saint HCM530 all case study except module 7

Case study 2

Needs Assessment for Stroke Services in Ontario, Canada
The Queen’s Health Policy Research Unit (QHPRU) estimated the need for stroke services in Ontario,
Canada using measures of prevalence and incidence of (1) modifiable and nonmodifiable risk factors for
stroke; (2) acute cases of stroke; (3) major sequelae of stroke (Hunter D , 2000 and Hunter D, 2004).
They identified the effective health services that are targeted at each of these three dimensions, and
linked these steps to estimate need for health services. They compared the estimate of need for health
services to compiled measures of levels of stroke-related health services in Eastern Ontario to see if
there was a gap (unmet need) or surplus (overmet need) of these services. The numbers below have
been changed slightly from the original source. (Textbook Case Study 4.3)
Download Case Reports:
http://mcgill.academia.edu/LorieKloda/Papers/78206/Creation_and_pilot_testing_of_StrokEngine_A
_stroke_rehabilitation_intervention_website_for_clinicians_and_families

Case Questions: Answer the case questions, with research from your book, CDC, NIH and other quality
sources to determine answers and solutions. You are to write a 2-3 page paper in APA formatting that
addresses the following questions. Note: A minimum of two references should be used, which should
include your textbook and the CDC, and others that support your responses in your paper. This is a
paper, so your answer should not be numbered, but rather it should use titles and subtitles.
1. Risk factors for stroke include heavy alcohol consumption, atrial fibrillation, diabetes,
hypercholesterolemia, hypertension, obesity, low physical activity, smoking, ischemic heart
disease, transient ischemic attack. Where might QHPRU get estimates of the incidence of these
conditions?
2. For each risk factor, or stroke sequelae, QHPRU listed the kind of intervention that would be
effective, and the proportion of people for whom this intervention would be appropriate.
According to Table 4.3, which three interventions are appropriate for hypercholesterolemia, and
for what proportion of high-risk individuals?
3. The following types of interventions were recommended for acute stroke services: (a) surgical
intervention (carotid endarterectomy); (b) thrombolytic therapy; (c) imaging of the brain, either
computed tomography (CT) or magnetic resonance imaging (MRI); (d) non-invasive imaging of
the vessels (ultrasonography or magnetic resonance angiography); (e) invasive imaging of the
vessels (cerebral angiography); (f) rehabilitation therapy. For what percent of at-risk individuals
are these services recommended?
4. Estimates of people in Eastern Ontario with hypercholesterolemia are as follows: aged 25-44:
30,000 men and 13,000 women; aged 45-64: 33,000 men and 42,500 women; aged 65 and above: 17,000 men and 42,000 women. How many residents in Ontario will need fasting
lipoprotein analysis and dietary and pharmacologic interventions for hypercholesterolemia?
5. It is estimated that Eastern Ontario provides dietary and pharmacologic intervention for
hypercholesterolemia to 66,000 and 15,500 patients respectively. What is the level of unmet
need in terms of the number of patients not receiving each of these two recommended
interventions? What percent of need is not currently being met in Eastern Ontario?
6. The incidence of acute stroke cases was estimated at 3,500 cases, 100 of whom died before
reaching the hospital. The prevalence of chronic stroke cases was estimated to be 4,300. Use
Table 4.4 to estimate the number acute and chronic stroke cases needing core stroke services,
and services for chronic stroke and disability.
7. It is estimated that Eastern Ontario provides thrombolytic therapy and carotid endarterectomy
to 50 and 200 patients respectively. CT and MRI brain imaging is provided to 1,000 and 150
patients respectively. Non-invasive and invasive imaging of the vessels is provided to 425 and
170 patients respectively. Rehabilitation is provided to 1,400 acute stroke survivors, and
homecare services are provided to 1,400 chronic stroke with disability patients. What is the level
of unmet need in terms of the number of patients not receiving each of recommended services
for acute or chronic stroke victims? What percent of need is not currently being met in Eastern
Ontario?

HCM530
Case Study 3

Age and Gender Adjustment in Two Managed Care Organizations
The purpose of standardization is to make two or more populations “similar” along dimensions in which
they differ. Earlier, we demonstrated two methods of age-adjustment. For example, we know that
Florida has proportionately more older folks, and older folks die at higher rates than younger folks. In
order to compare the mortality rate of Florida to Alaska, we needed to control for this disparity by
adjusting for differences in the age mix of the two states. Conceptually, we can adjust for more than one
dimension, e.g., age and gender, if we want to compare two or more populations, know that the age
and gender mix will be different in those two populations, and also know that some disease-specific
mortality rates depend on both age and gender. Such is the case with cardiovascular disease in two large
MCOs, Bluegrass East (BGE) and Bluegrass West (BGW), the former with 100,000 members, and the
latter with 120,000 members. Suppose we want to compare the cardiovascular mortality rate of BGE
and BGW. Suppose that BGE has a higher proportion of older folks, and a higher proportion of women,
than BGW. Assume that the crude disease-specific mortality rate for cardiovascular disease is 290 (per
100,000) in BGE and 160 (per 100,000) in BGW. (Textbook Case Study 6.2)
Case Questions: Answer the case questions, with research from your book, CDC, NIH and other quality
sources to determine answers and solutions. You are to write a 2-3 page paper in APA formatting that
addresses the following questions. Note: A minimum of two references should be used, which should
include your textbook and the CDC, and others that support your responses in your paper. This is a
paper, so your answer should not be numbered, but rather it should use titles and subtitles.
1. From these statistics alone, which MCO has the higher cardiovascular mortality rate?
2. The member mix in BGE and BGW is quite different. In BGW, 90% of the population is less than
55 years old compared to 77% in BGE. Refer to Table 6.7 to guide the calculation of age-adjusted
cardiovascular mortality rates using the direct age-adjustment technique and the U.S.
population as the standard. With age-adjusted rates, which MCO has the higher mortality rate?
3. Now assume that 60% of the members in BGW are men compared to 40% in BGE. Men have
higher cardiovascular mortality rates than women. Refer to Table 6.8 to calculate age and
Gender adjusted cardiovascular mortality rates. With age- and gender-adjusted rates, which
MCO has the higher cardiovascular mortality rate?

HCM530

Case Study 4

Risk Adjustment with Multivariate Techniques (New York)

The state of New York (http://www.health.state.ny.us/nysdoh/consumer/heart/1996-98cabg.pdf) has

reported risk adjusted mortality statistics for coronary artery bypass graft surgery (CABG) for a number

of years, as discussed earlier in the text. New York uses the second major approach to risk adjustment, a

multivariate model. Such models control for different kinds of patient characteristics that are likely to

influence mortality. Table 4.1 reports the multivariate model used to calculate this risk-adjusted

measure. (Textbook Case Study 6.4)

Table 4.1: Multivariable risk factor equation for CABG hospital deaths in New York State in 1998.

Logistic Regression

Patient Risk Factor Prevalence (%) Coefficient P-Value Odds Ratio

Demographics

Age …. 0.0671 <0.0001 1.069

Female Gender 28.92 0.5105 <0.0001 1.666

Hemodynamic State

Unstable 1.32 1.0423 <0.0001 2.836

Shock 0.45 1.8458 <0.0001 6.333

Comorbidities

Diabetes 30.91 0.3607 0.0010 1.434

Malignant Ventricular Arrhythmia 2.228 0.9759 <0.0001 2.654

COPD 15.97 0.5012 <0.0001 1.651

Renal Failure (no dialysis),

Creatinine > 2.5 1.89 0.9213 <0.0001 2.513

Renal Failure requiring Dialysis 1.89 0.9213 <0.0001 5.688

Hepatic Failure 0.10 3.0535 <0.0001 21.190

Severity of Atherosclerotic Process

Aortoiliac Disease 5.42 0.5481 0.0006 1.730

Stroke 7.01 0.4775 0.0016 1.621

Ventricular Function

Ejection Fraction <20 1.77 1.4235 <0.0001 4.151

Ejection Fraction 20-29 7.40 0.8183 <0.0001 2.267

Ejection Fraction 30-39 14.49 0.6186 <0.0001 1.856

Previous Open Heart Operations 5.98 0.6800 <0.0001 1.974

Intercept = -9.4988

C Statistic = 0.793

Case Questions: Answer the case questions, with research from your book, CDC, NIH and other quality sources to determine answers and solutions. You are to write a 2-3 page paper in APA formatting that addresses the following questions. Note: A minimum of two references should be used, which should include your textbook and the CDC, and others that support your responses in your paper. This is a mpaper, so your answer should not be numbered, but rather it should use titles and subtitles.

1. Which factors are supposedly related to CABG morality?

2. Which factors are the most strongly related to CABG mortality?

3. How could one derive an expected mortality rate from the multivariate model?