Measurement and Finance

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Measurement and Finance

• H Edu 5100

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Quantitative perspectives

• The size and demographic characteristics of the
  population
• The direct measures of health and ill health in a
  population
• Use of services

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Census data

• Every 10 years
• Textbook numbers
• 1996 79.9 of lived in MSAs
• 1980 78
• 1960 63

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Census data

• Textbook numbers
• 1998 48.9 male (49.1 in 2000 census)
• 87.3 non-Black (87.7 in 2000 census)
• 35.2 median age (35.3 in 2000 census)
• 12.7 was 65 and over (12.4 in 2000)
• (80.2 lived in MSA from 2000 census)

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Why?

• What do these data tell us?
• Why do we need them?

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Epidemiology

• The study of how and why diseases are distributed
  in the population
• Why some get sick and some dont

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Some key words

• Study
• Distribution
• Determinants
• Health-related states
• Populations
• Control

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1/2

• 1 numerator
• 2 denominator

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Rate

• Denominator 1,000 or 10,000
• Base
• Comparisons

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Rate

• Denominator population at risk
• Numerator the events
• The population at risk has to be all of the
  people or things that the numerator could have
  happened to

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Remember

• The numerator has to have all the events youre
  measuring
• The denominator must include exactly the number
  that the numerators event could have happened to
• Rates with the same base can be compared

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Definitions

• Risk the probability of an unfavorable event.
• Risk factors factors associated with an
  increased risk of acquiring disease

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Try this

• There are more drownings in Los Angeles each year
  than in Las Vegas.
• Los Angeles must have a less adequate swimming
  instruction program.

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Los Angeles

• Whats the population at risk?
• Los Angeles has a much larger population at risk.
• Las Vegas is in the desert, reduces the
  population exposed to the risk of drowning.

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Do this on your own

• A new and puzzling disease has become epidemic in
  the Midwest. It is significant that 80 percent of
  those affected live within a mile of a railroad
  track. It is therefore obvious that railroads
  must be somehow related to the disease

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What sounds best?

• We reduced the rate from 2/1000 to 1/1000
• We reduced the rate from 20/10,000 to 10/10,000
• We reduced the rate from 2,000/2,000,000 to
  1,000/1,000,000

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Check-off list

• Establish a problem exists
• Confirm the homogeneity of the events
• Collect all the events
• Characterize the events

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Characterizing events
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Check-off list (cont)

• Look for patterns and trends
• Formulate an hypothesis
• Test the hypothesis
• Write up results

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Epidemic Curves

• Endemic whenever diseases are regularly and
  continuously present
• Epidemic the occurrence of disease that clearly
  exceeds normal expectancy.
• Pandemic epidemic that has gone international

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Pneumonia and influenza
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Respiratory Insuficiency
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Viral Hepatitis
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Malaria in Bakersfield, CA
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You figure it out
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Incidence and prevalence

• Prevalence how many people have a disease at
  any one moment.
• Incidence how many incidents of the disease are
  just starting. The new cases.

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Illness Among 20 People
Figure V-1
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20 More
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The Anteater
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Anteater

• At dinner 3,126 red and 5,210 black ants
• 3 red to 5 black ratio (not rate)
• Prevailing ratio in the area is 9 red and 10
  black.
• For every 10 black ants along Random Path, 9 red
  ants could come to dinner, but only 6 do.

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Ant Queens

• What are the odds of each ant being dinner?
• Does this mean well have to move?
• Can I handle the loss with a few more eggs and if
  so, how many more eggs?

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Ant Queens

• Both queens kept track of the next 1,000 ants to
  graduate from the nursery.
• By the end of the season, the ultimate fate of
  each was known.

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Red Ant Queen

• Grim Reaper visited in forms such as birds,
  careless feet, being sat upon, etc.
• Anteater accounted for 400

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Black Ant Queen

• 500 ended up as dinner

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Direct comparison

• Red ants have 80 percent of the risk that black
  ants have
• (400/1000 vs 500/1000)
• The anteater could know this

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Retrospective and Prospective

• Retrospective (case control) begin after the
  fact and look back
• Prospective (cohort) start with a condition in
  question and watch it over a period of time to
  see what happens

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See if you understand

• The smoking histories of all patients entering a
  hospital with cold sores who enter the same
  hospital
• Retrospective

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See if you understand

• The physical examination records of all incoming
  freshmen class of 1928 at U.C. are examined to
  see if their recorded height and weight are
  related to their chance of developing coronary
  heart disease by 1968.
• Prospective

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See if you understand

• All the mothers of Grass Valley who delivered a
  baby in 1970 are interviewed to see if the number
  of colds they had during their pregnancy is
  related to any defects apparent at birth in their
  infant.
• Retrospective

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See if you understand

• A whole town is examined and all who are judged
  to be well are questioned extensively about their
  diet to see whether or not their eating habits
  will predict their risk of developing subsequent
  bowel cancer.
• Prospective

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See if you understand

• All the patients being discharged from one
  hospital in NYC with a diagnosis of myocardial
  infarction (heart attack) are characterized by
  certain demographic variables and compared to NYC
  population to see if any of these characteristics
  are determinants of survival from a heart attack
  there.
• Retrospective

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Cause and Association

• Association relationships which may exist
  between the occurrence of one thing (like a risk
  factor) and the occurrence of another (like a
  disease).
• Causality

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Causality

• If you have it and the disease is more likely
  to occur, and
• When you take it away, the disease is less
  likely to occur, then
• it is considered a cause of the disease.

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Five basic criteria

• Consistency
• Strength
• Specificity
• Time relationship
• Coherence

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Practice 1

• During the previous year, nine residents of a
  community died from the same type of cancer. List
  some of the reasons that might justify an
  investigation.

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Practice 1 ideas

• Determine how many cases to expect
• Research
• Control and prevention
• Why people died
• Training
• Politics
• Legal concerns

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Practice 2

• During August, a county health department
  received reports of 12 new cases of tuberculosis
  and 12 new cases of aseptic meningitis.
  Tuberculosis does not have a seasonal
  distribution however, aseptic meningitis, which
  is caused primarily by an infection, is highly
  seasonal, and peaks from August-October. What
  additional information is needed to determine
  whether either of these groups of cases is an
  outbreak?

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Practice 2 ideas

• How many diseases usually occur

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Practice 3

• You are called to help investigate a cluster of
  17 men who developed leukemia in a community.
  Some of them worked as electrical repair men, and
  others were ham operators. Which study design
  would you choose to investigate a possible
  association between exposure to electromagnetic
  fields and leukemia?

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Practice 3 ideas

• Case-control
• Compare the 17 people already identified with the
  control
• Were they exposed to the same electromagnetic
  fields

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Practice 4

• The manager of a grocery store has reported a
  rash illness among the stores workers. What type
  of study would you use to determine the source of
  the outbreak? Why? What is the appropriate
  measure of association? Review the table on
  exposure to celery and calculate the measure of
  association and interpret your results.

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Practice 4 table
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Practice 4 table
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Practice 4 table
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Practice 4 ideas

• Cohort study
• Relative risk attack rate for workers exposed
  to celery divided by the attack rate for those
  who were not exposed.
• Attack rate for exposed 25/56 or 44.6
• Attack rate for non-exposed 5/70 or 7.1
• Relative risk 44.6/7.16.3
• Compare other vegetables and fruits
• Look for significance

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Vital Statistics

• Births
• Deaths
• Fetal deaths
• Marriages
• Divorces

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Infant Mortality
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Infant Mortality Rates
Source http//www.geographyiq.com/ranking/ranking
_Infant_Mortality_Rate_aall.htm
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Infant Mortality Rate

• Utah 5.3 deaths per 1,000 live births

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Morbidity sickness disease

• State health department data

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Health status health-related behaviors
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Causes of death in the U.S. 2001
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Causes of death in the U.S. 1900
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Healthy People 2010
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Use of health care services

• Hospital discharge data
• Health department data

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Sources and Uses of Health Care Funds
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Flow of funds

• Exchange
• Two-party transaction
• Derived demand

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Role of Government
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Sources

• Shift to third-party payment
• Payments are made from

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Income and ethnicity as determinants of mortality
(1996 data)
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Use of funds

• Intensity of services
• Hospitals
• Nursing homes
• Doctors, nurses and other health care workers
• Drugs
• Administration
• Public health
• Research