Evaluation of Reportable Disease Surveillance in KY by County & Region ERRT Meeting Frankfort, 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 KY Is Cancer an Infectious Disease?

Is County Reporting Rate Related to Size of Hospital or Metro/Non-Metro Status? 2000 Census County Metro/Non-Metro Status & 2002 Acute Care Hospitals Non-metro Metro

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 12 Counties w 20 or More Cases by Rate 7 Counties w Cases by Rate KY Rate – 31.8

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 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 1/3 rd of KY Rate Outbreaks in High Rate ADDs?

Most “Important” Diagnoses in High Rate ADDs “Important” = Rate Higher than KY Rate & 10 or More Cases/ADD Cases/100,000 Population

Is Salmonella Concentrated in Certain Counties? Rates are Not Reliable if County Frequencies Less Than ~20

What About Pertussis? Pertussis is Concentrated in Jefferson & Oldham Counties

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 ~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

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?