It is incumbent upon all researchers who use the electronic health record (EHR), including data scientists, to understand the quality of such data.EHR data may be subject to measurement error or misclassification that have the potential to bias results, unless one applies the available computational techniques specifically created for this problem.In this article, we begin with a discussion of data-quality issues in the EHR focusing on health outcomes.We review the concepts of sensitivity, specificity, positive and negative predictive values, and demonstrate how the imperfect classification of a dichotomous outcome variable can bias an analysis, both in terms of prevalence of the outcome, and relative risk of the outcome under one treatment regime (aka exposure) compared to another.This is then followed by a description of a generalizable approach to probabilistic (quantitative) bias analysis using a combination of regression estimation of the parameters that relate the true and observed data and application of these estimates to adjust the prevalence and relative risk that may have existed if there was no misclassification.We describe bias analysis that accounts for both random and systematic errors and highlight its limitations.We then motivate a case study with the goal of validating the accuracy of a health outcome, chronic infection with hepatitis C virus, derived from a diagnostic code in the EHR.Finally, we demonstrate our approaches on the case study and conclude by summarizing the literature on outcome misclassification and quantitative bias analysis.

Purpose: To demonstrate how selection into a healthcare facility can induce bias in an electronic medical record-based study of community deprivation and chronic hepatitis C virus infection, in order to more accurately identify local risk factors and prevalence. Methods: We created a catchment model that attempted to define the probability of selection into a retrospective cohort. Then using the inverse of this probability, we compared naive unweighted and weighted models to demonstrate the impact of selection bias. Results: ZIP code-level ecological plots of the cohort demonstrated that there was a pattern of the community deprivation, hepatitis C outcome, and distance to the health center (an intuitive proxy for being within catchments). The naive multilevel analysis found that living in an area with greater deprivation resulted in 1.25 times greater odds of HCV (95% CI: 1.06, 1.48), whereas the weighted analysis found less certainty of this effect due to a selection bias. Conclusions: We observed that selection into the catchment area of the studied healthcare facility may bias the association of community deprivation and hepatitis C. This may be mitigated through inverse probability weighting. (c) 2021 Elsevier Inc. All rights reserved.

OBJECTIVES:We conducted a qualitative study of primary care providers to assess the challenges and opportunities in implementing a universal screening program for Hepatitis C Virus (HCV) at an urban community-based health center serving a largely disadvantaged population.METHODS:Qualitative semi-structured interviews of prescribing providers took place pre- and post-educational intervention, at a single federally qualified health center in Wilmington, Delaware, between September 2018 and July 2019. The intervention included a two-day didactic session and shadowing specialist providers. Data captured provider perspectives on universal screening and treatment. The interviews were transcribed verbatim, then grouped into codes, then finally, themes.RESULTS:Emergent themes included hesitancy in managing universal screening programs in the primary care environment, positive attitudes surrounding treatment, fewer HCV cases than expected, and concern with both patient-level barriers and practice-level barriers. Pre-intervention and post-intervention themes were similar.CONCLUSIONS:Implementation programs exploring universal HCV screening in the primary care environment should include educational opportunities that are available to all individuals in the practice, sustained organizational support, and available patient literature targeted to patients with varying health literacy and in languages other than English. In short, universal HCV screening and treatment is feasible in the primary medical environment but requires ongoing support and education for providers to ensure success.

Abstract Background Hepatitis C infection (HCV) is a curable disease that can be effectively managed by non-specialists. Delaware has high HCV rates but limited resources to care for individuals with HCV. Successful HCV micro-elimination starts with universal HCV screening and case identification. Methods ChristianaCare (CC) and Westside Family Healthcare (WFH), Delaware’s largest federally qualified health center (FQHC), created a multidisciplinary initiative to support comprehensive HCV care from July 2018-2020 (Figure 1). As part of this partnership, universal opt-out HCV screening in eligible (no prior HCV RNA result) adults ≥ 18 years was implemented at a pilot site in Wilmington in 2019. To characterize screening practices, pre- (risk-based screening) and post-intervention (universal screening) electronic health record data was collected following the first 6 months of the intervention (Jan-June 2019). An HCV dashboard was created and updated monthly to evaluate trends in 2019 screening rates. Collaboration was supported through a 2-year CC Harrington grant. Figure 1. Components of Federally Qualified Health Center HCV Medical Care Model Table 1. Pilot Site Patient Characteristics Results Pre- and post-intervention patient characteristics and screening data are presented in Table 1 and Figure 2 respectively. 39% of patients had screening ordered during the first 6 months of universal screening, a 4% increase from baseline. HCV seroprevalence [amongst resulted tests] remained unchanged from baseline at 5%. During the universal screening period, 2.5% (12/482) of individuals with resulted tests had HCV compared to 4.0% (29/795) tested during risk-based screening. HCV dashboard data demonstrated a trend of increased ordering and fulfillment of screening tests (Figure 3). Figure 3. 2019 HCV Dashboard Conclusion The early adoption of universal HCV screening in adults (prior to 2020 USPSTF update) at an urban FQHC, together with an initiative to provide multidisciplinary HCV care at this FQHC (Figure 1), led to increasing rates of ordered screening. The presented 6-month data does not fully account for lag times between test ordering and fulfillment, resulting in under-reporting of universal HCV screening rates. Multidisciplinary care models to address HCV in patients’ medical homes are vital to HCV eradication with the robust implementation of universal HCV screening a vital first step in this continuum. Disclosures Deborah A. Kahal, MD,MPH, FACP, Gilead (Speaker’s Bureau)Viiv (Speaker’s Bureau)

BACKGROUND:Hepatitis C virus (HCV) is the most common blood-borne pathogen in the U.S., and Delaware has one of the highest sero-prevalence rates in the country. As a cause of significant morbidity and mortality, it is a public health priority to identify and link individuals with HCV to care. The demand of patients with HCV far exceeds the current availability of providers in Delaware that offer HCV management. .OBJECTIVE:To propose a framework for enabling non-specialist providers within Westside Family Healthcare to manage patients with HCV.METHODS:As a recipient of a Harrington Value Institute Community Partnership grant, the HIV Community Program of Christiana Care Health System (CCHS) started working together with the NE Wilmington pilot site of Westside in July 2018 to: 1) provide HCV education to Westside, 2) implement an HCV care model at Westside, and 3) conduct programmatic evaluation of this framework's effectiveness. Our goal is to improve Westside rates of HCV knowledge amongst patients and staff, as well as to improve the HCV care continuum, starting with universal HCV screening.RESULTS AND CONCLUSIONS:Results from the first year of collaboration will be available in August 2019.  Implementation of this partnership will enable future expansion and continuation of HCV management amongst Westside sites.

The increasing interconnectedness of the world and the movement of people (voluntary and involuntary) challenges all those in health to understand the global burden of disease. There subsequently arises the need to develop tools to address health disparities through direct clinical care and health systems level change. At the same time there is the essential need for education on cross-cultural interactions and mutually respectful, sustainable interactions, especially when operating in a global space.