000 youth-parent/caregiver dyads. Data were collected at three timepoints (May to August 2020). Here, we show that both family- and neighborhood-level disadvantage were associated with parents’ reports of greater family COVID-19 exposure risk and diagnoses, less perceived exposure risk, more frequent parent-youth conversations about COVID-19 risk/prevention and reassurance, and greater youth preventative behaviors. More disadvantaged families may be adaptively incorporating more protective strategies to reduce emotional distress and likelihood of COVID-19 infection. The results highlight the importance of parent-youth communication and disease-preventative practices for buffering the economic and disease burdens of COVID-19, along with policies and programs that reduce these burdens for families with socioeconomic disadvantage.

Relation of Neighborhood Disadvantage to Heart Failure Symptoms and Hospitalizations

Residence in socioeconomically deprived neighborhoods may influence patient's health-related behaviors and overall health. We evaluated the association of neighborhood disadvantage on heart failure (HF) symptom burden and hospitalization rates. We characterized neighborhood deprivation in 359 HF subjects (age 56 ± 13 years, 52% black) in metropolitan Atlanta using the Area Deprivation Index (ADI). ANOVA was used to compare HF symptoms measured using the Kansas City Cardiomyopathy Questionnaire, and HF Self-Care Index across ADI tertiles. Zero-inflated Poisson regression was used to compare rates of recurrent HF hospitalization (HFH) across ADI tertiles. Subjects living in more deprived neighborhoods were more likely to be black, have Medicare or Medicaid insurance, and have a lower ejection fraction than those living in less deprived neighborhoods (all p ≤ 0.005). Subjects in more deprived neighborhoods had more severe HF symptoms (p < 0.001), but there was no difference in HF Self-Care Index scores across ADI tertiles. Subjects living in more deprived neighborhoods had a higher odds of being hospitalized for HF than subjects in less deprived neighborhoods. Once subjects had experienced a HFH, however, the association between ADI and the risk of recurrent HFH varied by racial group. In whites, increasing ADI was associated with a marginally decreased risk of recurrent HFH, while there was no association between ADI and recurrent HFH in blacks. In conclusion, patients with HF living in more deprived neighborhoods have greater symptom burden and are more likely to experience a HFH than those living in less deprived neighborhoods.

Incorporating a location-based socioeconomic index into a de-identified i2b2 clinical data warehouse

OBJECTIVE

Clinical research data warehouses are largely populated from information extracted from electronic health records (EHRs). While these data provide information about a patient's medications, laboratory results, diagnoses, and history, her social, economic, and environmental determinants of health are also major contributing factors in readmission, morbidity, and mortality and are often absent or unstructured in the EHR. Details about a patient's socioeconomic status may be found in the U.S. census. To facilitate researching the impacts of socioeconomic status on health outcomes, clinical and socioeconomic data must be linked in a repository in a fashion that supports seamless interrogation of these diverse data elements. This study demonstrates a method for linking clinical and location-based data and querying these data in a de-identified data warehouse using Informatics for Integrating Biology and the Bedside.

MATERIALS AND METHODS

Patient data were extracted from the EHR at Nebraska Medicine. Socioeconomic variables originated from the 2011-2015 five-year block group estimates from the American Community Survey. Data querying was performed using Informatics for Integrating Biology and the Bedside. All location-based data were truncated to prevent identification of a location with a population <20 000 individuals.

RESULTS

We successfully linked location-based and clinical data in a de-identified data warehouse and demonstrated its utility with a sample use case.

DISCUSSION

With location-based data available for querying, research investigating the impact of socioeconomic context on health outcomes is possible. Efforts to improve geocoding can readily be incorporated into this model.

CONCLUSION

This study demonstrates a means for incorporating and querying census data in a de-identified clinical data warehouse.