Claudia Chernov

Rationale, design and respondent characteristics of the 2013–2014 New York City Health and Nutrition Examination Survey (NYC HANES 2013–2014)

Purpose Capacity to monitor non-communicable diseases (NCDs) at state or local levels is limited. Emerging approaches include using biomeasures and electronic health record (EHR) data. In 2004, New York City (NYC) performed a population-based health study on adult residents using biomeasures (NYC Health and Nutrition Examination Study, or NYC HANES), modeled after NHANES. A second NYC HANES was launched in 2013 to examine change over time, evaluate municipal policies, and validate a proposed EHR-based surveillance system. We describe the rationale and methods of NYC HANES 2013–2014. Methods NYC HANES was a population-based, cross-sectional survey of NYC adults using three-stage cluster sampling. Between August 2013 and June 2014, selected participants completed a health interview and physical exam (blood pressure, body mass index, and waist circumference). Fasting biomeasures included diabetes, lipid profiles, kidney function, environmental biomarkers, and select infectious diseases. Results Of the 3065 households approached, 2742 were eligible and 1827 were successfully screened (67%). A total of 1524 of eligible participants completed the survey (54%), for an overall response rate of 36%. Conclusion Completing a second NYC HANES a decade after the first study affords an opportunity to understand changes in prevalence, awareness and control of NCDs and evaluate municipal efforts to manage them.

Exposure to Secondhand Smoke Among Nonsmokers in New York City in the Context of Recent Tobacco Control Policies: Current Status, Changes Over the Past Decade, and National Comparisons

INTRODUCTION Exposure to secondhand smoke is hazardous and can cause cancer, coronary heart disease, and birth defects. New York City (NYC) and other jurisdictions have established smoke-free air laws in the past 10-15 years. METHODS NYC Health and Nutrition Examination Survey (HANES) 2013-2014 was a population-based survey of NYC residents, aged 20 years and older, in which biospecimens were collected and cotinine levels were measured. Secondhand smoke exposure was assessed by demographics and risk factors and compared with that from NYC HANES 2004 and national HANES. RESULTS More than a third (37.1%, 95% confidence interval [CI] = 33.3%-41.2%) of nonsmoking adult New Yorkers were exposed to secondhand smoke, defined as a cotinine level of 0.05-10ng/mL. This was significantly lower than in 2004 NYC HANES, when 56.7% (95% CI = 53.6%-59.7%) of nonsmokers were exposed to secondhand smoke, but was greater than the proportion of adults exposed nationwide, as measured by national HANES (24.4%, 95% CI = 22.0%-26.9% in 2011-2012). Men, non-Hispanic blacks, adults aged 20-39, those with less education, and those living in high-poverty neighborhoods were more likely to be exposed. CONCLUSIONS There has been a large decrease in secondhand smoke exposure in NYC, although disparities persist. The decrease may be the result of successful policies to limit exposure to secondhand smoke in public places and of smokers smoking fewer cigarettes per day. Yet NYC residents still experience more secondhand smoke exposure than US residents overall. Possible explanations include multiunit housing, greater population density, and pedestrian exposure. IMPLICATIONS Measuring exposure to secondhand smoke can be difficult, and few studies have monitored changes over time. This study uses serum cotinine, a nicotine metabolite, from a local population-based examination survey, the NYC HANES 2013-2014, to examine exposure to secondhand smoke in an urban area that has implemented stringent antismoking laws. Comparison with NYC HANES conducted 10 years ago allows for an assessment of changes in the last decade in the context of municipal tobacco control policies. Results may be helpful to jurisdictions considering implementing similar tobacco control policies.

Can Electronic Health Records Be Used for Population Health Surveillance? Validating Population Health Metrics Against Established Survey Data

Introduction: Electronic health records (EHRs) offer potential for population health surveillance but EHR-based surveillance measures require validation prior to use. We assessed the validity of obesity, smoking, depression, and influenza vaccination indicators from a new EHR surveillance system, the New York City (NYC) Macroscope. This report is the second in a 3-part series describing the development and validation of the NYC Macroscope. The first report describes in detail the infrastructure underlying the NYC Macroscope; design decisions that were made to maximize data quality; characteristics of the population sampled; completeness of data collected; and lessons learned from doing this work. This second report, which addresses concerns related to sampling bias and data quality, describes the methods used to evaluate the validity and robustness of NYC Macroscope prevalence estimates; presents validation results for estimates of obesity, smoking, depression and influenza vaccination; and discusses the implications of our findings for NYC and for other jurisdictions embarking on similar work. The third report applies the same validation methods described in this report to metabolic outcomes, including the prevalence, treatment and control of diabetes, hypertension and hyperlipidemia. Methods: NYC Macroscope prevalence estimates, overall and stratified by sex and age group, were compared to reference survey estimates for adult New Yorkers who reported visiting a doctor in the past year. Agreement was evaluated against 5 a priori criteria. Sensitivity and specificity were assessed by examining individual EHR records in a subsample of 48 survey participants. Results: Among adult New Yorkers in care, the NYC Macroscope prevalence estimate for smoking (15.2%) fell between estimates from NYC HANES (17.7 %) and CHS (14.9%) and met all 5 a priori criteria. The NYC Macroscope obesity prevalence estimate (27.8%) also fell between the NYC HANES (31.3%) and CHS (24.7%) estimates, but met only 3 a priori criteria. Sensitivity and specificity exceeded 0.90 for both the smoking and obesity indicators. The NYC Macroscope estimates of depression and influenza vaccination prevalence were more than 10 percentage points lower than the estimates from either reference survey. While specificity was > 0.90 for both of these indicators, sensitivity was < 0.70. Discussion: Through this work we have demonstrated that EHR data from a convenience sample of providers can produce acceptable estimates of smoking and obesity prevalence among adult New Yorkers in care; gained a better understanding of the challenges involved in estimating depression prevalence from EHRs; and identified areas for additional research regarding estimation of influenza vaccination prevalence. We have also shared lessons learned about how EHR indicators should be constructed and offer methodologic suggestions for validating them. Conclusions: This work adds to a rapidly emerging body of literature about how to define, collect and interpret EHR-based surveillance measures and may help guide other jurisdictions.

The Burden of Depression in New York City Adults: Results from the 2013–14 NYC Health and Nutrition Examination Survey

Depression is responsible for a large burden of disability in the USA. We estimated the prevalence of depression in the New York City (NYC) adult population in 2013–14 and examined associations with demographics, health behaviors, and employment status. Data from the 2013–14 New York City Health and Nutrition Examination Survey, a population-based examination study, were analyzed, and 1459 participants met the inclusion criteria for this analysis. We defined current symptomatic depression by a Patient Health Questionnaire (PHQ-9) score ≥ 10. Overall, 8.3% of NYC adults had current symptomatic depression. New Yorkers with current symptomatic depression were significantly more likely to be female, Latino, and unemployed yet not looking for work; they were also significantly more likely to have less than a high school education and to live in a high-poverty neighborhood. Socioeconomic inequalities in mental health persist in NYC and highlight the need for better diagnosis and treatment.

NYC HANES 2013–14 and Reflections on Future Population Health Surveillance

Accurate and reliable population health data are critical to public health and enable evidence-based planning, policy-making, and program evaluation. Public health agencies rely on local data to identify and monitor the burden of disease in a population over time and to answer important health policy questions. The New York City Health and Nutrition Examination Survey (NYC HANES), a local, representative heath examination survey, was conducted twice in NYC, once in 2004 and again in 2013–14 [1, 2]. Data from NYC HANES have served as a strong complement to existing population health surveillance data, especially in the context of New York City’s urban environment. In this special issue, we describe a range of findings from NYC HANES 2013–14 that collectively illustrate the unique contribution of examination surveys to population health surveillance. Yet, few public health agencies implement examination surveys, despite their important contributions, in part because such surveys can be expensive and difficult to conduct. We explore the value and challenges of surveys like NYC HANES, and we also describe emerging population health surveillance approaches that might provide complementary information to improve public health. NYC HANES was modeled on the National Health and Nutrition Examination Survey (NHANES), using a similar sampling design, instruments, protocols, and testing laboratories. Results from NYC HANES 2004 showed for the first time how many New Yorkers suffered from diagnosed and undiagnosed chronic conditions like diabetes, high cholesterol, and depression, and whether their conditions were well controlled. NYC HANES 2004 findings [3] helped identify and support public health policies to improve New Yorkers’ health, such as laws to restrict the use of artificial trans-fat in restaurants and to reduce exposure to secondhand smoke, the creation of a diabetes A1c Registry to improve diabetes diagnosis and control, and an educational campaign to inform the public of high levels of mercury in certain fish. Ten years later, in 2013–14, the NYC Health Department and researchers at the CUNYSchool of Public Health (now at NYU School of Medicine) conducted a second NYC HANES to collect information about the health of New Yorkers, to assess health changes since 2004, and to support evaluation of health policies implemented over the past decade. Unique strengths of a study like NYCHANES include the ability to quantify and characterize the burden of undiagnosed disease by combining self-reported survey data with objective measurements from laboratory testing or physical examination. Also, by remaining consistent with the national HANES design, comparisons can be J Urban Health https://doi.org/10.1007/s11524-018-0284-0