Caryn Roth, Yosef Khan, Randi Foraker, Peter Embi San Francisco, CA March 21, 2013

Outline
Background Study Design & Methodology Results Conclusions

Outline
Background Study Design & Methodology Results Conclusions

Percent Obese (BMI 30) by State

Body Mass Index (BMI) =

Centers for Disease Control and Prevention. Obesity and Overweight. BRFSS 2011

Obesity-related illnesses cost $190.2 billon/year

Institute of Medicine Report. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. 2012.

Genetics, Lifestyle and Environment

Das UN. Obesity: genes, brain, gut, and environment. Nutrition. 2010;26(5):459-73.

Jilcott Pitts SB, Edwards M, Moore JB, Shores KA, Dubose KD, McGranahan D. Obesity is Inversely Associated with Natural Amenities and Recreation Facilities Per Capita. Journal of physical activity & health. 2012.
7

Wang MC, Kim S, Gonzalez AA, MacLeod KE, Winkleby MA. Socioeconomic and foodrelated physical characteristics of the neighbourhood environment are associated with body mass index. Journal of epidemiology and community health. 2007.

Secondary Use of EHR Data

Non-direct care use of PHI including but not limited to analysis, research, quality/safety measurement, public health, payment, provider certification or accreditation, and marketing and other business including strictly commercial activities
Safran C, Bloomrosen M, Hammond W, Labkoff S, Markel-Fox S, et al. Toward a national framework for the secondary use of health data: an american medical informatics association white paper. Journal of the American Medical Informatics Association. 2007.
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Too much data or not enough?

Is it really too much data?

Outline
Background Study Design & Methodology Results Conclusions

Research Question
Can we apply secondary use of EHRderived clinical data to study associations between obesity and environmental factors?

Study objectives
Investigate possible spatial associations between access to fresh food and community physical recreation facilities and the prevalence of obesity and overweight in Franklin County, Ohio

Further investigate associations with respect to income level, education level, age, and population characteristics

Diverse Data Sources

OSUWMC Information Warehouse Neilson Marketing Data North American Industry Classification System (NAICS)/Zip Code Business Patterns Other Public Data Sources

OSUWMC Information Warehouse

Information Warehouse Dataset

One year of inpatient and outpatient visits Patients aged 18-65 Address of record within Franklin County, Ohio Most recent visit where height and weight was recorded Gender, race, year of birth and zip code 62,701 unique patient encounters

Nielsen PrimeLocation
Consumer Behavior Trends Telephone, mail, online surveys Barcode scanners, smartphone apps, etc. Extensive data: Population Size Education Income & Poverty Available through Ohio Department of Health

North American Industry Classification System (NAICS) and ZIP Code Business Patterns Website

713940: Fitness and Recreational Sports Centers

NAICS 445110: Supermarkets and Other Grocery Stores (Not Convenience)

Farmers Markets
Manual compilation

Farmers Markets Manual Compilation

All Potential Variables

Source Variables Information Warehouse Zip Code Year of Birth Gender Race Height & Weight BMI (outcome variable) PrimeLocation Median Household Income Average Household Income Median Household Effective Buying Income Average Household Effective Buying Income Families below Poverty Percent of Civilian Labor Force Unemployed Population Pop 25+, No High School Degree Pop 25+, High School Degree Pop 25+, College Degree or Higher Fitness and recreational Sports Centers Supermarkets and Other Grocery Stores Farmers Markets

NAICS Manual Search

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Methodology Overview
Collected and merged data by zip code Calculated BMI for each patient Developed multinomial logistic regression model, clustered by zip code Examined co-linearity Used fractional polynomial model comparisons Assessed interactions Allowed all eliminated variables to reenter model

Outline
Background Study Design & Methodology Results Conclusions

BMI Categories
25000 20779 20000 15000 10000 5000 0 19567 22355

Normal (18.5 BMI < 25)

Overweight Obese (25 BMI < 30) (30 BMI < 45)

Mean BMI by Zip Code

Multinomial Logistic Regression (ORs, 95% CI)

Overweight % College educated 0.94 [0.92, 0.97] per 10% increase Farmers markets per 1,000 people Grocery Stores per 1,000 people 0.42 [0.32, 0.55] 0.74 [0.57, 0.98] Obese 0.80 [0.77, 0.84] 0.19 [0.10, 0.36] 0.58 [0.36, 0.93]

* Adjusted for age, race, gender

Multinomial Logistic Regression (ORs, 95% CI)

Overweight % College educated 0.94 [0.92, 0.97] per 10% increase Farmers markets per 1,000 people Grocery Stores per 1,000 people 0.42 [0.32, 0.55] 0.74 [0.57, 0.98] Obese 0.80 [0.77, 0.84] 0.19 [0.10, 0.36] 0.58 [0.36, 0.93]

* Adjusted for age, race, gender

For every additional farmers market per 1,000 people, the odds of being overweight relative to normal are reduced by 58% (=1.0 - 0.42)

Multinomial Logistic Regression (ORs, 95% CI)

Overweight % College educated 0.94 [0.92, 0.97] per 10% increase Farmers markets per 1,000 people Grocery Stores per 1,000 people 0.42 [0.32, 0.55] 0.74 [0.57, 0.98] Obese 0.80 [0.77, 0.84] 0.19 [0.10, 0.36] 0.58 [0.36, 0.93]

* Adjusted for age, race, gender

% Obese By Zip Code

All Grocery Stores

% Obese By Zip Code

Grocery Stores 40,000 Square Feet

Outline
Background Study Design & Methodology Results Conclusions

Implications
Augmenting data proved useful Zip code is an available linker in the EHR Collecting and linking data is tedious and painful We should integrate/capture environmental data in EHR better to study these and other associations

Caveats & Limitations

Model not show causation Zip Code may describe area incompletely Analysis limited to one region in Ohio

Future Directions
Expand beyond one region & hospital system Use additional area-level data to study these associations Investigate linking these data

Summary
We identified geographic-level factors associated with elevated BMI in one region Combining patient-level EHR data with publicly available geographic-level data is useful for developing hypotheses about population health across a diverse community We can enhance the potential of secondary use of EHR-derived data by looking beyond the record for supplemental data sources

Thank You!
Yosef Khan Randi Foraker Peter Embi

The OSU Department of Biomedical Informatics Gary Philips, OSU Department of Biostatistics Eric Greene & Chip Allen, Ohio Department of Health

Photo Credits
Centers for Disease Control and Prevention (Slides 4, 20) Wordle.com (Slide 5) City of Berkeley Public Health Division (Slide 6) National Human Genome Research Institute (Slide 6) Voice of San Diego (Slide 7) hailbritannica.com (Slide 8) Flikr Creative CommonsSodapop (Slide 9), Patrick Michael McLeod (Slide 12) tinyoranges.com (Slide 10) The Ohio State University Wexner Medical Center (Slide 17)

Questions?
caryn.roth@osumc.edu