Persistent Cardiometabolic Health Gaps: Can Therapeutic Care Gaps Be Precisely Identified from Electronic Health Records
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Population
2.2. Data Sources
2.3. Study Outcomes: Health and Care Gaps
2.4. Statistical Analysis
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
- 250.xx, primary diabetes (except for 250.x1 and 250.x3, which specify type I)
- 357.2, polyneuropathy in diabetes
- 362.0x, diabetic retinopathy
- 366.41, diabetic cataract
- ≥2 diagnoses from inpatient or outpatient encounters on separate days, OR
- ≥1 diagnosis from an inpatient or outpatient encounter and ≥1 evidence of insulin, OR
- ≥1 diagnosis from an inpatient or outpatient encounter and ≥1 evidence of oral antihyperglycemic, OR
- ≥2 qualifying lab values on separate days, OR
- ≥1 qualifying lab value and ≥1 evidence of insulin, OR
- ≥1 qualifying lab value and ≥1 evidence of oral antihyperglycemic
- Hemoglobin A1c ≥ 6.5%, OR
- Oral Glucose Tolerance Test ≥ 200 mg/dL, OR
- Random/Fasting Plasma Glucose in any setting ≥ 200 mg/dL, OR
- Fasting Plasma Glucose in an inpatient ≥ 126 mg/dL
- Patients whose problem list or previous encounters specify Type 1 (250.x1, 250.x3) AND contain no ICD9 codes for type II diabetes (defined above), OR
- All medication orders are for Insulin (no oral antidiabetic medication orders) AND contain no ICD9 codes for type II diabetes (defined above).
- 401.x
- 402.x
- 403.x
- 404.x
- 405.x
- ≥2 diagnoses from inpatient or outpatient encounters on separate days, OR
- ≥2 qualifying BP measurements on separate days,
- BP ≥ 140/90 for any patient
- BP ≥ 130/80 for diabetics
- Problem list specifies “white coat hypertension,” “prehypertension,” or “elevated blood pressure”
- All ICD9s explicitly reference 796.2 (elevated BP reading without a diagnosis of hypertension)
- Exclude BP measurements made in inpatient, emergency department, or ambulatory surgery center settings from contributing to a diagnosis.
- 272.x
- ≥2 diagnoses from inpatient or outpatient encounters on separate days, OR
- ≥1 diagnosis from inpatient or outpatient encounters on separate days AND ≥ 1 qualifying lab value or ≥ 1 medication order, OR
- ≥2 qualifying lab values on separate days
- LDL ≥ 160 mg/dL (4.14 mmol/L)
Patient Medication Adherence | Hypertension Health Gap (n =83,033) | Hyperlipidemia Health Gap (n = 54,647) | Diabetes Health Gap (n = 31,297) | ||||||
---|---|---|---|---|---|---|---|---|---|
PCT | Unadjusted | Adjusted a | PCT | Unadjusted | Adjusted a | PCT | Unadjusted | Adjusted a | |
White | |||||||||
80%+ PDC | 7.7% | Ref | Ref | 27.1% | Ref | Ref | 33.7% | Ref | Ref |
0–79% PDC | 36.6% | 1.10 (1.05–1.15) | 1.01 (0.96–1.05) | 6.8% | 2.89 (2.70–3.09) | 2.94 (2.74–3.15) | 10.9% | 1.10 (0.99–1.21) | 1.14 (1.03–1.26) |
Patient did not retrieve medication | 39.4% | 1.39 (1.36–1.43) | 1.20 (1.16–1.23) | 27.3% | 1.61 (1.53–1.69) | 1.68 (1.61–1.77) | 25.3% | 1.24 (1.16–1.33) | 1.26 (1.17–1.36) |
No medication order | 16.3% | 1.43 (1.39–1.48) | 1.21 (1.17–1.25) | 38.9% | 4.64 (4.44–4.84) | 6.11 (5.83–6.4) | 30.2% | 5.67 (5.26–6.11) | 5.52 (5.11–5.96) |
African American | |||||||||
80%+ PDC | 12.3% | Ref | Ref | 25.5% | Ref | Ref | 31.2% | Ref | Ref |
0–79% PDC | 40.6% | 0.96 (0.83–1.11) | 0.87 (0.75–1.01) | 10.2% | 2.67 (2.09–3.42) | 2.70 (2.09–3.48) | 15.8% | 1.22 (0.92–1.61) | 1.27 (0.95–1.69) |
Patient did not retrieve medication | 33.5% | 1.53 (1.37–1.70) | 1.30 (1.16–1.45) | 23.5% | 2.06 (1.69–2.51) | 2.07 (1.68–2.53) | 23.1% | 1.41 (1.11–1.78) | 1.49 (1.17–1.91) |
No medication order | 13.6% | 1.54 (1.33–1.77) | 1.30 (1.12–1.51) | 40.9% | 3.64 (3.05–4.34) | 4.71 (3.88–5.73) | 30.0% | 6.92 (5.38–8.90) | 7.31 (5.63–9.49) |
Asian | |||||||||
80%+ PDC | 8.5% | Ref | Ref | 22.2% | Ref | Ref | 32.4% | Ref | Ref |
0–79% PDC | 38.8% | 1.16 (1.05–1.28) | 1.05 (0.95–1.17) | 7.2% | 2.87 (2.51–3.29) | 3.25 (2.81–3.75) | 10.6% | 1.22 (1.02–1.46) | 1.28 (1.06–1.53) |
Patient did not retrieve medication | 38.0% | 1.50 (1.41–1.59) | 1.28 (1.19–1.36) | 25.9% | 1.64 (1.48–1.81) | 1.75 (1.58–1.95) | 27.7% | 1.34 (1.18–1.53) | 1.42 (1.24–1.62) |
No medication order | 14.6% | 1.59 (1.46–1.73) | 1.31 (1.20–1.43) | 44.7% | 3.30 (3.01–3.60) | 5.43 (4.90–6.02) | 29.3% | 5.21 (4.57–5.93) | 5.37 (4.69–6.14) |
Other | |||||||||
80%+ PDC | 9.1% | Ref | Ref | 23.9% | Ref | Ref | 34.2% | Ref | Ref |
0–79% PDC | 35.1% | 0.98 (0.91–1.07) | 0.89 (0.82–0.97) | 8.2% | 2.76 (2.45–3.09) | 2.92 (2.58–3.29) | 13.7% | 1.12 (0.96–1.30) | 1.19 (1.02–1.38) |
Patient did not retrieve medication | 39.1% | 1.57 (1.50–1.66) | 1.33 (1.27–1.41) | 25.4% | 1.84 (1.68–2.01) | 1.93 (1.76–2.12) | 25.6% | 1.22 (1.08–1.37) | 1.26 (1.12–1.42) |
No medication order | 16.8% | 1.64 (1.54–1.75) | 1.37 (1.29–1.47) | 42.5% | 3.57 (3.30–3.86) | 5.13 (4.70–5.60) | 26.5% | 5.89 (5.22–6.65) | 6.14 (5.42–6.95) |
Patients with or without Therapeutic Care Gap for Hypertension | |||||
---|---|---|---|---|---|
Baseline Status | Category | With Care Gap (n = 25,060) | No Care Gap (n = 44,892) | Uncertain (n = 13,028) | p-Value |
Diagnosed CM Diseases | 1 | 19.5% | 21.8% | 31.3% | <0.001 |
2 | 49.0% | 49.5% | 48.4% | ||
3 | 31.5% | 27.7% | 20.3% | ||
Gender | Female | 56.4% | 55.8% | 56.0% | 0.44 |
Male | 43.6% | 44.2% | 44.0% | ||
Age | 35–44 | 3.2% | 3.2% | 5.7% | <0.001 |
45–54 | 11.5% | 13.1% | 17.0% | ||
55–64 | 21.0% | 22.6% | 24.2% | ||
65–74 | 29.8% | 29.0% | 26.9% | ||
75+ | 34.6% | 32.1% | 26.2% | ||
Race | White | 67.6% | 66.7% | 68.8% | <0.001 |
Black | 5.4% | 4.8% | 4.1% | ||
Asian | 9.9% | 11.2% | 9.4% | ||
Other | 17.1% | 18.3% | 17.7% | ||
Hispanic | Yes | 10.0% | 10.0% | 9.9% | 0.95 |
No | 90.0% | 90.0% | 90.1% | ||
BMI | <25 | 22.4% | 21.9% | 24.3% | <0.001 |
25–29 | 34.0% | 35.3% | 35.6% | ||
30–34 | 24.3% | 22.6% | 22.8% | ||
35+ | 19.0% | 18.6% | 16.8% | ||
Missing | 0.3% | 0.6% | 0.5% | ||
Smoking Status | Yes | 5.9% | 6.3% | 6.7% | <0.001 |
Passive or quit | 40.9% | 38.0% | 35.9% | ||
No | 53.2% | 55.7% | 57.4% | ||
Charlson Score | 0 | 51.6% | 59.9% | 63.2% | <0.001 |
1–2 | 39.1% | 33.7% | 30.8% | ||
3+ | 9.3% | 6.4% | 5.9% | ||
Baseline SBP | Mean(std) | 153.4 (13.4) | 151.9 (12.6) | 150.4 (11.9) | 0.34 |
Baseline DBP | Mean(std) | 81.7 (11.3) | 81.9 (10.9) | 82.7 (10.3) | 0.31 |
Baseline Adherence | ≥80% | 10.2% | 15.4% | 5.7% | <0.001 |
0–79% | 41.3% | 84.6% | 24.8% | ||
Not retrieved | 48.5% | 0% | 41.1% | ||
No medication order | 0% | 0% | 28.4% |
Patients with or without Therapeutic Care Gap for Dyslipidemia | |||||
---|---|---|---|---|---|
Baseline Status | Category | With Care Gap (n = 10,972) | No Care Gap (n = 26,748) | Uncertain (n = 3644) | p-Value |
Diagnosed CM Diseases | 1 | 20.3% | 22.3% | 10.6% | <0.001 |
2 | 46.1% | 50.2% | 43.2% | ||
3 | 33.6% | 27.5% | 46.2% | ||
Gender | Female | 56.7% | 60.8% | 60.4% | <0.001 |
Male | 43.3% | 39.2% | 39.6% | ||
Age | 35–44 | 5.8% | 6.1% | 3.8% | <0.001 |
45–54 | 21.4% | 21.8% | 16.4% | ||
55–64 | 32.8% | 30.7% | 27.0% | ||
65–74 | 26.0% | 24.5% | 27.9% | ||
75+ | 14.0% | 17.0% | 24.9% | ||
Race | White | 60.7% | 61.8% | 61.8% | <0.001 |
Black | 4.7% | 3.7% | 4.1% | ||
Asian | 14.0% | 15.6% | 14.4% | ||
Other | 20.6% | 19.0% | 19.7% | ||
Hispanic | Yes | 12.5% | 9.9% | 11.3% | <0.001 |
No | 87.5% | 90.1% | 88.8% | ||
BMI | <25 | 19.6% | 24.4% | 20.9% | <0.001 |
25–29 | 37.9% | 37.7% | 37.3% | ||
30–34 | 24.8% | 22.7% | 24.4% | ||
35+ | 17.4% | 14.9% | 17.0% | ||
Missing | 0.3% | 0.4% | 0.4% | ||
Smoking Status | Yes | 8.0% | 5.9% | 6.6% | <0.001 |
Passive or quit | 33.9% | 31.8% | 36.5% | ||
No | 58.1% | 62.3% | 57.0% | ||
Charlson Score | 0 | 65.6% | 68.6% | 57.3% | <0.001 |
1–2 | 29.1% | 27.1% | 35.4% | ||
3+ | 5.3% | 4.3% | 7.3% | ||
Baseline LDL-C | Mean(std) | 155.2 (33.7) | 148.0 (29.2) | 138.1 (29.3) | 0.02 |
Baseline Adherence | ≥80% | 15.6% | 10.2% | 25.6% | <0.001 |
0–79% | 7.3% | 6.0% | 18.5% | ||
Not retrieved | 13.7% | 14.3% | 55.9% | ||
No medication order | 63.5% | 69.5% | 0% |
Patients with or without Therapeutic Care Gap for Diabetes | |||||
---|---|---|---|---|---|
Baseline Status | Category | With Care Gap (n = 10,051) | No Care Gap (n = 7703) | Uncertain (n = 4927) | p-Value |
Diagnosed CM Diseases | 1 | 1.8% | 1.2% | 2.0% | <0.001 |
2 | 19.0% | 16.5% | 18.5% | ||
3 | 79.2% | 82.8% | 79.5% | ||
Gender | Female | 45.6% | 48.2% | 48.3% | <0.001 |
Male | 54.4% | 51.8% | 51.7% | ||
Age | 35–44 | 6.6% | 5.0% | 5.7% | |
45–54 | 21.9% | 17.5% | 17.9% | <0.001 | |
55–64 | 28.6% | 28.0% | 25.8% | ||
65–74 | 26.5% | 28.3% | 27.0% | ||
75+ | 16.5% | 21.3% | 23.5% | ||
Race | White | 52.8% | 52.6% | 51.4% | 0.13 |
Black | 4.5% | 5.4% | 5.2% | ||
Asian | 18.5% | 18.2% | 19.0% | ||
Other | 24.0% | 23.9% | 24.4% | ||
Hispanic | Yes | 15.2% | 16.2% | 15.7% | 0.31 |
No | 84.8% | 83.8% | 84.3% | ||
BMI | <25 | 13.0% | 13.4% | 15.1% | <0.001 |
25–29 | 29.6% | 29.2% | 31.5% | ||
30–34 | 28.2% | 27.6% | 27.4% | ||
35+ | 28.8% | 29.5% | 25.5% | ||
Missing | 0.4% | 0.3% | 0.5% | ||
Smoking Status | Yes | 6.0% | 6.2% | 6.3% | 0.31 |
Passive or quit | 35.4% | 36.9% | 35.7% | ||
No | 58.6% | 56.8% | 58.6% | ||
Charlson Score | 0 | 42.9% | 42.6% | 45.6% | 0.001 |
1–2 | 46.2% | 46.5% | 44.5% | ||
3+ | 10.9% | 10.9% | 9.9% | ||
Baseline HbA1c | Mean(std) | 8.3 (1.5) | 8.2 (1.4) | 8.0 (1.3) | 0.20 |
Baseline Adherence | ≥80% | 21.8% | 91.7% | 35.5% | <0.001 |
0–79% | 5.1% | 8.3% | 29.1% | ||
Not retrieved | 57.9% | 0% | 14.8% | ||
No medication order | 15.1% | 0% | 20.7% |
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Disease | Health Gap | Criteria a | |
---|---|---|---|
Health Gap Criteria | Hypertension | Yes | Diastolic BP ≥ 90 mmHg OR systolic BP ≥ 140 mmHg in two consecutive clinical encounters |
Dyslipidemia | Yes | If CHD 10-year risk b > 20% then LDL health gap was defined as ≥ 100 mg/dL If there were 2+ risk factors b or the 10-year risk ≤ 20% then the LDL health gap was defined as ≥ 130 mg/dL If there were 0–1 risk factors then the LDL health gap was defined as ≥ 160 mg/dL | |
Type II Diabetes | Yes | HgA1c ≥ 7.0%. | |
Therapeutic Care Gap Criteria | Medication Order Status Prior to Gap Identification | Care Gap Present | Criteria of Actions Taken to Close Therapeutic Inertia |
Medication ordered by physician and retrieved by patient with PDC ≥ 80% | No | Treatment is intensified by increasing the dose of at least one medication or by adding a second medication to the existing regimen | |
Yes | Medication is the same as the pre-health gap medication(s), or no medication was prescribed in the post health gap period | ||
Uncertain | Part of the medication regimen has been changed or, for medications that are not changed, doses are the same | ||
Medication ordered by physician and retrieved by patient with PDC < 80% | No c | Reorder the existing medication d | |
Yes | There was no continuation of the medication order | ||
Uncertain | Patient continued to have low adherence and it is unknown whether the physician had a discussion with the patient to improve adherence | ||
Medication ordered by physician but not retrieved by the patient | No | A medication was re-ordered in the post health gaps period d | |
Yes | No medication was prescribed in the post health gap period | ||
No Medication ordered | No | A medication was ordered in the post health gap period | |
Yes | No medication was ordered in the post health gap period, and it is uncertain if the patient refused to take a medication or discontinued as a primary care patient with the physician |
Baseline Status | Category | Percent of Total Population (n = 252,181) | Percent of the Total Source Population with a Diagnosis | ||
---|---|---|---|---|---|
Hypertension | Hyperlipidemia | Diabetes | |||
n = 191,876 | n = 188,366 | n = 57,534 | |||
Total | 100% | 76% | 75% | 3% | |
Diagnosed CM Diseases | 1 | 43.6% | 28.7% | 28.1% | 2.2% |
2 | 38.6% | 47.9% | 48.1% | 19.9% | |
3 | 17.8% | 23.4% | 23.8% | 77.9% | |
Gender | Female | 54.6% | 55.0% | 52.0% | 51.0% |
Male | 45.4% | 45.0% | 48.0% | 49.0% | |
Age | 35–44 | 7.6% | 6.3% | 6.1% | 5.0% |
45–54 | 20.8% | 18.4% | 18.6% | 17.0% | |
55–64 | 26.6% | 25.7% | 26.6% | 25.6% | |
65–74 | 25.0% | 26.4% | 27.1% | 28.2% | |
75+ | 19.9% | 23.2% | 21.7% | 24.2% | |
Race | White | 64.6% | 66.3% | 64.4% | 55.2% |
Black | 3.5% | 4.0% | 3.2% | 5.4% | |
Asian | 13.5% | 11.7% | 14.1% | 17.0% | |
Other | 18.4% | 18.1% | 18.3% | 22.4% | |
Hispanic | Yes | 9.6% | 9.9% | 9.7% | 14.3% |
No | 90.4% | 90.1% | 90.3% | 85.7% | |
BMI | <25 | 26.1% | 24.0% | 24.8% | 16.1% |
25–29 | 36.9% | 35.8% | 37.9% | 31.1% | |
30–34 | 21.8% | 23.1% | 22.5% | 26.9% | |
35+ | 14.7% | 16.6% | 14.3% | 25.5% | |
Missing | 0.6% | 0.6% | 0.5% | 0.5% | |
Charlson Score | 0 | 68.6% | 65.1% | 67.0% | 47.9% |
1–2 | 26.7% | 29.5% | 28.0% | 42.3% | |
3+ | 4.6% | 5.4% | 5.0% | 9.8% | |
% with qualified biometric measure a | Yes | 95.4% | 98.2% | 91.9% | 95.1% |
Health Gap b | Yes | 54.3% c | 43.8% | 33.5% | 57.2% |
% of patient with dispense data | Yes | 81% | 85% | 75% | 78% |
Patient Medication Adherence b | Hypertension Health Gap (n = 83,033) | Hyperlipidemia Health Gap (n = 54,647) | Diabetes Health Gap (n = 31,297) | ||||||
---|---|---|---|---|---|---|---|---|---|
PCT | Unadjusted | Adjusted a | PCT | Unadjusted | Adjusted a | PCT | Unadjusted | Adjusted a | |
80%+ PDC b | 36.7% d | Ref | Ref | 25.7% d | Ref | Ref | 34.0% d | Ref | Ref |
0–79% PDC | 8.2% | 1.07 (1.02–1.12) | 0.97 (0.91–1.02) | 7.4% | 3.21 (2.76–4.34) | 3.23 (2.50–4.39) | 11.6% | 1.17 (1.06–1.30) | 1.15 (1.08–1.33) |
Patient did not retrieve medication | 38.9% | 1.44 (1.41–1.47) | 1.23 (1.21–1.26) | 26.6% | 1.67 (1.61–1.74) | 1.76 (1.69–1.83) | 27.5% | 1.25 (1.19–1.32) | 1.30 (1.23–1.37) |
No medication order c | 16.1% | 1.48 (1.44–1.53) | 1.25 (1.22–1.29) | 40.4% | 4.19 (4.05–4.33) | 5.80 (5.58–6.02) | 26.8% | 5.62 (5.32–5.94) | 5.66 (5.35–5.99) |
Medication Adherence | Therapeutic Care Gap Present | HTN with BP Health Gap (n = 82,980) a | Hyperlipidemia with LDL Health Gap (n = 41,405) b | Diabetes with HbA1c Health Gap (n = 23,131) c | |||
---|---|---|---|---|---|---|---|
Overall | No | 30.2% | 26.5% | 45.4% | |||
Yes | 54.1% | 64.6% | 33.3% | ||||
Uncertain | 15.7% | 8.9% | 21.3% | ||||
80%+ PDC d | No | n = 26,172 (31.5%) | 22.1% | n = 5617 (13.6%) | 18.5% | n = 9579 (41.4%) | 23.9% |
Yes | 37.9% | 50.8% | 47.8% | ||||
Uncertain | 40.0% | 30.8% | 28.3% | ||||
0–79% PDC e | No | n = 15,299 (18.4%) | 46.7% | n = 3427 (8.3%) | 12.1% | n = 3171 (13.7%) | 17.0% |
Yes | 37.5% | 32.0% | 13.0% | ||||
Uncertain | 15.8% | 55.9% | 70.0% | ||||
Patient did not retrieve medication | No | n = 29,524 (35.6%) | 41.3% | n = 8697 (21.0%) | 60.9% | n = 7212 (31.2%) | 84.4% |
Yes | 58.7% | 39.1% | 15.6% | ||||
No medication order | No | n = 11,985 (14.4%) | 0% | n = 23,664 (57.1%) | 17.9% | n = 3169 (13.7%) | 50.1% |
Yes | 100% | 82.1% | 49.9% |
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Yan, X.; Stewart, W.F.; Husby, H.; Delatorre-Reimer, J.; Mudiganti, S.; Refai, F.; Hudnut, A.; Knobel, K.; MacDonald, K.; Sifakis, F.; et al. Persistent Cardiometabolic Health Gaps: Can Therapeutic Care Gaps Be Precisely Identified from Electronic Health Records. Healthcare 2022, 10, 70. https://doi.org/10.3390/healthcare10010070
Yan X, Stewart WF, Husby H, Delatorre-Reimer J, Mudiganti S, Refai F, Hudnut A, Knobel K, MacDonald K, Sifakis F, et al. Persistent Cardiometabolic Health Gaps: Can Therapeutic Care Gaps Be Precisely Identified from Electronic Health Records. Healthcare. 2022; 10(1):70. https://doi.org/10.3390/healthcare10010070
Chicago/Turabian StyleYan, Xiaowei, Walter F. Stewart, Hannah Husby, Jake Delatorre-Reimer, Satish Mudiganti, Farah Refai, Andrew Hudnut, Kevin Knobel, Karen MacDonald, Frangiscos Sifakis, and et al. 2022. "Persistent Cardiometabolic Health Gaps: Can Therapeutic Care Gaps Be Precisely Identified from Electronic Health Records" Healthcare 10, no. 1: 70. https://doi.org/10.3390/healthcare10010070