By Yolande Pengetnze, MD, MS, FAAP, is PCCI’s Senior Vice President of Clinical Leadership
With the recent launch of Dallas County Health and Human Services’ (DCHHS) Diabetes and Hypertension Surveillance Systems, powerful new tools designed to track and better understand diabetes and hypertension across Dallas County, data is rolling in showing that more than one million residents of Dallas County are living in very high vulnerability ZIP Codes for these harmful chronic illnesses.
The Diabetes and Hypertension Surveillance Systems (also identified as DiSS and HySS, respectively), developed in collaboration with Parkland Health (Parkland), DCHHS, and PCCI, are publicly accessible dashboards available on the DCHHS Chronic Disease Prevention webpage. Both systems are powered by a combination of PCCI’s Community Vulnerability Compass (CVC) and clinical factors, which uniquely provide insights from social and health data to anticipate a community's susceptibility and identify inequities across adverse outcomes from diabetes and hypertension. The Diabetes and Hypertension Vulnerability Indexes are ranked from very low to very high risk, indicating the increased level of vulnerability to poor outcomes from both diseases in the community.
The surveillance systems integrate multiple data sources to provide insight into key indicators and their impact by ZIP Code or census tract:
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Clinical indicators such as prior emergency department (ED) visits, medication adherence/prescription fills, and biomarker measurements of diabetes and hypertension control, like hemoglobin A1C and blood pressure, respectively etc.
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Social Determinants of Health (SDOH) indicators, including education and literacy, household income, disease burden, food insecurity, access to greenspace, etc.
In my experience, medication adherence for diabetes and hypertension patients is a strong indicator of vulnerability. Those patients who either can’t obtain necessary medication or infrequently use their medication are more likely to have poorly controlled hypertension or diabetes, which can lead to complications such as stroke, heart attacks, kidney disease, and frequent emergency room visits and hospitalizations.
Since the surveillance systems launched on Sept. 10, we’ve already uncovered some key data insights, with the DiSS finding 19 ZIP Codes in the very high vulnerability range, affecting more than 521,400 residents. The leading root causes for the very high vulnerability include a high number of ED visits for diabetes in the last 12 months, the density of people with diabetes in the community, and lack of walkable space in the neighborhoods.
On the HySS front, we found that more than 519,530 residents live in 19 ZIP Codes ranked very high vulnerability for hypertension. The leading factors for vulnerability include recent ED visits for hypertension in the last 12 months, the prevalence of mental and behavioral health diagnosis in the community, and overall community social vulnerability.
Importantly, however, we also see how neighboring ZIP Codes with similar social vulnerability levels might have very different drivers of vulnerability. For example, ZIP Code 75216 has a very high vulnerability for diabetes, primarily driven by the high prevalence of obesity, hypertension, and mental and behavioral health issues in the community. The adjacent ZIP Code, 75241, also has very high vulnerability to diabetes, but while the prevalence of obesity and hypertension remains a leading driver of vulnerability, the lack of internet connectivity now plays a more significant role.
The ZIP Code, 75216, was at the top of both most vulnerable lists with ED visits and high blood pressure diagnosis as shared leading indicators.
These eye-opening insights only scratch the surface of what the surveillance systems can tell us. The deeper insights come from the fact that we can go into neighborhoods at the census tract level where we have seen neighborhoods of very high vulnerability separated from a very low vulnerability census tract by only a single street. By identifying where risks are concentrated, public health leaders and community-based organizations can target and tailor outreach, education, resource allocation, and community partnerships to the neighborhoods most in need, ensuring interventions are more effective, efficient, and equitable.
The DiSS and HySS systems were developed using PCCI’s CVC, a powerful, web-based, interactive dashboard specifically engineered to support safety-net hospitals, health systems, managed care organizations, payer plans, philanthropic entities, and community-based organizations in understanding and mitigating social vulnerabilities. By leveraging precise, hyper-local data on SDOH, CVC enables stakeholders to implement highly targeted interventions that address the underlying drivers of health disparities.
The dashboards also give insights to how neighboring ZIP Codes with similar social vulnerability levels might have very different drivers of vulnerability. For example, ZIP Code 75216 has a very high vulnerability for diabetes, primarily driven by the high prevalence of obesity, hypertension, and mental and behavioral health issues in the community. The adjacent ZIP Code, 75241, also has very high vulnerability to diabetes, but while the prevalence of obesity and hypertension remains a leading driver of vulnerability. Additionally, the lack of internet connectivity now plays a more significant role.
PCCI’s CVC has been incorporated into a variety of use case solutions throughout Texas, including the acclaimed Pediatric Asthma Surveillance System on the DCHHS website, tracking factors affecting asthma risk among vulnerable children in Dallas County. CVC, which offers analysis at a block group level, has also been adopted across the Parkland Health system, providing root-cause understanding of patient vulnerabilities to drive strategy and interventions. DCHHS is also using CVC to strategically prioritize outreach and campaigns based on SDOH and demographic insights. Additionally, the University Heath (San Antonio) Transplant Center is leveraging CVC to obtain a deeper understanding of the context and complexities of the social barriers to health, access, and well-being of Transplant Institute patients.
These innovative surveillance systems are changing how we can act to protect our communities from chronic illnesses by combining clinical data with social and demographic information down to the census tract level. Because of that, we can better identify at-risk populations, guide policy, and ensure that prevention and treatment efforts are effectively coordinated to reach those most in need. These insights and data are critical to coordinate support and align interventions to maximize our collective impact and we're excited to make these tools available to the Dallas community and beyond.
Yolande Pengetnze, MD, MS, FAAP, is PCCI’s Senior Vice President of Clinical Leadership where she leads multiple projects including population health quality improvement projects focusing on preterm birth prevention and pediatric asthma at the individual and the population level. Dr. Pengetnze received her MD from the University of Yaoundé in Cameroon and completed a Pediatric Residency at Maimonides Medical Center in New York. She was a faculty member at UTSW’s General Pediatric Hospitalist Division where she completed a General Pediatric/Health Services Research Fellowship training and earned a Master of Sciences in Clinical Sciences.