Electronic Medical Record Review

for Chronic Health Study in

Coal-Dependent Communities in

Southwest Virginia

Interim Report – May 2015

Susan L. Meacham, PhD, RDN

Professor of Nutrition Discipline of Family Medicine, Preventive

Medicine and Public Health

Highlights preliminary EMR findings in

chronic disease study in SW and SS VA

Prevalence and Predictors

- Occupation as a predictor health risk (Female, Tobacco)

- Diabetes (none) and Hypertension (Tobacco)

- Chronic Kidney Disease higher in SS VA (Diabetes)

- Congestive Heart Failure higher in SW (No predictors)

- Chronic Lung Diseases higher in SW (Mining, smoking)

- Cancer in SW VA higher in women, no diff miner vs non-

miner occupation

- Improve documentation of lifestyle (physical activity,

smoking, diet, substance abuse etc.)

Comparing Health Disparity Areas in VA

Poverty

Percentage (%)Diabetes Obesity

Comparisons: Geographic, Economic, Rurality

1980VA Study Counties and Health Districts

Southwest, Other, Southside, Eastern VA

North Hampton

Accomack

N=1,352 alumni

VCOM’s D.O. Alums in Appalachia

• Phase I and II Literature Review, Agency Data Reporting – continuing

• Journal of Occupational and Environmental Medicine

• Journal of American Osteopathic Association

• Phase III Electronic Medical Record (EMR) Data –

• Interim Report May 2015 - VCEA

• Facility Data Collection Completed in

• 2 Southwest VA coal communities (oversampled > 700)

• 1 Southside VA tobacco communities (~ 200)

• 2015 Reporting –

• 4 Publication drafts, 4 conferences, 14 posters

• 2015 Facility Data Collection Continuing in

• 1 Eastern VA, complete (~ 200)

• 1 SW VA comparison, in progress (~ 200)

• 1 Eastern VA, in final approval (~ 200)

VCOM Phase III Methods

EMR Extracting Staff

- All HIPAA and protection of human subjects trained

- Pilot practice - 20 pilot records for inter-reviewer reliability

Most reviews done by 3 persons, in communication

2 are Health Information Management (HIM) Staff

13-14 yrs experience, as team

1 has MS in Public Health, Va Tech PhD candidate

3 yrs, project consultant

Systematic randomization of electronic records

ex: every 5th or 12th record per year, i.e., 2012

Completing on-line, secured, de-identified data entry

interim analysis, returned for updates as needed

Preliminary Visual Reporting of Facilities,

EMR Residence and Coal Mines in SW VA

Characteristics of Population by Occupation

Disabled, Retired and Working

Variables Disabled Retired Working

P-Value

Gender: <0.0001*

· Female 90(31.9%) 65(23.0%) 127(45.0%)

· Male 100(30.1%) 122(36.7%) 110(33.2%)

Lifestyle

· AlcoholConsumption 25(28.7%) 9(10.3%) 53(60.9%)

<0.0001*

· TobaccoUse 122(36.4%) 106(31.6%) 107(31.9%) <0.0001*

· IlicitDrugsAbuse 9(50.0%) 1(5.6%) 8(44.4%) 0.81**

· PrescriptionDrugsAbuse 8(44.0%) 4(22.0%) 6(33.0%)

0.48**

Pneumoconiosis 35(36.1%) 35(36.1%) 27(27.8%) <0.0001*

CoalMiners 41(28.7%) 91(61.5%) 20(13.2%) <0.0001*

Variables OddRatio Wald95%C.I P-Value

Gender(Female) 1.989 1.066-3.713 0.031

CoalMiner(Yes) 0.61 0.309-1.203 0.153

Pneumoconiosis 1.3 0.732-2.308 0.371

TobaccoUsed(Current) 2.275 1.334-3.881 0.003

TobaccoUsed(Former) 1.926 1.085-3.417 0.025

AlcoholUsed(Current) 0.485 0.191-1.232 0.128

AlcoholUsed(Former) 1.886 0.700-5.079 0.209

Predictive Risk Factors for Disability

Results: Female and Tobacco Use

Not predictive for disability - coal miner, CWP, alcohol use

Disease Prevalence

Diabetes mellitus 26.5%

Hypertension 41.5%

Analyzed Groups P-value

Physical Activity Frequency vs DM 0.543

Alcohol Use vs DM 0.061

Tobacco Use vs DM 0.255

Physical Activity Frequency vs HTN 0.430

Alcohol Use vs HTN 0.735

Tobacco Use vs HTN 0.012

Effects of Lifestyle Factors on

Diabetes Mellitus and Hypertension

Results: Only tobacco use

associated with hypertension, not

diabetes.

No association with physical activity

or alcohol use with diabetes or

hypertension

Variables Coal Regions Tobacco Region P-Value

Gender: 0 .64

Female 320 (49.9%) 76 (52.1%)

Male 321 (50.1%) 70 (47.9%)

Race: <.001*

Caucasian 553 (86.0%) 38 (25.7%)African-American 4 (0.6%) 30 (20.3%)

Asian or Hispanic 2 (0.4%) 0 (0.0%)

Unspecified 84 (13.1%) 80 (54.1%)

Coal Miner: < .001*

Yes 162 (25.2%) 0 (0.0%)

No 343 (53.3%) 20 (13.5%)

Unspecified 138 (21.5%) 129 (86.5%)

Diabetes Mellitis (ICD 250) 205 (29.0%) 60 (30.5%) .72

Hypertension (ICD 101) 313 (44.2%) 77 (39.1%) .2

CKD(ICD 585) 74 (10.5%) 38 (19.3%) .001*

Prevalence of Chronic Kidney Disease

Results: Higher in SS VA and African-American

Variables (Reference

Group) Odds Ratio Wald P-Value

Facility (Southern VA) 0.23 5.62 0.02*

Gender (Male) 0.939 0.02 0.88

Coal Miner (No) 0.806 0.20 0.65

Ethnicity (Caucasian)

African-American 2.28 2.23 0.14

Asian or Hispanic 4.16 1.17 0.28

Unspecified 0.000 .00 1.00

Diabetes (Yes) 0.445 7.40 0.01*

Hypertension (Yes) 0.916 0.09 0.78

Predictive Risk Factors for Chronic Kidney DiseaseResults: CKD likely if in SS VA and have Diabetes

Not predictive for CKD – gender, coal miner, ethnicity or HTN

Variables SW VA SS VA P-Value

Ethnicity

• Caucasian

• African American

• Hispanic/Asian

• (Unspecified)

553 (93.6%)

4 (11.8%)

2 (100 %)

84 (51.2%)

38 (6.4%)

30 (88.2%)

0 (0.0%)

80 (48.8 %)

<.0001*

Physical Activity

• Inactive

• Light

• Moderate

• Heavy

26 (89.7%)

53 (100%)

46 (95.8%)

8 (80%)

3 (10.3%)

0 (0%)

2 (4.2%)

2 (20%)

.02*

Smoker

• Current/Former

• Never

352 (83.0%)

266 (43.0%)

72 (55.8%)

57 (44.2%)

.8

Prevalence of Congestive Heart Failure

Results: No diff - ethnicity, Yes diff - physical activity

Framingham Variables SW VA SS VA P-Value

Family History of Heart Disease

• 1st Degree (Parent and/or Sib)

• Not 1st Degree

557 (74.9%)

151 (93.8%)

187 (25.1%)

10 (6.2 %)

<.0001*

Total Cholesterol (mg/dl)

• < 160

• > 160

37 (82.2%)

29 (76.9%)

8 (17.8%)

9 (23.7%)

0.5

Systolic BP (mmHg)

• < 140

• > 140

529 (79.2%)

179 (75.5%)

139 (20.8%)

58 (24.5%)

0.2

HDL (mg/dl)

• < 50

• > 50

47 (77.0%)

20 (66.7%)

14 (23.0%)

10 (33.3%)

0.3

Prevalence of CHF and Framingham Heart Study

Results: Diff in family history, no diff in known risk factors

PREDICTIVE RISK

FACTORS FOR

CONGESTIVE HEART

FAILURE

Demographic/Social

Factors

Reference P-Value

Gender Male 0.49

Ethnicity Caucasian 1.00

Physical Activity Heavy 0.99

Smoking Never 0.84

Framingham Risk Factors Reference P-Value

Family History of Heart

Disease

1st Degree (Parent and/or

Sibling)

0.99

Total Cholesterol > 160 0.95

Systolic BP > 140 0.42

HDL > 50 0.14

Geographic Factor Reference P-Value

Southwest vs. Southside Southside 0.99

Predicting CHF - Demographic, social, risk factors, location

Results – no predictors

Interpreting Results:

Raw data on frequency of CHF in SW and SS VA shows a

significant difference in congestive heart failure

prevalence, higher in SW VA

However, when considering demographics, geographic

and known risk factors there were no differences between

the communities.

The statistical mode was ‘strong enough’ and able to

predict half of the time .

Predicting CHF and interpreting results

Model P-value = .04 and R2 = 48.4%

Female

Male

All cancer and respiratory cancer mortality rates for males

and females in Southwest and Southside Virginia, and ‘other’

counties by decade from 1960-2012 (VDH).

Male

Female

Coal miner (%) Non-miner (%)

Occupation 30.6% (n=155) 69.4% (n=351)

Family history of cancer

1st degree relative (%) 16.1 13.1

2nd degree relative (%) 5.8 4.3

1st + 2nd degree (%) 4.5 1.7

Confirmation of diagnosis

ICD Codes (%) 91.0 91.2

Lab information (%) 91.0 92.6

Clinical exam (%) 91.0 91.5

Physician’s impression (%) 90.3 89.7

Cancer in coal miners and non-coal miners, family history

reporting and confirmation of diagnosis

Results: No diff

Percent County, Town Zip Code

3.0-3.9 Tazewell, Richlands

Tazewell, North Tazewell

Tazewell, Cedar Bluff

Tazewell, Bluefield

Wise, Wise

Lee, Pennington Gap

Lee, Jonesville

Russell, Honaker

Wise, Coeburn

Dickenson, Clintwood

Russell, Castlewood

24641

24630

24609

24605

24293

24277

24263

24260

24230

24228

24224

4.0-4.9 Tazewell, Tazewell

Buchanan, Grundy

Russell, Lebanon

Scott, Gate City

24651

24614

24266

24251

5.0-5.9 Wise, Big Stone Gap 24219

Zip code of residents with cancer mortality as a percentage of

all causes of mortality in SW VA; rates of 3.0-3.9% (blue), 4.0-

4.9% (yellow), and 5.0-5.9% (red) (VDH, 1999-2012).

Results: Cancers, particularly lung cancers,

- remain a concern in SW VA communities*

- rates increasing in women, decreasing in men (VDH)

- no differences by occupation, miners vs other (EMR)

- contradict popular beliefs and previous reports

associating coal mining with higher rates of cancer

*SW VA counties in 2010 and 2013 were ranked 116 and 123

out of 132 counties in VA and behind others in achieving

Healthy People 2020 goals for cancer prevention and

treatment.

Do Hospital Providers Ask About

Physical Activity?

An Assessment of Three Virginia Hospitals

Cody Goessl, MS, ATC1 and Susan Meacham, PhD, RD2

1PhD Candidate, Fralin Translational Obesity Research Center, Virginia Tech2Preventive Medicine, Via College of Osteopathic Medicine-Virginia

Campus

Presentation, 2nd in category, Society of Behavioral Medicine, San Antonio TX, May 2015

Common Disease Name/ICD-9

Inactiven (%)

Light n (%)

Moderate n (%)

Heavy n (%)

No Data Available n (%)

Chronic Heart Failure428

1 (2.7%) 2 (5.5%) 1 (2.7%) 2 (5.5%) 30 (83.3%)

ChronicBronchitis491

5 (2.5%) 15 (7.6%) 3 (1.5%) 3 (1.5%) 171 (86.8%)

Emphysema492

1 (16.6%) 0 0 0 5 (83.3%)

Asthma493

4 (12.5%) 3 (9.4%) 3 (9.4%) 0 22 (68.8%)

COPD496

2 (3.3%) 2 (3.3%) 1 (1.7%) 0 55 (91.2%)

Chronic Kidney Disease585

3 (3.6%) 4 (4.8%) 1 (1.2%) 0 75 (90.3%)

Number and percentage of physical activity

documentations in SW and SS VA EMR by patient ICD codes

Common Disease Name/ICD-9

Inactive n (%)

Light n (%)

Moderaten (%)

Heavyn (%)

No Data Availablen (%)

Cancer (Neoplasm)140-239

2 (2.5%) 4 (5.1%) 3 (3.8%) 1 (1.3%) 69 (87.3%)

Diabetes250

7 (2.9%) 16 (6.6%) 9 (3.7%) 5 (2.1%) 204 (84.6%)

Other Metabolic/Immunity Disorder270-279

19 (4.4%)

29 (6.7%) 24 (5.5%) 5 (1.1%) 358 (82.3%)

Mental Disorder300-326

10 (3.5%)

19 (6.7%) 20 (7.1%) 6 (2.1%) 228 (80.6%)

Hypertension401

4 (1.8%) 9 (4.1%) 9 (4.1%) 2 (0.9%) 195 (89.0%)

Ischemic Heart Disease410-414

12

(4.8%)18 (7.2%) 6 (2.4%) 1 (0.4%) 212 (85.1%)

(continued) Number and percentage of

physical activity documentations

Summary EMR initial findings in SW and SS VA

Prevalence and Predictors

•2 studies lifestyle more important to health than occupation as

coal miner or living in coal community.

•2 studies chronic disease (kidney and heart) were not associated

with coal communities

•1 study chronic respiratory diseases were linked to the coal

mining occupation (CWP) and smoking.

•3 studies cancer still a concern, lifestyle factors contributing

•1 Suggest more lifestyle factor documentation, discussions

Future Directions for VCOM

Complete data collection with EMR reviews and publications

Report VA prevalence rates of chronic disease by region

Focus on lung conditions and cancers

Report economic factors associated with chronic disease

George Davis, PhD, Ag Econ/Nutrition, Foods Exercise

Report on Sociocultural and Mental Health

Conclusions/Discussion

Our current data confirms inadequate evidence to

support previous publication results on MTM effects on

chronic conditions

Ongoing are studies on cancers, non-malignant lung

conditions and mental health

Need for multidisciplinary, collaborative approaches to

study mechanisms of cause – effect relationships

Need to know what’s ‘right’ in positive trends in health

disparities to encourage healthy attitudes and

behaviors

This study is sponsored by Appalachian Research Initiative for

Environmental Science (ARIES). ARIES is an industrial affiliates

program at Virginia Tech, supported by members that include

companies in the energy sector. The research under ARIES is

conducted by independent researchers in accordance with the

policies on scientific integrity of their institutions. The views, opinions

and recommendations expressed herein are solely those of the

authors and do not imply any endorsement by ARIES employees,

other ARIES-affiliated researchers or industrial members. Information

about ARIES can be found at http://www.energy.vt.edu/ARIES.”

Thank you!

- Medical facilities administration and staff!

- Special thanks –

- VCOM Development and Alumni Relations - Diane Sutphin

- VCOM Biostatistician – Dalia Meisha- VCOM Students

VCOM OMS IV 2015 – Alyson Snyder, Diabetes, Elective Summer Research

VCOM OMS III 2016 – Tom Taber, Economics

VCOM OMS I 2017 – Katie Kennedy, Kristy Atkinson, Cancer

VT PhD Candidate – Cody Goessl, Public Health, Public Health Intern,

VT PH - Chad Hall

2015 Post baccalaureate - Reuel Edson, Chris Grogg, Kevin Lavender, Kate Slaymaker

Aidan Wang

- VCOM Faculty and staff (DO/MD/PhD/DVM/DDS)

- Virginia Department of Health

- University of Pittsburgh, J. Buchanich, E. Talbott

- ARIES, VA Center for Coal /Energy Research, M. Karmis, J. Craynon

- Industry Leaders!!

Acknowledgements

Thanks!

Appalachia provides valuable ‘positives’

that can support a sustainable,

healthy human existence

in balance with the environment.

Health is right outside!