saint HCM530 full course [ all discussions all case study midterm final except module 7 case study

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?

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.

Question 2. Question :

Managerial epidemiology is integrated through general management functions. Explain each of the management functions in terms of the managerial epidemiology, i.e., what are the:

a. Planning functions, example(s)?

b. Directing functions, example(s)?

c. Controlling functions, example(s)?

d. Organizing functions, example(s)?

e. Financing function, example(s)?

Question 3. Question :

Describe the “natural history of disease” and disease progression from its inception to its resolution.

Question 4. Question :

What are some of the many epidemiologic contributions to quality assurance in healthcare and public health?

Question 5. Question :

December 31, 2009: A 48 year old male computer technician with hypertension, smoker, sedentary lifestyle, who does not do any aerobic exercise, enjoys fast food, eating it three times per day, with a family history of coronary artery disease (CAD), and a personal history of high cholesterol has a stressful deadline at work, which requires him to travel 17 hours on a plan to go on location in Australia. Unfortunately, he suffers an acute myocardial infarction in route to location and dies. He is now part of our epidemiology population mortality statistics. Calculate the U.S. Mortality Rates, which includes our computer technician in terms of crude rate of mortality, adjusted mortality rates and cause-Specific mortality rate using the 2009 statistics.

Input Data for Calculations:

___________________

-2009 U.S. Census: 305,529,237 Total

-2009 U.S. Census: Males 148,094,000

-2009 U.S. Census: Females 153,388,000

Population by Age and Sex: 2009

Age

Both sexes

Male

Female

Number

Percent

Number

Percent

Number

Percent

.35 to 39

20,445

6.8

10,169

6.9

10,275

6.7

.40 to 44

20,877

6.9

10,322

7.0

10,556

6.9

.45 to 49

22,712

7.5

11,162

7.5

11,550

7.5

.50 to 54

21,654

7.2

10,611

7.2

11,043

7.2

.55 to 59

18,755

6.2

9,083

6.1

9,671

6.3

___________________

-2009 U.S. Deaths: 2,436,682

-2009 U.S. Male Deaths 1,217,047

-2009 U.S. Female Deaths 1,219,635

___________________

2009 Deaths By Gender/Age All races, male

All ages……………1,217,047

1-4 years………………14,872

5-14 years………………2,507

15-24 years…….………3,244

25-34 years…..………22,294

35-44 years……………29,150

45-54 years……………46,498

55-64 years…….……114,615

65-74 years…….……183,945

75-74 years…….……225,740

75-84 years…….……311,135

>=85 years…….……262,839

Not stated……………………206

2009 CVD/ Heart Attack Mortality,

Male/Age

Age (All)

186,464

35-44

55,957

45-54

115,615

55-64

276,844

65-74

677,598

Source: CDC (2009)

________________

Case Questions:

a. Calculate the Crude mortality rate for the entire U.S. in 2009.

b. Calculate a total adjusted mortality rates by gender for all men (males-only).

c. Calculate an age/sex adjusted mortality rate using the demographics of the diseased computer technician.

d. Compare b) morality rate calculated with c) mortality rate calculated. Is the adjusted mortality rate for males, age 45-54 years of age higher or lower than for all males, all ages?

e. Calculate a Cause-Specific mortality rate for deaths related to Cardiovascular Disease (Heart Attacks), using the demographics of our computer technician.

Question 6. Question :

Case Study #1: 2.1. Food poisoning outbreak at Bluegrass Hospital

An outbreak of food poisoning occurred among the 400 staff and patients at Bluegrass Hospital a few hours after eating dinner. Among the 60 people who became ill, the Symptoms were mainly nausea, vomiting and diarrhea. The infection control nurse investigated the outbreak and reported results in

Table 2.5 Below

Case1Midterm

____________________

Questions: 5 pts each

1. What is the “crude” attack rate?

2. What are the food-specific attack rates for those who consumed, and did not consume each food item?

3. How many times more likely are people who consumed specific food items to get sick compared to those who did not consume each item?

4. Which food item is the most likely cause of this “common source” outbreak?

5. What are the incubation period and most likely cause of the outbreak?

Question 7. Question :

Case Study #2: Osteoporosis Marketing Plan

You are the Director of Community Relations, reporting to the Chief Operating Officer (COO) at Allright Memorial Hospital, Anywhere, USA. You have been asked by your COO to spearhead a community council with local public health officials, who will be focused on women over 50 for the prevention of osteoporosis. Your committee’s strategic plan SWOT analyses revealed the following information.

_________

Background:

The purpose of this project is to create an intervention prevention program that minimizes osteoporosis in women over 50 and with the health risks associated with the condition for Anywhere, USA. Per the Centers for Medicare and Medicaid (CMS), abstracted from medical claims data, “an estimated 10 million Americans have osteoporosis and 34 million Americans have low bone mass, placing them at an increased risk for osteoporosis. An analysis, using the Anywhere, USA state hospital database shows a slightly higher rate of risk than the national average. The report shows that osteoporosis is responsible for more than 1.5 million fractures annually, including 300,000 hip fractures, 700,000 vertebral fractures, 250,000 wrist fractures, and more than 300,000 fractures of other sites. Osteoporosis can be prevented. Early diagnosis and treatment can reduce or prevent fractures from occurring”. (CMS 2007)

The Committee Objectives:

1. To research and identify best community partners and interventions for prevention of high risk osteoporosis residents in Anywhere, USA.

2. To use create a health promotion marketing plan for early bone density screening targeted throughout the Anywhere, USA communities.

Targets: At Risk Population for Osteoporosis

Age: Postmenopausal woman over >= 50 years of age

Race: Caucasian, Asian, African-American and Hispanic women

History: Women who have a family or personal history of fractures after age 50

Health Conditions: Women who have menopause before the age of 45 due to a medical condition or unknown cause.

Healh Behaviors: Women who have premature menopause due to anorexia, bulimia, tabacco and alcohol use, or excessive exercise.

Nutrient Deficiencies: Calcium and/or vitamin D deficiency

Lifestyle: Sedentary, inactive lifestyle

Medical Treatements: Steroid (corticosteroids), radiation and/or chemotherapy treatments

Source: NIH 2010, Chart: Meyer 2010

________________

Case Questions:

1. Using reliable primary resources do research and determine who the best community partners, and the most effective interventions for prevention promotion for high risk osteoporosis residents in Anywhere, USA. Your own hospital is one community partner, and it radiology services (bone density machines) are a resource. What other and resources within the community would be appropriate?

2. Create a health promotion marketing plan for early bone density screening targeted throughout the Anywhere, USA communities using the 4-Ps. Your marketing plan also needs a mission statement, a statement of purpose, objectives and timelines of how you will implement the program.

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