nyc syndromic surveillance ifh hit meaningful use workshop 10/1/2010 marlena plagianos, ms nycdohmh...
TRANSCRIPT
NYC Syndromic Surveillance
IFH HIT Meaningful Use Workshop10/1/2010
Marlena Plagianos, MSNYCDOHMH
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What is Biosurveillance?
• “Collection and integration of timely health-related information for public health action achieved through the early detection, characterization, and situation awareness of exposures and acute human health events of public health significance.”
Aaron T Fleischauer, PhD; Pamela S Diaz, MD; Daniel M Sosin MD . Biosurveillance:
A Definition, Scope and Description of Current Capability for a National Strategy.
Advances in Disease Surveillance 2008;5:175
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Traditional Surveillance
• Case definitions• Historically low
compliance• Laboratory
confirmation can be slow
• Still important (e.g. H1N1 in NYC)
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Laboratory Confirmation
•Making firm diagnosis commonly relies on lab result•Limited in-house testing in outpatient setting (minutes)•Commercial laboratory testing takes time (days-weeks)
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Syndromic Surveillance
• Pre-diagnostic indicators of disease• Readiness scenarios: bioterrorism,
pandemics• Objectives:
– Timely, sensitive, specific surveillance– Detect outbreak before ‘astute clinician’
• Typical Process
Collect data
Process & code data
Establish baseline
Identify outbreak
Sound alarm
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New and Exciting Data Types
Data source Level of data
Data type Setting Care phase
Medication sales Aggregate Drug category Pre-clinical Pre-diagnostic
School absences Aggregate Frequency Pre-clinical Pre-diagnostic
Nurse hotline call Individual Call type Pre-clinical Pre-diagnostic
Chief complaint / Reason for Visit
Individual Text, brief Clinical Pre-diagnostic
EMS call Individual Run type Clinical Pre-diagnostic
Temperature Individual Vital sign Clinical Pre-diagnostic
Radiology Report Individual Text, narrative Clinical Pre-diagnostic
Chest X-ray Individual CPT code Clinical Pre-diagnostic
Diagnosis code Individual ICD9 code Clinical Diagnostic
Progress Note Individual Text, narrative Clinical Diagnosis
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EHR Syndromic Surveillance
• The Primary Care Information Project (PCIP) uses different EHR data sources to conduct & pilot its syndromic surveillance activities
• Some syndromes tracked using EHR data are:– Influenza-like Illness (ILI)– Fever– Gastrointestinal Illness (GI)
• Case definitions for these syndromes based upon text in these structured fields:– Chief Complaint– Measured Temperature– Diagnosis (ICD-9 CM Code)
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Data processing and syndrome coding
Respiratory conditions
%Macro Resp; *Respiratory; IF CC=:'COUGH' OR CC=:'COUGHING' OR CC=:'SOB' OR CC=:'DIFFICULTY BREATHING' OR CC='BREATHING PROBLEMS' OR CC=:'SHORTNESS OF BREA' OR CC=:'DIFF BREA' CC='URI' ORTHEN RESP=1; ELSE DO; RESP=
Misspelling INDEX(CC,"COUG") + INDEX(CC,"COUH") +Shortness of breath
INDEX(CC,"S.O.B") + INDEX(CC,"SOB") + INDEX(CC,"S O B") + INDEX(CC,"S O B") + INDEX(CC,"S.OB");
Difficulty breathing
INDEX(CC,"BREAT") + INDEX(CC,"BEATH") + INDEX(CC,"DIB") + INDEX(CC,"D I B") + INDEX(CC,"D.I.B") + INDEX(CC,"BRATHING") + INDEX(CC,"DIFF BR") + INDEX(CC,"DIFF, BR") +
Upper respiratory infection
INDEX(CC,"URI ") + INDEX(CC,"URI/") + INDEX(CC,"URI;") + INDEX(CC,"U R I") + INDEX(CC,"URI,") + INDEX(CC,"U.R.I") +
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Analysis:Calculate Baseline
Expected disease level
• Approaches: Moving average, regression, time series methods.• Length of baseline: Years, months, days
Adjustments
• Long: Seasonal, secular, environmental (e.g. heat, pollen)• Short: Day of week, weekend/weekday, holidays, reporting failures
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Analysis:Test Observed vs. Expected
Significance tests
Predetermined number of standard deviations
Crossing statistical thresholds Signal
H1N1 in New York City:
Where did patients seek treatment?
Emergency Departments or
Primary Care Clinics?
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Objective
• To determine whether the timing of the increase in patient visits was different at emergency departments from primary care clinics during the spring 2009 H1N1 influenza outbreak across the 5 boroughs of NYC
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Study Sites
l 58 Primary Care Providers (PCP): – 9 Institute for Family
Health (IFH) clinics– 49 practices enrolled
in the NYCDOHMH PCIP (30 visits/day)
v 50 Emergency Departments– 247 visits/day
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Methods
• Influenza-like Illness (ILI) as a broad estimate of H1N1
• Fever + respiratory related reason for visit or diagnosisPCP
• Chief complaint of fever + a sore throat or cough, or a chief complaint of fluED
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Methods
Compared number of days to a significant increase at EDs to PCP clinics using a log-rank test
• City-wide• By borough to see if there was a geographic difference
Two Waves:
• 4/24-5/8• 5/14-6/4
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Results, April 24-May 8
Median Days to Increase in ILI
Facilities with Increase in ILI
1-sided log rank
Borough ED PCP ED PCP p-valueAll 4 12 43/50 (86%) 36/58 (62%) <0.0001
Bronx 5 12 8/9 (88%) 10/17 (59%) 0.045
Brooklyn 3 14 12/15 (80%) 6/9 (67%) 0.025
Manhattan 4 13 13/15 (87%) 11/19 (58%) 0.008
Queens 3 7 8/8 (100%) 6/7 (86%) 0.007
Staten Island 14 10 2/3 (67%) 3/3 (100%) 0.902
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Results, May 14-June 4
Median Days to Increase in ILI
Facilities with Increase in ILI
1-sided log rank
Borough ED PCP ED PCP p-valueAll 4 8 47/50 (94%) 50/58 (86%) <0.0001
Bronx 1 6 9/9 (100%) 16/17 (82%) 0.004
Brooklyn 4 12 13/15 (87%) 7/9 (78%) 0.039
Manhattan 4 7 14/15 (93%) 17/19 (89%) 0.016
Queens 4 8 8/8 (100%) 5/7 ( 71%) 0.091
Staten Island 5 8 3/3 (100%) 3/3 (100%) 0.012
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Findings
• Emergency Departments experienced an increase in patients with ILI before Primary Care Providers
• PCPs were vastly under-utilized during the outbreak
• NYCDOHMH changed messaging to encourage visiting PCPs instead of EDs for mild illness
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Future of Syndromic Surveillance
Meaningful Use
• Capability to submit syndromic data to health departments Regional Health Information Organizations (RHIOS), Hubs
Data Validation and Quality Assurance
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Online Resources
CDC Flu Surveillancehttp://www.cdc.gov/flu/weekly/fluactivity.htm
Distribute
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