Farrokh Alemi

Enhancing spatial detection accuracy for syndromic surveillance with street level incidence data

BackgroundThe Department of Defense Military Health System operates a syndromic surveillance system that monitors medical records at more than 450 non-combat Military Treatment Facilities (MTF) worldwide. The Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE) uses both temporal and spatial algorithms to detect disease outbreaks. This study focuses on spatial detection and attempts to improve the effectiveness of the ESSENCE implementation of the spatial scan statistic by increasing the spatial resolution of incidence data from zip codes to street address level.MethodsInfluenza-Like Illness (ILI) was used as a test syndrome to develop methods to improve the spatial accuracy of detected alerts. Simulated incident clusters of various sizes were superimposed on real ILI incidents from the 2008/2009 influenza season. Clusters were detected using the spatial scan statistic and their displacement from simulated loci was measured. Detected cluster size distributions were also evaluated for compliance with simulated cluster sizes.ResultsRelative to the ESSENCE zip code based method, clusters detected using street level incidents were displaced on average 65% less for 2 and 5 mile radius clusters and 31% less for 10 mile radius clusters. Detected cluster size distributions for the street address method were quasi normal and sizes tended to slightly exceed simulated radii. ESSENCE methods yielded fragmented distributions and had high rates of zero radius and oversized clusters.ConclusionsSpatial detection accuracy improved notably with regard to both location and size when incidents were geocoded to street addresses rather than zip code centroids. Since street address geocoding success rates were only 73.5%, zip codes were still used for more than one quarter of ILI cases. Thus, further advances in spatial detection accuracy are dependant on systematic improvements in the collection of individual address information.

Predicting in-hospital survival of myocardial infarction. A comparative study of various severity measures.

This study reports on the ability of several indices to predict in-hospital survival from acute myocardial infarction. The following indices were included: Acute Physiological and Chronic Health Evaluation (APACHE II), Medisgroups (MDGRP), Computerized Severity Index (CSI), Patient Management Categories (PMC), Coded Disease Staging (CDS), Ischemic Heart Disease Index (IHDI), and Predictive Index for Myocardial Infarction (PIMI). An arbitrary strategy of predicting that all patients will live was also applied and correctly classified 78% of the cases. Severity indices improve these predictions by up to 6% more. Comparison of relative accuracy of the indices showed that all indices were more accurate than PIMI and, for medically treated patients, CSI was more accurate than MDGRP, CDS, APACHE II, and IHDI. There were no other statistically significant difference in the predictive ability of remaining indices. Indices based on discharge abstracts were as accurate as some of the indices based on physiologic variables, in particular PMC was as accurate as CSI, MDGRP, APACHE, and IHDI, and CDS was as accurate as MDGRP, APACHE, and IHDI. This study was limited in scope and application and should not be generalized to other settings until additional data confirm the findings. We discuss the implications of these findings for measuring quality of care and suggest improvements for design of future severity indices.

An Evaluation of Multiple Trauma Severity Indices Created by Different Index Development Strategies

Evaluation of the effectiveness of emergency trauma care systems is complicated by the need to adjust for the widely variable case mix found in trauma patient populations. Several strategies have been advanced to construct the severity indices that can control for these population differences. This article describes a validity and reliability comparison of trauma severity indices developed under three different approaches: 1) use of a multi-attribute utility (MAU) model; 2) an actuarial approach relying on empirical data bases; and 3) an “ad hoc” approach. Seven criteria were identified to serve as standards of comparison for four different indices. The studys findings indicate that the index developed using the MAU theory approach associates most closely with physician judgments of trauma severity. When correlated with a morbidity outcome measure, the MAU-based index shows higher levels of agreement than the other indices. The index development approach based on the principles of MAU theory has several advantages and it appears to be a powerful tool in the creation of effective severity indices.

Policy issues relevant to evaluation of interactive health communication applications

This article provides an analysis of policy-related issues associated with the evaluation of interactive health communication (IHC) applications. These include an assessment of the current health and technology policy environment pertinent to public (government, education, public health) and private (medical care providers, purchasers, consumers, IHC developers) IHC stakeholders and discussion of issues likely to merit additional consideration by these stakeholders in the future.

Continuous self-improvement: systems thinking in a personal context.

BACKGROUND Continuous quality improvement (CQI) thinking and tools have broad applicability to improving peoples lives--in continuous self-improvement (CSI). Examples include weight loss, weight gain, increasing exercise time, and improving relationship with spouse. In addition, change agents, who support and facilitate organizational efforts, can use CSI to help employees understand steps in CQI. A STEP-BY-STEP APPROACH: Team members should be involved in both the definition of the problem and the search for the solution. How do everyday processes and routines affect the habit that needs to change? What are the precursors of the event? Clients list possible solutions, prioritize them, and pilot test the items selected. One needs to change the daily routines until the desired behavior is accomplished habitually and with little external decision. DISCUSSION CSI is successful because of its emphasis on habits embedded in personal processes. CSI organizes support from process owners, buddies, and coaches, and encourages regular measurement, multiple small improvement cycles, and public reporting.

Trajectory of Illness for Patients with Congestive Heart Failure

BACKGROUND AND OBJECTIVE This study describes progression to death for patients with congestive heart failure (CHF). METHODS We used SAS procedure Proc Traj to fit a semiparametric model to longitudinal data on prognosis of patients with CHF in the 12 months prior to death. Data were collected on 744 patients with CHF in 2010 at Bay Pines VA Healthcare System; 386 subjects had sufficient data points (minimum of five encounters) to trace their risk in 12 months prior to death. The prognosis of the patient was calculated using the comorbidities of the patient. RESULTS Unexpected death occurred in 20.5% of patients; all remaining patients had a gradual progression toward death. For 13.3% of patients, progression toward death started 12 months prior to death. For 29.9% of patients, increased risk started at 6 months prior to death. For 36.3% of patients, it started 3 months prior to death. One month prior to death, 79.5% of the patients had a more than 97% chance of mortality. It may be possible to use progression toward death over 3 consecutive months as a predictor of need for hospice consultation. CONCLUSIONS Five typical illness trajectories have been described for patients with progressive heart failure. The needs of patients and their caregivers are likely to vary according to the trajectory patients are following. Contrary to reports in the literature about unexpected death in patients with CHF, the majority of decedents in our study had a predictable and gradual progression toward death. Recognizing these trajectories may help clinicians implement an appropriate plan to meet the needs of patients and their caregivers.

Rapid improvement teams.

BACKGROUND Suggestions, most of which are supported by empirical studies, are provided on how total quality management (TQM) teams can be used to bring about faster organizationwide improvements. SUGGESTIONS Ideas are offered on how to identify the right problem, have rapid meetings, plan rapidly, collect data rapidly, and make rapid whole-system changes. Suggestions for identifying the right problem include (1) postpone benchmarking when problems are obvious, (2) define the problem in terms of customer experience so as not to blame employees nor embed a solution in the problem statement, (3) communicate with the rest of the organization from the start, (4) state the problem from different perspectives, and (5) break large problems into smaller units. Suggestions for having rapid meetings include (1) choose a nonparticipating facilitator to expedite meetings, (2) meet with each team member before the team meeting, (3) postpone evaluation of ideas, and (4) rethink conclusions of a meeting before acting on them. Suggestions for rapid planning include reducing time spent on flowcharting by focusing on the future, not the present. Suggestions for rapid data collection include (1) sample patients for surveys, (2) rely on numerical estimates by process owners, and (3) plan for rapid data collection. Suggestions for rapid organizationwide implementation include (1) change membership on cross-functional teams, (2) get outside perspectives, (3) use unfolding storyboards, and (4) go beyond self-interest to motivate lasting change in the organization. CONCLUSIONS Additional empirical investigations of time saved as a consequence of the strategies provided are needed. If organizations solve their problems rapidly, fewer unresolved problems may remain.

Time-Between Control Charts for Monitoring Asthma Attacks

BACKGROUND The monitoring of peak expiratory flow rate (PEFR) is crucial for effective management of asthma. Daily PEFR monitoring is recommended, yet the data are rarely used by patients to help them understand their progress or by clinicians to modify treatment plans. Time-between control charts, which have been shown to be specially suited for monitoring rare events, can be used to monitor asthma attacks. METHODS Each patient is asked to record his or her PEFR value once a day, and these data are used to construct the control chart. PEFR data for three previously reported cases are presented and used to illustrate the control chart methodology. If duration of consecutive attacks is plotted and the observed duration exceeds the upper control limit (UCL), the patient is getting worse. If length of consecutive symptom-free days is plotted and the observed duration exceeds the UCL, the patient is getting better. In both circumstances, the clinician and the patient explore what brought about the prolonged recovery or periods of deterioration. The object is to increase time until the next attack. DISCUSSION Using time-between control charts in monitoring asthma attacks has the advantage of providing a visual display of data that, unlike eyeballing of trends, clarifies when patients should seek additional clinical advice. The control limit allows clinicians and patients to ignore random variations and focus on real changes in underlying patterns of asthma attacks.

Medication adherence among homeless patients: A pilot study of cell phone effectiveness

Purpose: We examined the feasibility of using cell phones to monitor medication adherence among homeless participants and collected data for research purposes. Data sources: Ten homeless individuals with a co‐occurring substance use and psychiatric disorders who were receiving psychopharmacologic treatment participated in the study. All psychopharmacologic treatment was provided by a psychiatric mental health nurse practitioner. Cell phones were provided to participants with unlimited phone service for 45 days. An automated telephone system was programmed to call participants daily for 30 days. All participant responses were reported to a computer and reviewed by study staff on a daily basis. Conclusions: The automated calls reached study participants 93% of days and, when reached, participants reported 100% adherence with the prescribed medication regimen. Exit interviews indicated strong support for the usefulness of the phone and the value of the call and survey as reminders to take their medication. No patients dropped out of this study. Implications for practice: This pilot study establishes the feasibility of using cell phones to monitor and manage medication regimens for hard‐to‐reach populations, such as the homeless with co‐occurring disorders. It also establishes that this technology would work for research data collection. Disclaimer The views expressed in this article do not represent the views of the Veterans Administration or the United States Government.

Rehearsing decisions may help teenagers: An evaluation of a simulation game☆

This paper presents a new approach to preventing adolescent pregnancy. Information alone is not sufficient to prevent teenage pregnancy. The teenagers ability to choose and remain committed to a decision also needs to be developed. Because decision making skills are best learned through practice in an environment with frequent feedback, we have developed a computer game which simulates the consequences of different sexual roles. In addition, the game is intended to increase communication about sex between teenagers and their role models (peers, teachers and/or parents). Increased communication is expected to reduce the feeling of guilt and lead to either consistent abstention from sex or consistent contraceptive use. The paper reports on the development of the computer game and the preliminary evaluation of its impact.