PCCI identifies more than 4.2 million Texas residents living in high or very high vulnerability neighborhoods in the five most populous counties

Researchers at Parkland Center for Clinical Innovation (PCCI) have completed a vulnerability assessment of Texas’s five most populous counties using PCCI’s Community Vulnerability Compass (CVC). The assessment found that in Harris, Dallas, Bexar, Tarrant, and Travis counties, a total of more than 4.2 million residents live in high or very high vulnerability block groups.

PCCI’s CVC analysis of these counties included a true, holistic analysis, at a block-group level, of 27 clinical and socio-economic indicators underpinning the health, resiliency, and economic vibrancy of their neighborhoods, down to the block group level. A block group is a statistical geographic subdivision of a census tract used by the U.S. Census Bureau for data tabulation and presentation, and it typically contains between 600 and 3,000 people.

Root causes that trigger a block group to be rated as high or very high vulnerability include socioeconomic challenges, access to healthcare, and several non-medical drivers of health (NMDOH), such as unsafe neighborhoods, chronic diseases, education attainment, and life expectancy. The “very high” designation indicates that these neighborhood block groups are in the top 20 percent of vulnerability when compared to the rest of the state. CVC vulnerability groupings are broken into quintiles and clustered into very low, low, moderate, high and very high areas. Groupings can be localized to specific catchment areas, with the ability to include or exclude individual block groups.

“Going well beyond typical ZIP Code analyses, this assessment offers a deeper look into Texas’ major metropolitan areas,” said Steve Miff, PhD, President and CEO of PCCI. “Our researchers use the CVC’s data insights to reveal the challenges and opportunities our community leaders can leverage to better understand the conditions their residents are experiencing and develop suitable approaches to address the needs of those populations. What we are seeing is that 33 percent (1 of 3) residents in our five largest counties are facing daily challenges that put their health and wellness at risk.”

In its statewide assessment, PCCI’s CVC found that nearly 43 percent of Bexar County’s block groups fall into the high or very high vulnerability rating, the highest percent of the five largest counties.

Following Bexar County was Harris County, with nearly 41 percent of its block groups falling into the high or very high vulnerability category. Dallas County followed with nearly 40 percent of its block groups in the high or very high level.

Rounding out the most populous five counties, nearly 31 percent of Tarrant County and nearly 12 percent of Travis County block groups were in the high or very high vulnerability category.

“As we train the next generation of physicians, they must understand the critical window into the drivers of their local community’s health the CVC powerfully highlights so we can continue to forge strategy to drive sustainable improvements.” – Stuart D. Flynn, MD, Founding Dean of the Anne Burnett Marion School of Medicine at Texas Christian University. 

• Harris County’s high or very high vulnerability block groups (1,154 of 2,830 total block groups) represent 1.7 million residents. Drilling down into vulnerability root causes, the CVC found the top three challenges in the most vulnerable block groups are neighborhood safety¹, followed by health insurance coverage² and mental health³.

• Dallas County’s high or very high vulnerability block groups (627 out of 1,570) represent 1.1 million residents. The CVC found that the top three issues in Dallas County’s most vulnerable block groups are clean air⁴, neighborhood safety, with health insurance coverage⁵ and education attainment⁶ tied for third.

• Bexar County’s high or very high vulnerability block groups (486 out of 1,139) represent 657,131 residents. For Bexar County, the CVC found that the top three challenges in Bexar County’s most vulnerable block groups were neighborhood safety, followed by chronic diabetes⁷ and households without vehicles⁸.

• Tarrant County’s high or very high vulnerability block groups (382 out of 1,246) represent 618,942 residents. Additionally, the CVC found that the top three challenges for Tarrant County’s most vulnerable block groups are clean air, chronic obesity⁹, and neighborhood safety.

• Travis County’s high or very high vulnerability block groups (89 out of 766) represent 140,760 residents. The CVC analysis found that the top three challenges for Travis County’s most vulnerable block groups are chronic alcohol abuse¹⁰, neighborhood safety, and green space access¹¹.

“Each of these counties have unique and distinct challenges so there is no one solution to address issues across all of Texas,” Dr. Miff said. “The power of the CVC is that it gives us the ability to surface insights not only at the county level, but for each neighborhood making up these regions. This refined geographic precision allows us to learn the true nature and shared characteristics of neighborhood vulnerabilities so that our health and community leaders can create sustainable, customized solutions to address those vulnerabilities.”

About PCCI

The Parkland Center for Clinical Innovation (PCCI) is a not-for-profit, mission-driven organization with industry-leading expertise in the responsible application of artificial intelligence, machine learning and NMDOH data modeling to address the needs of vulnerable populations. PCCI started as a department within Parkland Health and was spun out as an independent organization in 2012. PCCI strives to leapfrog the status quo by harnessing the transformative potential of data. Our unique capabilities allow us to provide innovative, actionable solutions that more effectively identify needs, prioritize services, empower providers, and engage patients. 

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¹Neighborhood Safety: Crime and violent crime rates per 1,000 residents in the past year

²Health Insurance Coverage: Percentage of uninsured

³Mental Health: Percentage of adults ages 18+ who stated that their mental health was not good for 14 or more of the past 30 days

⁴Clean Air: An indication of the level of air pollution

⁵Health Insurance Coverage: Percentage of uninsured

⁶Education Attainment: Percentage of population without high school degree

⁷Chronic Diabetes: Prevalence of diagnosed diabetes among adults ages 18+

⁸Households without Vehicles: Percentage of households without a vehicle

⁹Chronic Obesity: A BMI of 30 or greater indicates obesity, according to the CDC.

¹⁰Alcohol Abuse: Prevalence of binge drinking among adults ages 18+

¹¹Green Space: Number of parks within ZIP Code boundaries

PCCI Publishing: Oxford Academic – The Association of Social Determinants of Health and Penicillin Allergy Labels

Published in Oxford Academic, Oxford University Press’s academic research platform, a new paper co-authored by PCCI’s Yolande M Pengetnze, MD, MS, Senior Vice President Clinical Leadership, looks at how social determinants of health are related to penicillin allergy labels that are associated with numerous adverse outcomes including poor infectious outcomes and antimicrobial resistance.

The primary independent variable was social vulnerability  defined by PCCI’s Community Vulnerability Compass including 27 indicators of social vulnerability.

Go here to view the abstract: https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/ciaf153/8099189?redirectedFrom=fulltext#google_vignette

NEJM Catalyst – Pediatric Asthma Surveillance System (PASS): Community-Facing Disease Monitoring for Health Equity

In 2024, the highly respected medical journals, The New England Journal of Medicine Catalyst, published a peer-reviewed paper authored by experts from PCCI, Parkland Health and the Dallas County Health & Human Services department about the innovative Pediatric Asthma Surveillance System (PASS) that allow Dallas County residents suffering from asthma understand their risks.

The PASS dashboard, hosted on the DCHHS website, has served the county for two years leveraging innovative data management that gives asthma risks down to the block level.

See the abstract below:

PCCI Publishing: Virtual Health Care Encounters for Lung Cancer Screening in a Safety-Net Population

Recently published in the Journal of Clinical Oncology, is a publication co-authored by George “Holt” Oliver, PhD, MBA, VP Clinical Informatics at PCCI, that examines how lung cancer screening was conducted during the COVID-19 pandemic to help determine the difference between virtual and in-person encounters in an urban, safety-net health care system.

https://ascopubs.org/doi/pdfdirect/10.1200/CCI.24.00086

PCCI Publishing: Supporting Access to HIV Pre-Exposure Prophylaxis in a Shifting Financial and Insurance Landscape

In a peer reviewed paper published in AJPM Focus, Jacqueline Naeem, VP of Clinical and Social Health at PCCI joined other experts to share information on efforts to expand the use of HIV pre-exposure prophylaxis with the support of community based organizations in Dallas, Texas.

https://www.ajpmfocus.org/article/S2773-0654(24)00129-9/fulltext

Using Machine Learning to Identify Patients at Risk of Acquiring HIV in an Urban Health System

In the peer reviewed Journal of Acquired Immune Deficiency Syndrome (JAIDS), the identification of patients who are at risk for contracting HIV and are candidates for preventative measures is discussed as a machine learning model to predict risk for HIV may enhance patient selection for proactive outreach. This important paper’s authors include PCCI’s Arun Kumar Nethi, MS, Data & Applied Scientist, and Albert Karam, VP, Data Strategy Analytics.

To view the publication, go to: https://journals.lww.com/jaids/fulltext/2024/09010/using_machine_learning_to_identify_patients_at.6.aspx

Dallas County celebrates the second anniversary of PASS, a celebrated tool helping asthma sufferers understand their vulnerability

In March of 2023, Dallas County Health & Human Services (DCHHS) announced the unveiling of the Pediatric Asthma Surveillance System* (PASS) that is helping asthma sufferers better understand the harmfulness of their environment to their condition. In the two years since its deployment on the DCHHS website, PASS has positively impacted the residents of Dallas County and has supported the efforts of Parkland Health (Parkland) and DCHHS in reducing poor health outcomes related to pediatric asthma.

“Dallas County is one of the few, if not only, communities in the country that offer this kind of support to residents suffering from asthma,” said Steve Miff, PhD, CEO and President of Parkland Center for Clinical Innovation (PCCI). “We are very proud of the success of this model program showing how properly applied artificial intelligence systems can be used to directly inform and affect those in need in our community.”

PASS is a community-wide effort between Dallas County Health and Human Services, PCCI, and Parkland. Publicly available at the DCHHS website, it has been visited by more than 6,000 Dallas County residents, was honored by the Dallas County Commissioners for its service to asthma sufferers, and described by the Dallas Morning News as “a win for Dallas County.” PASS has also been featured in the highly respected New England Journal of Medicine Catalyst.

“PASS is the direct result of the joint Parkland-DCHHS Community Health Needs Assessment, which identified the need for an actionable dashboard to help stakeholders collaborate using a single source of truth,” said Teresita Oaks, Director of Community Health Programs at Parkland Health. “By integrating health and social data, PASS enables our community to take a proactive approach in addressing pediatric asthma and reducing disparities in care.”

PASS includes a novel, validated Pediatric Asthma Vulnerability Index that integrates health and social data insights to identify communities where children have higher vulnerability to poor asthma outcomes and highlight areas of health disparities. It can also predict the probability of a community-level asthma-related emergency department (ED) visit or hospitalization within three months, by incorporating the effect of 10 community indicators, such as socioeconomic conditions, demographic characteristics, medication use patterns, health services utilization, and environmental conditions, on community-level asthma risk.

“One of the most impactful outcomes of PASS has been the identification of neighborhoods with the highest burden of pediatric asthma,” Philip Huang, MD, MPH, Director/Health Authority, DCHHS. “By leveraging real-time data, PASS has enabled us to pinpoint geographic areas where asthma prevalence and hospitalizations are disproportionately high, so we can more effectively target our resources and interventions to the communities that need them the most.”

The Pediatric Asthma Vulnerability Index and all indicators are categorized as Very High, High, Moderate, Low, or Very Low Risk based on their impact on pediatric asthma vulnerability in the community. On the website dashboard, users can drill down from the Vulnerability Index view to specific indicator views by clicking on specific indicators of interest or navigating to the “Other Indicators” tab. The user can also navigate the map from a ZIP Code view to a census tract view and can select a specific geography of interest for further analysis.

At every geographic level, a risk-driven, color-coded map is displayed in the center with demographic data included below the map. The top indicators contributing to the Vulnerability Index are displayed to the right of the map. To the right of each gauge, an impact score shows the degree to which the indicator contributes to the Vulnerability Index within a selected geographic area. Each gauge has a central black line indicating the vulnerability quintile of the indicator within Dallas County.

“The two years PASS has been running have been a huge benefit to Dallas County as community residents and stakeholders have had single source of precise, timely, and actionable data insights at a highly localized level to identify areas at high-risk for poor asthma outcomes,” said Yolande Pengetnze, MD, Senior Vice President, Clinical Leadership at PCCI. “More importantly, PASS strengthens public health leaders’ ability to plan, design, deploy, and evaluate pediatric asthma programs because they now have a single source of truth as a robust data source.”

Additional indicators are presented under “Other Indicators.” While these indicators were not retained in the Vulnerability Index prediction model, they provide the user with additional, actionable insights into drivers of asthma vulnerability in the community, such as the proportion of the population reporting tobacco smoking in the neighborhood.

“In this example,” said Dr. Pengetnze, “If a child with poorly controlled asthma lives in a census tract with a high prevalence of smokers and low controller medication use, the clinical provider might initiate caregiver education about secondhand smoking and medication adherence. Additionally, public health entities might address access to medication and smoking cessation programming at the community level.”

The PASS supports Parkland’s and DCHHS’ communitywide pediatric asthma programming and has been has also been used to engage parents or caregivers to participate in Parkland’s educational, interactive, pediatric asthma text-messaging program designed to help parents manage their child’s asthma.

To access PASS live, go to: https://www.dallascounty.org/departments/dchhs/public-health/chronic-disease/asthma-control-overview.php

*This work is funded in part by Lyda Hill Philanthropies. Lyda Hill Philanthropies encompasses the charitable giving for founder Lyda Hill and includes her foundation and personal philanthropy. Our organization is committed to funding transformational advances in science and nature, empowering nonprofit organizations and improving the Texas and Colorado communities. Because Miss Hill has a fervent belief that “science is the answer” to many of life’s most challenging issues, she has chosen to donate the entirety of her estate to philanthropy and scientific research. For more details visit lydahillphilanthropies.org.