@article{Sell_2017, title={In Denial: Symptom Negation in New York City Emergency Department Chief Complaints}, volume={9}, url={https://ojphi.org/ojs/index.php/ojphi/article/view/7649}, DOI={10.5210/ojphi.v9i1.7649}, abstractNote={<div style="left: 82px; top: 292.246px; font-size: 12.9074px; font-family: sans-serif; transform: scaleX(1.08211);" data-canvas-width="58.10914814814815">Objective</div><div style="left: 95.6667px; top: 305.868px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.06066);" data-canvas-width="348.7968703703704">To describe the effect of symptom negation in emergency</div><div style="left: 82px; top: 321.054px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.989243);" data-canvas-width="358.12247222222203">department (ED) chief complaint data received by the New York City</div><div style="left: 82px; top: 336.239px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.989714);" data-canvas-width="358.1444148148148">(NYC) Department of Health and Mental Hygiene (DOHMH), and to</div><div style="left: 82px; top: 351.424px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.02298);" data-canvas-width="359.37190925925927">devise a solution to avoid syndrome and symptom misclassification</div><div style="left: 82px; top: 366.609px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.968142);" data-canvas-width="359.890787037037">for commonly used negations using SAS Perl Regular Expression</div><div style="left: 82px; top: 381.794px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00185);" data-canvas-width="88.19631481481481">(PRX) functions.</div><div style="left: 82px; top: 410.691px; font-size: 12.9074px; font-family: sans-serif; transform: scaleX(1.11815);" data-canvas-width="75.28890740740741">Introduction</div><div style="left: 95.6667px; top: 424.313px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.946508);" data-canvas-width="346.1379444444445">In July 2016, 77% of ED data was transmitted daily via Health</div><div style="left: 82px; top: 439.498px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.01573);" data-canvas-width="361.22670370370355">Level 7 (HL7) messages, compared to only 27% in July 2015</div><div style="left: 82px; top: 454.683px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.01539);" data-canvas-width="359.0750388888889">(Figure). During this same period, chief complaint (CC) word count</div><div style="left: 82px; top: 469.868px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.960142);" data-canvas-width="359.9733944444444">has increased from an average of 3.8 words to 6.0 words, with a</div><div style="left: 82px; top: 485.054px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.0431);" data-canvas-width="359.53970555555526">twenty-fold increase in the appearance of the word “denies” in the</div><div style="left: 82px; top: 500.239px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.01801);" data-canvas-width="359.22347407407403">chief complaint (Figure). While HL7 messages provide robust chief</div><div style="left: 82px; top: 515.424px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.982373);" data-canvas-width="360.5800425925926">complaint data, this may also introduce errors that could lead to</div><div style="left: 82px; top: 530.609px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00464);" data-canvas-width="217.27038888888896">symptom and syndrome misclassification.</div><div style="left: 82px; top: 559.505px; font-size: 12.9074px; font-family: sans-serif; transform: scaleX(1.07341);" data-canvas-width="53.062351851851844">Methods</div><div style="left: 95.6667px; top: 573.128px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.04535);" data-canvas-width="346.0114518518517">Using SAS 9.4 and Tableau 9.3, we examined data submissions</div><div style="left: 82px; top: 588.313px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.957113);" data-canvas-width="359.8585185185185">from 14 EDs responsible for 97% of the occurrences of the word</div><div style="left: 82px; top: 603.498px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00131);" data-canvas-width="214.0306296296296">‘denies’ in chief complaints in July 2016.</div><div style="left: 95.6667px; top: 618.683px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.977413);" data-canvas-width="344.47288888888886">To account for variation in chief complaint format among hospitals,</div><div style="left: 82px; top: 633.868px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.96121);" data-canvas-width="360.101177777778">we developed three PRX patterns to identify entire phrases in the</div><div style="left: 82px; top: 649.054px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.02904);" data-canvas-width="359.20282222222227">chief complaint data field that began with conjugations of the word</div><div style="left: 82px; top: 664.239px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.990672);" data-canvas-width="360.43935185185177">“deny” followed by various combinations of words, punctuation,</div><div style="left: 82px; top: 679.424px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00181);" data-canvas-width="131.88788888888894">spaces, and/or characters.</div><div style="left: 95.6667px; top: 694.609px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.116);" data-canvas-width="342.0721111111109">Pattern 1: ’/DEN(Y|I(ES|ED|NG))(\s|\w|(\/)|(\+)|,|(\\)){1,}</div><div style="left: 82px; top: 709.794px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00328);" data-canvas-width="116.1795740740741">((\.)|(\|)|($)|(;)|(\))|(-))/’</div><div style="left: 95.6667px; top: 724.979px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.11465);" data-canvas-width="342.4206111111111">Pattern 2: ’/DEN(Y|I(ES|ED|NG))(\s|\w|(\/)|(\+)|(\\)){1,}</div><div style="left: 82px; top: 740.165px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00327);" data-canvas-width="132.1976666666667">((\.)|(\|)|($)|(;)|(\))|(-)|(,))/’;</div><div style="left: 95.6667px; top: 755.35px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00197);" data-canvas-width="186.8347222222222">Pattern 3: ’/DENIES:( |\w|\.|,){1,}/’);</div><div style="left: 95.6667px; top: 770.535px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.01169);" data-canvas-width="345.15569074074057">We separated the ‘denies’ statement from the chief complaint and</div><div style="left: 82px; top: 785.72px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00708);" data-canvas-width="358.53550925925924">identified commonly negated symptoms. We then defined symptoms</div><div style="left: 82px; top: 800.905px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.999525);" data-canvas-width="360.7620370370374">using keyword searches of the chief complaint and the ‘denies’</div><div style="left: 82px; top: 816.091px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.976838);" data-canvas-width="359.6390925925926">statement. We compared symptom classification with and without</div><div style="left: 82px; top: 831.276px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00128);" data-canvas-width="204.7114814814815">the consideration of symptom negation.</div><div style="left: 82px; top: 860.172px; font-size: 12.9074px; font-family: sans-serif; transform: scaleX(1.08548);" data-canvas-width="46.62155555555556">Results</div><div style="left: 95.6667px; top: 873.794px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.931907);" data-canvas-width="345.81525925925916">Of the 14 EDs analyzed, we applied pattern 1 to 8 of the ED’s,</div><div style="left: 82px; top: 888.979px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.946031);" data-canvas-width="359.94887037037034">pattern 2 to 5 EDs, and patterns 2 and 3 to 1 ED. Approximately</div><div style="left: 82px; top: 904.165px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.987828);" data-canvas-width="358.21927777777756">98% of denies statements were extracted from chief complaints. Only</div><div style="left: 82px; top: 919.35px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.02897);" data-canvas-width="359.26477777777797">2% of symptom negation was not captured due to uncommon chief</div><div style="left: 82px; top: 934.535px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.954964);" data-canvas-width="359.6236037037035">complaint format whose symptom negation didn’t meet one of the</div><div style="left: 82px; top: 949.72px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00137);" data-canvas-width="182.83342592592592">previously described PRX patterns.</div><div style="left: 95.6667px; top: 964.905px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.975219);" data-canvas-width="346.44643148148134">The most common words associated with a “denies” statement</div><div style="left: 82px; top: 980.091px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.987796);" data-canvas-width="360.2328333333336">were: pain, chest, fever, loc, shortness, breath, vomiting, nausea,</div><div style="left: 82px; top: 995.276px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00242);" data-canvas-width="358.39998148148146">travel, headache, recent, trauma, history, abdominal, injury, diarrhea,</div><div style="left: 82px; top: 1010.46px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.01407);" data-canvas-width="358.9459648148147">SOB (shortness of breath), V (vomit), Head, N (nausea), PMH (past</div><div style="left: 82px; top: 1025.65px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00188);" data-canvas-width="358.57294074074076">medical history), suicidal, dizziness, homicidal and D (diarrhea) (see</div><div style="left: 82px; top: 1040.83px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.02732);" data-canvas-width="36.91518518518519">Table).</div><div style="left: 95.6667px; top: 1056.02px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00794);" data-canvas-width="345.10147962962964">By not taking negation into consideration in symptom definitions,</div><div style="left: 82px; top: 1071.2px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00054);" data-canvas-width="360.84593518518506">between 3.5% and 16.5% of symptom visits were misclassified.</div><div style="left: 82px; top: 1086.39px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.02345);" data-canvas-width="359.4880759259258">Symptom misclassification varied greatly by hospital, ranging from</div><div style="left: 82px; top: 1101.57px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00089);" data-canvas-width="60.587370370370365">0% to 55%.</div><div style="left: 464.667px; top: 292.246px; font-size: 12.9074px; font-family: sans-serif; transform: scaleX(1.10391);" data-canvas-width="77.45735185185185">Conclusions</div><div style="left: 478.333px; top: 305.868px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.04535);" data-canvas-width="348.6058407407405">As hospitals in NYC implement HL7 messaging, symptom</div><div style="left: 464.667px; top: 321.054px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.01743);" data-canvas-width="359.21960185185173">negation is becoming increasingly common in chief complaint data.</div><div style="left: 464.667px; top: 336.239px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.01718);" data-canvas-width="359.0634222222223">Current symptom definitions are based on keyword searches that do</div><div style="left: 464.667px; top: 351.424px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.971591);" data-canvas-width="360.21734444444445">not take into account symptom negations. This leads to symptom</div><div style="left: 464.667px; top: 366.609px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.01941);" data-canvas-width="359.1395759259259">misclassification, and could potentially cause false signals or inflate</div><div style="left: 464.667px; top: 381.794px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.997125);" data-canvas-width="358.39998148148135">syndrome baselines, causing true signals to go undetected. SAS PRX</div><div style="left: 464.667px; top: 396.98px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00577);" data-canvas-width="358.6749092592592">functions can be used to flexibly identify symptom negation patterns</div><div style="left: 464.667px; top: 412.165px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.985615);" data-canvas-width="360.37352407407434">and exclude them from syndrome definitions. Future studies will</div><div style="left: 464.667px; top: 427.35px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00551);" data-canvas-width="358.6839444444443">quantify the effect symptom negation has had on signal frequency in</div><div style="left: 464.667px; top: 442.535px; font-size: 12.9074px; font-family: serif; transform: scaleX(0.979063);" data-canvas-width="357.8965925925925">NYC, and examine symptoms associated with other forms of negation</div><div style="left: 464.667px; top: 457.72px; font-size: 12.9074px; font-family: serif; transform: scaleX(1.00165);" data-canvas-width="304.3179444444443">such as “Personal Medical History”, “No” and “Negative.”</div><div style="left: 464.667px; top: 483.37px; font-size: 11.3889px; font-family: serif; transform: scaleX(0.982272);" data-canvas-width="355.2877777777777">Most Common Symptoms Denied in Emergency Department Chief Complaints</div>}, number={1}, journal={Online Journal of Public Health Informatics}, author={Sell, Jessica}, year={2017}, month={May} }