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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Response to letter of Henry R Rolka
Practice-Based Detection in the Multi-Level Public Health Surveillance Context
Practice-Based Surveillance: Creating New Opportunities for Family Medicine and Public Health
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Phiip Sloane, Chapel Hill, NC Professor
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I thank Dr. Rolka for the thoughtful comments. We agree that more work needs to be done to determine whether, and to what extent, primary care surveillance would augment emergency department surveillance. RE the cost of implementing the system change at a practice level, Dr. Rolka's estimate of $50 million is way high because it is based on a false assumption. What will determine the cost of system development is not the number of practices, but the number of different electronic billing systems. Once a vendor wrote a program to create a de-identified data set (i.e., about $1500), then all practices using that particular system would be able to use the same program. I have no idea how many different billing vendors there are but suspect that the top 100 vendors supply the vast majority of practices, and that, therefore, the figure for system development would be more like $150,000 rather than $50 million. The real expense, however, would be in data interpretation -- in finding the nugget of meaningful new-outbreak data among the gravel of spurious outliers. That problem is the crux of all syndromic surveillance systems -- and it would apply to both primary care-based systems and emergency department-based systems. I am by no means convinced that syndromic surveillance is cost-effective -- indeed, I'm not sure we'll ever be able to design a system as sensitive and specific as astute clinicians. Our point is that, if you're going to invest in syndromic surveillance, the primary care office should not be ignored. Competing interests: None declared |
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Henry R Rolka, Atlanta, GA USA Sr Advisor, Div. of Emergecy Preparedness and Response, Centers for Disease Control and Prevention
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This is an important report of high relevance to the rapidly developing public health practice of systematically using ‘secondary data’ (refers to reuse of clinical data already accumulated for some other purpose and available in health information technology systems) for exploiting its surveillance value. The results of this study confirm that a population occurrence may be detected earlier by surveillance of office-based ambulatory care vs. emergency department encounters. This is consistent with the intuitive notion that people will generally seek out health care from a primary vs. a secondary or tertiary care setting for non life-threatening conditions. The authors deserve praise for the research and report providing evidence to support the conclusion that further development of ‘syndromic surveillance systems’ should include primary care offices. In reading this conclusion, two areas of consideration come to mind. The first one relates to future work about the correspondence between detection methodology and the data. The EARS algorithm is an elegant adaptable stand-alone application that can be geographically ported as needed in a matter of hours to days. It would be useful to obtain comparative multifactor evidence (1) from varying socio-demographic settings, (2) for other ‘outbreak’ examples and (3) which compares different detection algorithms. For instance, would an urban gastrointestinal outbreak be detected earlier in family medicine practice encounter data or through emergency departments? How would the EARS algorithm perform compared to a scan statistic or other statistical process control models and methods for determining baseline? Under what circumstances can we generalize and how can multiple data sources be used to achieve improved detection timeliness and specificity? The second consideration relates to economics. Sloane et al. conclude that this sort of surveillance component activity in an office setting is “low cost” and requires minimal staff effort. The cost for the software to generate the daily summary was $1,500. Thinking of this expense for one office practice does not seem like a large expense. Effective public health surveillance and response, however, frequently requires sharing and coordination of timely information for multiple purposes. Information technology, messaging and data analytic standards are necessary enablers of efficient sharing and coordination of information. Software components purchased independently may or may not conform to interoperable data exchange standards for coordinating across systems and public health jurisdictions. Also, considering the nationally estimated 34,490 group practices with 3 or more physicians (see reference #5 at http://www.cdc.gov/nchs/products/pubs/pubd/hestats/electronic/electronic.htm#5), the cost for implementation nationally just for independent purchase of the summary report programming is over $50 million. It is therefore worth mentioning, that to accomplish data extraction utility in a way where information could be coordinated via interoperable standards, it is important to consider extant national data systems such as the Centers for Disease Control and Prevention’s BioSense Program. That way coordination can be facilitated across jurisdictions as well as levels of public health. The findings and conclusions in this commentary are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention. Competing interests: None declared |
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David L Buckeridge, Montreal, Canada Assistant Professor, Department of Epidemiology and Biostatistics
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The authors describe an approach to syndromic surveillance that employs methods similar to those used elsewhere, but their focus on a single practice has implications that are both novel and profound (1). From a methodological perspective, the authors have implemented a standard approach to syndromic surveillance. As noted in the article, other groups have relied on billing-data from ambulatory physician encounters for syndromic surveillance (2). The particular approach used by the authors relies on standard methods for grouping records from individual visits into syndromes and for detecting temporal aberrancies in the aggregated syndromes. The truly innovative aspect of the authors’ work is that they consider syndromic surveillance from the perspective of a single primary care practice. Surveillance initiatives are usually initiated by public health agencies or academic medical centers with a focus that spans multiple ambulatory practices or emergency departments (2-4). The authors’ focus on surveillance within a single practice highlights some interesting issues. First, in conducting syndromic surveillance within a practice, the authors are taking a population perspective (5), which is to be applauded heartily. The methods and skills used for syndromic surveillance are the same as those required for any population or practice-level analysis. So, with minor modifications, a system for syndromic surveillance has a ‘dual use’ of enabling physicians to monitor the sugar control of patients with diabetes or the immunization status of children. Second, the system that the authors describe provides the foundation for routine, rapid, and meaningful interaction between primary care providers and public health. In most surveillance systems, results of analyses are not returned in a consistent and timely manner to those that collect the data. With a practice-based system, however, the results of regional analyses could be returned easily to practitioners. This would allow physicians to place their practice in context, whether in regard to the likely onset of the influenza season or to the management of diabetics. Automated systems could also funnel requests in real-time from public health to clinicians for additional diagnostic testing to confirm the onset of the influenza season or to rule-out rare but serious infections in suspicious cases. This type of interaction has clear and profound implications in the setting of pandemic influenza and other emerging diseases. Many of the details of enhanced interaction between primary practice and public health via automated surveillance require additional thought (e.g., a payment mechanism for additional testing at the request of public health), but the development of the capacity for automated surveillance within primary care practice opens the door to new opportunities for practice management and to enhanced communication between primary practice and public health. 1. Sloane PD, MacFarquhar JK, Sickbert-Bennett E, Mitchell CM, Akers R, Weber DJ, et al. Syndromic surveillance for emerging infections in office practice using billing data. Ann Fam Med 2006;4(4):351-8. 2. Lombardo J, Burkom H, Elbert E, Magruder S, Lewis SH, Loschen W, et al. A systems overview of the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE II). J Urban Health 2003;80(2 Suppl 1):i32-42. 3. Heffernan R, Mostashari F, Das D, Karpati A, Kulldorff M, Weiss D. Syndromic surveillance in public health practice, New York City. Emerg Infect Dis 2004;10(5):858-64. 4. Yih WK, Caldwell B, Harmon R, Kleinman K, Lazarus R, Nelson A, et al. National Bioterrorism Syndromic Surveillance Demonstration Program. MMWR Morb Mortal Wkly Rep 2004;53 Suppl:43-9. 5. House JS, Roux AD. Physicians, families, and population health. Ann Fam Med 2005;3(2):100-1. Competing interests: None declared |
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