Population Surveillance and Monitoring
Disparities research must move beyond improving process measures on patients within clinical settings or research participants in community settings, to measuring population health outcomes for high-disparity populations at the local community level. Many studies have improved documentation of asthma environmental trigger counseling or peak flow testing within a safety-net primary care practice, or improvement in knowledge or stage-of-change among participants in a health education project. However, to reduce disparities, these interventions should translate into reductions in emergency department visits and hospital admissions for low-income children living with in the zip codes served by that health center, or into increases in screening rates or reductions in smoking rates in a defined community.
The program director works in concert with the Biomedical Informatics Program to maximize the data management capabilities in the MSM National Center for Primary Care (NCPC). The goal is to provide rapid-cycle feedback to research scientists and practitioners and to the communities in which they work, employing novel approaches to an integrative health information system. This data will enable the CERP to monitor the impact of its initiatives and that of the ACTSI as a whole, and to propose new projects. Sources for these data include but are not limited to:
* Medicaid claims data: Through the NCPC's involvement with ResDAC (a consortium of MSM, Boston University, University of Minnesota, and Dartmouth), it has gained unique access to and experience with Medicaid data from CMS in a MAX-file format that allows apples-to-apples comparisons of data across multiple states. Our disease management work in Georgia gives us experience in rapid analysis of monthly data feeds from the GA Medicaid program.
* Emergency Department Visits and Hospital Discharge Data: the NCPC has entered into a data use agreement with the GA Hospital Association to obtain a 100% sample of ED visits and hospital discharge data in Georgia. This enables NCPC research faculty to examine emergency department visits and hospital admissions at the zip code or county level, providing a unique opportunity to look at health outcomes of the uninsured, which are often not captured in various sources of administrative claims data.
* Laboratory data: NCPC faculty are able to obtain standardized reports of practice-level data on HbA1c and lipid levels from a local reference lab that provides service to most of the community health centers and primary care practices in the Atlanta area. Compilation of the data by neighborhood practices or zip code clusters would enable primary care providers, community health promoters, and the CERP's Community Health Workers to focus on aggressive glycemic control for entire communities that have been identified as having high rates of adverse diabetic outcomes, as well as individual patients.
* Behavioral Risk Factor Surveillance System (BRFSS): is a telephone-based surveillance system that has been employed at the state level for the past decade or more. It provides continuously-updated information on behavioral risk factors such as physical activity, fruit and vegetable consumption, smoking and seat belt use. It also includes information on use of screening and other health services. Data is now available from the CDC on Fulton and DeKalb counties, and from the Fulton County Department of Health and Wellness on certain sectors of the county.
* Primary data sets generated by conducting health needs and priorities assessments in targeted high-disparity communities. Utilizing key informant interviews, man-in-the-street interviews, focus groups, and door-to-door surveys, NCPC faculty can develop small-area needs assessments that are more informative than those derived from the sources listed above. Their superiority lies first in the fact that they can better reach the population of interest, and primary assessments are more likely to identify the health problems which the community regards as its highest priority. Historically, academics and public health experts have lost the confidence of communities by using morbidity and mortality data to identify the most important health problems (for instance, heart disease, the leading cause of death in most communities), while people in the community feel that other issues deserve more attention (for instance, teen pregnancy, STDs, violence, drug abuse, and other problems with social roots).