Katharine H. McVeigh

Effectiveness of Intensive Case Management for Substance-Dependent Women Receiving Temporary Assistance for Needy Families

OBJECTIVE We tested the effectiveness of a long-term coordinated care strategy--intensive case management (ICM)--compared with usual care (UC) among a group of substance-dependent women receiving Temporary Assistance for Needy Families (TANF). METHODS Substance-dependent women on TANF (N=302) were recruited from welfare offices. They were assessed and randomly assigned to ICM or UC; follow-up was at 3, 9, and 15 months. UC consisted of a health assessment at the welfare office and a referral to substance abuse treatment and TANF services. ICM clients received ICM services in addition to UC services. RESULTS ICM clients had significantly higher levels of substance abuse treatment initiation, engagement, and retention compared with UC clients. In some cases, ICM treatment attendance rates were double those of UC rates. Additionally, almost twice as many ICM clients were abstinent at the 15 month follow-up compared with UC clients (P<.0025). CONCLUSIONS ICM is a promising intervention for managing the chronic nature of substance dependence among women receiving TANF. Future research should refine long-term care strategies-such as ICM-that address the chronic nature of substance dependence among low-income populations.

Case Fatality Rates Based on Population Estimates of Influenza-Like Illness Due to Novel H1N1 Influenza: New York City, May–June 2009

Background The public health response to pandemic influenza is contingent on the pandemic strains severity. In late April 2009, a potentially pandemic novel H1N1 influenza strain (nH1N1) was recognized. New York City (NYC) experienced an intensive initial outbreak that peaked in late May, providing the need and opportunity to rapidly quantify the severity of nH1N1. Methods and Findings Telephone surveys using rapid polling methods of approximately 1,000 households each were conducted May 20–27 and June 15–19, 2009. Respondents were asked about the occurrence of influenza-like illness (ILI, fever with either cough or sore throat) for each household member from May 1–27 (survey 1) or the preceding 30 days (survey 2). For the overlap period, prevalence data were combined by weighting the survey-specific contribution based on a Serfling model using data from the NYC syndromic surveillance system. Total and age-specific prevalence of ILI attributed to nH1N1 were estimated using two approaches to adjust for background ILI: discounting by ILI prevalence in less affected NYC boroughs and by ILI measured in syndromic surveillance data from 2004–2008. Deaths, hospitalizations and intensive care unit (ICU) admissions were determined from enhanced surveillance including nH1N1-specific testing. Combined ILI prevalence for the 50-day period was 15.8% (95% CI:13.2%–19.0%). The two methods of adjustment yielded point estimates of nH1N1-associated ILI of 7.8% and 12.2%. Overall case-fatality (CFR) estimates ranged from 0.054–0.086 per 1000 persons with nH1N1-associated ILI and were highest for persons ≥65 years (0.094–0.147 per 1000) and lowest for those 0–17 (0.008–0.012). Hospitalization rates ranged from 0.84–1.34 and ICU admission rates from 0.21–0.34 per 1000, with little variation in either by age-group. Conclusions ILI prevalence can be quickly estimated using rapid telephone surveys, using syndromic surveillance data to determine expected “background” ILI proportion. Risk of severe illness due to nH1N1 was similar to seasonal influenza, enabling NYC to emphasize preventing severe morbidity rather than employing aggressive community mitigation measures.

Improving 24-Month Abstinence and Employment Outcomes for Substance-Dependent Women Receiving Temporary Assistance for Needy Families With Intensive Case Management

OBJECTIVE We examined abstinence rates among substance-dependent women receiving Temporary Assistance for Needy Families (TANF) in intensive case management (ICM) over 24 months and whether ICM yielded significantly better employment outcomes compared with a screen-and-refer program (i.e., usual care). METHODS Substance-dependent (n = 302) and non-substance dependent (n = 150) TANF applicants in Essex County, New Jersey, were recruited. We randomly assigned substance-dependent women to ICM or usual care. We interviewed all women at 3, 9, 15, and 24 months. RESULTS Abstinence rates were higher for the ICM group than for the usual care group through 24 months of follow-up (odds ratio [OR] = 2.11; 95% confidence interval [CI] = 1.36, 3.29). A statistically significant interaction between time and group on number of days employed indicated that the rate of improvement over time in employment was greater for the ICM group than for the usual care group (incidence rate ratio = 1.03; 95% CI = 1.02, 1.04). Additionally, there were greater odds of being employed full time for those in the ICM group (OR = 1.68; 95% CI = 1.12, 2.51). CONCLUSIONS ICM is a promising intervention for managing substance dependence among women receiving TANF and for improving employment rates among this vulnerable population.

The Epidemiology of Nonspecific Psychological Distress in New York City, 2002 and 2003

The 30-day prevalence of nonspecific psychological distress (NPD) is 3%, nationwide. Little is known about the prevalence and correlates of NPD in urban areas. This study documents the prevalence of NPD among adults in New York City (NYC) using population-based data from the 2002 and 2003 NYC Community Health Surveys (CHS) and identifies correlates of NPD in this population. We examined two cross-sectional random-digit-dialed telephone surveys of NYC adults (2002: N = 9,764; 2003: N = 9,802). Kesslers K6 scale was used to measure NPD. Age-adjusted 30-day prevalence of NPD declined from 6.4% [95% Confidence Interval (CI): 5.8–7.0] in 2002 to 5.1% [95% CI: 4.5–5.6] in 2003. New Yorkers who were poor, in poor health, chronically unemployed, uninsured, and formerly married had the highest prevalence of NPD. Declines occurred among those who were married, white, recently unemployed, and female. NPD prevalence in NYC is higher than national estimates. A stronger economy and recovery from September 11th attacks may have contributed to the 2003 decline observed among selected subgroups. The excess prevalence of NPD may be associated with substantial economic and societal burden. Research to understand the etiology of this high prevalence and interventions to promote mental health in NYC are indicated.

Effects of individual and neighborhood characteristics on the timeliness of provider designation for early intervention services in New York City.

Background: The Early Intervention (EI) Program of the New York City (NYC) Department of Health and Mental Hygiene provides therapeutic services to children under 3 years of age with developmental delays or disabilities. Although the EI Program targets delivery of services within 21 days of the meeting at which the Individualized Family Service Plan (IFSP) is developed, the designation of a service provider alone often takes longer than that. Objective: This study examined associations between individual and neighborhood characteristics and timeliness of provider designation in NYC. Methods: Multivariable logistic regression analyses were performed for 14,623 children who had their initial IFSPs developed in Fiscal Year 2004. Results: Provider designation was delayed 13.4% of the time for speech therapy, 10.0% of the time for special instruction, 8.2% of the time for occupational therapy, and 4.2% of the time for physical therapy. Individual characteristics independently associated with provider designation delay were: being older than 24 months, having the IFSP meeting between July and December, having an adaptive delay, and having speech therapy or special instruction in the IFSP. Neighborhood characteristics independently associated with provider designation delay included living in a low-income neighborhood and living in a heavily Spanish-speaking neighborhood. Conclusion: Delayed provider designation occurs because of both individual and neighborhood factors. Interventions are needed to address shortages of providers in certain neighborhoods or with specific skills, and to address surges in administrative program functions at certain times of the year.

Profiling risk of fear of an intimate partner among men and women

OBJECTIVE Fear of a partner, a component of intimate partner violence (IPV), can be used in clinical IPV assessment. This study examines correlates of fear in a population-based, urban sample to inform a gender-specific health care response to IPV. METHODS This study used pooled data on 9687 men and 13,903 women collected in 2002, 2004 and 2005 through three random-digit-dial surveys of New York City adults. Bivariate and multivariable analyses were used to examine associations between fear and sociodemographic and health-related factors. RESULTS There was no significant difference in age-adjusted prevalence of reported fear of a partner between women (2.7%) and men (2.2%). In multivariable analysis, fear was correlated with being female, younger age, divorced or separated marital status, poor self-reported health status, and multiple sex partners. The most striking gender difference was in the stronger association with multiple sex partners among women (adjusted Odds Ratio [aOR]=6.2; p<0.01). Binge drinking was correlated with fear only among low-income adults (aOR=2.8; p<0.01). CONCLUSION IPV is a health concern for both men and women, and a risk profile for fear can guide IPV assessment in health care. Physicians should consider multiple sex partners in women and alcohol misuse in low-income patients as potential markers for IPV.

Racial and Ethnic Differences in Depression by Partner Status and the Presence of Children in the Household

PURPOSE Single motherhood is a well-established risk factor for depression in women. The goal of this study is to analyze the relationships among partner status, having children, and depression among women of White, Black, and Hispanic race/ethnicity. METHODS Stratified analyses were conducted on 2002, 2003, 2005, 2006, and 2008 cross-sectional survey data from 10,520 White women, 7,655 Black women, and 7,343 Hispanic women aged at least 18 years and residing in New York City. Depression was evaluated using Kesslers K6 scale. Race/ethnicity-specific logistic regression analysis assessed the association between partner status and depression among women with and without children. RESULTS Partner status was significantly associated with depression among White (p < .0001) and Hispanic (p = .0001) women, but not among Black women (p = .82), after adjusting for age, nativity, employment, education, poverty level, general health, and health insurance. Among White women, the conditional odds of depression were elevated for single relative to partnered women both with (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.57-2.81; p < .0001) and without (OR, 1.29; 95% CI, 1.06-1.56; p = .01) children, but the size of the effect was significantly larger for those with children than for those without children (p = .006). Among Hispanic women, the conditional odds of depression were elevated for single relative to partnered women with children (OR, 1.58; 95% CI, 1.29-1.95; p < .0001), but not for single versus partnered women without children (OR, 1.09; 95% CI, 0.82-1.46; p = .54). Among Black women, there was no evidence of elevated depression in single relative to partnered women, either overall or conditional on the presence of children (with children: OR, 1.21 [95% CI, 0.95-1.54; p = .13]; without children: OR, 0.75 [95% CI, 0.56-1.02; p = .06]). CONCLUSION Past focus on single mothers as a high-risk group has oversimplified the relationship between partner status and depression, obscuring important distinctions between women of different racial backgrounds.

Victimization and Health Risk Factors Among Weapon-carrying Youth

OBJECTIVE To compare health risks of 2 subgroups of weapon carriers: victimized and nonvictimized youth. METHODS 2003-2007 NYC Youth Risk Behavior Surveys were analyzed using bivariate analyses and multinomial logistic regression. RESULTS Among NYC teens, 7.5% reported weapon carrying without victimization; 6.9% reported it with victimization. Both subgroups were more likely than non-weapon carriers to binge drink, use marijuana, smoke, fight, and have multiple sex partners; weapon carriers with victimization also experienced persistent sadness and attempted suicide. CONCLUSIONS Subgroups of weapon carriers have distinct profiles. Optimal response should pair disciplinary action with screening for behavioral and mental health concerns and victimization.

Innovations in Population Health Surveillance: Using Electronic Health Records for Chronic Disease Surveillance

With 87% of providers using electronic health records (EHRs) in the United States, EHRs have the potential to contribute to population health surveillance efforts. However, little is known about using EHR data outside syndromic surveillance and quality improvement. We created an EHR-based population health surveillance system called the New York City (NYC) Macroscope and assessed the validity of diabetes, hyperlipidemia, hypertension, smoking, obesity, depression, and influenza vaccination indicators. The NYC Macroscope uses aggregate data from a network of outpatient practices. We compared 2013 NYC Macroscope prevalence estimates with those from a population-based, in-person examination survey, the 2013-2014 NYC Health and Nutrition Examination Survey. NYC Macroscope diabetes, hypertension, smoking, and obesity prevalence indicators performed well, but depression and influenza vaccination estimates were substantially lower than were survey estimates. Ongoing validation will be important to monitor changes in validity over time as EHR networks mature and to assess new indicators. We discuss NYCs experience and how this project fits into the national context. Sharing lessons learned can help achieve the full potential of EHRs for population health surveillance.

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.