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Developing a reference standard for pertussis by applying a stratified sampling strategy to electronic medical record data


Objective — 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.

Study Design and Setting — 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 (26.0%) 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.

Conclusion — 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.



McBurney SH, Kwong JC, Brown KA, Rudzicz F, Chen B, Candido E, Crowcroft NS. Ann Epidemiol. 2023; 77:53-60. Epub 2022 Nov 11.

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