Public Health Agencies’ Telephone-Based Surveillance Systems Response Time
John Bowen over at Hometown Security (easily one of my favorite homeland security blogs these days) posted on a news report regarding a RAND report that came out last week, and the subject matter was something near and dear to my heart, so I had to take the matter into my own hands.
I’d also like to take a moment to introduce a new effort here, and it has to do with that little icon to the left. Blogging on Peer-Reviewed Research is something that I’ve seen popping up on some of my other favorite blogs, and because I’m dealing with a peer-reviewed article for this post, I thought it would be a great time to introduce you all to the concept. I’m a big fan of this effort because of my ongoing stance on open access and scholarly journals. I think that everyone should have access to this information, and keeping it locked up behind some truly ridiculous ($30 per article!?) pay wall harms us all ultimately. I could spend all day giving you articles – liberating them as it were; or I could blog on them, giving you, my readers, an idea into what’s happening in the ivory tower. So, I’m a huge supporter of the BPR effort, and will do my best to live up to their guidelines. Now, onto the good stuff.
To be published in the February edition of the American Journal of Public Health (whose parent association, the APHA, I’m finally a member of), Dausey et al, of the RAND Corporation give us a report on the status of telephone-based disease surveillance systems. These systems should adhere to CDC guidelines and have been given the goal of connecting a doctor or nurse with a local public health agencies “action agent.” This is the person whose job it is at the health agency to receive calls on so-called reportable diseases and conditions – things like hepatitis, tuberculosis and salmonellosis as well as more exotic things like anthrax exposure or smallpox and then act on them. Once this call is received, the health agency can begin contact tracing, community notification, disease investigation, or again, in more exotic cases, something more draconian.
Two of the CDC’s standards that were tested in this study, but focuses on connecting the caller with an action agent in a reasonable amount of time. The CDC standards call for this connection to be made in 30 minutes or less. By and large, this was the focus of the study, and will be the focus of this post.
Dausey, et al built a random sample of health departments across the country by pulling from a frame that divided the country into four census “regions” and four population-size categories (except for exceptionally small departments). 25 were selected from each population category in order to note differences between the largest and smallest. Ultimately, 74 health departments were contacted.
The study (basically) went as follows:
…[A] trained test caller contacted participating health departments asserting that he or she was a doctor or nurse at a local health care facility calling with an urgent case report regarding an infectious disease.
The results were eye-opening, to say the least.
The average time it took to connect to an action officer was 63 minutes (range = 0 – 1,003). While this seems like a terribly long time (and it is) this average time was extremely skewed by insanely long times. The authors note that the mean of the median connection times (Read: the average of the middle length wait from each health department. For example, here are the connection lengths of five calls to the City of Samplia, 1 minute, five minutes, ten minutes, 90 minutes, 1,000 minutes – ten minutes is the median, so averaging the medians takes out the “oops, we forgot to connect you,” and the “hey, you got the action officer on the first call”) was only eight minutes. The more critical of you will note that it only takes one time to forget to connect for something catastrophic to happen, but a good guess of the call wait is still pretty short.
Unfortunately, crappy reporting got John when he said:
If two-thirds did not call back within 30 minutes, and almost 40 percent didn’t call back at all, that’s basically 100 percent that didn’t meet the CDC recommendations, isn’t it?
The authors found found that nearly40% of health departments failed to connect to a public health official on one or more of up to ten calls placed to the health agency. A better way to put it is that over 91% of all calls eventually made it to an action agent. Not perfect, but certainly much better than 40% not connecting at all.
Also, it’s not exactly true that more than two-thirds of health departments did not connect within thirty-minutes or less. In fact, more than two-thirds of health departments did not connect all of the calls received within the recommended thirty minutes. Of all of the calls that were made, nearly 78% per connected with a public health official in 30 minutes or less. Once again, far from perfect, but still much better than the media would have us believe.
I think that the authors put it best when they said:
This finding confirms that consistent and timely responses are achievable by health departments; the large percentage of departments that were not yet able to meet this standards shows that substantial progress is needed to fully achieve this goal.
In the author’s conclusion section, they note that there is some disagreement over the CDC standards, namely that the CDC recommends a single dedicated all-hours telephone line for reporting diseases, yet this study found that not to be significant toward improving response. The CDC has also vacillated on the length of time that would be acceptable to be connected with an action officer between 15 and 30 minutes. Some health departments maintain that either length of time is unrealistic and that even 60 minutes is tough to do.
While I understand the need for prompt response, I wonder how much more can be done if an action officer is presented in 30 minutes as opposed to 60 minutes? A call at three in the morning, even if an action agent is reached within thirty minutes, won’t cause the entire public health department, including labs, to jump out of bed.
I’d like to close with a big thank you to John Bowen for the heads up, and pass along this really great comment from the authors:
The field of public health is moving toward performance measurement, accountability, and quality improvement. The study provides an example of objective performance measurement and suggests methods of quality improvement.
I couldn’t agree more.
Photo credit: seychelles88