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McBurney SH, Kwong JC, Brown KA, Rudzicz F, Chen B, Candido E, Crowcroft NS. Validating pertussis data measures using electronic medical record data in Ontario, Canada 1986-2016. Vaccine X 2023; 15:100408. [PMID: 38161988 PMCID: PMC10755117 DOI: 10.1016/j.jvacx.2023.100408] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/14/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024] Open
Abstract
Background Pertussis is a reportable disease in many countries, but ascertainment bias has limited data accuracy. This study aims to validate pertussis data measures using a reference standard that incorporates different suspected case severities, allowing for the impact of case severity on accuracy and detection to be explored. Methods We evaluated 25 pertussis detection algorithms in a primary care electronic medical record database between January 1, 1986 and December 30, 2016. We estimated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We used sensitivity analyses to explore areas of uncertainty and evaluated reasons for lack of detection. Results The algorithm including all data measures achieved the highest sensitivity at 20.6%. Sensitivity increased to 100% after reclassifying symptom-only cases as non-cases, but the PPV remained low. Age at first episode was significantly associated with detection in half of the tested scenarios, and false negatives often had some history of immunization. Conclusions Sensitivity improved by reclassifying symptom-only cases but remained low unless multiple data sources were used. Results demonstrate a trade-off between PPV and sensitivity. EMRs can enhance detection through patient history and clinical note data. It is essential to improve case identification of older individuals with vaccination history to reduce ascertainment bias.
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Affiliation(s)
- Shilo H. McBurney
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S121-2, Providence, RI 02912, United States of America
| | - Jeffrey C. Kwong
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada
- Public Health Ontario, 661 University Avenue, Suite 1701, Toronto, ON M5G 1M1, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 King’s College Circle, 6th Floor, Toronto, ON M5S 1A8, Canada
- ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON M5G 1V7, Canada
| | - Kevin A. Brown
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada
- Public Health Ontario, 661 University Avenue, Suite 1701, Toronto, ON M5G 1M1, Canada
- ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, 40 St. George Street, Room 4283, Toronto, ON M5S 2E4, Canada
- Faculty of Computer Science, Dalhousie University, Halifax, Nova Scotia, Canada
- Vector Institute for Artificial Intelligence, 661 University Ave Suite 710, Toronto, ON M5G 1M1, Canada
| | - Branson Chen
- ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Elisa Candido
- ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Natasha S. Crowcroft
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada
- Immunization, Vaccines and Biologicals, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
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McBurney SH, Kwong JC, Brown KA, Rudzicz F, Chen B, Candido E, Crowcroft NS. Developing a reference standard for pertussis by applying a stratified sampling strategy to electronic medical record data. Ann Epidemiol 2023; 77:53-60. [PMID: 36372292 DOI: 10.1016/j.annepidem.2022.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 10/13/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE Pertussis surveillance remains essential in Canada, but ascertainment bias limits the accuracy of surveillance data. Introducing other sources to improve detection has highlighted the importance of validation. However, challenges arise due to low prevalence, and oversampling suspected cases can introduce partial verification bias. The aim of this study was to build a reference standard for pertussis validation studies that provides adequate analytic precision and minimizes bias. METHODS We used a stratified strategy to sample the reference standard from a primary care electronic medical record cohort. We incorporated abstractor notes into definite, possible, ruled-out, and no mention of pertussis classifications which were based on surveillance case definitions. RESULTS We abstracted eight hundred records from the cohort of 404,922. There were 208 (26%) definite and 261 (32.6%) possible prevalent pertussis cases. Classifications demonstrated a wide variety of case severities. Abstraction reliability was moderate to substantial based on Cohen's kappa and raw percent agreement. CONCLUSIONS When conducting validation studies for pertussis and other low prevalence diseases, this stratified sampling strategy can be used to develop a reference standard using limited resources. This approach mitigates verification and spectrum bias while providing sufficient precision and incorporating a range of case severities.
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Affiliation(s)
- Shilo H McBurney
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Jeffrey C Kwong
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Public Health Ontario, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Kevin A Brown
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Public Health Ontario, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, Toronto, ON, Canada; International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Vector Institute for Artificial Intelligence, Toronto, ON, Canada
| | | | | | - Natasha S Crowcroft
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
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Cadieux G, Campbell J, Dendukuri N. Systematic review of the accuracy of antibody tests used to screen asymptomatic adults for hepatitis C infection. CMAJ Open 2016; 4:E737-E745. [PMID: 28018889 PMCID: PMC5173481 DOI: 10.9778/cmajo.20160084] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Several expert groups, including the United States Preventive Services Task Force and the Canadian Task Force on Preventive Health Care, have recently examined or are currently examining whether primary care physicians should screen asymptomatic adults for hepatitis C virus (HCV) infection. To inform decision-making on HCV screening, we performed a systematic review of the accuracy of antibody tests compared with other immunoassays and RNA detection for screening asymptomatic adults for HCV infection in Canada. METHODS MEDLINE and Embase databases were searched from 1990 to 2016; resulting citations were uploaded into DistillerSR and independently screened by 2 reviewers. Original research studies, systematic reviews and meta-analyses were eligible for inclusion. At least 80% of the study population had to be asymptomatic, nonpregnant, treatment-naïve adults with unknown liver enzyme values and unknown HCV status. Risk of bias was assessed with the use of the Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2) tool; the quality of the body of evidence was assessed by means of GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. RESULTS Of 1537 articles identified, 81 underwent full-text review, and 9 studies met the inclusion criteria. Compared with RNA detection, the sensitivity of the third-generation enzyme-linked immunosorbent assay was variable (61.0%-81.8%), and its specificity was high (97.5%-99.7%). As expected, there were more false-positive results when comparing antibody tests to RNA detection than to other immunoassays. Our GRADE assessment suggested that there was a high concern for risk of bias, particularly verification bias, and substantial inconsistency between studies in terms of their design. INTERPRETATION More research is needed to better characterize the accuracy of antibody tests used to screen for HCV infection in the general population. Jurisdictions that recently adopted birth cohort screening for HCV infection are encouraged to evaluate and report on the accuracy of HCV screening tests and screening benefits and harms. PROSPERO registration: no. CRD42016039710.
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Affiliation(s)
- Geneviève Cadieux
- Dalla Lana School of Public Health (Cadieux, Campbell), University of Toronto, Toronto, Ont.; Department of Epidemiology, Biostatistics and Occupational Health (Dendukuri), McGill University, Montréal, Que
| | - Jennifer Campbell
- Dalla Lana School of Public Health (Cadieux, Campbell), University of Toronto, Toronto, Ont.; Department of Epidemiology, Biostatistics and Occupational Health (Dendukuri), McGill University, Montréal, Que
| | - Nandini Dendukuri
- Dalla Lana School of Public Health (Cadieux, Campbell), University of Toronto, Toronto, Ont.; Department of Epidemiology, Biostatistics and Occupational Health (Dendukuri), McGill University, Montréal, Que
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