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Module 1 Discussion

The discussion question for this module is a series of questions related to a case study found in Chapter 1 of the text. Please answer all three questions (found below) in your initial response.

Chapter 1 (pp 7-15): CASE STUDY—GROUP HEALTH EAST (GHE)

100,000-member managed care organization
Mixed model
55-year-old administrator (Mr. Jones)
Two large multi-specialty groups, each with a separate clinic
500 individual MDs in community
Affiliated with two major hospitals in Boston
Each clinic maintains a functional design
Two divisions (support services and clinical services)
Considering moving to a “matrix model”

Initial Discussion Questions:

What are the advantages and disadvantages of a matrix model for GHE in terms of direct and indirect costs, as well as benefits such as improved coordination?
How many product lines should the organization identify?
How should the organization determine which product lines ought to maintain separate identities as part of the matrix design?
Be sure in your initial response you support your findings and post with at least two quality, primary sources, which may include you textbook. Cite and reference your sources. (write 5-6 sentence summaries for each question).

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Module 2 Discussion

The discussion question for this module is a series of questions related to a case study found in Chapter 3 of the text. Please answer all three questions (found below) in your initial response.

Chapter 3: CASE STUDY (3.2)—Breast Cancer Screening

In Case Study 3.2 in the text, Pisano and colleagues (2006) compared the performance of digital to film mammography for breast cancer screening. Now assume that the sensitivity and specificity of digital mammography is 85% and 95% respectively, the sensitivity and specificity of film mammography is 55% and 85% respectively, and that 0.03% of women below the age of 50 have breast cancer, and 12% of symptomatic women have breast cancer.

Initial Discussion Questions:

How successful is film mammography in identifying women with breast cancer, or ruling out the disease in women without breast cancer?
Are there any recent advances (previous 5 years) that could improve the success rates? If so, please explain what they are.
Be sure in your initial response you support your findings and post with at least two quality, primary sources, which may include you textbook. Cite and reference your sources. (write 5-6 sentence summaries for each question). Saint HCM530 Full Course Work latest

Module 3 Discussion

The discussion question for this module is a series of questions related to a case study found in Chapter 3 of the text. Please answer all three questions (found below) in your initial response.

Chapter 5: CASE STUDY (5.3)—Inpatient Quality of Care Indicators for Bluegrass Hospital
Suppose that the Kentucky Hospital Association (KHA) decided to provide a service to its member hospitals by using the inpatient claims database to calculate inpatient quality of care indicators for each hospital. They provide a report to each hospital comparing them to national norms. Table 5.5 presents some of these indicators for Bluegrass Hospital, a fictional 200-bed hospital located in Central Kentucky. Upon receiving this report, Bluegrass Hospital organizes a quality improvement (QI) team to evaluate and develop recommendations.

Initial Discussion Questions:

From an evaluation of the report card only, Bluegrass Hospital would seem to be deficient in which areas? Why?
Since the report is based on an evaluation of administrative data, what should the first course of action be? Why?
Research an inpatient quality of care indicator and provide a 5-6 sentence summary of an article from peer reviewed literature that describes how performance on that indicator can be improved upon.

Module 4 Discussion

Clinical, research and managerial epidemiologists deal in risk. Risk is the chance that a person may or may not develop the condition, with or without exposure, in a defined time period. There is more than one type of risk.

Type of Risk

Absolute risk(incidence, prevalence)

Relative risk (RR)(Odds Ratio)

Attributable
risk/fraction

Risk Objective

To determine the rates of disease by person, place and time

To identify the risk factors for the disease

To develop approaches for disease prevention

Example

Birth/death rates are absolute!

What are the odds?

Increase/decrease in incidence/proportion?

What do we know about the absolute, relative risk and attributable risk of smoking and lung cancer?
How may this knowledge help in private and public health epidemiology?
Be sure in your initial response to provide at least two examples from peer reviewed literature that expound upon this relationship (write 5-6 sentence summaries for each article).

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.

Where does the CEA fit into public health and clinical epidemiological research, as well as, health services research?
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. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f1?>Introduction

F. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f9?>Case-Control Studies

B. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f5?>Observation

G. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f10?>Prospective Studies

C. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f6?>Record Reviews and Historical Studies

H. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f11?>Clinical Trials

D. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f7?>Surveys, Questionnaires, and Interviews

I. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f12?>Identification and Recruitment of Subjects

E. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f8?>Epidemiologic Studies

J. .hhs.gov/ohrp/archive/irb/irb_chapter4.htm#f13?>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.

What are those study designs and how are they defined?
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)

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

Why is it a challenge in defining diseases as either totally chronic or totally infectious (acute) in nature?
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).

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?

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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). Saint HCM530 Full Course Work latest

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)

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? Saint HCM530 Full Course Work latest

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 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 =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

Case1 Midterm

____________________

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 : Saint HCM530 Full Course Work latest

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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. Saint HCM530 Full Course Work latest

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. Saint HCM530 Full Course Work latest

________________

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.

final 1

Managerial Epidemiology: What is the cost-effectiveness analysis and what is it used for in healthcare and public health? Provide an example study.

Question 2. Question :

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. Saint HCM530 Full Course Work latest

Question 3. Question :

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?

Question 4. Question :

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.

Question 5. Question :

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?

Question 6. Question :

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). Saint HCM530 Full Course Work latest

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

e. Reduction in CRC incidence, %

f. Reduction in CRC mortality, %

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

1,390

970

626

2,464

1,383

2,530

j. Incremental cost, thousand $

13,615

9,054

4,834

-2,198

2,887

-180

k. Incremental cost ($)/life-years saved compared with no screening

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. Saint HCM530 Full Course Work latest

_____________

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?

Question 7. Question :

NOTE: Essay Question is in 2 parts. This is Part 1 to be completed and then go , to Part 2 and complete 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?

Question 8. Question :

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.

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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. Saint HCM530 Full Course Work latest

(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?

Saint HCM530 Full Course Work latest