1.Managerial Epidemiology:
What is the cost-effectiveness analysis and what is it used
for in healthcare
and public health? Provide an example study. (Points :
10)
Question
2.2.Qualitative, Quantitative (Cause-Effect): You are the
Chief Operating Officer of a hospital. The Human Resources
Director
reports to you. Two of your valued Directors have a random
drug
screening for controlled substances with a group of hospital
cohorts, and the
result comes up as positive for heroine. Your experience with
epidemiology and your understanding of cause-effect makes you
skeptical of
these general screening results. You request that the
specimens be sent
out to a specialty lab for confirmatory testing with gas
chromatography
specific for heroine. The results of the confirmatory testing
show that
both Directors are negative (0 mg/dl) for all control
substances, including
heroine. A further investigation revealed that both Directors
attended
a morning meeting the day of the random test and had eaten
poppy seed
muffins. You do research and find that poppy seed muffins
produce a
byproduct in the body that mimics opiates/heroine in a
screening.
Discuss
why these results occurred , i.e., the two very different
results
between a screening, and the confirmatory test in terms of a)
qualitative and
b) quantitative testing, c) specificity, d) reliability.
(Points : 10)
Question 3.3.Research
Methods: Why is the randomized clinical trial (RCT) research
considered
the “gold standard” in clinical epidemiology research? What
is an IRB
and why is it requirement when performing research with human
beings? (Points
: 10)
Question 4.4.Decision
Making: Clinical epidemiology research should be based on
empirical
evident. Define empirical evidence and what it means in
decision making
in both private and public health decision making in regard
to interventions,
i.e., the implementation of medical testing, processes or
public health
programs. (Points : 10)
Question 5.5.Risk
Factor Research: Why is the Framingham Heart Study a pivotal
research
program in healthcare today? What are some of the milestones
the study
has given to clinical epidemiology? (Points : 10)
Question
6.6.Case 1 of 2 (50 Pts): Cost-Effectiveness Analysis
(CEA): In Wu et al. (2006) researchers performed an analysis
to
evaluate the cost-effectiveness of doing stool DNA testing in
addition to
other types of traditional screenings, i.e., fecal occult
blood testing
annually, flexible sigmoidoscopy or colonoscopy, every 5 and
10 years for
colorectal cancer in countries where colon cancer prevalence
is low.
Also, evaluated was the cost/benefit of doing no screenings
(Wu, 2006).
The
subjects were people 50 to 75 years of age in Taiwan. The
researchers
used the annual cost of $13,000 per life-year saved (which is
roughly the per
capita GNP of) as the ceiling ratio for assessing whether DNA
testing was
cost-effective (Wu, 2006).
Simulated results for screening
strategies to prevent Colon Rectal Cancer (CRC)
Variable
Screening Strategy
No Screening
DNA (3yrs)
DNA (5yrs)
DNA (10yrs)
Occult Blood
Flexible Sigmoid. (5yrs)
Colonoscopy (10 yrs)
a. Total cases of CRC, n
2,917
2,435
2,654
2,710
2,129
2,253
1,780
b. CRC deaths, n
1,729
1,345
1,467
1,574
1,059
1,328
1,077
c. Perforation deaths, n
0
3
2
1
5
3
12
e. Reduction in CRC incidence, %
0
17
9
7
27
23
39
f. Reduction in CRC mortality, %
0
22
15
9
39
23
39
g. Life expectancy, year
15.7337
15.7476
15.7434
15.74
15.7584
15.7477
15.759
h. Total costs, thousand $
22,022
35,637
31,077
26,856
19,824
24,909
21,843
i. Incremental life-year saved, year
0
1,390
970
626
2,464
1,383
2,530
j. Incremental cost, thousand $
0
13,615
9,054
4,834
-2,198
2,887
-180
k. Incremental cost ($)/life-years saved compared with no screening
0
9,794
9,335
7,717
Dominant ‡
2,087
Dominant †
* Values obtain from a cohort of 100,000 persons 50 years of age
who
were followed for 25 years.
† The other screening strategy is more effective and less costly
than stool DNA testing strategy.
‡ The screening is more effective and less costly than No Screening.
Adapted from: Wu et al. BMC Cancer
2006 6:136 doi:10.1186/1471-2407-6-136
_____________
Reference:
Wu, Grace HM. Wang, Yi-Ming . Yen, Amy MF. Wong, Jau-Min Lai,
Hsin-Chih Warwick, Jane and Chen, Tony HH. (2006)
Cost-effectiveness
analysis of colorectal cancer screening with stool DNA
testing in
intermediate-incidence countries. BMC Cancer 2006, 6:136
doi:10.1186/1471-2407-6-136
QUESTIONS:
In your own words and
1) From the research results shown in the chart above, which
type of
screening had the highest and which had the lowest reduction
in colon-rectal
cancer mortality?
2) How do you interpret the findings (Conclusion) in regard to
the A-K
results in regard to the cost/effectives of doing DNA-testing
at 3 years, 5
years, 10 years, or not doing DNA tests at all?
(Points : 50)
Question
7.7.NOTE: Essay Question is in 2 parts. This is Part
1 to be completed and then go
it.
Case #2 of 2: (50 pts) Cost/Benefit literature review for
vaginal birth
after cesarean (VBAC)
A client had a cesarean delivery in a hospital setting for
breech
presentation with her first pregnancy. She is pregnant again
and after
exploring her delivery options, has decided she wants to
attempt a vaginal
birth after cesarean (VBAC). She has had an uncomplicated
pregnancy this time
and the fetus is not breech. The same OB-GYN will be
assisting in her
delivery. The OB-GYN performs a systematic review of the
literature to assess
the benefits and harms of VBAC versus repeat cesarean
delivery.
Part 1 of 2: Researching Empirical Evidence
1. What kinds and sources of data does the OB-GYN need to review
in
order to make a rational clinical planning decision?
2.
Which types of studies available on this topic would be the
most useful
in clinical decision making?
3.
What types of studies would you want to exclude?
4.
Why would there be a lack of randomized clinical trials
(RCT’s)
available to address this clinical question?
(Points : 20)
Question 8.8.NOTE:
This is Part 2 of the final essay question: The last essay
question requires you to do a 2×2 table in addition
to calculations. The tables may be done by copying the table
from the question directly into your answer and then filling
the table out.
Case:
Calculating Odds Ratio
In planning for her delivery, the client reads about birthing
centers and
asks the midwife if it is safe to have a VBAC in a
freestanding birthing
center. The midwife reviews the data from national studies of
VBACs in
birthing centers compared to VBACs in hospital settings and
obtains the
following statistics to aid her in clinical decision
making:
N= 1913 Birthing Center based VBAC Rates
• 87% delivered vaginally
• 24% of women were transferred to the hospital prior to
delivery
• There were 25 women who experienced a serious adverse
outcome (of which 6
were uterine rupture)
• There were 7 perinatal deaths (0.5%)
• There were 15 infants with low apgar scores (below 7) after
5 minutes of
life (1.0%)
N= 1913
Hospital based VBAC Rates (Control)
• 76% delivered vaginally
• There were 32 women who experienced a serious adverse
outcome (of which 15
were uterine ruptures)
• There were 3 perinatal deaths
• There were 2 infants with low apgar scores (less than 7)
after 5 minutes of
life
(Part 2
of 2): Construct the following for 1 and 2 and answer
question 3
1. Construct a 2 x 2 table, calculate, and interpret the odds
ratio of
women who suffered a serious adverse outcome from attempting
a VBAC delivery
in order to estimate the relative risk to a mother delivering
VBAC in
midwifery based freestanding birthing centers. Cases are
those with a serious
outcome, controls are those without. The exposure is
treatment in a birthing
center. The not exposed group is treatment in a hospital.
Exposure
Cases
Controls
Birthing Center
Hospital
2. Construct
a 2 x 2 table, calculate, and interpret the odds ratio of
infants who
suffered a serious adverse outcome (including death) from
attempting a VBAC
delivery in order to estimate the relative risk to an infant
delivered VBAC
in midwifery based freestanding
Cases
Controls
3. What
does the midwife conclude regarding the safety to mother and
baby by
attempting a VBAC in midwifery based birthing centers? What
clinically is the
best decision for this client and her unborn baby?
(Points : 30)
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