COHRI: Using axiUm for Evidence-Based Research

Paul Stark, MS, ScD Professor, Tufts University School of Dental Medicine

Chair, Board of Directors, COHRI

: Using axiUm for Evidence-Based Research

Outline

• COHRI

• Electronic health records (EHRs)

– Importance of standardization

• Research goal

• Dental Data repository (DDR)

• Using the DDR for research

• Closing thoughts

What is ?

• Consortium for Oral Health Research and Informatics

• Founded in 2007

• Comprised of 35 member institutions, and over 100 individuals

Vision

Linking resources for better research and patient care

Member Institutions

• Academic Centre for Dentistry (ACTA) • Baylor College of Dentistry • Columbia University • Creighton University • Harvard University • Indiana University • Medical University of South Carolina • Meharry Medical College • Midwestern University • New York University • Nova Southeastern University • Oregon Health & Science University • Temple University • Tufts University School of Dental Medicine • University of California, San Francisco • University of Florida • University of Illinois at Chicago

• University of Kentucky • University of Louisville • University of Michigan • University of Minnesota • University of Nevada, Las Vegas • University of New England • University of Oklahoma • University of Pacific • University of Pittsburgh • University of Southern California • University of Tennessee • University of Texas Dental Branch at Houston • University of Texas, San Antonio • University of Washington • Virginia Commonwealth University • West Virginia University • Willamette Dental Group

EHRs in Dental Schools

• Most dental schools and more and more private practices use electronic health records

• ~85% of schools use axiUm EHR system

• Difficult to query data from EHRs

Health History forms

• COHRI has developed standardized health history forms

– Medical history form

– Dental history form

• Why?

Total of 927 questions in medical history forms from four dental schools –

Only 9 questions (1%) overlap!

Medical History Overlap

• Diabetes

• Alcohol consumption

• Pregnant

• Allergy to local anesthetics

• Rheumatic fever

• Heart attack

• Hypertension

• Asthma

• Seizure

Total of 284 questions in dental history forms from four dental schools -

Only 7 questions (2%) overlap!

Dental History Overlap

• Sensitive to cold, hot, sweet, or pressure

• Difficulty and/or pain chewing, talking, or using jaw

• Clench, brux, or grind teeth

• Have a partial or complete denture

• Periodontal treatment or surgery

• Root canal treatment

• Braces or orthodontic work

Research Goal

• Establish an Oral Health Data Repository that can accept and integrate data from disparate dental data sources, and allow end users to explore and extract information to support their specific research or decision making needs

• Why important?

– Few high quality datasets in dentistry

– Need for evidence-based decisions about dental treatments

G08 Grant

• G08: Resource development grant – National Library of Medicine (NIH)

– $407,000 over 3 years (9/30/09-9/29/12)

• Objective: to establish an Oral Health Data Repository that can accept and integrate data from disparate dental data sources, and allow end users to explore and extract information to support their specific research or decision making needs.

• Participating Institutions: – University of Texas at Houston

– University of California at San Francisco

– Tufts University School of Dental Medicine

– Harvard School of Dental Medicine

About i2b2 (Informatics for Integrating Biology at the Bedside)

• NIH-funded National Center for Biomedical Computing (NCBC)

• Established in 2004

• Developing a scalable computational framework to address the bottleneck limiting the translation of genomic findings and hypotheses in model systems or organisms relevant to human health.

• I2b2.org

Types of Data that can be collected

• Clinical Data

– Demographics

– Diagnoses

– Procedures

– Medications

– Clinical Notes

– Lab Test Results

– Imaging

• Biological Data

– SNP’s

– Gene Expression Data

• Study Data

Approach

Limited dataset 16

EHR Data for Extraction

• Demographics

• Diagnoses

• Procedures

• Medical and dental histories

• Odontogram

• Periodontal Chart

Data in Repository # of patients

• Demographics = 1.1 million

• Diagnoses = 125k

• Procedures = 517k

• Medical and dental histories = 124k

• Odontogram = 195k

• Periodontal Chart = 78k

Periodontal Data

• Clinical Attachment Loss

• Bleeding on Probe

• Pocket Depth

• Recession

• Plaque

• Mobility 6 sites per tooth!

Initial Exam

Last Exam

Number of Patients

HARVARD 36,768

TUFTS 186,074

UCSF 661,068

UTH 237,026

N=1,120,936

Demographics – Sex

Male 41%

Female 54%

Unknown 5%

UTH

Male 37%

Female 43%

Unknown 20%

UCSF

Male 42%

Female 53%

Unknown 5%

HARVARD

Male 40%

Female 50%

TUFTS

Unknown 10%

Top 10 Procedures

Top 10 Diagnoses

How Can You Use the DDR for Research?

What is the association between diabetes and periodontitis in adults?

• Identify the Population: – Adults (> 18 y) who have treatment at a university

dental clinic

• Identify the Intervention: – Self-report of diabetes

• Identify the Comparison: – No self-report of diabetes

• Identify the Outcome: – Periodontitis, as defined as presence of any tooth

mobility

Developing the PICO question

The PICO Question

In adults who seek treatment at a university dental clinic, is there an association between self-report of diabetes and periodontitis, as defined as the presence of tooth mobility?

Create 2x2 table to test the association between diabetes and periodontitis

Tooth Mobility (Outcome)

Total

Yes No

Diabetes (Exposure)

Yes a b a+b

No c d c+d

Total a+c b+d N

Dental Data Repository https://cohri.uth.tmc.edu

Patient_count: 5762

Create 2x2 table to test the association between diabetes and periodontitis

Tooth Mobility (Outcome)

Total

Yes No

Diabetes (Exposure)

Yes 5,762 b a+b

No c d c+d

Total a+c b+d N

Patient_count: 36441

Create 2x2 table to test the association between diabetes and periodontitis

Tooth Mobility (Outcome)

Total

Yes No

Diabetes (Exposure)

Yes 5,762 b a+b

No 36,441 d c+d

Total 42,203 b+d N

Gather the other 2 cells to complete the table…

Create 2x2 table to test the association

Tooth Mobility (Outcome)

Total

Yes No

Diabetes (Exposure)

Yes 5,762 2,191 7,953

No 36,441 26,752 63,193

Total 42,203 28,943 71,146

OR= 1.93 SE= 0.02 95% CI= [1.83,2.03]

Tooth Mobility (Outcome)

Total

Yes No

Diabetes (Exposure)

Yes 5,762 2,191 7,953

No 36,441 26,752 63,193

Total 42,203 28,943 71,146

Based on these data, there does appear to be an association between self-reported diabetes and periodontitis, as defined by presence of any tooth mobility.

Benefits of COHRI

• Access to our products

– Medical history

– Dental history

– Diagnostic codes

• Access to data repository

• Access to individuals

– Biostatisticians

– Informaticians

– Epidemiologists

Research Team

UT-Houston • Muhammad Walji, PhD • Elmer Bernstam, MD, MSE • Mamta Puppala – Programmer • Phillip Reeder – CCTS • Krishna Kookal - Programmer • Duong Tran, DDS - GRA • Johnny Phan – Programmer

Tufts • Paul Stark, MS, ScD • Angel Park, MS, MPH • Tofool Alghanem, DDS, MS

UCSF • Joel White, DDS, MS • Ram Vaderhobli, BDS, MS

Harvard • Elsbeth Kalenderian DDS, MPH

The project is supported in part by Award Number G08LM010075 from the National Library Of Medicine.

Thank you!

Any questions?

[email protected]