The 10th Annual Utah Health Services Research Conference: A High-Quality Electronic Health Record and EDW: Tools to Eliminate Health Disparities. By: Carrie L. Byington, H.A. and Edna Benning Presidential Professor of Pediatrics Director, Utah Center for Clinical and Translational Science AVP Faculty and Academic Affairs, Health Sciences Health Services Research Conference: March 16, 2015 Patient Centered Research Methods Core, University of Utah, CCTS

1. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Carrie L. Byington, MD
H.A. and Edna Benning Presidential Professor of Pediatrics
Director, Utah Center for Clinical and Translational Science
AVP Faculty and Academic Affairs, Health Sciences
A High-Quality Electronic HealthA High-Quality Electronic Health
Record and EDW: Tools toRecord and EDW: Tools to
Eliminate Health DisparitiesEliminate Health Disparities

3. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Etiologies of Health Disparities
• Insurance coverage
• Access to care
– Preventive Services
• Cultural and language barriers
• Geographic or facility barriers
– Relevant to care of children
• Stereotyping, overt or implicit bias

4. 134 133 133
140
155
0
40
80
120
160
200
Total White, non-
Hispanic
Black, non-
Hispanic
Hispanic Asian/Pacific
Islander
Note: Complications of care include postoperative pneumonia, urinary tract infection, and blood clot in the leg.
Note: Estimates are adjusted by age, gender, age–gender interactions, comorbidities, and DRG clusters.
Source: Agency for Healthcare Research and Quality. National Healthcare Disparities Report. 2006.
Asians/Pacific Islanders and Hispanics are more likely to die
from complications in hospital care than Whites or Blacks
Deaths per 1,000 discharges with complications
of care in hospitalization, 2003

5. Centers for Disease Control and Prevention

7. 7
36
43
54
70
85 87
767370
62
53
46
83 84
69
63
0
20
40
60
80
100
1993 1994 1995 1996 1997 1998 1999 2000
White
Black
Quality improvement efforts in dialysis care are associated with
improved quality overall and smaller disparities between black and
white patients
Note: p<0.001.
Source: A. R. Sehgal, “Impact of Quality Improvement Efforts on Race and Sex Disparities in Hemodialysis,” Journal
of the American Medical Association, Feb. 26, 2003 289(8):996–1000.
Percentage of patients age 18 and over receiving
adequate hemodialysis dose, 1993–2000

8. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
IOM Recommendation
• Efforts designed to improve the quality of
health services may result in decreasing
disparities
• If every person received the indicated care at
the right time, then theoretically differences
(and disparities) in their care would not exist
• The rigorous application of evidence-
based care to reduce disparities is needed

9. The Febrile Infant:
Using Evidence to
Reduce Disparities

10. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Background
• Fever in infants 1-90 days of age is one of the most
common reasons for medical encounters
– 58% of all ED visits at PCMC
• Fever of ≥38°C is associated with serious bacterial
infection (SBI)
– Bacteremia, meningitis, and UTI
• 42% of febrile infants with bacteremia or bacterial
meningitis evaluated by experienced PROS
practitioners appeared clinically well
– Pantell 2004

11. •Integrated not-for-profit
•24 Hospitals
•144 Clinics
•736 employed & 2,000+
affiliated physicians
•Serves >90% of Utah
Infants
•Guidance Council
Mechanism
Intermountain Healthcare

12. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Evidence Base
• Screening Criteria are essentially equivalent
(Rochester, Philadelphia, Boston) AHRQ
March 2012
• UTI most common SBI
• Age and Viral status effect risk of having SBI
• Bacterial epidemiology allows tailored
antimicrobial therapy

13. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Evidence Base Continued
• Early discharge can be accomplished
safely
Generated in Utah @ University and
Intermountain with support of the CCTS

14. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Intermountain EDW
• The EDW is a large database comprised
of data from most of Intermountain’s
electronic systems
• Includes
– financial and clinical datasets.
• Data are integrated, organized, structured
and cataloged to facilitate population-
based analysis, queries, and research.

15. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Methods
• We developed and validated a surrogate
definition that allows us to identify febrile
infants using an administrative database
• Sensitivity of surrogate definition: 93%
• Specificity of surrogate definition: 90%

16. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Identifying Febrile Infants

17. Pediatrics July 2012
An Evidence-Based Care Process Model

20. Measure Baseline Implementation P-Value
Core Labs 60% 80% <0.001
HR 68% 74% <0.001
Viral Testing 76% 84% <0.001
Antibiotic
Formulary
77% 92% <0.001
D/C Antibiotics 47% 63% <0.001
D/C Home 48% 75% <0.001
Quality Measures-Decreased
Variation

21. Outcome P-Value
 Diagnosis of UTI (29%) <0.001
 Diagnosis of Viral Illness (40%) <0.001
 Antibiotics in LR Infants (26%) 0.002
 Length of Stay (27%) <0.001
= Readmission (< 1%) 0.70
Admission of Bacteremia or Meningitis at First
Encounter
91% vs. 99% (p=0.06)
Infant Outcomes

23. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Did racial and ethnic
disparities exist?

24. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
• We used validated definitions for febrile
infants
• Infants were classified as White (W) or
Under-represented minorities (URM)
– URM infants included
• American Indian, Asian, Black, Native American,
Pacific Islander race or those of any race identified
as Hispanic/Latino
• We evaluated quality indicators before
and after EB-CPM

25. Infant Cohort
• 16,987 Febrile Infant Episodes from July 1,
2004- June 30, 2014
– PRE EB-CPM July 2004-December 2007
– POST EB-CPM January 2008-June 2014
• 6011 episodes (35%) in URM infants

26. Insurance Coverage
PRE-EBCPM
Medicaid
•White Infants 22.9%
•URM Infants 48.2%
P< 0.001
POST-EBCPM
Medicaid
•White Infants 27.7%
•URM Infants 56.3%
P< 0.001

27. Disparities PRE-EBCPM
White URM P-Value
Identification
of HR
47.2% 43.8% 0.01
HR discharged
home for care
9.3% 12.1% 0.004
Unscheduled
Admission
5.3% 9.1% < 0.001

28. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Post EB-CPM
• URM infants were more likely to be
diagnosed with SBI
–11.9% vs. 8.3% (p < 0.001)
• The proportion of URM infants admitted
increased
–40.3% to 43.5% (p=0.02)
• Unscheduled admissions decreased
–9.1% to 4.1% (p < 0.001)

29. CENTER FOR CLINICAL & TRANSLATIONAL SCIENCE
Conclusions
• Following implementation of an EB-CPM
we demonstrated
– Decreased variation in care
• Geographic and facility based
– Lower costs
– Improved outcomes for all infants
– Elimination of disparities between White and
URM infants

31. Questions?
Primary Children’s Medical Center Foundation
Robert Wood Johnson Foundation
NIH/NCRR M01-RR00064 and 1UL1RR024764
NIH/NICHD K24 HD047249
NIH/NIAID U01-A1061611 and U-01 A1074419 and U-01 AI082482
AHRQ R18HS018034
The HA and Edna Benning Society
Carrie.byington@hsc.utah.edu
Mankind has three great enemies, fever, famine, and war.
And of these by far the greatest is fever.―William Osler, 1897