The Patient Outcomes Research To Advance Learning (PORTAL) Network Adult Overweight and Obesity Cohort: Development and Description

Using a Multi-Institutional Pediatric Learning Health System to Identify Systemic Lupus Erythematosus and Lupus Nephritis: Development and Validation of Computable Phenotypes

BACKGROUND AND OBJECTIVES

Performing adequately powered clinical trials in pediatric diseases, such as SLE, is challenging. Improved recruitment strategies are needed for identifying patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Electronic health record algorithms were developed and tested to identify children with SLE both with and without lupus nephritis. We used single-center electronic health record data to develop computable phenotypes composed of diagnosis, medication, procedure, and utilization codes. These were evaluated iteratively against a manually assembled database of patients with SLE. The highest-performing phenotypes were then evaluated across institutions in PEDSnet, a national health care systems network of >6.7 million children. Reviewers blinded to case status used standardized forms to review random samples of cases (n=350) and noncases (n=350).

RESULTS

Final algorithms consisted of both utilization and diagnostic criteria. For both, utilization criteria included two or more in-person visits with nephrology or rheumatology and ≥60 days follow-up. SLE diagnostic criteria included absence of neonatal lupus, one or more hydroxychloroquine exposures, and either three or more qualifying diagnosis codes separated by ≥30 days or one or more diagnosis codes and one or more kidney biopsy procedure codes. Sensitivity was 100% (95% confidence interval [95% CI], 99 to 100), specificity was 92% (95% CI, 88 to 94), positive predictive value was 91% (95% CI, 87 to 94), and negative predictive value was 100% (95% CI, 99 to 100). Lupus nephritis diagnostic criteria included either three or more qualifying lupus nephritis diagnosis codes (or SLE codes on the same day as glomerular/kidney codes) separated by ≥30 days or one or more SLE diagnosis codes and one or more kidney biopsy procedure codes. Sensitivity was 90% (95% CI, 85 to 94), specificity was 93% (95% CI, 89 to 97), positive predictive value was 94% (95% CI, 89 to 97), and negative predictive value was 90% (95% CI, 84 to 94). Algorithms identified 1508 children with SLE at PEDSnet institutions (537 with lupus nephritis), 809 of whom were seen in the past 12 months.

CONCLUSIONS

Electronic health record-based algorithms for SLE and lupus nephritis demonstrated excellent classification accuracy across PEDSnet institutions.

Characteristics of adults with overweight and obesity who have not attempted weight loss in the prior 12 months

OBJECTIVE

To determine weight-related characteristics of adults with overweight or obesity who had not attempted weight loss in the prior 12 months.

METHODS

Adults from the obesity cohort of the PORTAL clinical data research network were randomly selected to complete a survey in 2015. It included topics of experiences with health care providers, weight history, and health-promoting behaviors.

RESULTS

A total of 2811 adults completed the survey, of whom 24% reported not attempting weight loss in the previous 12 months. Controlling for sociodemographic characteristics and body mass index, respondents who reported that their health care provider never talked about weight were more likely to not attempt weight loss in the previous 12 months compared with respondents who reported providers frequently brought up weight (OR: 0.45; 95% CI: 0.24, 0.66). Respondents who perceived themselves as normal weight or underweight were 4.22 times more likely (95% CI: 3.53, 5.05) to not attempt weight loss compared with respondents who perceived themselves as overweight. Respondents who reported that they never tried to lose at least 10 lbs, ate 0-2 servings of fruits and vegetables daily, or engaged in 0-29 min of physical activity weekly were less likely to attempt weight loss.

CONCLUSIONS

Receiving advice on weight loss from health care providers to improve awareness of overweight and obesity status may be important factors for a person's weight management. Provider discussions about weight may be a strategy to motivate weight loss attempts.

Behavioural and psychosocial factors associated with 5-year weight trajectories within the PORTAL Overweight/Obesity Cohort

Objective

The purpose of this study was to model weight trajectories over a 5‐year time period (2012–2016) and their association with behavioural and psychosocial characteristics and health care–related experiences using data from the Patient Outcomes Research to Advance Learning (PORTAL) overweight/obesity cohort.

Methods

Weight trajectories for each eligible patient in the PORTAL overweight/obesity cohort (n = 2864) were identified first using growth modelling; trajectories were then grouped using a hierarchical cluster analysis. Weight trajectory clusters that emerged were compared on demographics, and predictors of cluster membership were examined. Clusters were also compared on responses to a survey assessing health behaviours, quality of life, and health care experience completed in 2015 by 49% of the total sample (n = 1391).

Results

Seven distinct weight trajectory clusters were identified: (a) significant weight loss then maintenance; (b) higher stable weight; (c) moderate stable weight; (d) steady weight loss then relapse; (e) weight gain then weight loss; (f) steady weight gain then maintenance; and (g) lower stable weight. Age, sex, race/ethnicity, and body mass index at baseline predicted patient's weight trajectory (P < .001). Over two thirds of patients maintained their weight over the 5‐year period. Significant weight loss then maintenance, weight gain then weight loss, and higher stable weight patients were more likely to report receiving weight counselling from their provider. Patients in the significant weight loss then maintenance and lower stable weight clusters were more likely to be physically active than the other clusters.

Conclusion

Findings suggest variability in patterns of weight change among adults with overweight or obesity who have access to health care and that these patterns differ on demographic, behavioural and psychosocial factors, and health care experience.

Antiobesity Medication Use in 2.2 Million Adults Across Eight Large Health Care Organizations: 2009-2015

OBJECTIVE

The aim of this study was to examine the prescribing patterns and use of antiobesity medications in a large cohort of patients using data from electronic health records.

METHODS

Pharmacy- and patient-level electronic health record data were obtained on 2,248,407 adults eligible for weight-loss medications from eight geographically dispersed health care organizations.

RESULTS

A total of 29,964 patients (1.3% of total cohort) filled at least one weight-loss medication prescription. This cohort was 82.3% female, with median age 44.9 years and median BMI 37.2 kg/m² . Phentermine accounted for 76.6% of all prescriptions, with 51.7% of prescriptions being filled for ≥ 120 days and 33.8% filled for ≥ 360 days. There was an increase of 32.9% in medication days for all medications in 2015 compared with 2009. Higher prescription rates were observed in women, black patients, and patients in higher BMI classes. Of 3,919 providers who wrote at least one filled prescription, 23.8% (n = 863) were "frequent prescribers" who wrote 89.6% of all filled prescriptions.

CONCLUSIONS

Weight-loss medications are rarely prescribed to eligible patients. Phentermine accounted for > 75% of all medication days, with a majority of patients filling it for more than 4 months. Less than one-quarter of prescribing providers accounted for approximately 90% of all prescriptions.

Racial/Ethnic Disparities in the Prevalence of Diabetes and Prediabetes by BMI: Patient Outcomes Research To Advance Learning (PORTAL) Multisite Cohort of Adults in the U.S

OBJECTIVE

To examine racial/ethnic disparities in the prevalence of diabetes and prediabetes by BMI category.

RESEARCH DESIGN AND METHODS

In a consortium of three U.S. integrated health care systems, 4,906,238 individuals aged ≥20 years during 2012-2013 were included. Diabetes and prediabetes were ascertained by diagnosis and laboratory results; antihyperglycemic medications were also included for diabetes ascertainment.

RESULTS

The age-standardized diabetes and prediabetes prevalence estimates were 15.9% and 33.4%, respectively. Diabetes but not prediabetes prevalence increased across BMI categories among all racial/ethnic groups (P for trend < 0.001). Racial/ethnic minorities reached a given diabetes prevalence at lower BMIs than whites; Hawaiians/Pacific Islanders and Asians had a diabetes prevalence of 24.6% (95% CI 24.1-25.2%) in overweight and 26.5% (26.3-26.8%) in obese class 1, whereas whites had a prevalence of 23.7% (23.5-23.8%) in obese class 2. The age-standardized prediabetes prevalence estimates in overweight among Hispanics (35.6% [35.4-35.7%]), Asians (38.1% [38.0-38.3%]), and Hawaiians/Pacific Islanders (37.5% [36.9-38.2%]) were similar to those in obese class 4 among whites (35.3% [34.5-36.0%]), blacks (36.8% [35.5-38.2%]), and American Indians/Alaskan Natives (34.2% [29.6-38.8%]). In adjusted models, the strength of association between BMI and diabetes was highest among whites (relative risk comparing obese class 4 with normal weight 7.64 [95% CI 7.50-7.79]) and lowest among blacks (3.16 [3.05-3.27]). The association between BMI and prediabetes was less pronounced.

CONCLUSIONS

Racial/ethnic minorities had a higher burden of diabetes and prediabetes at lower BMIs than whites, suggesting the role of factors other than obesity in racial/ethnic disparities in diabetes and prediabetes risk and highlighting the need for tailored screening and prevention strategies.

Safety and Effectiveness of Longer-Term Phentermine Use: Clinical Outcomes from an Electronic Health Record Cohort

OBJECTIVE

The aim of this work was to study weight loss and risk of cardiovascular disease (CVD) or death associated with longer-term phentermine use.

METHODS

Using electronic health record data, 13,972 adults were identified with a first phentermine fill in 2010 to 2015, creating exposure categories according to a patient's duration of use (referent: ≤ 3 months). Multivariable linear models were used to compare percent weight loss across categories at 6, 12, and 24 months, and Cox proportional hazards models were used to compare risk of composite CVD or death, up to 3 years after starting phentermine.

RESULTS

The cohort was 84% female and 45% white, with a mean (SD) baseline age 43.5 (10.7) years and BMI of 37.8 (7.2) kg/m² . In multivariable models, longer-term users of phentermine experienced more weight loss; patients using continuously for > 12 months lost 7.4% more than the referent group at 24 months (P < 0.001). The composite CVD or death outcome was rare (0.3%, 41 events), with no significant difference in hazard ratios between groups.

CONCLUSIONS

Greater weight loss without increased risk of incident CVD or death was observed in patients using phentermine monotherapy for longer than 3 months. Despite the limitations of the observational design, this study supports the effectiveness and safety of longer-term phentermine use for low-risk individuals.

Patient Engagement and Attitudes Toward Using the Electronic Medical Record for Medical Research: The 2015 Greater Plains Collaborative Health and Medical Research Family Survey

BACKGROUND

Electronic health records (EHRs) are ubiquitous. Yet little is known about the use of EHRs for prospective research purposes, and even less is known about patient perspectives regarding the use of their EHR for research.

OBJECTIVE

This paper reports results from the initial obesity project from the Greater Plains Collaborative that is part of the Patient-Centered Outcomes Research Institute's National Patient-Centered Clinical Research Network (PCORNet). The purpose of the project was to (1) assess the ability to recruit samples of adults of child-rearing age using the EHR; (2) prospectively assess the willingness of adults of child-rearing age to participate in research, and their willingness (if parents) to have their children participate in medical research; and (3) to assess their views regarding the use of their EHRs for research.

METHODS

The EHRs of 10 Midwestern academic medical centers were used to select patients. Patients completed a survey that was designed to assess patient willingness to participate in research and their thoughts about the use of their EHR data for research. The survey included questions regarding interest in medical research, as well as basic demographic and health information. A variety of contact methods were used.

RESULTS

A cohort of 54,269 patients was created, and 3139 (5.78%) patients responded. Completers were more likely to be female (53.84%) and white (85.84%). These and other factors differed significantly by site. Respondents were overwhelmingly positive (83.9%) about using EHRs for research.

CONCLUSIONS

EHRs are an important resource for engaging patients in research, and our respondents concurred. The primary limitation of this work was a very low response rate, which varied by the method of contact, geographic location, and respondent characteristics. The primary strength of this work was the ability to ascertain the clinically observed characteristics of nonrespondents and respondents to determine factors that may contribute to participation, and to allow for the derivation of reliable study estimates for weighting responses and oversampling of difficult-to-reach subpopulations. These data suggest that EHRs are a promising new and effective tool for patient-engaged health research.

Associations of overweight/obesity and socioeconomic status with hypertension prevalence across racial and ethnic groups

Racial/ethnic disparities in the prevalence of diagnosed hypertension are persistent but may be partially explained by racial/ethnic differences in weight category and neighborhood socioeconomic status. The authors compared hypertension prevalence rates among 4 060 585 adults with overweight or obesity across 10 healthcare systems by weight category and neighborhood education level in geographically and racially diverse individuals. Data were obtained from electronic health records. Hypertension was defined as at least two outpatient visits or one inpatient hospitalization with a coded diagnosis. Logistic regression, adjusted for age, sex, and site, with two-way interactions between race/ethnicity and weight category or neighborhood education, was used to examine the association between hypertension and race/ethnicity, with whites as the reference. Results documented that odds ratios for hypertension prevalence were greater for blacks, American Indians/Alaskan Natives, Asians, and Native Hawaiians/other Pacific Islanders compared with whites and lower for Hispanics in similar weight categories and neighborhood education levels. Although two-way interactions were statistically significant, the magnitude of the odds of hypertension compared with whites did not substantially vary across weight or neighborhood education. Hypertension odds were almost double relative to whites for blacks and Native Hawaiians/other Pacific Islanders across most weight categories and all neighborhood education levels. Odds of hypertension were about 50% greater for Asians relative to whites across weight categories. Results suggest that other factors might be associated with racial/ethnic disparities in hypertension. More research is needed to understand the many factors that may contribute to variation in diagnosed hypertension across racial/ethnic groups with overweight or obesity.

Mental illness in bariatric surgery: A cohort study from the PORTAL network

OBJECTIVE

To compare bariatric surgery outcomes according to preoperative mental illness category.

METHODS

Electronic health record data from several US healthcare systems were used to compare outcomes of four groups of patients who underwent bariatric surgery in 2012 and 2013. These included the following: people with (1) no mental illness, (2) mild-to-moderate depression or anxiety, (3) severe depression or anxiety, and (4) bipolar, psychosis, or schizophrenia spectrum disorders. Groups were compared on weight loss trajectory using generalized estimating equations using B-spline bases and on all-cause emergency department visits and hospital days using zero-inflated Poisson and negative binomial regression up to 2 years after surgery. Models were adjusted for demographic and health covariates, including baseline healthcare use.

RESULTS

Among 8,192 patients, mean age was 44.3 (10.7) years, 79.9% were female, and 45.6% were white. Fifty-seven percent had preoperative mental illness. There were no differences between groups for weight loss, but patients with preoperative severe depression or anxiety or bipolar, psychosis, or schizophrenia spectrum disorders had higher follow-up levels of emergency department visits and hospital days compared to those with no mental illness.

CONCLUSIONS

In this multicenter study, mental illness was not associated with differential weight loss after bariatric surgery, but additional research could focus on reducing acute care use among these patients.

Cardiometabolic Risk Factors Among 1.3 Million Adults With Overweight or Obesity, but Not Diabetes, in 10 Geographically Diverse Regions of the United States, 2012-2013

INTRODUCTION

Various phenotypes of overweight and obesity pose various health risks. The objective of this study was to determine the prevalence of 4 commonly measured cardiometabolic risk factors (CRFs) among adults with overweight or obesity, but not diabetes, at the time of the study.

METHODS

We analyzed data for 1,294,174 adults (aged ≥20 y) who were members of one of 4 integrated health systems. Each cohort member had a body mass index in 2012 or 2013 that indicated overweight or obesity. We determined the presence of 4 CRFs within 1 year of the first BMI measurement: elevated blood pressure (systolic ≥130 mm Hg or diastolic >85 mm Hg or ICD-9-CM [International Classification of Diseases, Ninth Revision, Clinical Modification] diagnosis code 401.0-405.9); elevated triglycerides (≥150 mg/dL or ICD-9-CM 272.1); low high-density lipoprotein cholesterol (<40 mg/dL for men or <50 mg/dL for women or ICD-9-CM 272.5); and prediabetes (fasting glucose 100-125 mg/dL or HbA_1c 5.7%-6.4% or ICD-9-CM 790.2x). We tested the risk of having 1 or more CRFs after adjusting for obesity class and demographic characteristics with multivariable logistic regression.

RESULTS

Among participants with overweight (52.5% of the sample), 18.6% had none of the 4 CRFs. Among the 47.5% of participants with obesity, 9.6% had none; among participants with morbid obesity, 5.8% had none. Age was strongly associated with CRFs in multivariable analysis.

CONCLUSION

Almost 10% of participants with obesity had no CRFs. Overweight or obesity increases cardiometabolic risk, but the number and type of CRFs varied substantially by age, even among participants with morbid obesity.

Interacting effects of obesity, race, ethnicity and sex on the incidence and control of adult-onset asthma

Background

To improve care and control for patients with adult-onset asthma, a better understanding of determinants of their risk and outcomes is important. We investigated how associations between asthma, asthma control and obesity may be modified by patient demographic characteristics.

Methods

This retrospective study of adults enrolled in several health plans across the U.S. (n = 2,860,305) examined the interacting effects of obesity, age, race, and sex on adult-onset asthma and asthma control. Multivariable adjusted Cox and logistic regression models estimated hazard ratios (HR), and 95 % confidence intervals (CI) for the associations between body mass index (BMI) and study outcomes, and interactions of BMI with demographic characteristics.

Results

Compared with individuals who had a BMI <25 kg/m², the hazard of adult-onset asthma progressively increased with increasing BMI, from a 12 % increase among persons with a BMI of 25.0–29.9 kg/m² (HR 1.12, 95 % CI 1.10, 1.14) to an almost 250 % increase among persons with a BMI ≥50 kg/m² (HR 2.49, 95 % CI 2.38, 2.60). The magnitude of the association between obesity and asthma risk was greater for women (compared with men) and lower for Blacks (compared with non-Hispanic Whites). Among individuals with asthma, obesity was associated with poorly controlled and high-risk asthma.

Conclusions

The present study demonstrates that the magnitude of the associations between obesity and adult-onset asthma incidence and control are modified by race, age, and sex. Understanding the role of obesity in the development of adult-onset asthma will help to improve asthma treatment algorithms and to develop targeted interventions.