Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Mar;54(3):430-439.
doi: 10.1016/j.amepre.2017.10.004. Epub 2017 Dec 11.

Measures of SES for Electronic Health Record-based Research

Affiliations

Measures of SES for Electronic Health Record-based Research

Joan A Casey et al. Am J Prev Med. 2018 Mar.

Abstract

Introduction: Although infrequently recorded in electronic health records (EHRs), measures of SES are essential to describe health inequalities and account for confounding in epidemiologic research. Medical Assistance (i.e., Medicaid) is often used as a surrogate for SES, but correspondence between conventional SES and Medical Assistance has been insufficiently studied.

Methods: Geisinger Clinic EHR data from 2001 to 2014 and a 2014 questionnaire were used to create six SES measures: EHR-derived Medical Assistance and proportion of time under observation on Medical Assistance; educational attainment, income, and marital status; and area-level poverty. Analyzed in 2016-2017, associations of SES measures with obesity, hypertension, type 2 diabetes, chronic rhinosinusitis, fatigue, and migraine headache were assessed using weighted age- and sex-adjusted logistic regression.

Results: Among 5,550 participants (interquartile range, 39.6-57.5 years, 65.9% female), 83% never used Medical Assistance. All SES measures were correlated (Spearman's p≤0.4). Medical Assistance was significantly associated with all six health outcomes in adjusted models. For example, the OR for prevalent type 2 diabetes associated with Medical Assistance was 1.7 (95% CI=1.3, 2.2); the OR for high school versus college graduates was 1.7 (95% CI=1.2, 2.5). Medical Assistance was an imperfect proxy for SES: associations between conventional SES measures and health were attenuated <20% after adjustment for Medical Assistance.

Conclusions: Because systematically collected SES measures are rarely available in EHRs and are unlikely to appear soon, researchers can use EHR-based Medical Assistance to describe inequalities. As SES has many domains, researchers who use Medical Assistance to evaluate the association of SES with health should expect substantial unmeasured confounding.

PubMed Disclaimer

Figures

Figure 1
Figure 1
ORs of MA by self-reported and area-level SES measures. Notes: ORs and 95% CIs from weighted, age- and sex-adjusted logistic regression models with robust SEs. GED, general equivalency diploma; MA, Medical Assistance
Figure 2
Figure 2
ORs of six health outcomes by individual and area-level SES measures. Notes: ORs and 95% CIs from three weighted logistic regression models with robust SEs: base model, adjusted for age and sex; MA-adjusted model, adjusted age, sex, and MA; and fully-adjusted model, adjusted for age, sex, MA, educational attainment, income, marital status, and area-level poverty. (A) MA, proportion of time under observation on MA, and educational attainment; (B) income, marital status, and area-level poverty quartile. CRS, chronic rhinosinusitus; GED, general equivalency diploma; MA, Medical Assistance; T2DM, type 2 diabetes

References

    1. Kawachi I, Subramanian SV. Income Inequality. In: Kawachi I, Berkman L, Glymour MM, editors. Social Epidemiology. 2. New York, NY: Oxford University Press; 2014. https://doi.org/10.1093/med/9780195377903.003.0004. - DOI
    1. Adler NE, Rehkopf DH. U.S. disparities in health: descriptions, causes, and mechanisms. Annu Rev Public Health. 2008;29:235–252. https://doi.org/10.1146/annurev.publhealth.29.020907.090852. - DOI - PubMed
    1. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff (Millwood) 2002;21(2):60–76. https://doi.org/10.1377/hlthaff.21.2.60. - DOI - PubMed
    1. Krieger N. Epidemiology and the web of causation: has anyone seen the spider? Soc Sci Med. 1994;39(7):887–903. https://doi.org/10.1016/0277-9536(94)90202-X. - DOI - PubMed
    1. Casey JA, Schwartz BS, Stewart WF, Adler N. Using electronic health records for population health research: a review of methods and applications. Annu Rev Public Health. 2015;37:61–81. https://doi.org/10.1146/annurev-publhealth-032315-021353. - DOI - PMC - PubMed

Publication types