摘要：Objectives. We tested telephone-based disease surveillance systems in local health departments to identify system characteristics associated with consistent and timely responses to urgent case reports. Methods. We identified a stratified random sample of 74 health departments and conducted a series of unannounced tests of their telephone-based surveillance systems. We used regression analyses to identify system characteristics that predicted fast connection with an action officer (an appropriate public health professional). Results. Optimal performance in consistently connecting callers with an action officer in 30 minutes or less was achieved by 31% of participating health departments. Reaching a live person upon dialing, regardless of who that person was, was the strongest predictor of optimal performance both in being connected with an action officer and in consistency of connection times. Conclusions. Health departments can achieve optimal performance in consistently connecting a caller with an action officer in 30 minutes or less and may improve performance by using a telephone-based disease surveillance system in which the phone is answered by a live person at all times. Performance measurement and improvement in US health departments has received increased attention in recent years. Several factors, including the development of the National Public Health Performance Standards, 1 increased interest in the accreditation of health departments, 2 and the need to measure and report to Congress and the public on progress made in public health preparedness have contributed to this attention. 3 The goal of Congress and others is to augment the level of accountability in the public health system while supporting a process for quality improvement. 4 Disease surveillance is a high priority in public health practice, which often lacks adequate performance measurement and improvement strategies. 5 Assessing information about threats to public health, including those caused by infectious disease, and ensuring that adequate services are provided to meet these threats are core functions of health departments. 6 The telephone-based disease surveillance (TBDS) systems that local health departments have in place to receive case reports from the field are among the first lines of defense in identifying these threats. For more than 20 years, the Centers for Disease Control and Prevention (CDC) has provided health departments with guidelines to evaluate the performance of their TBDS systems. 7 , 8 In 2003, the CDC expanded its guidelines and developed performance standards to evaluate the ability of health departments to receive urgent case reports 24 hours a day, 7 days a week 9 . These standards, although not binding performance obligations, emphasized the need for TBDS systems to consistently receive urgent case reports in a timely manner. The CDC encouraged health departments to regularly test their TBDS systems to assess their compliance with these standards because of concerns regarding the reliability of self-assessments not based on test results. The standards, however, were not, accompanied by guidance on how health departments should measure their performance, and it was unclear at the time whether the goals were achievable. To address this gap, Dausey et al. developed a method to assess whether local health departments could meet these standards and pilot-tested it in a convenience sample of 19 health departments. 10 The pilot tests found dramatic variations both in the response capabilities of TBDS systems and in their structure. 11 These findings suggested that there may be certain types of TBDS systems that perform better than others. In addition, these findings raised questions about whether TBDS systems could consistently achieve optimal performance as outlined by the CDC and whether quality improvement in these systems was possible. No research has described how health departments might improve their performance in receiving and responding to urgent case reports or which components of TBDS systems contribute to better performance. Literature exists on telephone response systems in other sectors that operate 24 hours a day, 7 days a week, ranging from emergency medicine to environmental hazard control. For example, literature exists on the effectiveness of the emergency response infrastructure in these areas, 12 – 15 as well as on the evaluation of emergency response in the field of emergency management. 16 , 17 Factors found to be associated with successful response in other sectors include structuring the system so that callers reach a live person, using a single telephone number instead of multiple numbers, building redundancies into the system in case of failure, requiring telephone operators to go through extensive training, and using formal protocols for call triage. We sought to identify the characteristics of TBDS systems associated with the ability of health departments to meet the CDC’s standard requiring that all urgent case reports be connected to a trained public health professional in 30 minutes or less. We tested the TBDS systems of a random sample of 74 local health departments from across the United States.
