1. health and fitness

From infection to perfection:
Enhancing infectious disease
surveillance data quality
Presented by:
Alex Marchand-Austin, Public Health Ontario Laboratory
Lori Newman, Surveillance Services
Acknowledgements
PublicHealthOntario.ca
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Objectives
• To identify circumstances at each stage of the public health
process that may impact data quality
• To discuss potential solutions to address data quality impacts
• To complete disease-specific scenarios that highlight common
data quality issues
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Agenda
Topic
Time
Introduction
10:30
Review of public health system
10:40
Interactive audience session
11:00
Summary
11:30
Q&A
11:40
Evaluation
11:55
PublicHealthOntario.ca
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From infection to perfection:
Enhancing infectious disease
surveillance data quality
Presented by:
Alex Marchand-Austin, Public Health Ontario Laboratory
Lori Newman, Surveillance Services
Acknowledgements
PublicHealthOntario.ca
6
Objectives
• To identify circumstances at each stage of the public health
process that may impact data quality
• To discuss potential solutions to address data quality impacts
• To complete disease-specific scenarios that highlight common
data quality issues
PublicHealthOntario.ca
7
Agenda
Topic
Time
Introduction
10:30
Review of public health system
10:40
Interactive audience session
11:00
Summary
11:30
Q&A
11:40
Evaluation
11:55
PublicHealthOntario.ca
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What is data quality?
• “The state of completeness, validity, consistency, timeliness
and accuracy that makes data appropriate for a specific use”
• In the context of a medical registry:
• “The totality of features and characteristics of a data set, that bear on
its ability to satisfy the needs that result from the intended use of the
data”
• Good quality data satisfy the objectives of the surveillance
system and the needs of the data users
Sources:
• The Government of British Columbia
• Arts DG, De Keizer NF, Scheffer GJ, 2002
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From Data to Action
Source: Wager KA, Frances WL, Glaser JP, 2013.
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Use of good quality data
Source: Centers for Disease Control and Prevention Available. 2014, Jan.
Available from: http://www.cdc.gov/globalhealth/immunization/sis/data_detail.htm
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The prevalence of illness pyramid
Source: Foodnet Working Group. 1997, Dec.
Available from http://wwwnc.cdc.gov/eid/article/3/4/97-0428
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Symptom
onset
Laboratory
testing &
reporting
Provincial
surveillance
PHU
investigation &
reporting
PublicHealthOntario.ca
National &
international
reporting
14
Health care providers – Role
• Assess the health status of the patient
• Complete or refer for testing, as required
• Provide treatment to the patient and follow-up if needed
• Maintain current knowledge
• Notify public health (the Medical Officer of Health)
• First opportunity for public health to become aware of a possible case
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Health care providers – Potential issues
• Patient history
• Poor patient recall (e.g., symptom onset date)
• Information not asked/not recorded in the patient file
• Ordering the correct test
• Collecting the appropriate specimen
• Completeness of the laboratory requisition
• Notification of public health
• Duty to report (Health Protection and Promotion Act, s. 25-31 and s. 38)
• Timeliness (Infectious Diseases Protocol, Appendix A)
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Health care providers – What is the impact?
• Incomplete or inaccurate client and case information:
• Delays in public health notification and intervention
• Incomplete counts of cases that do not require laboratory confirmation
(e.g., probable cases)
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Solutions?
• Discuss in small groups and bring back for large group
discussion
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Provincial
surveillance
Symptom
onset
Visit health
care
provider
PublicHealthOntario.ca
PHU
investigation
and reporting
National and
international
reporting
19
Laboratory – Role
• There are three main providers of clinical laboratory services
in Ontario:
• Community Laboratories
• Hospital Laboratories
• Public Health Ontario Laboratories (PHOL)
• Offer testing within a given scope as determined by the
Laboratory Medical Director
• Out of scope testing sent to reference laboratories
• Regulated by MOHLTC under Laboratory and Specimen
Collection Centre Licensing Act. R.S.O. 1990
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Laboratory – Role (PHOL)
• Reference clinical microbiology testing
• Primary testing for infectious diseases of public health concern
• Subset of all testing in the province for some organisms (e.g.,
Campylobacter), all testing for others (e.g., HIV confirmatory)
• Environmental microbiology testing
• Clinical consultation
• Outbreak and incident management support
• Laboratory-based surveillance
• No regulatory function over community hospital laboratories
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Laboratory – Potential issues
• Issues with specimen collection
•
•
•
•
Quality of specimen
Handling of specimen
Appropriateness of specimen
Completeness of the requisition
• Notification of public health
• Duty to report (Health Protection and Promotion Act, s. 29, and the
Laboratory and Specimen Collection Centre Licensing Act)
• Timeliness (Infectious Diseases Protocol, Appendix A)
• Misdirected results
• Multiple results (preliminary, final, duplicate copies)
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Laboratory – What is the impact?
• Delays in public health notification and intervention
• Resource intensive follow up
• Resolving sampling issues
• Interpretation of results from problematic samples (e.g., indeterminate)
• Incomplete counts of cases
• Difficulty linking laboratory/iPHIS data on incomplete demographics
• Missed cases due to false negatives
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Solutions?
• Discuss in small groups and bring back for large group
discussion
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Laboratory
testing &
reporting
Symptom
onset
Visit health
care provider
PublicHealthOntario.ca
Provincial
surveillance
National &
international
reporting
25
Public health units – Role
• To report cases, contacts, and outbreaks of reportable
diseases in iPHIS in accordance with:
•
•
•
•
Health Protection and Promotion Act
Ontario Regulation 569 and 559/91
Infectious Diseases Protocol, Appendices A & B
iPHIS User Guides, Bulletins, Enhanced Surveillance Directives
• To perform case and contact follow-up and management
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Public health units – Potential issues
• Data collection
• Available tools (e.g., data collection forms) or resources (e.g.,
investigators)
• Client recall (e.g., food consumed prior to symptom onset)
• Client health status (e.g., case too ill to speak with an investigator)
• Client lost to follow-up
• Incomplete or inaccurate client records
• Variety of individuals completing data collection (e.g., community
physicians might not prioritize the same data elements that the PHU
does)
• Mobile/dynamic population
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Public health units – Potential issues
• Data entry
• Completeness or accuracy of data in iPHIS
• Timeliness of data entry (i.e., within timeframes outlined in iPHIS
Bulletin #17)
• Training and communications
• Inconsistent practices between users and PHUs
• System limitations and configuration
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Public health units – Potential issues
• Data cleaning
• Identification of data quality issues and cleaning processes differ by PHU
• Automated applications to identify data quality issues are only effective
for the known issues included in the algorithm
• Data cleaning is often done by using place holders (e.g., entry of
unknown/inaccurate values to prevent being included in the data set)
• Staff completing data cleaning may not be the same staff entering the
data, thereby never addressing data quality issues at the source
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Public health units – What is the impact?
• Incomplete or inaccurate client and case information
• Incorrect case counts due to misclassification of cases
• Reduced ability to detect outbreaks and unusual events locally
• Difficulty identifying groups at risk and common exposures
• Delays public health action
• Impacts the accuracy and completeness of epidemiologic
analyses, reports, and studies
• Significant workload required to complete data auditing and
cleaning
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Public health unit reports
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Solutions?
• Discuss in small groups and bring back for large group
discussion
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Laboratory
testing &
reporting
Symptom
onset
Visit health
care provider
PublicHealthOntario.ca
PHU
investigation &
reporting
National &
international
reporting
33
Public Health Ontario (PHO) – Role
• To support the public health system and health care partners
with information, tools, and resources for the prevention and
control of infectious diseases with respect to surveillance
• Includes:
• Developing operational documents (e.g., iPHIS User Guides, bulletins,
best practices)
• Completing limited data entry on behalf of the PHUs (e.g., emm
types, phage types, TB medical surveillance clients)
• Creating provincial outbreaks in iPHIS
• Issuing Enhanced Surveillance Directives
• Laboratory surveillance tools (e.g., OUT-TB, STI Online)
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Ministry of Health and Long-Term Care
(MOHLTC) – Role
• Chief Medical Officer of Health & the Public Health Division:
• The steward for the public health sector
• Develops legislation, formulates policy, sets standards, provides funding
and oversees the public health sector, establishes indicators, and
ensures accountability
• Coordinates the provincial response to any major public health events
or emergencies
• Health Services Information Cluster (HSC I&IT):
• Provides information management and information technology
solutions that support the business requirements of the MOHLTC
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Provincial – Potential issues
• Incomplete or inaccurate information entered in iPHIS
• e.g., subtyping sent to PHO but no case exists in iPHIS
• Available resources versus volume of cases
• Data Reporting
• Data timeliness, completeness, accuracy, and reliability in iPHIS varies
by public health unit and by user
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PHO & MOHLTC – What is the impact?
• May result in the entire case record being removed from analyses
(for incomplete data)
• Impacts the ability to gain a more complete and reliable description
of Ontario infectious disease characteristics, including monitoring
changes in morbidity and mortality
• Reduced ability to detect outbreaks and unusual events provincially
• Impacts the accuracy and completeness of epidemiologic analyses,
reports, tools (e.g., Query), and studies
• Results in a weaker evidence base from which to guide public health
action
• Program/surveillance evaluation: poor data quality may affect the
evaluation and recommendations of provincial programs
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Provincial Reports
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Other provincial uses
of iPHIS data
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Solutions?
• Discuss in small groups and bring back for large group
discussion
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Laboratory
testing &
reporting
Symptom
onset
Visit health
care provider
PublicHealthOntario.ca
Provincial
surveillance
PHU
investigation &
reporting
41
National and International Reports
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Summary
• Data quality issues can occur at various stages of the case
identification and reporting process
• Initially, the impact may not appear significant
• However, as data is aggregated for local, provincial, national
and international reporting, the data quality issues have a
greater and greater impact
• Ensuring high quality data is essential to having complete,
accurate, and reliable information to guide public health
decision making, policies, programs, and interventions
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Scenarios
• At your table there are four disease-specific scenarios
•
•
•
•
Human immunodeficiency virus (HIV)
Salmonella
Tuberculosis (TB)
Measles
• Please complete at least one scenario as a group
• Designate a person at each table to take notes, which we will
discuss as a larger group at the end of the session
• Facilitators will be circulating to answer any questions
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Group Discussion
• What measures can be taken to reduce poor data quality
during different phases of data collection?
• From your experience with the case study exercise, how does
data quality impact public health action?
• What specific steps can you implement within your PHU to
help improve data quality?
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Questions?
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Evaluation
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