Conclusion Commed MD

1

CONCLUSION COMMUNITY MEDICINE Health

- /

- WHO : social well-being and infirmity

Health - Physical

- Mental emotional (), Intellectual (

)

- Social

> Indicator for social well-being

- Basic needs ()

- Health system () : access to health care

- Occupation

- Environment Health measures

Spiritual ()

- meaning and purpose of life

Model of health

1. Health-illness continuum

2. Clinical model

Health = no dz. or injury, not be sick

3. Role performance model

=

4. Adaptive model

5. Eudemonistic model

realization of persons potential

2

6. Agent-host-environment model ******

Disease :

Illness :

5 Stages of Illness

1.

2.

3.

4.

5. ,

Literature review

Background question What is DM? Textbook

Foreground question case 25 55

Information source

1. Textbook-like ex. PIER, UpToDate, Dynamed, EBM

2. Synopses : preappraised synthesis ? ? ex. ACP journal,

InfoPOEM, DARE Bandolier

3. Synthesis : Systematic reviews and Guidelines ex.

Cochrance Database

4. Primary study ex. Mudline, PubMed. Clinical Queries

6. Others ex. Google scholar, MEDLINE Plus, SumSearch, TRIP

= PICO/PECO

Patient/Population : Who?

Intervention/Exposure : What has been expose?

Control : Compare to whom?

Outcome : What expected to find?

3

What to look for journal

1. Background 2. Method

3. Result 4. Discussion

Hierarchy of strength of evidence

1. N-of-I random trial

2. Systematic review of randomized trial

3. Single random trial

4. Systematic review of observational studies addressing patient important outcome

5. Single observational studies addressing patient important outcome

6. Physiological studies

7. Unsystematic clinical observation

**RCT ***

Evidence that an association is cause and effect***

1. Temporality ex.

2. Strength cause effect

3. Dose-response cause effect

4. Reversibility

5. Consistency

6. Biologic plausibility

7. Specificity ex.

8. Analogy effect ex. chocolate white chocolate

1.

2. ,

3.

4

4.

5.

1.

2.

3. ()

4.

5.

6.

7.

8.

4

1. /

- / /

-

2. = +

1.

2.

3. /

4. / / /

5.

6.

7.

8. / /

3.

, , , , , ,

4.

5

: , , ,

1.

1.1

1.2 ,

1. (vital events registers)

2. (Population Housing Census)

3. (Routine Health service records)

4. (Epidemiological surveillance data)

5. (Disease registers)

6. (Sample survey)

7.

2.

2.1 2

2.2

3.

4.

- (census) =

- (sample survey) =

1. (Qualitative data)

-

-

-

2. (Quantitative data)

- (discrete) :

- (continuous) :

6

-

- ,

Health Indicators

2 ASEAN USA 2013?

What is the health indicator that has been used to indicate country development?

Ans. Under 5 years mortality rate (U5MR)

What is the health indicator that has been used by WHO, UNICEF and World Bank?

Ans. U5MR

What is the target year of Millenium Development Goals?

Ans. 1990 2015 U5MR 2/3

What is the formula of infant mortality rate (IMR)?

Ans

IMR = 1 1,000

( 1 1,000 )

What is the formula of neonatal mortality rate?

Ans. IMR 28

What is the formula of under-five mortality rate (U5MR)?

Ans.

U5MR = 5 1 1,000

What is the formula of maternal mortality rate (MMR)?

Ans.

= 1,000

6 wk

7

What is the meaning of life expectancy at birth?

=

What are the latest life expectancy at birth of Thai male and Thai female?

71 , 77 2 74

(Qualitative research)

(Naturalistic inquiry) (Holistic

perspective)

(Inducing analysis) *

*

, (), , ,

,

!!!

1. health indicator CMF 2014? >>

2. ? ?

-

-

Others

- Proportion () = A/A+B ()

- Ratio () = A/B ()

- Rate Proportion , /, / ...

- Incident () - Prevalence ()

- Morbidity = complication

- Mortality = population - Fatality =

8

:

- , (), ,

, , , !!

5

1. / (Ethnographic/Anthropological)

8

2. (Biographic research)

3. (Phenomenological research)

4. (Grounded theory research)

5. (Case study research)

Triangulation ()

1. (data triangulation)

2. (investigator triangulation)

3. (theory triangulation)

, , /

, /,

/, ,

, ()

, , ,

,

9

, //, ,

, , ,

, , ,

Others

- = indept interview sensitive, private

- discussion homogenous ~ 7 14

- fact

1. (Validity) , , , /

2. (Reliability) ,

3. (Sensitivity) true + in all disease, Rule out

4. (Specificity) true - in all normal, Rule in

5. (Efficiency)

1.

1.1 5D

Disease =

Death =

Disability =

Discomfort =

Dissatisfaction =

1.2 , ,

1.3 ,

10

1.4 ,

2.

2.1

2.2

2.3 (Public hearing)

2.4 ****

3.

3.1 (size) :

3.2 (severity) Rabies HIV

3.3 / (Ease of management)

3.4 / (Community concern)

3.5 (impact)

0

Community = ( )

1.

S specificity

P performance ()

I involvement ()

R realism ()

O observability ()

2.

3.

4.

11

Methods

Seek information : , IT, Location, Demography, Environment

Define key persons

Planning & organization

Appointment, Interview, focus group

Participation

Logistics

Health behavior

Behaviors = action that has a specific frequency, duration and purpose whether conscious or

unconscious

3 words

Actions =

Practices =

Behaviors =

1. Family genetics

2. Behaviorist learning theories**

2.1 Classical conditioning = automatic response with a neutral stimulus

comfort eating :

2.2 Operant conditioning = respond to reward or punishment

/

3. Social learning / ,

/

Related term

Life style Customs

Traditions Culture

12

Types of Health-Related Behaviors

1. Preventative Health Behaviors ,

2. Illness Behaviors , /

3. Sick-roll Behaviors /

Stages of change model**

1. Pre-contemplation HIV

2. Contemplation AIDS

3. Preparation (small change) plan condom condom

4. Action +

5. Maintenance sustaining change over time

prevention of disease**

Healthy person Early signs Disease Death

1 prevention 2 prevention 3 prevention

Vaccine Screening Treatment

//

1. Active surveillance : , ,

37 C

2. Passive surveillance : ( 506, 506/2)

24 hrs.

Index case = case Dx.

Suspected case = case

Confirm case = case

1. Timely

2. Valid & Sensitive

3. Simple

13

4. Representative

5. Magnitude

STEPS OF INVESTIGATION

1.

2.

3. :

4. : Time Place Person

5.

6.

7.

= 2 5 (incidence = ) . X normal curve

2

ILI = Influenza like illness = 38 C ,

1

=

suicide Ottawa charter (2529) 5

1. 2. 3. ( : ) 4. 5.

1. - : .. - -

14

2. (30 )

* USA PCU . PCU

* Hg, Formaldehyde NS

3. . ,

1. , , 1669

2. . ,

3. 4. 100%

-

- insulin resistance DM - scleroderma, asthma, Alzheimer

genotoxin histone (epigenetic mech. expose sen ) 1. // - - 50% 2. 3. 4.

15

1. / : heat cramp, heat stroke ( loss water and electrolyte), sunburn 2. / : (> 85dB) & high pitch 3. / : , Byssinosis ( ), Bagassosis (), Farmers lung ()

1.

2. (zoonosis) : Anthrax

3. : Actinomycetes, Aspergillosis, Penicillium

- benzene aplastic anemia, AML(acute myeloid leukemia)

- polyutethane by product

- N - Hexane : wrist and foot drop, glove and stocking sensation

- lead poisoning : anemia

- :

-other

Data : /

(discrete data), (continuous data)

(Variable) 1

/

2 (,) 2 (, , , )

1. vs.

/ /

16

2. vs.

3. vs.

/ BMI

1. Hard outcome (/) : CBC

2. Soft outcome ( ) :

1.

2. /

20 , ...km, 3d/wk

- (Nominal scale) =

- (Ordinal scale) =

?

- (Interval scale) 0 : 0 4 C, -4 0,

50 ( 0 ), IQ

(Ratio scale) 0 ,

- : 0-5,000, 5,001-10,000, 10,001-15,000 ordinal

- Ratio

17

Ex.

Nominal Ordinal Ratio

A B AB O

70 85 150 230

FBS 65 120 180 320

Hct 10 20 35 50

1.

2.

3. Hct ratio

4. = 1, = 2

1 2 +, -, ,

Qualitative research

Characteristic

1. Data words > numbers

2. Naturalistic inquire

3. Researcher as the key instrument

4. Emergent design flexibility

5. Inductive reasoning for data analysis

open question

Sampling for qualitative method

-

-

- flexible

, ..

= , snow ball :

(,)

18

a (k)

a+b

Collection methods

1. observation 2

2. interview

- in-depth interview () private

- focus group discussion

- ()

- / 6 12

- modulator

Data analysis

- Before analysis : Triangulation ( 3 )

1. Data triangulation A , 1 , 2

2. Investigator triangulation B A, C A, D A

3. Theory triangulation , ,

3

- Data analysis

- Giving meaning

- Index & Coding

- Analysis, conclusion

Report writing

- Narrative

- bias

- /

Disease frequency

1. (ratio) = a/b

2. (proportion) = a/a+b

3. (rate) =

19

Incidence () new case case

1. Cumulative incidence (Risk) = probability of diseases

= New cases occurring during periods of observation

Population at risk at the beginning of observation

proportion rule out

2. Incidence rate (Incidence density)

= New cases occurring during periods of observation

Person time at risk during of observation

death loss follow up

CI ID Denominator () /

Numerator ()

0 1 or 1% - 100% 0 1 3. Calculate Attack Rate

= # of new cases among the population during the time period x 100%

Population at risk

ex. A cohort of 75 persons (45 male, 30 female) picnic. 46 gastroenteritis 12 .

crude and sex-specific

; crude attack rate = 46/75 x 100 = 61%

female sex-specific attack rate = 12/30 x 100 = 40%

male sex-specific attack rate = 34/45 x 100 = 75.5%

Prevalence () case

.

Prevalence = cross sectional studies

Limitation = onset ? case

Factor : bias studying old case

20

Prevalence = Incident Duration

= prevalence studies

Case control = cohort =

1. Cohort = dz. free !! ()

- share common characteristic dz. free expose (E) & non-expose (NE)

outcome

- IP

- subject

- outcome outcome

2

1. Prospective (concurrent) cohort study !!

- 2 group (E, NE) follow them to see who get dz.

- exposure observer dz. more valid information on

exposure

2. Retrospective (historical) cohort study

- 2 group (E, NE) find out who got the dz.

- exposure dz. observer

- quick, cheap

- appropriate to examine outcome with long latency periods

- /

21

Studied population

Exposed Non-exposed

+10 yr. dz. Not dz. dz. Not dz.

+20 yr. dz. Not dz. dz. Not dz.

Advantage

- direct estimate of risk (cumulative incidence)

- estimates if rate of disease occurrence over time (incidence rate)

- **Good for rare exposures

- outcome single exposure smoking CVD, CA, COPD

- case & effect relationships

- avoid recall bias

- avoid survival bias

Disadvantage

- need large sample size

- &

- loss to FU(follow up) bias

- bias

- rare outcome

1. relative risk (RR) expose non-expose

relative risk (RR) = Cumulative incidence in Exposed

Cumulative incidence in non exposed

Disease develop No disease

Exposed a b

Not exposed c d

RR = a/a+b

c/c+d

22

2. Rate ratio also called- incidence rate ratio (IRR) or incidence density ratio (IDR)

Disease develops Person-year at risk

Exposed a nE

Not exposed c nNE

3. incidence rate different (IRD) or incidence density different (IDD) = a/nE - c/nNE

- IRD = 0 : : expose = neutral factor

- IRD > 1 : expose risk factor

- IRD < 1 : expose protective factor

2. Case control studies ()

- case = outcome

- control = outcome

- case

case = / (), control =

Type

1. Unmatched case control study

2. Matched case control study , . .

3. Nested case control study : original cohort

FU

Dz. Non-dz.

Case Control

Compare exposure frequency

Odds = Probability that an event will happen = P

Probability that an event will not happen 1 P

IRR= a/nE

c/nNE

23

Cases Controls

Exposed a b Not exposed c d Total a + c b + d Odds ratio (OR) = a/c = ad

b/d bc

OR = 1 = same

OR > 1 = risk factor

OR < 1 = protective factor

Advantage

- rare case

- sample size < cohort

Disadvantage

- CI, ID

- recall bias case expose

- selection bias control

- rare exposure ( )

3. Cross sectional studies

-

- / ex. ED depression

Disease Non Disease

Exposed a b

Not exposed c d

Prevalence ratio = a / c + b acute dz.

c / c + d

Prevalence odds ratio = a / c = ad chronic dz.

b / d bc

Odds of exposure among cases = a / (a+c) = a

c / (a+c) c

Odds of exposure among controls = b / (b+d) = b

d / (b+d) d

24

Limitation

- Duration of disease may influence be exposure

- Lacking information on time onset

- selection bias

Statistic interfere hypothesis testing

P value hypothesis testing

- Null hypothesis =, , ex x1 =x2

- no difference

- 1 or 2 tailed test

- Alternative hypothesis >, 50)

- Shapiro Wilk test (sample size < 50)

Confident interval (Internal estimate)

- proportion

- mean

- median

- relative risk

- odds ratio

- Hazard ratio

- Correction coefficient

sig. 0.05 normal distribution

25

95% CI = 95% 95% ( large sample size)

100 BMI ~35 45%

95 5

Type I and Type II error ()

P value

null alternative ()

p value 0.05 significant reject null

p value >0.05 significant reject null

Pearson chi-square

- Qualitative vs. qualitative variable

- independent sample

- both must be nominal scale

- no zero cell

- (expected value) < 5 20% cell

Student T-test

- Qualitative vs. quantitative variable

- Null hypothesis: Mean 1 = Mean 2

-

-

= =

5%

=

=

26

- Independent sample

Pearson collection

- Quantitative vs. quantitative variable

- interval & ratio scale

- 3 dimensions

- Statistical significance p-value

- Strength correlation coefficient (cc)

( max(+1), min(-1) = strong asso./ 0 = weak asso.)

- Direction positive() or negative() cc

RR, OR, HR

Disease Non-Disease

Exposed a b

Not exposed c d

Risk ratio ( cohort) = a/a+b

c/c+d

Odds ratio (, research) = a / c

b / d

Hazard ratio() HR =IRR OR IDR

Cumulative incident = IRR or tDR

27

no yes yes no

Exposure outcome /

Research design

Observational

- Descriptive Studies

- /

- No assignment of exposure or risk factor - Intent is to observe and record.

Single event = Case Report. Several events = Case Series.

- Analytic Studies - Cross-Sectional Studies

study Prevalence = Proportion of the population with the outcome at any point in time Most useful if exposure continues right up to time that outcome is recognized. Often conducted as screening and classification preamble to prospective studies

Epidemiology of purine-rich food problems in rural KhonKaen : 1/3

Assign Exposure?

Experimental

Random allocation

5 RCT (true) Non- RCT (Quasi)

Observational

Comparison group

Analytic study

Cohort

case control

(out come exposure)

cross section

Descriptive study

yes no

28

- , , new hypothesis - Data is frequently available through current records or statistics.

- / (/) - temporary weakness

- Case-Control Studies (Retrospective) Review past histories of the subjects risk factor 2 main purpose

- descriptive : risk factor profile - analytic : associations between outcome and risk factors

: Odds ratio (OR) = Odds of case/Odds of control = ad/bc

- rare dz. - risk factor 1 outcome - efficient

- Data Quality : inadequate detail - Recall bias - Sampling bias : not representative - others : 1 outcome, *** prevalence & incident ***, Subject to confounding factors, Cannot prove contributory cause

- Cohort Studies (Prospective) !!! risk factor outcome frequency of outcome : RR (Relative Risk or Risk Ratio)

- RR > 1 = risk factor - RR = 1 = same - RR < 1 = protective factor

2 main purpose - Descriptive : incidence - Analytic : associations between risk factors and outcome

- incidence (more powerful)

29

- associating the cause with the effect (powerful) historical cohort weaknesses as the case/control - No recall bias. - many outcomes

- - - subject - patient attrition (subject )

- Patients may change their behaviors or risk factors after the initial grouping misclassification - subject to confounding - risk ( risk )

- Retrospective(Historical) Cohort Studies retrospective study subject / risk factor retro /

outcome all the events - exposure, latent period, and subsequent development of disease :

request meticulous record-keeping : bias (same retrospective)

Experimental Study

- Unique factor of RCT

1. intervention

2. Randomization of subject selective bias

3. Control group comparison : placebo or Tx.

-

- bias

- Most powerful study designed to show contributory cause

-

- most expensive : money, time, and number of patients.

- patient attrition and compliance may invalidate the results.

30

- On-treatment analysis

- Intention-to-treat analysis !!!

- problematic for ethical reasons : placebo /

- Quasi-Experimental design

- 3 intervention, random, control intervention

- design

- Study design is highly dependent on the type of analysis.

- Type of analysis is dependent on the hypothesis posed.

- The hypothesis is dependent on the intent of your research.

- Others

- case report = 1 1 .

- case study report = 1 .

- cross sectional study = prevalence study

- surveillance = incidence study

- ecological study =

Sample allocation

Random sampling = Randomized sample population

Sample allocation = Randomized sample

Population =

Target Population =

Study population = eligibility criteria

Eligibility criteria = inclusion + exclusion criteria

Sample =

Sample unit =

Sample allocation selection bias

- randomization, binding, allocation concealment

- block randomization

31

block of 4 : aabb, abab, baba

Random 1 a, 2 a, 3 b, 4 b

Allocation concealment ** bias allocation

1 1, 2 2, 3 3

Blinding blind blind

single, double, triple

** bias allocation

** concealment over 30-40%

Study Pop, sampling, sample size

General population

Inclusion criteria

Target population

Exclusion criteria ex. Target population , , ,

Study population

eg. In = , ex =

; study population = target population target

population

Probability sampling

1. Simple random ()

label

:

:

2. Stratified random ()

- ex. /, /

-

- design effect

32

3. Systemic ()

- (random start)

- 1,000 30 = 33.33 : random start

1 33.33 10 + 33.33 43.33 43 + 33.33 76.66 77

4. Cluster (/)

- subject , ,

-

- cluster effect (design effect)

Non probability sampling :

1. Convenience (accidental) /

BMI complex

2. Purposive (judgmental) : focus group

3. Quota 30 . MD =

4. Snowball (network, chain) ,

sensitive subject indept interview

sample size

representative sample

- probability sampling

- adequate sample size

- (study population)

1. ?

2.

3. sample size

1. !!!

2. BP, Cholesterol

3. : OR, HR

4. : Student T-test

33

1 (max = 1)

error research design

5. related sample before/after

- matching

- correlation

1. sample size

n =

1

2

2

2

2. sample size

n =

1

2

2 2

2

1. (single group)

2. : sample random or systemic sampling

3. infinity ()

1. Yamane table

- , , sample random

- 3

1. error = 0.05 2

2. P = 0.5

3. Z 1.96 2

Q 1 P =

P

P

P = 20 5

20 5

20 30

standard deviation

0 =

12

2

2

= 0

1+ 0

34

2. Krejcle & Morgan table

- , , sample random

- 4

1. error = 0.05 2

2. P = 0.5

3. Z2 3.8416 3.84

4. N 1 N

( small sample techniques)

sample size 1,000 non-response ~10% ( 100 90 90

100 1,000 1000/90100) 100/90 1,000 = 1,111.11 ~ 1,112

- ()

-

- P = 0.5 maximize

- sample method

- scale

- related observation

-

- non-respondents

-

HIV 2543 2544 = 12%

3% N=2000

= 95%

0 =

12

2

2

= 1.96 2 0.12 (0.88)

(0.03)2= 451

35

2.

= 0

1+ 0

= 451

1+451

2000

= 368

Applicability of literature and Patient value and Circumstance

HIV case report

Clinical research

- Validity or Internal validity bias

- Applicability or External validity

- Generalise

- Research design quantitative

- Randomization

1. interaction effect of selection biases and x (x )

..? ..

2. (Reactive or interaction effect of pretesting)

pretest & posttest pretest video VCD

3. (Reactive effect of experimental procedures) blind

//placebo

placebo / placebo

4. (Multiple-treatment interference)

Patient value, Patient circumstance

Evidence-Based Practice

1. Definition

- 3

1. clinical expertise () : specialist

36

2. Best research evidence /

3. Patient /

guideline

2. EEP Process

1. ? CA breast

2.

3. evidence

evidence

1. Systematic review

2. Randomized control trial

3. Cohort

4. Case-control

5. Case series, case report

6. Editorial, Expert opinion : specialist !!

evidence

Internal validity, external validity, reliability, size of effect (impact) = product =

1. outcome ?

2.

3. intervention

37

yes

no

yes

no

design

Sequence of Research

Choosing the research question

Developing the protocol ()

Pretest & Revising the protocol ()

Carrying out the study

Analyzing the findings

Drawing & Disseminating the conclusions

4 Major Epidemiological prototypes

Decision 1

alter the events

under study?

for observation

make measurement

on more than

one occasion?

The process

Truth in universe Trust in study Finding in study

Research question Study plan Actual study

Experimental study

intervention

RCT randomized trial of impact of

health education on exercise

Observational study

Case control study comparing the

exercise history of CVD & non CVD Pt.

Longitudinal study Cohort study exercise habit dev.

subsequently develop CVD

/ Cross sectional

1 occasion

inference inference

implement

External

validity Internal

validity

38

. 8 400 350

- internal validity : 350 400 ? ( 50

, )

- external validity : 2

#1 8 .?

#2 .?

Threats of validity

1. Subject selection bias

- Healthy subject bias :

- Neyman (Incidence/Prevalence) bias :

- Volunteer bias :

- Hawthrone effect :

2. Blinding

3. Confounding () :

4. Contamination control

5. Cointervention

6. Regression toward the mean

mean

7. Cohort effect

8. Ecological fallacy CA

CA

Measurement instrument

Reliability Accuracy/validity

- -

- power of detect effect - Validity of conclusion

- threatend by random error - Systematic error

39

Interbserver

Reliability

- test retest : 2

- intraobserver : observer 2

intraobserver

- interbserver () : 1 2

A

B

Enhancing reliability

- Standardizing the measurement method :

- Training and certifying the observer

- Refining the instruments : calibrate

- Automatic the instruments

- Repetition

Diagnostic study

Gold standard : : accepted standard /

- long time reference test compare accuracy

- expensive CT, MRI ()

- Invasive angiogram

test

Test : Dx

- accuracy - short time

- safety - cheap

Test

Cholangiocarcinoma HCC, Pancreatitis CA, Hepatitis, Cirrhosis

2 test Gold standard and test Gold

standard or new test / test 2 test

Stab

ility

40

Evaluator : Blinding the result of test and gold standard

: bias 2

Gold standard + Gold standard - Test + True positive False positive Test - False negative True negative

Sensitivity ()

Gold standard + Gold standard - Test + a b Test - c d

a + c b + d

=

=

+

** Sen. screening

-

Specificity

Gold standard + Gold standard - Test + a b Test - c d

a + c b + d

=

=

+

- Spec.

- CA, HIV

- Sen. Spec.

Receiver operating characteristic (ROC) curves Sen. Spec.

41

Cutoff point DM

Ideal test = upper left corner (100% Spec. & Sen.)

Slope = Sen./1 Spec. = LR+

Prevalence ()

Gold standard + Gold standard - Test + a b a + b Test - c d c + d

a + c b + d a + b + c + d

=

=

+

+ + +

Accuracy ( )


a + c b + d a + b + c + d

= +

=

+

+ + +

= (Sen.)(Prev.) + (Spec.)(1 Prev)

Positive predictive value (PPV)


=

+ =

+

Cutoff point = point w/ maximum

positive likelihood ratio

42

Negative predictive value (NPV)


=

+ =

+

Prev. Sen. Spec. PPV NPV

Stable properties of test

- Sen.

- Spec.

Unstable test

- PPV for rule in

- NPV for rule out

- Accuracy

- Prevalence

- Prev. PPV , NPV, Prev. PPV , NPV,

Positive likelihood ratio (LR+)


a + c b + d a + b + c + d

+ = .

. =

+

+

LR+ = (Sen.)/(1-Spec.)

population

prevalence

43

Negative likelihood ratio (LR-) ][


a + c b + d a + b + c + d

+ = .

. =

+

+

LR- = (1-Sen.)/(Spec.)

LR+ rule in disease ()

LR- rule out disease ()

Others

- Prev. = pretest prob.

- Odd = P/1-P

- Pretest odd = pretest prob./1- pretest prob.

- Posttest odd = LR Pretest odd

- Post test prob. = post test odd/1+posttest odd

- Fagan nomogram posttest prob. pretest prob. & LR+

- Agreement (Kappa)

- Applicability () : available (), affordable (), accurate precise

Outcome measurement!

*

Review : type of data

1. nominal : / ,

2. Ordinal : /

3 Interval :

-outcome data - -

-Qualitative research

44

Outcome =

1. 1 Outcome =

2. 2 Outcome = - /

3. composite Outcome = set of Outcome Outcome Outcome

4. target (ultimate) Outcome !!! surrogate

outcome

5. Surrogate (intermediate substitute) Target

Surrogate Target

- dyslipidemia - carbiovascular event

-serum transaminase - Liver toxicity

- serum creatinine - renal toxicity

-EKG - cardio toxicity

-Quality of life - Health status

- Dyslipdemia target outcome lipid ? surrogate outcome

CVD ?

Intention to treat

control control

1. compliance/ adherence to intervention Pt.

2. non-compliance

- S/E

- Misunderstanding

- Run out of prescription medications

PER-PROTOCOL analysis or explanatory

s/e control

Cross-over : Pt. pre protocol

Co - interventions ( interventions ): interventions

Blinding : Masking : Unaware

1 allocation concealment (researcher)

45

2. Unaware of Tx. ( Patient & physician & assessing outcome)

=

VDO @ . .

1.

2.

3. &

: () 13

1./

2.

3. &

4. - & 20% 100%

" "

:

AIC : Aim (beautiful community)

: Influence

: Coordination / Cooperation

- !!

- Heath economics economics

(Clinical decision analysis : CDA)

-

-

-

46

Decision tree

1. (Structure the problem) : ,

2. probability

3. (Apply value) ,

4. (Expected value)

5. (sensitivity analysis)

Provider cost =

Payer cost = . .

Pt. cost = Pt.

Society cost =

(Discount rate : DR)

- 1 1 10

- /

P = F / (1 + r)n Or F = P x (1+r)n

F = Future, P = Present value, r = DR, n =

1 10 =? DR = 10%

P = 106 / (1 + 0.1)10 = 385,543.3

2. 1 5 DR = 8%

F = 106 x (1 + 0.08)5 = 1,46932 x 106

1.efficacy () clinical trial

2. effectiveness () DX , Pt. s/e ,

3. efficiency ()

- 1 , 2

- cost & conse , 2

4 Equity ()

47

1. : cost - Identification analysis (CIA) or cost - minimization (CMA)

(Equal outcome)

- Bowel sound - prefer

-

2. - (cost effectiveness analysis : CEA)

- (Unequal outcome)

- 1

3. - (cost benefit analysis : CBA)

- (Unequal)

- Monetary unit Net benefit , Benefit cost ratio ( =

< 1 = costing = ) , Incremental analysis

- Moneytary approach

1. Human capital approach :

300 350 = 300 350

2. Willingness to pay :

4. - (cost utility A. : CUA)

- (Unequal)

- utility unit

- , QALYs (Quality Adjusted life years)

-

1. Direct : visual analogue scale (VAS) , standard gamble (SG) , Time trade-off (TTO)

2. Multi-attribute Physical, mental, social well-being: SF - 36, Health utility index (HUI),

EQ-5D

utility unit = 1 QALYS

utility unit = 0.56 - 15 = 0.56 x 15 = 8.4

utility unit = 0.67 ( 1 0.67) - 22 = 22 x 0.67 = 14.34

12000 cost / QALYs = 1428.6

18000 cost / QALYs = 1221.2 - prefer

Motility, morbidity

48

Economics Evacuation of Health care services

1. (libertarianism) ,

America

2. (Egalitarianism) : ,

1. (available)

- ?

1. (public)

2. (private-not-for-profit) ( .)

3. (Private for profit)

2. (accessible)

- ?

-

- (Geographical access)

-

3. (Acceptable)

- -

-

-

4. (Affordable)

-

- (user charge)

- 3rd party payer =

- /

-

1. (collective financing) : ,

2. (private financing)

- 10%

49

-

-

5 (efficiency)

- ?

6. (Equity)

- input / output ( )

Cost Of Health problems

1. direct cost ()

- medical : drug , x ray ,lab

-Non-medical : , food ,

2. indirect cast ( )

- Morbidity work absence , darning

- Mortality : value of life lost

3. Intangible cost ()

- Pain, Suffering, Grief

*

4

1. efficacy () : ? control situation /

2. effectiveness () ? : compliance

3. efficiency () A 100 90, B 100 80 prefer A

4. equity ()

Type of economic analysis

1. cost-identification (CIA) :

2. cost-effectiveness (CEA) : cost Case

50

3. cost-benefit (CBA) : (benefit percent ratio) vaccine

case

4.cost- utility (CUA) cost QALYs gained

(Cost) 1

- ()

- : Opportunity cost ()

Input

1. (capital cost) eg.

2. (operating cost)

2.1 labour cost eg.

2.2 Material cost eg.

Output

1. Morbidity

2. Mortality

3. life expectancy

4. Happiness, well-being

: 264 MED 39th

Documents

Conclusion Commed MD