Publications by authors named "Hye-Chung Kum"

30 Publications

  • Page 1 of 1

A Position Statement on Population Data Science: The Science of Data about People.

Int J Popul Data Sci 2018 Feb 22;3(1):415. Epub 2018 Feb 22.

Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.

Information is increasingly digital, creating opportunities to respond to pressing issues about human populations using linked datasets that are large, complex, and diverse. The potential social and individual benefits that can come from data-intensive science are large, but raise challenges of balancing individual privacy and the public good, building appropriate socio-technical systems to support data-intensive science, and determining whether defining a new field of inquiry might help move those collective interests and activities forward. A combination of expert engagement, literature review, and iterative conversations led to our conclusion that defining the field of Population Data Science (challenge 3) will help address the other two challenges as well. We define Population Data Science succinctly as and note that it is related to but distinct from the fields of data science and informatics. A broader definition names four characteristics of: data use for positive impact on citizens and society; bringing together and analyzing data from multiple sources; finding population-level insights; and developing safe, privacy-sensitive and ethical infrastructure to support research. One implication of these characteristics is that few people possess all of the requisite knowledge and skills of Population Data Science, so this is by nature a multi-disciplinary field. Other implications include the need to advance various aspects of science, such as data linkage technology, various forms of analytics, and methods of public engagement. These implications are the beginnings of a research agenda for Population Data Science, which if approached as a collective field, can catalyze significant advances in our understanding of trends in society, health, and human behavior.
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http://dx.doi.org/10.23889/ijpds.v3i1.415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142960PMC
February 2018

Identifying and prioritizing benefits and risks of using privacy-enhancing software through participatory design: a nominal group technique study with patients living with chronic conditions.

J Am Med Inform Assoc 2021 May 19. Epub 2021 May 19.

Population Informatics Lab, School of Public Health, Texas A&M University, College Station, Texas, USA.

Objective: While patients often contribute data for research, they want researchers to protect their data. As part of a participatory design of privacy-enhancing software, this study explored patients' perceptions of privacy protection in research using their healthcare data.

Materials And Methods: We conducted 4 focus groups with 27 patients on privacy-enhancing software using the nominal group technique. We provided participants with an open source software prototype to demonstrate privacy-enhancing features and elicit privacy concerns. Participants generated ideas on benefits, risks, and needed additional information. Following a thematic analysis of the results, we deployed an online questionnaire to identify consensus across all 4 groups. Participants were asked to rank-order benefits and risks. Themes around "needed additional information" were rated by perceived importance on a 5-point Likert scale.

Results: Participants considered "allowance for minimum disclosure" and "comprehensive privacy protection that is not currently available" as the most important benefits when using the privacy-enhancing prototype software. The most concerning perceived risks were "additional checks needed beyond the software to ensure privacy protection" and the "potential of misuse by authorized users." Participants indicated a desire for additional information with 6 of the 11 themes receiving a median participant rating of "very necessary" and rated "information on the data custodian" as "essential."

Conclusions: Patients recognize not only the benefits of privacy-enhancing software, but also inherent risks. Patients desire information about how their data are used and protected. Effective patient engagement, communication, and transparency in research may improve patients' comfort levels, alleviate patients' concerns, and thus promote ethical research.
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http://dx.doi.org/10.1093/jamia/ocab073DOI Listing
May 2021

The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York.

Am J Emerg Med 2021 Apr 30;48:183-190. Epub 2021 Apr 30.

Population Informatics Lab, Texas A&M University, College Station, TX, USA; Texas A&M University, School of Public Health, Department of Health Policy & Management, College Station, TX, USA.

Background: One of the proposed benefits of expanding insurance coverage under the Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for non-urgent visits related to lack of health insurance coverage and access to primary care providers. The objective of this study was to estimate the effect of the 2014 ACA implementation on ED use in New York.

Methods: We used the Healthcare Cost and Utilization Project State Emergency Department and State Inpatient Databases for all outpatient and all inpatient visits for patients admitted through an ED from 2011 to 2016. We focused on in-state residents aged 18 to 64, who were covered under Medicaid, private insurance, or were uninsured prior to the 2014 expansion. We estimated the effect of the expanded insurance coverage on average monthly ED visits volumes and visits per 1000 residents (rates) using interrupted time-series regression analyses.

Results: After ACA implementation, overall average monthly ED visits increased by around 3.0%, both in volume (9362; 95% Confidence Intervals [CI]: 1681-17,522) and in rates (0.80, 95% CI:0.12-1.49). Medicaid covered ED visits volume increased by 23,972 visits (95% CI: 16,240 -31,704) while ED visits by the uninsured declined by 13,297 (95% CI:-15,856 - -10,737), and by 1453 (95% CI:-4027-1121) for the privately insured. Medicaid ED visits rates per 1000 residents increased by 0.77 (95% CI:-1.96-3.51) and by 2.18 (95% CI:-0.55-4.92) for those remaining uninsured, while private insurance visits rates decreased by 0.48 (95% CI:-0.79 - -0.18). We observed increases in primary-care treatable ED visits and in visits related to mental health and alcohol disorders, substance use, diabetes, and hypertension. All estimated changes in monthly ED visits after the expansion were statistically significant, except for ED visit rates among Medicaid beneficiaries.

Conclusion: Net ED visits by adults 18 to 64 years of age increased in New York after the implementation of the ACA. Large increases in ED use by Medicaid beneficiaries were partially offset by reductions among the uninsured and those with private coverage. Our results suggest that efforts to expand health insurance coverage only will be unlikely to reverse the increase in ED use.
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http://dx.doi.org/10.1016/j.ajem.2021.04.076DOI Listing
April 2021

Emergency Department Utilization by Adolescents Experiencing Homelessness in Massachusetts.

Med Care 2021 Apr;59(Suppl 2):S187-S194

Population Informatics Lab, Texas A&M University, College Station.

Background: Adolescents who experience homelessness rely heavily on emergency departments (EDs) for their health care.

Objectives: This study estimates the relationship between homelessness and ED use and identifies the sociodemographic, clinical, visit-level, and contextual factors associated with multiple ED visits among adolescents experiencing homelessness in Massachusetts.

Research Design: We used the Healthcare Cost and Utilization Project State Emergency Department Databases on all outpatient ED visits in Massachusetts from 2011 to 2016. We included all adolescents who were 11-21 years old. We estimated the association between homelessness and ED utilization and investigated predictors of multiple ED visits among adolescents who experience homelessness using multivariate logistic and negative binomial regressions.

Results: Our study included 1,196,036 adolescents, of whom about 0.8% experienced homelessness and this subset of adolescents accounted for 2.2% of all ED visits. Compared with those with stable housing, adolescents who were homeless were mostly covered through Medicaid (P<0.001), diagnosed with 1 or more comorbidities (P<0.001), and visited the ED at least once for reasons related to mental health; substance and alcohol use; pregnancy; respiratory distress; urinary and sexually transmitted infections; and skin and subcutaneous tissue diseases (P<0.001). Homeless experience was associated with multiple ED visits (incidence rate ratio=1.18; 95% confidence intervals, 1.16-1.19) and frequent ED use (4 or more ED visits) (adjusted odds ratio=2.21; 95% confidence interval, 2.06-2.37). Factors related to clinical complexity and Medicaid compared with lack of coverage were also significant predictors of elevated ED utilization within the cohort experiencing homelessness.

Conclusions: Adolescents who experience homelessness exhibit higher ED use compared with those with stable housing, particularly those with aggravated comorbidities and chronic conditions. Health policy interventions to integrate health care, housing, and social services are essential to transition adolescents experiencing homelessness to more appropriate community-based care.
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http://dx.doi.org/10.1097/MLR.0000000000001436DOI Listing
April 2021

Communicating With Patients About Software for Enhancing Privacy in Secondary Database Research Involving Record Linkage: Delphi Study.

J Med Internet Res 2020 12 15;22(12):e20783. Epub 2020 Dec 15.

Population Informatics Lab, Department of Health Policy & Management, Texas A&M University School of Public Health, College Station, TX, United States.

Background: There is substantial prior research on the perspectives of patients on the use of health information for research. Numerous communication barriers challenge transparency between researchers and data participants in secondary database research (eg, waiver of informed consent and knowledge gaps). Individual concerns and misconceptions challenge the trust in researchers among patients despite efforts to protect data. Technical software used to protect research data can further complicate the public's understanding of research. For example, MiNDFIRL (Minimum Necessary Disclosure For Interactive Record Linkage) is a prototype software that can be used to enhance the confidentiality of data sets by restricting disclosures of identifying information during the record linkage process. However, software, such as MiNDFIRL, which is used to protect data, must overcome the aforementioned communication barriers. One proposed solution is the creation of an interactive web-based frequently asked question (FAQ) template that can be adapted and used to communicate research issues to data subjects.

Objective: This study aims to improve communication with patients and transparency about how complex software, such as MiNDFIRL, is used to enhance privacy in secondary database studies to maintain the public's trust in researchers.

Methods: A Delphi technique with 3 rounds of the survey was used to develop the FAQ document to communicate privacy issues related to a generic secondary database study using the MiNDFIRL software. The Delphi panel consisted of 38 patients with chronic health conditions. We revised the FAQ between Delphi rounds and provided participants with a summary of the feedback. We adopted a conservative consensus threshold of less than 10% negative feedback per FAQ section.

Results: We developed a consensus language for 21 of the 24 FAQ sections. Participant feedback demonstrated preference differences (eg, brevity vs comprehensiveness). We adapted the final FAQ into an interactive web-based format that 94% (31/33) of the participants found helpful or very helpful. The template FAQ and MiNDFIRL source code are available on GitHub. The results indicate the following patient communication considerations: patients have diverse and varied preferences; the tone is important but challenging; and patients want information on security, identifiers, and final disposition of information.

Conclusions: The findings of this study provide insights into what research-related information is useful to patients and how researchers can communicate such information. These findings align with the current understanding of health literacy and its challenges. Communication is essential to transparency and ethical data use, yet it is exceedingly challenging. Developing FAQ template language to accompany a complex software may enable researchers to provide greater transparency when informed consent is not possible.
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http://dx.doi.org/10.2196/20783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772068PMC
December 2020

Crash narrative classification: Identifying agricultural crashes using machine learning with curated keywords.

Traffic Inj Prev 2021 18;22(1):74-78. Epub 2020 Nov 18.

Center for Transportation Safety, Crash Analytics Team, Texas A&M Transportation Institute, College Station, Texas.

Objective: Traditionally, structured or coded data fields from a crash report are the basis for identifying crashes involving different types of vehicles, such as farm equipment. However, using only the structured data can lead to misclassification of vehicle or crash type. The objective of the current article is to examine the use of machine learning methods for identifying agricultural crashes based on the crash narrative and to transfer the application of models to different settings (e.g., future years of data, other states).

Methods: Different data representations (e.g., bag-of-words [BoW], bag-of-keywords [BoK]) and document classification algorithms (e.g., support vector machine [SVM], multinomial naïve Bayes classifier [MNB]) were explored using Texas and Louisiana crash narratives across different time periods.

Results: The BoK-support vector classifier (SVC), BoK-MNB, and BoW-SVC models trained with Texas data were better predictive models than the baseline rule-based algorithm on the future year test data, with F1 scores of 0.88, 0.89, 0.85 vs. 0.84. The BoK-MNB trained with Louisiana data performed the closest to the baseline rule-based algorithm on the future year test data (F1 scores, 0.91 baseline rule-based algorithm vs. 0.89 BoK-MNB). The BoK-SVC and BoK-MNB models trained with Texas and Louisiana data were better productive models for Texas future year test data with F1 scores 0.89 and 0.90 vs. 0.84. The BoK-MNB model trained with both states' data was a better predictive model for the Louisiana future year test data, F1 score 0.94 vs. 0.91.

Conclusions: The findings of this study support that machine learning methodologies can potentially reduce the amount of human power required to develop key word lists and manually review narratives.
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http://dx.doi.org/10.1080/15389588.2020.1836365DOI Listing
June 2021

Post-acute care referral in United States of America: a multiregional study of factors associated with referral destination in a cohort of patients with coronary artery bypass graft or valve replacement.

BMC Med Inform Decis Mak 2019 11 14;19(1):223. Epub 2019 Nov 14.

Department of Industrial and System Engineering, Texas A&M University, College Station, TX, USA.

Background: The use of post-acute care (PAC) for cardiovascular conditions is highly variable across geographical regions. Although PAC benefits include lower readmission rates, better clinical outcomes, and lower mortality, referral patterns vary widely, raising concerns about substandard care and inflated costs. The objective of this study is to identify factors associated with PAC referral decisions at acute care discharge.

Methods: This study is a retrospective Electronic Health Records (EHR) based review of a cohort of patients with coronary artery bypass graft (CABG) and valve replacement (VR). EHR records were extracted from the Cerner Health-Facts Data warehouse and covered 49 hospitals in the United States of America (U.S.) from January 2010 to December 2015. Multinomial logistic regression was used to identify associations of 29 variables comprising patient characteristics, hospital profiles, and patient conditions at discharge.

Results: The cohort had 14,224 patients with mean age 63.5 years, with 10,234 (71.9%) male and 11,946 (84%) Caucasian, with 5827 (40.96%) being discharged to home without additional care (Home), 5226 (36.74%) to home health care (HHC), 1721 (12.10%) to skilled nursing facilities (SNF), 1168 (8.22%) to inpatient rehabilitation facilities (IRF), 164 (1.15%) to long term care hospitals (LTCH), and 118 (0.83%) to other locations. Census division, hospital size, teaching hospital status, gender, age, marital status, length of stay, and Charlson comorbidity index were identified as highly significant variables (p- values < 0.001) that influence the PAC referral decision. Overall model accuracy was 62.6%, and multiclass Area Under the Curve (AUC) values were for Home: 0.72; HHC: 0.72; SNF: 0.58; IRF: 0.53; LTCH: 0.52, and others: 0.46.

Conclusions: Census location of the acute care hospital was highly associated with PAC referral practices, as was hospital capacity, with larger hospitals referring patients to PAC at a greater rate than smaller hospitals. Race and gender were also statistically significant, with Asians, Hispanics, and Native Americans being less likely to be referred to PAC compared to Caucasians, and female patients being more likely to be referred than males. Additional analysis indicated that PAC referral practices are also influenced by the mix of PAC services offered in each region.
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http://dx.doi.org/10.1186/s12911-019-0955-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854767PMC
November 2019

The Effects of Chronic Disease on Ambulatory Care-Sensitive Hospitalizations for Children or Youth.

Health Serv Insights 2019 15;12:1178632919879422. Epub 2019 Oct 15.

Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA.

Considerable research has focused on hospitalizations for ambulatory care-sensitive conditions (ACSHs), but little of that research has focused on the role played by chronic disease in ACSHs involving children or youth (C/Y). This research investigates, for C/Y, the effects of chronic disease on the likelihood of an ACSH. The database included 699 473 hospital discharges for individuals under 18 in Texas between 2011 and 2015. Effects of chronic disease, individual, and contextual factors on the likelihood of a discharge involving an ACSH were estimated using logistic regression. Contrary to the results for adults, the presence of chronic diseases or a complex chronic disease among children or youth was protective, reducing the likelihood of an ACSH for a nonchronic condition. Results indicate that heightened ambulatory care received by C/Y with chronic diseases is largely protective. Two of more chronic conditions or at least one complex chronic condition significantly reduced the likelihood of an ACSH.
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http://dx.doi.org/10.1177/1178632919879422DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6796197PMC
October 2019

Predictors of Multiple Emergency Department Utilization Among Frequent Emergency Department Users in 3 States.

Med Care 2020 02;58(2):137-145

Department of Health Policy & Management, School of Public Health.

Background: Research on frequent emergency department (ED) use shows that a subgroup of patients visits multiple EDs. This study characterizes these individuals.

Objective: The objective of this study was to determine how many frequent ED users seek care at multiple EDs and to identify sociodemographic, clinical, and contextual factors associated with such behavior.

Research Design: We used the 2011-2014 Healthcare Cost and Utilization Project State Emergency Department Databases data on all outpatient ED visits in New York, Massachusetts, and Florida. We studied all adult ED users with ≥5 visits in a year and defined multisite use as visits to ≥3 different sites. We estimated predictors of multisite use with multivariate logistic regressions.

Results: Across all 3 states, 1,033,626 frequent users accounted for 7,613,077 ED visits. Of frequent users, 25% were multisite users, accounting for 30% of the visits studied. Frequent users with at least 1 visit for mental health or substance use-related diagnosis were more likely to use multiple sites. Uninsured frequent users and those with public insurance were associated with less use of multiple EDs than those with private coverage while lacking consistent coverage by the same insurance within each year were associated with using multiple sites.

Conclusions: Health policy interventions to reduce duplicative or unnecessary ED use should apply a population health perspective and engage multiple hospitals. Community-level preventive approaches and a stronger infrastructure for mental health and substance use are essential to mitigate multisite ED use.
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http://dx.doi.org/10.1097/MLR.0000000000001228DOI Listing
February 2020

Patient perspectives on the linkage of health data for research: Insights from an online patient community questionnaire.

Int J Med Inform 2019 07 6;127:9-17. Epub 2019 Apr 6.

Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.

Objective: To examine the patient perspective on the risks and benefits of linking existing data sources for research.

Materials And Methods: Between December 2015 and February 2016, we fielded a questionnaire in PatientsLikeMe, an online patient community representing over 2500 health conditions. The questionnaire was developed using subject matter expertise and patient feedback from a concept elicitation phase (N = 57 patients). The final questionnaire consisted of 37 items.

Results: Of n = 5741 who opened the email invitation, n = 3516 respondents completed the questionnaire (61.2%). Of these, 73.8% were women, 86.4% were Caucasian, 14.5% were 65 or older, and 44.9% had completed college or post-graduate education. Questionnaire respondents indicated that the most important benefits of sharing data were "helping my doctor make better decisions about my health" (94%) and "helping make new therapies available faster" (94%). The most important data sharing risk identified was health data being "stolen by hackers" (87%). Of 693 patients who were not comfortable with researchers accessing their de-identified data, most reported that their comfort levels would increase if they were able to learn how their data was protected (84%). In general, responders felt more comfortable when unique identifiers such as social security number (90%) and insurance ID (82%) were removed from the data for linkage and research use.

Discussion: The majority of patients in a US-based online community are comfortable with researchers accessing their de-identified data for research purposes.

Conclusions: Developing methods to link databases minimizing the exposure of unique identifiers may improve patient comfort levels with linking data for research purposes.
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http://dx.doi.org/10.1016/j.ijmedinf.2019.04.003DOI Listing
July 2019

Self-Reported Quality, Health, and Cost-Related Outcomes of Care Coordination Among Patients with Complex Health Needs.

Popul Health Manag 2020 02 20;23(1):59-67. Epub 2019 May 20.

Department of Health Management and Policy, School of Public Health, Texas A&M Health Science Center, Texas A&M University, College Station, Texas.

Care coordination is an increasingly popular strategy to help patients with complex health conditions manage their diseases more effectively. The purpose of the current study was to assess associations between patient-reported receipt of care coordination and their experiences of health, health care quality, and cost-related outcomes. Regression analyses of data from 431 patients across 13 Texas providers indicate that patients who reported receiving care coordination had higher odds of perceiving having enough information about how to manage their conditions (OR 2.02,  < .01), having information about education and treatments available (OR 1.87,  < .01), and reporting better access to care (beta = .27,  < .01). Receipt of care coordination was not associated with patients' reports of how up-to-date their doctors were about care from other providers, patients' health-related functioning, or patients' intention to return to the emergency department. Patients' reasons for intending to return to the emergency department included the speed of care there relative to alternatives and satisfaction with the quality of care they had received previously in the emergency department. Results suggest that care coordination in usual practice may improve patient preventive care, but not some other health or cost-related outcomes.
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http://dx.doi.org/10.1089/pop.2019.0007DOI Listing
February 2020

A semi-automated tool for identifying agricultural roadway crashes in crash narratives.

Traffic Inj Prev 2019 10;20(4):413-418. Epub 2019 May 10.

a Center for Transportation Safety, Texas A&M Transportation Institute , College Station , Texas.

Crash reports contain precoded structured data fields and a crash narrative that can be a source of rich information not included in the structured data. The narrative can be useful for identifying vulnerable roadway users, such as agricultural workers. However, using the narratives often requires manual reviews that are time consuming and costly. The objective of this research was to develop a simple and relatively inexpensive, semi-automated tool for screening crash narratives and expediting the process of identifying crashes with specific characteristics, such as agricultural crashes. Crash records for Louisiana from 2010 to 2015 were obtained from the Louisiana Department of Transportation (LaDOTD). Records with narratives were extracted and stratified by vehicle type. The majority of analyses focused on a vehicle type of farm equipment (Type T). Two keyword lists, an inclusion list and an exclusion list, were created based on the published literature, subject-matter experts, and findings from a pilot project. Next, a semi-automated tool was developed in Microsoft Excel to identify agricultural crashes. Lastly, the tool's performance was assessed using a gold standard set of agricultural narratives identified through manual review. The tool reduced the search space (e.g., number of narratives that need manual review) for narratives requiring manual review from 6.7 to 59.4% depending on the research question. Sensitivity was high, with 96.1% of agricultural crash narratives being correctly classified. Of the gold standard agricultural narratives, 58.3% included an equipment keyword and 72.8% included a farm equipment brand. This article provides information on how crash narratives can supplement structured crash data. It also provides an easy-to-implement method to facilitate incorporating narratives into safety research along with keyword lists for identifying agricultural crashes.
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http://dx.doi.org/10.1080/15389588.2019.1599873DOI Listing
July 2020

Characteristics and predictors of adult frequent emergency department users in the United States: A systematic literature review.

J Eval Clin Pract 2019 Jun 2;25(3):420-433. Epub 2019 May 2.

Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, TX, USA.

Study Objective: We conducted a systematic literature review to identify and to update patient characteristics and contextual factors for adult frequent emergency department users (FEDUs) compared with non-FEDU in an era where the US health care system underwent substantial changes.

Methods: We searched MEDLINE, CINAHL, and EMBASE to identify all relevant articles after 2010 through July 2018 that describe FEDU. We included US studies on adult FEDU only and excluded studies on specific subgroups of FEDU. We included demographic, clinical, and health care utilization information, and two reviewers independently evaluated the studies using the Joanna Briggs Institute Critical Appraisal tool.

Results: The 11 studies included in the review indicated that FEDU were 4% to 16% of total ED users but accounted for 14% to 47% of ED visits, with six to nine visits per year on average. The majority of FEDU were young or middle-aged adults, females, of low socioeconomic status and high school or less education, with public insurance, multiple primary care provider visits, and chronic conditions. Fair or poor self-perceived health status, unemployment, unmet needs from primary care providers (PCPs), mental health, and substance abuse were predictors of FEDU.

Conclusion: FEDUs are disproportionally sicker and are also heavy users of non-ED health care service providers. The limited data for non-ED health services use in facility-specific studies of FEDU may contribute to findings in such studies that complex and unmet needs from PCPs contributed to ED visits. This suggests the need for more comprehensive data analysis beyond a few sites that can inform systemic management approaches.
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http://dx.doi.org/10.1111/jep.13137DOI Listing
June 2019

Hepatocellular Carcinoma Screening Is Associated With Increased Survival of Patients With Cirrhosis.

Clin Gastroenterol Hepatol 2019 04 26;17(5):976-987.e4. Epub 2018 Oct 26.

Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas. Electronic address:

Background & Aims: Hepatocellular carcinoma (HCC) screening of patients with cirrhosis is recommended by professional societies to increase detection of early stage tumors and survival, but is underused in clinical practice.

Methods: We conducted a retrospective cohort study of 13,714 patients diagnosed with HCC from 2003 through 2013 included in the Surveillance, Epidemiology, and End Results Program-Medicare database. We characterized receipt of HCC screening in the 3 years before HCC diagnosis using mutually exclusive categories (consistent vs inconsistent vs no screening) and the proportion of time covered with screening. Correlates for screening receipt were assessed using a multivariable 2-part regression model. We examined the association between screening receipt and early detection of tumors using multivariable logistic regression. We evaluated associations between screening receipt and overall survival using a Cox proportional hazards model, after adjustments for effects of lead-time bias and length-time bias on survival rate estimators.

Results: Most patients with cirrhosis (51.1%) did not receive any screening in the 3 years before a diagnosis of HCC, and only 6.8% of patients underwent consistent annual screening. The proportion with consistent screening increased from 5.4% in 2003 to 2006 to 8.8% in 2011 to 2013 (P < .001). The mean proportion of time covered was 13.4% overall, which increased from 11.7% in 2003 to 2006 to 15.2% in 2011 to 2013. Receipt of consistent screening was associated with detection of early stage tumors (odds ratio, 1.98; 95% CI, 1.68-2.33) and a reduced risk of death after correction for lead-time bias (hazard ratio, 0.76; 95% CI, 0.70-0.83). Inconsistent screening was associated with a slightly smaller increase in early detection of HCC (odds ratio, 1.31; 95% CI, 1.20-1.43) and a reduced risk of death (hazard ratio, 0.86; 95% CI, 0.83-0.90). After correction for lead- and length-time biases, higher proportions of patients with consistent (23%; 95% CI, 21%-25%) and inconsistent screening (19%; 95% CI, 19%-20%) survived for 3 years compared with patients without screening (13%; 95% CI, 12%-14%).

Conclusions: In an analysis of the Surveillance, Epidemiology, and End Results Program-Medicare database, we found HCC screening to be underused for patients with cirrhosis. This contributes to detection of liver tumors at later stages and shorter times of survival. However, the proportion of patients screened for HCC has increased over time.
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http://dx.doi.org/10.1016/j.cgh.2018.10.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6431264PMC
April 2019

Assessing the Effect of Clinical Inertia on Diabetes Outcomes: a Modeling Approach.

J Gen Intern Med 2019 03 18;34(3):372-378. Epub 2018 Dec 18.

Center for Remote Health Technologies and Systems, Texas A&M University, College Station, TX, USA.

Background: There are an increasing number of newer and better therapeutic options in the management of diabetes. However, a large proportion of diabetes patients still experience delays in intensification of treatment to achieve appropriate blood glucose targets-a phenomenon called clinical inertia. Despite the high prevalence of clinical inertia, previous research has not examined its long-term effects on diabetes-related health outcomes and mortality.

Objective: We sought to examine the impact of clinical inertia on the incidence of diabetes-related complications and death. We also examined how the impact of clinical inertia would vary by the length of treatment delay and population characteristics.

Design: We developed an agent-based model of diabetes and its complications. The model was parameterized and validated by data from health surveys, cohort studies, and trials.

Subjects: We studied a simulated cohort of patients with diabetes in San Antonio, TX.

Main Measures: We examined 25-year incidences of diabetes-related complications, including retinopathy, neuropathy, nephropathy, and cardiovascular disease.

Key Results: One-year clinical inertia could increase the cumulative incidences of retinopathy, neuropathy, and nephropathy by 7%, 8%, and 18%, respectively. The effects of clinical inertia could be worse for populations who have a longer treatment delay, are aged 65 years or older, or are non-Hispanic whites.

Conclusion: Clinical inertia could result in a substantial increase in the incidence of diabetes-related complications and mortality. A validated agent-based model can be used to study the long-term effect of clinical inertia and, thus, inform clinicians and policymakers to design effective interventions.
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http://dx.doi.org/10.1007/s11606-018-4773-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6420509PMC
March 2019

Post-acute Care for Children and Youth in Texas, 2011-2014.

Clin Med Insights Pediatr 2017 30;11:1179556517711445. Epub 2017 May 30.

Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, Texas A&M University, College Station, TX, USA.

Little is known about services provided to children and youth (C/Y) discharged from an acute care facility. Recent research has provided a foundation for efforts to supplement or complement that early work. This research investigates post-acute care (PAC) in Texas. It focuses on what differentiates those discharges that receive PAC from those that do not and on what differentiates those C/Y who receive PAC in a health care facility from those who receive home health services. The results show that only 6.4% of discharges involving C/Y receive PAC and that many factors affected the 2 issues under investigation quite differently. These results clearly demonstrate the low prevalence of PAC use for C/Y and the clear preference of using PAC home health in this population.
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http://dx.doi.org/10.1177/1179556517711445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965663PMC
May 2017

Posttraumatic Stress Disorder and Mobile Health: App Investigation and Scoping Literature Review.

JMIR Mhealth Uhealth 2017 Oct 26;5(10):e156. Epub 2017 Oct 26.

VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas Veterans Health Care System, Waco, TX, United States.

Background: Posttraumatic stress disorder (PTSD) is a prevalent mental health issue among veterans. Access to PTSD treatment is influenced by geographic (ie, travel distance to facilities), temporal (ie, time delay between services), financial (ie, eligibility and cost of services), and cultural (ie, social stigma) barriers.

Objective: The emergence of mobile health (mHealth) apps has the potential to bridge many of these access gaps by providing remote resources and monitoring that can offer discrete assistance to trauma survivors with PTSD and enhance patient-clinician relationships. In this study, we investigate the current mHealth capabilities relevant to PTSD.

Methods: This study consists of two parts: (1) a review of publicly available PTSD apps designed to determine the availability of PTSD apps, which includes more detailed information about three dominant apps and (2) a scoping literature review performed using a systematic method to determine app usage and efforts toward validation of such mHealth apps. App usage relates to how the end users (eg, clinicians and patients) are interacting with the app, whereas validation is testing performed to ensure the app's purpose and specifications are met.

Results: The results suggest that though numerous apps have been developed to aid in the diagnosis and treatment of PTSD symptoms, few apps were designed to be integrated with clinical PTSD treatment, and minimal efforts have been made toward enhancing the usability and validation of PTSD apps.

Conclusions: These findings expose the need for studies relating to the human factors evaluation of such tools, with the ultimate goal of increasing access to treatment and widening the app adoption rate for patients with PTSD.
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http://dx.doi.org/10.2196/mhealth.7318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5680516PMC
October 2017

Post-acute care for children with special health care needs.

Disabil Health J 2018 Jan 8;11(1):49-57. Epub 2017 Sep 8.

Texas A&M Health Science Center, School of Public Health, Department of Health Policy and Management, USA.

Background: Almost all studies of post-acute care (PAC) focus on older persons, frequently those suffering from chronic health problems. Some research is available on PAC for the pediatric population in general. However, very few studies focus on PAC services for children with special health care needs (SHCN).

Objective: To investigate factors affecting the provision of PAC to children with SHCN.

Methods: Pooled cross-sectional data from Texas Department of State Health Services hospital discharge database from 2011-2014 were analyzed. Publicly available algorithms identified chronic conditions, complex chronic conditions, and the principal problem leading to hospitalization. Analysis involved estimating two logistic regressions, with clustered robust standard errors, concerning the likelihood of receiving PAC and where that PAC was delivered. Models included patient characteristics and conditions, as well as hospital characteristics and location.

Results: Only 5.8 percent of discharges for children with SHCN resulted in the provision of PAC. Two-thirds of PAC was provided in a health care facility (HCF). Severity of illness and the number of complex chronic conditions, though not the number of chronic problems, made PAC more likely. Patient demographics had no effect on PAC decisions. Hospital type and location also affected PAC decision-making.

Conclusions: PAC was provided to relatively few children with SHCN, which raises questions concerning the potential underutilization of PAC for children with SHCN. Also, the provision of most PAC in a HCF (66%) seems at odds with professional judgment and family preferences indicating that health care for children with SHCN is best provided in the home.
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http://dx.doi.org/10.1016/j.dhjo.2017.08.010DOI Listing
January 2018

Does Maternity Care Coordination Influence Perinatal Health Care Utilization? Evidence from North Carolina.

Health Serv Res 2018 08 20;53(4):2368-2383. Epub 2017 Jul 20.

Departments of Health Services, Pharmacy, and Economics, Magnuson Health Sciences Center, University of Washington, Seattle, WA.

Objective: To examine effects of maternity care coordination (MCC) on perinatal health care utilization among low-income women.

Data Sources: North Carolina Center for Health Statistics Baby Love files that include birth certificates, maternity care coordination records, WIC records, and Medicaid claims.

Study Design: Causal effects of MCC participation on health care outcomes were estimated in a sample of 7,124 singleton Medicaid-covered births using multiple linear regressions with inverse probability of treatment weighting (IPTW).

Principal Findings: Maternity care coordination recipients were more likely to receive first-trimester prenatal care (p < .01) and averaged three more prenatal visits and two additional primary care visits during pregnancy; they were also more likely to participate in WIC and to receive postpartum family planning services (p < .01). Medicaid expenditures were greater among mothers receiving MCC.

Conclusions: Maternity care coordination facilitates access to health care and supportive services among Medicaid-covered women. Increased maternal service utilization may increase expenditures in the short run; however, improved newborn health may reduce the need for costly neonatal care, and by implication the need for early intervention and other supports for at-risk children.
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http://dx.doi.org/10.1111/1475-6773.12742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052008PMC
August 2018

Transitioning to Patient-Centered Medical Homes: Associations With Appointment Availability.

Mil Med 2017 03;182(3):e1741-e1746

Department of Management, Policy, and Community Health, The University of Texas School of Public Health, 1200 Pressler Street, Houston, TX 77030.

Introduction: Recent implementation of the Patient-Centered Medical Home (PCMH) in military primary care has gained significant traction and attention from leadership and policy makers. The study objective was to measure the rate of change in appointment availability before and after primary care clinics were certified as a medical home. Access to care is one core tenet of the medical home and appointment availability is an important indicator of access.

Materials And Methods: This was a retrospective, longitudinal observational study involving 21 U.S. Navy primary care clinics from 2011 to 2014. Appointment availability, as measured by third next available appointment, was constructed for 21 primary care clinics over a 29-month time period (14 months precertification, certification month, 14 months postcertification). A mixed-effects model with linear splines was applied where third next available appointment was the dependent variable. Main interest independent variables include time (precertification and postcertification). Remaining independent variables include categories pertaining to clinic characteristics, ancillary services, and nonemergent primary care treatable emergency department visits.

Results: Appointment availability improved slightly postcertification. Although there were statistically significant differences in appointment availability pre- and postcertification, the differences were so small that patients may not actually experience noticeable improvements.

Conclusion: Although slight improvements in appointment availability following medical home certification exist, adoption of the medical home model in the military setting may not have all the potential outcomes expected on the basis of prior findings in civilian settings. This study demonstrated that improvements in appointment availability following medical home certification exist, but are quite small. Patients, as a result, are unlikely to notice any improvements. Additional research should test other expected benefits of PCMH in military settings. At that point, military policy makers can decide which aspects of PCMH practices merit sustaining.
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http://dx.doi.org/10.7205/MILMED-D-16-00180DOI Listing
March 2017

Barriers to Remote Health Interventions for Type 2 Diabetes: A Systematic Review and Proposed Classification Scheme.

J Med Internet Res 2017 02 13;19(2):e28. Epub 2017 Feb 13.

Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, United States.

Background: Diabetes self-management involves adherence to healthy daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers have begun testing remote interventions for monitoring and assisting patients between clinic visits. Although some studies have shown success, there are barriers to widespread adoption.

Objective: The objective of our study was to identify and classify barriers to adoption of remote health for management of type 2 diabetes.

Methods: The following 6 electronic databases were searched for articles published from 2010 to 2015: MEDLINE (Ovid), Embase (Ovid), CINAHL, Cochrane Central, Northern Light Life Sciences Conference Abstracts, and Scopus (Elsevier). The search identified studies involving remote technologies for type 2 diabetes self-management. Reviewers worked in teams of 2 to review and extract data from identified papers. Information collected included study characteristics, outcomes, dropout rates, technologies used, and barriers identified.

Results: A total of 53 publications on 41 studies met the specified criteria. Lack of data accuracy due to input bias (32%, 13/41), limitations on scalability (24%, 10/41), and technology illiteracy (24%, 10/41) were the most commonly cited barriers. Technology illiteracy was most prominent in low-income populations, whereas limitations on scalability were more prominent in mid-income populations. Barriers identified were applied to a conceptual model of successful remote health, which includes patient engagement, patient technology accessibility, quality of care, system technology cost, and provider productivity. In total, 40.5% (60/148) of identified barrier instances impeded patient engagement, which is manifest in the large dropout rates cited (up to 57%).

Conclusions: The barriers identified represent major challenges in the design of remote health interventions for diabetes. Breakthrough technologies and systems are needed to alleviate the barriers identified so far, particularly those associated with patient engagement. Monitoring devices that provide objective and reliable data streams on medication, exercise, diet, and glucose monitoring will be essential for widespread effectiveness. Additional work is needed to understand root causes of high dropout rates, and new interventions are needed to identify and assist those at the greatest risk of dropout. Finally, future studies must quantify costs and benefits to determine financial sustainability.
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http://dx.doi.org/10.2196/jmir.6382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5329647PMC
February 2017

Military Deployments and Mental Health Utilization Among Spouses of Active Duty Service Members.

Mil Med 2016 10;181(10):1269-1274

Department of Management, Policy, and Community Health, The University of Texas School of Public Health, 1200 Pressler Street, Houston, TX 77030.

Since the onset of the wars in Iraq and Afghanistan attention has increased on the importance of mental health with military service members. An integral component, although far less studied, are the ties between mental health and military spouses. Military deployments place considerable stress on military families. This study analyzed the mental health utilization of military spouses of active duty service members assigned to an aircraft carrier between 2011 and 2014. A negative binomial generalized estimating equation was used to examine the rate of change in mental health utilization over time against various deployment phases. Associations emerged between select deployment phases (i.e., deployment 1, between deployments, deployment 2) with increases in mental health utilization ranging between 12% and 20% for military spouses. This study demonstrated, for military spouses, the in between deployment phase has associations with mental health utilization rates similar to actual deployed periods. As a result, military leaders should continue to monitor the well-being of their service members' families throughout all deployment phases.
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http://dx.doi.org/10.7205/MILMED-D-15-00583DOI Listing
October 2016

Changes in North Carolina maternal health service use and outcomes among medicaid-enrolled pregnant women during state budget cuts.

J Public Health Manag Pract 2015 Mar-Apr;21(2):208-13

Department of Maternal and Child Health, University of North Carolina at Chapel Hill (Dr Cilenti); Department of Health Policy and Management, Texas A & M University, College Station (Drs Kum and Wells); North Carolina State Center for Health Statistics, Raleigh (Dr Whitmire); RTI Health Solutions, Durham, North Carolina (Mr Goyal); and Department of Health Policy and Administration, Pennsylvania State University, University Park, State College (Dr Hillemeier).

Objectives: The recent recession has weakened the US health and human service safety net. Questions about implications for mothers and children prompted this study, which tested for changes in maternal service use and outcomes among North Carolina women with deliveries covered through Medicaid before and after a year of significant state budget cuts.

Methods: Data for Medicaid covered deliveries from April-June 2009 (pre) and from April-June 2010 (post) were derived from birth certificates, Medicaid claims and eligibility files, and WIC (Special Supplemental Food Program for Women, Infants and Children) records. These time periods represent the quarter immediately before as well as the final quarter of a state fiscal year 2010 (July 2009-June 2010) characterized by substantial state budget cuts, including an October 2009 reduction in reimbursement rates for maternity care coordination. We examined how often women received medical care, maternity care coordination, family planning services, and the average numbers of obstetrical encounters, as well as the prevalence of excessive pregnancy weight gain, preterm delivery, and low birth weight.

Results: By the end of a year of substantial state budget cuts, women covered through Medicaid had fewer obstetrical visits in all trimesters as well as postpartum (P < .001). Maternal weight gain, preterm delivery, and low birth weight were stable.

Conclusions: One key aspect of medical service use decreased for women enrolled in Medicaid by the end of a year of major state health and human services budget cuts. Maternal and infant child health outcomes measured in this study did not change during that year. Future monitoring is warranted to ensure that maternal health service access remains adequate.
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http://dx.doi.org/10.1097/PHH.0000000000000118DOI Listing
November 2016

Predictors of Colorectal Cancer Screening: Does Rurality Play a Role?

J Rural Health 2015 19;31(3):254-68. Epub 2015 Jan 19.

Department of Health Policy and Management, Texas A&M Health Science Center School of Public Health, College Station, Texas.

Purpose: The purpose of this study was to explore the associations between sociodemographic factors such as residence, health care access, and colorectal cancer (CRC) screening among residents of Texas.

Methods: Using the 2012 Behavioral Risk Factor Surveillance Survey, we performed logistic regression analyses to determine predictors of CRC screening among Texas residents, including rural versus urban differences. Our outcomes of interest were previous (1) CRC screening using any CRC test, (2) fecal occult blood test (FOBT), or (3) endoscopy, as well as up-to-date screening using (4) any CRC test, (5) FOBT, or (6) endoscopy. The independent variable of interest was rural versus urban residence; we controlled for other sociodemographic and health care access variables such as lack of health insurance.

Results: Multivariate analysis showed that individuals who were residents of a rural/non-Metropolitan Statistical Area (MSA) location (OR = 0.70, 95% CI = 0.51-0.97) or a suburban county (OR = 0.61, 95% CI = 0.39-0.95) were less likely to report ever having any CRC screening compared to residents of a center city of an MSA. Residents of a rural/non-MSA location were less likely (OR = 0.49, 95% CI = 0.28-0.87) than residents of a center city of an MSA to be up-to-date using FOBT. There was decreased likelihood of ever being screened for CRC among the uninsured (OR = 0.43, 95% CI = 0.31-0.59).

Conclusions: Effective development and implementation of strategies to improve screening rates should aim at improving access to health care, taking into account demographic characteristics such as rural versus urban residence.
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http://dx.doi.org/10.1111/jrh.12104DOI Listing
July 2016

Effects of maternity care coordination on pregnancy outcomes: propensity-weighted analyses.

Matern Child Health J 2015 Jan;19(1):121-7

Department of Health Policy and Administration, The Pennsylvania State University, 504S Ford Building, University Park, PA, 16802, USA,

Care coordination services that link pregnant women to health-promoting resources, avoid duplication of effort, and improve communication between families and providers have been endorsed as a strategy for reducing disparities in adverse pregnancy outcomes, however empirical evidence regarding the effects of these services is contradictory and incomplete. This study investigates the effects of maternity care coordination (MCC) on pregnancy outcomes in North Carolina. Birth certificate and Medicaid claims data were analyzed for 7,124 women delivering live infants in North Carolina from October 2008 through September 2010, of whom 2,255 received MCC services. Propensity-weighted analyses were conducted to reduce the influence of selection bias in evaluating program participation. Sensitivity analyses compared these results to conventional ordinary least squares analyses. The unadjusted preterm birth rate was lower among women who received MCC services (7.0 % compared to 8.3 % among controls). Propensity-weighted analyses demonstrated that women receiving services had a 1.8 % point reduction in preterm birth risk; p < 0.05). MCC services were also associated with lower pregnancy weight gain (p = 0.10). No effects of MCC were seen for birthweight. These findings suggest that coordination of care in pregnancy can significantly reduce the risk of preterm delivery among Medicaid-enrolled women. Further research evaluating specific components of care coordination services and their effects on preterm birth risk among racial/ethnic and geographic subgroups of Medicaid enrolled mothers could inform efforts to reduce disparities in pregnancy outcome.
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http://dx.doi.org/10.1007/s10995-014-1502-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4459720PMC
January 2015

Privacy-by-Design: Understanding Data Access Models for Secondary Data.

AMIA Jt Summits Transl Sci Proc 2013 18;2013:126-30. Epub 2013 Mar 18.

NC-TraCS & Dept of Computer Science, University of North Carolina, Chapel Hill, NC.

Today there is a constant flow of data into, out of, and between ever-larger and ever-more complex databases about people. Together, these digital traces collectively capture our social genome , the footprints of our society. The burgeoning field of population informatics is the systematic study of populations via secondary analysis of such massive data collections (termed "big data") about people. In particular, health informatics analyzes electronic health records to improve health outcomes for a population. Privacy protection in such secondary data analysis research is complex and requires a holistic approach which combines technology, statistics, policy and a shift in culture of information accountability through transparency rather than secrecy. We review state of the art in privacy protection technology and policy frameworks from widely different fields, and synthesize the findings to present a comprehensive system of privacy protection in population informatics research using the privacy-by-design approach. Based on common activities in the workflow, we describe the pros and cons of four different data access models - restricted access, controlled access, monitored access, and open access - that minimize risk and maximize usability of data. We then evaluate the system by analyzing the risk and usability of data through a realistic example. We conclude that deployed together the four data access models can provide a comprehensive system for privacy protection, balancing the risk and usability of secondary data in population informatics research.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845756PMC
December 2013

Privacy preserving interactive record linkage (PPIRL).

J Am Med Inform Assoc 2014 Mar-Apr;21(2):212-20. Epub 2013 Nov 7.

Population Informatics Research Group, Department of Computer Science, UNC-CH & Department of Health Policy and Management, Texas A&M Health Science Center, USA.

Objective: Record linkage to integrate uncoordinated databases is critical in biomedical research using Big Data. Balancing privacy protection against the need for high quality record linkage requires a human-machine hybrid system to safely manage uncertainty in the ever changing streams of chaotic Big Data.

Methods: In the computer science literature, private record linkage is the most published area. It investigates how to apply a known linkage function safely when linking two tables. However, in practice, the linkage function is rarely known. Thus, there are many data linkage centers whose main role is to be the trusted third party to determine the linkage function manually and link data for research via a master population list for a designated region. Recently, a more flexible computerized third-party linkage platform, Secure Decoupled Linkage (SDLink), has been proposed based on: (1) decoupling data via encryption, (2) obfuscation via chaffing (adding fake data) and universe manipulation; and (3) minimum information disclosure via recoding.

Results: We synthesize this literature to formalize a new framework for privacy preserving interactive record linkage (PPIRL) with tractable privacy and utility properties and then analyze the literature using this framework.

Conclusions: Human-based third-party linkage centers for privacy preserving record linkage are the accepted norm internationally. We find that a computer-based third-party platform that can precisely control the information disclosed at the micro level and allow frequent human interaction during the linkage process, is an effective human-machine hybrid system that significantly improves on the linkage center model both in terms of privacy and utility.
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http://dx.doi.org/10.1136/amiajnl-2013-002165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3932473PMC
May 2014

Informing child welfare policy and practice: using knowledge discovery and data mining technology via a dynamic Web site.

Child Maltreat 2008 Nov 18;13(4):383-91. Epub 2008 Jun 18.

University of North Carolina at Chapel Hill, School of Social Work, Chapel Hill, NC 27599-3550, USA.

Proper management and implementation of an effective child welfare agency requires the constant use of information about the experiences and outcomes of children involved in the system, emphasizing the need for comprehensive, timely, and accurate data. In the past 20 years, there have been many advances in technology that can maximize the potential of administrative data to promote better evaluation and management in the field of child welfare. Specifically, this article discusses the use of knowledge discovery and data mining (KDD), which makes it possible to create longitudinal data files from administrative data sources, extract valuable knowledge, and make the information available via a user-friendly public Web site. This article demonstrates a successful project in North Carolina where knowledge discovery and data mining technology was used to develop a comprehensive set of child welfare outcomes available through a public Web site to facilitate information sharing of child welfare data to improve policy and practice.
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http://dx.doi.org/10.1177/1077559508318951DOI Listing
November 2008