Evaluation of Reportable DiseaseSurveillance in KY by County & Region

ERRT MeetingFrankfort, KY

August 30, 2005

Lyle B. Snider, Ph.D.Big Sandy Regional Public Health

Epidemiologist

Presentation Outline Evaluation of Surveillance Programs 2004 KY Reportable Disease Case

Frequencies and Rates/100,000 population by County & Region

2004 Diagnosis Frequencies and Rates by Region

2004 Reporting Agency Frequencies by Region

Surveillance of local health care provider quality

Evaluation of Surveillance Programs

Source: May 2005 Introduction to Surveillance Course Emory School of Public Health – next door

to CDC Phillip S. Brachman, MD, Emory Univ.

School of Public Health Updated Guidelines for Evaluating Public

Health Systems. MMWR Recommendations and Reports. July 27, 2001/Vol. 50/No. RR-13

We Were There: Emory Univ. School of Public Health

Figure 2: Simplified example of steps in a surveillance system

Occurrence of health-related event

Health-related event recognized by reporting source

Health-related event reported To responsible public health agency

Control & prevention activities Feedback to Stakeholders

MMWR, 2001, Vol 50/No. RR-13, p. 22

Surveillance System Attributes Related to Level of Usefulness

Simplicity Structure & Ease of Operation

Flexibility How easy is it to add a new disease,

revise a case definition, or adapt to new technology

Data quality – completeness & validity

Surveillance System Attributes #2

Acceptability Willingness of persons and organizations to

participate in the surveillance system Sensitivity

The proportion of cases detected by the surveillance system – Focus of this presentation

Ability to detect outbreaks, including the ability to monitor changes in the number of cases over time.

Predictive value positive proportion of reported cases that actually have the

health-related event under surveillance

Surveillance System Attributes #3

Representativeness Degree of accuracy in describing the occurrence of

a health-related event over time & its distribution in the population by place and person

Timeliness Assessed by time between steps in surveillance

system Stability

reliability (i.e., the ability to collect, manage, and provide data properly without failure)

availability (the ability to be operational when it is needed)

KY Regions Used in This Analysis

Appalachian KY 51 Counties & ~ 1 Mil. Population

Metro/Non-metro - Defined by the Office of Management and Budget (OMB) Almost 100 (out of a total of 120) counties

and ~ 50% of the population are Non-metro (rural)

Area Development Districts – 15 of them

Appalachian KYIs Cancer an

Infectious Disease? http://www.kcr.uky.edu/

Is County Reporting Rate Related to Size of Hospital or Metro/Non-Metro Status?

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Adair

Allen

Anderson

Ballard

Barren

Bath

Bell

Boone

BourbonBoyd

Boyle

Bracken

Breathitt

Breckinridge

Bullitt

Butler

Caldwell

Calloway

Campbell

Carlisle

Carroll

Carter

Casey

Christian

Clark

Clay

Clinton

Crittenden

Cumber-land

Daviess

Edmonson

Elliott

Estill

Fayette

Fleming

Floyd

Franklin

Fulton

Gallatin

Garrard

Grant

Graves

Green

Greenup

Hancock

Hardin

Harlan

Harrison

Hart

Henderson

Henry

Hickman

Hopkins

Jackson

Jefferson

Jessamine Johnson

Kenton

Knott

Knox

Larue

Laurel

Lawrence

Lee

Leslie Letcher

Lewis

LincolnLivingston

Logan

Lyon

Mc-Cracken

McCreary

McLeanMadison Magoffin

Marion

Marshall

Martin

Mason

MeadeMenifee

Mercer

Metcalfe

Monroe

Montgomery

Morgan

Muhlen-berg

Nelson

Nicholas

Ohio

Oldham Owen

Owsley

Pendleton

Perry

Pike

Powell

Pulaski

Robertson

Rockcastle

Rowan

Russell

ScottShelby

Simpson

Spencer

Taylor

ToddTrigg

Trimble

Union

Warren

Wash-ington

Wayne

Webster

Whitley

Wolfe

Wood-ford

Grayson

2000 Census Rural/Urban Designation and Acute Care Hospitals 2002

Rural/Urban Designation

Rural

UrbanL.B. Snider, Ph.D.University of Kentucky Center for Rural HealthData Obtained From the KY Office of Inspector Generaland the U.S. Census Bureau

Number of Acute Hospital Beds

## 25 - 49# 50 - 99# 100 - 199# 200 - 415

1 - 24

$

Critical Access Hospitals

Cities With More Than 1 Acute Care Hospital

Ashland, Boyd & Greenup Co.'s, 2 Hosp., 174-301 BedsBowling Green, Warren Co., 2 Hosp., 211-294 BedsLexington, Fayette Co., 5 Hosp., 166-456 BedsLouisville, Jefferson Co., 9 Hosp., 127-889 BedsPaducah, McCracken Co., 2 Hosp., 286-349 Beds

2000 Census County Metro/Non-Metro Status & 2002 Acute Care Hospitals

Non-metroMetro

The 2004 Incidence of Communicable Diseases in KY

1,320 confirmed cases reported for all diagnoses & 31.8 cases/100,000 pop Does NOT include animal rabies, TB,

influenza isolates, STDs or Unconfirmed Reports

Jefferson Co had the most – 203 cases, followed by Kenton Co – 91, Fayette Co – 77

Five counties had no cases and half of the 120 counties had five or fewer cases

~ 20 cases needed for reliable rate estimate

2004 KY Reportable Disease Case Frequencies & Rates/100,000 Population by County

COUNTY Freq 04 PopRate/

100,000

Casey 20 16,059 124.5Graves 29 37,401 77.5Kenton 91 152,890 59.5Boone 55 101,354 54.3Warren 51 97,168 52.5Campbell 43 87,256 49.3Christian 32 70,649 45.3McCracken 24 64,700 37.1Jefferson 203 700,030 29.0Fayette 77 266,358 28.9Daviess 26 92,587 28.1Hardin 25 96,066 26.0

12 Counties w 20 or More Cases by Rate

COUNTY Freq 04 PopRate/

100,000

Grant 18 24,317 74.0Scott 17 38,029 44.7Nelson 18 40,406 44.5Henderson 19 45,426 41.8Oldham 19 52,100 36.5Hopkins 17 46,818 36.3Pike 19 67,080 28.3

7 Counties w 17-19 Cases by Rate

KY Rate – 31.8

0

10

20

30

40

50

60

NorthernKentucky

Purchase Barren River BuffaloTrace

LakeCumberland

Pennyrile

2004 KY Communicable Disease Case Report Frequency & Rate per 100,000 Population by ADD

KY Rate 31.8

21687

10421

66 70

0

10

20

30

40

50

60

Cumber

land V

alley

Green

Rive

r

KY Rive

r

Kentu

ckian

a

Linco

ln T

rail

Blueg

rass

Big San

dy

Gatew

ayFivc

o

2004 KY Communicable Disease Case Report Frequency & Rate per 100,000 Population by ADD

KY Rate 31.875

19535

15

17

65 25035 69

0

5

10

15

20

25

30

35

None < 100 < 200 200+ Metro Non-Metro

2004 KY Communicable Disease Case Reports per 100,000 Population by Largest Hospital in County and Metro (Urban)/Non-Metro (Rural Status)2004 KY Communicable Disease Case Reports

per 100,000 Population by Largest Hospital in County and Metro (Urban)/Non-Metro (Rural)

The 2004 KY 10 Most Common Reported Communicable Disease Diagnoses

DiagnosisFre-

quency %Cumulative

%

Salmonella 362 27.4% 27.4%Campylobacteriosis 272 20.6% 48.0%Pertussis 98 7.4% 55.5%

Hepatitis B 83 6.3% 61.7%Shigellosis 75 5.7% 67.4%Streptococcal Disease, Invasive, Group A 61 4.6% 72.0%

Cryptosporidiosis 47 3.6% 75.6%Histoplasmosis 47 3.6% 79.2%Legionellosis 44 3.3% 82.5%

E Coli O157:H7 31 2.3% 84.8%

Total of 34 Diagnoses

Why is Northern KY Rate (53) so Much Higher Than KY’s (32)?

Also wide range of rates among ADDs Northern KY rate of 53

cases/100,000 is ~4 times the Fiveco rate of 12

Alternatively, Fivco Rate is Only 1/3rd of KY Rate

Outbreaks in High Rate ADDs?

COUNTY Freq 04 PopRate/

100,000

Boone 55 101,354 54.3Campbell 43 87,256 49.3Carroll 2 10,344 19.3Gallatin 1 7,979 12.5Grant 18 24,317 74.0Kenton 91 152,890 59.5Owen 2 11,300 17.7Pendleton 4 15,134 26.4N KY Total 216 410,574 26.4

Most “Important” Diagnoses in High Rate ADDs“Important” = Rate Higher than KY Rate & 10

or More Cases/ADD

Dx KYNorthern

KYPur-chase

Barren River

Salmonella 8.7 8.5 23.7 11.7Campylobacteriosis 6.6 11.2 9.8 8.3Hepatitis B 2.0 4.4Shigellosis 1.8 10.0Streptococcal Disease, Invasive, Group A 1.5 4.9Cryptosporidiosis 1.1 4.5Histoplasmosis 1.1 6.0Hepatitis A 0.7 2.4

Cases/100,000 Population

Is Salmonella Concentrated in Certain Counties?

Rates are Not Reliable if County Frequencies Less Than ~20

County

Salmonella Frequency

2004 Population

Rate/ 100,000

KY 362 4,145,922 8.7

Jefferson 48 700,030 6.9Fayette 25 266,358 9.4Graves 14 37,401 37.4

What About Pertussis?

Pertussis is Concentrated in Jefferson & Oldham Counties

CountyPertussis

Frequency2004

PopulationRate/

100,000

KY 98 4,145,922 2.4

JEFFERSON 53 700,030 7.6OLDHAM 13 52,100 25.0KENTON 4 152,890 2.6

Who Submits the Communicable Disease Reports?

Data on Reporting Agencies is VERY Difficult to Analyze – The Following Results Have a Large Margin of Error

1,320 Cases 67 Had NO Data Relating to Agency That

Reported the Case There Were ~1,625 Reports of the

Remaining 1,250+ Cases Because Some Cases Were Reported by 2 or 3 Agencies

~ 180 Agencies Reported Cases ~80 Agencies Reported Only 1 Case

6 Agencies Made Half of Reports

Reporting AgencyFre-

quency %Cumulative

%

STATE LAB 336 20.7% 20.7%LAB CORP 127 7.8% 28.5%St. Elizabeth's Med Center 105 6.5% 35.0%Norton/KOSAIR Hospitals 100 6.2% 41.1%QUEST 85 5.2% 46.4%UK HOSP 61 3.8% 50.1%

~60 Cases, (4% of Total) Were Submitted by Ambulatory Care Practices: Lexington Clinic, Louisville Community Health Centers, Pediatricians, etc.

Distribution of Reporting Agencies in High Rate ADDs

Northern KY: Amost Half are from 1 Agency (St. Elizabeth Medical Center) State Lab Reported Only 5%

Barren River & Purchase Distribution of Agencies Similar to KY Distribution State Lab Reported More Than Any

Other Agency ~ 20%

Surveillance of Local Health Care Providers Quality

Mandated by "Essential Public Health Service 9: Evaluate effectiveness, accessibility,

and quality of personal and population-based health services".

HHS Hospital Compare http://www.hospitalcompare.hhs.gov/

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30%

40%

50%

60%

70%

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100%

ACE Inhibitor forLVSD

Smoking CessationAdvice/Counseling

Beta Blocker atArrival

Central BaptistSt. JosephUniv of KYU.S. Ave.KY Ave.

CMS Hospital Compare Indicators for Select Heart Attack Care Indicators

Percent of Patients

Receiving Indicated Care (If

Appropriate)

Does It Matter if There is Wide Variation in Rates by ADD & County?

Cost effectiveness??

The East KY Infectious Disease Cooperative

See Handout Began in February, 2005 Led by Pikeville Hospital: Tamara

Musgrave, Infectious Disease MD, and Janie Hall, RN, Infection Control

No Additional Meetings Currently Planned

What Can We Do to Get More Complete Reporting?