SAINT HCM530 ALL MODULES CASE STUDY EXCEPT 7 MOULE AND DISCUSSIONS MOULE 5,6,7 AND 8

Module 5 Discussion

The cost effectiveness analysis (CEA) is one type of a benefit analysis tool used in managerial epidemiology. Others include cost-utility, cost-effectiveness, cost-consequence, and cost of illness. Since medical quality and health services have a high individual perception regarding value, different stakeholders will have different perspectives when performing and interpreting a CEA. Different decision makers, i.e., physicians, administrators, employers, payers, government and other public and private officials all have varying perspectives. Therefore, it is the common perspective that is generally most useful when making comparisons among the various interpretations of the CEA or other cost/benefit analysis results and outcomes.

1. Where does the CEA fit into public health and clinical epidemiological research, as well as, health services research?

2. What are some examples and characteristics of medical cost and effectiveness measures?

Be sure in your initial response to provide at least two examples from peer reviewed literature that further clarify or illustrate your response (write 5-6 sentence summaries for each article).

Module 6 Discussion

How research is designed is important to its validity. In research, and particularly government funded research, the Institutional Review Board is the authority on requirements for research design.

DHHS, Institutional Review Board Guidebook. Chapter 4: Considerations of Research Design
A. Introduction	F. Case-Control Studies
B. Observation	G. Prospective Studies
C. Record Reviews and Historical Studies	H. Clinical Trials
D. Surveys, Questionnaires, and Interviews	I. Identification and Recruitment of Subjects
E. Epidemiologic Studies	J. Assignment of Subjects to Experimental and Control Groups

Four common research designs used in epidemiological studies are cohort, case control, longitudinal, and cross-sectional studies. However, there are also prospective and retrospective, quantitative, qualitative and quasi (mixed) research designs. Data is what drives medical research and its design. Medical research drives scientific findings that ultimately result in improving human health. All of the various research study designs that fall into either descriptive or analytical epidemiology.

All research studies fall into either descriptive or analytical epidemiology.

1. What are those study designs and how are they defined?

2. What are the strengths and weaknesses of each of the designs you have defined?

Be sure in your initial response to provide at least two examples from peer reviewed literature that further clarify or illustrate your response (write 5-6 sentence summaries for each article).

Module 7 Discussion

In last week’s discussion, we looked at types of research designs. This week, we will look at requirements of designs using real people, i.e., the clinical trials.



Office for Human Research Protections (OHRP)

1. There are two types of clinical studies, i.e., clinical trials and observational studies. How do they differ and provide examples of each?

2. Who can participate in a clinical study and what is the process to protect them from harm?

Be sure in your initial response to provide at least two examples from peer reviewed literature that helps to support your position (write 5-6 sentence summaries for each article).

Module 8 Discussion

Disease may be classified as acute, subacute or chronic. It may be emerging or reemerging. 1. Why is it a challenge in defining diseases as either totally chronic or totally infectious (acute) in nature? 2. What are examples of emerging and reemerging diseases? Would HIV be considered an emerging or reemerging?

Be sure in your initial response to provide at least two examples from peer reviewed literature that helps to support your position (write 5-6 sentence summaries for each article).

hCM530

Case Study 1

Outbreak of Influenza in a Kentucky Nursing Home
Assume that an outbreak of Influenza A occurred among 400 residents of a New York Nursing Home
during December 2006 and January 2007, despite the vaccination of 375 of them between mid-October
and mid-November of 2006. The residents, 70% of whom were female, had a mean age of 85 years and
shared common recreational and dining areas. (Textbook Case Study 2.2)
Case Questions: Base your reply upon this influenza outbreak case, research of influenza, and proposed
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. If 75 of the residents developed influenza-like illness (ILI), what proportion of the residents
became sick?
2. Of those with ILI, 40 developed pneumonia, 25 required hospitalizations, and two died. What
proportion of those with ILI developed pneumonia? What percent of those with ILI and
pneumonia were hospitalized? What proportion of those with ILI died?
3. Of the 375 residents who were vaccinated, 60 developed ILI. Of the 25 residents who were not
vaccinated, 20 developed ILI. What percent of vaccinated residents developed ILI? What percent
of unvaccinated residents developed ILI? How many more times higher is the rate of ILI among
those who were unvaccinated compared to those who were vaccinated?
4. Of the 375 vaccinated residents, 35 developed pneumonia following ILI compared to 15
residents among the 25 who were not vaccinated. What percent of vaccinated residents
developed pneumonia following ILI? What percent of unvaccinated residents developed
pneumonia following ILI? How many more times higher is the pneumonia following ILI among
those who were unvaccinated compared to those who were vaccinated?
5. What was the vaccine efficacy for preventing LIL and pneumonia?

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?

HCM530

Case Study 5



Planning with Electron-Beam Computed Tomography (EBCT)

The use of electron-beam computed tomography (EBCT) for screening of asymptomatic high risk cardiac

population to assess for developing coronary heart disease is a new low risk alternative to the traditional

invasive heart catheterization. The cardiac CT is recommended by the American College of Cardiology

(ACC) as a secondary prevention test to screen prior to a myocardial infarction and death. Garcia (2005)

cites that 1 in 20 emergency department (ED) patients present with chest pain and 3-5% of heart attacks

have been missed by ED physicians. Another 20-40% of patients who have an invasive heart

catheterization are negative. He recommends the cardiac CT as a method to solve some of these issues;

however, continued validation is needed. The CT is not an answer for all patients, such as the obese,

where visualization is difficult, or those with irregular heart rhythms. Hospitals and clinics across the

nation are now purchasing the EBCT scanners. This case study will discuss the screening ability and

healthcare planning challenges when bringing in new technology to the healthcare market.

A recent purchase of an EBCT scanner was installed in a central U.S. clinic which serves a 300-bed

tertiary hospital. The hospital and clinic took great care in training all staff in its use and patient

preparation methods, including running a pilot on several local volunteers. Three months post pilot

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. What are the sensitivity, specificity, and predictive values of EBCT?

2. Compare Valanis’s criteria for a good screening program with the eight criteria which the

ACC/American Heart Association (AHA) panel proposed for selection of a screening procedure.

3. Provide descriptive epidemiology of this IL region to support the need to purchase a cardiac CT

4. (Health care planning) What should be done at this point to encourage use of this

screening/diagnostic test for coronary heart disease?

Compare and contrast clinical health services to public health and epidemiology in terms of a) how they are defined, b) goals, c) their target focus and d) functions.