Disability ( Health Burden ) for Medical Undergraduates

Disability ( Health Burden )

االصابات و االعاقة( Measure of Morbidity =

Disease Burden)Methodology & Demography

Physician - Epidemiologist / Khaled M. AlmazAssistant lecturer, Community Medicine Department,

Aswan University hospital, Aswan, EgyptMaster Degree in Public Health , October 2011Master Degree in Internal Medicine , April 2015

Identify pattern of Food IntakeIndirect Methods for Nutrition

AssessmentNutrition Assessment at the National

Level

National Food Consumption and Food Balance Sheet.

Vital statistics Assessment of the Ecological factors.

الحيويه = Vital statistics االحصاءاتالمباشرة غير الطرق

بعض االحصاءات الدولتوجد لدى بعض • التي تستعمل كمؤشر عن الكفاية الحيويه

التغذوية..:-وهي تشمل •

االعمار, الوفيات وسجالت1.

واالصابة باالمراض,2.

.االمراضوأسباب 3.

Vital statisticsIndirect indicators : for the nutritional status of the community :1. Mortality rate : - Infant mortality, neonatal mortality, still birth, per-natal mortality rates. - Child ( = under five mortality rates ).2. Morbidity statistics : Life expectancy (Survival Rate) (Disease

Burden).3. Morbidity statistics : Incidence rate - Prevalence rate.

Classification for estimating Mortality and DisabilityDeaths were classified using a tree structure, in which the first level of disaggregation comprises three broad cause categories of diseases :-1.Group I: communicable diseases,

perinatal, and nutritional conditions;2.Group II: non-communicable diseases;3.Group III: injuries.

Morbidity statistics to assess the frequency of the

disease

Incidence rate.

Prevalence rate.

Disease burden.

Morbidity statistics : Incidence rate - Prevalence rate

Incidence rate : new cases of Nutritional Diseases ( Over Nutrition / or / Under-Nutrition = Deficiency ).

Prevalence rate : new + old : all cases of Nutritional Diseases ( Over Nutrition / or / Under-Nutrition = Deficiency ).

(service statistics derived from hospitals) e.g. 1. protein energy malnutrition among (marasmus- kwashiorkor), 2. Rickets among hospital attendants.3. iron deficiency anemia among hospital attendants.4. keratomalacia among hospital attendants.

Measuring Disability

A. Instruments used to measure functional ability

The Index of Activities of Daily Living (ADL), and Instrumental Activities of

Daily Living (IADL)

• If the person could do the 6 basic activities of ADL without difficulty or help

from another person, he was considered non disabled in ADL activities.

• If the person could do one or more of the 6 activities of ADL with difficulty,

he was considered having mild-moderate disability.

• If the person could not do one or more of the 6 activities of ADL except with

help from another person, he was considered having severe ADL disability.

B. Techniques used to measure functional ability

• 1- Direct observation is rarely used because it is so time consuming.

• 2- Direct tests of functioning, such as range of limb movement, walking time or standards such as joint pain scores and erythrocyte sedimentation rate, while objective may not necessarily give an accurate indication of ability or performance.

• 3- Interview with the person concerned Most measures of functional disability are self-report methods.

Respondents are asked to report limitations on their activities.

The main criticism of this type of measure is subjectivity.

C . Methods for Quantifying Disability

1- Direct Methods

2- Indirect Methods

1- Direct methods Cross sectional study

•Cross sectional census and surveys which measure prevalence in a given period, this may be relevant

for defining the extent and demographic pattern of disabilities in a population and thus indicating the need

for rehabilitative services.

Longitudinal / Cohort study

•To measure the incidence rates or trend of disability in a given population longitudinal

studies are needed.

Disability in Community ..

Cross-sectional studies have demonstrated that with an increasing number of chronic diseases there is a stepwise increase in disability in ADLs, IADLs and mobility.

2. Indirect methods:Indirect methods is used for ranked the disease as a cause of disability. So, it used to apply primary preventive measures against diseases accused to have higher score in doing disability.

Disability-Adjusted Life Years (DALYs): The DALYs for a given disease

condition are the sum of years of life lost due to premature mortality and the number of years of

life lived with disability- adjusted to the severity of disability.

Healthy Life Years (Heal Y): Healthy life years (Heal Y) lost as a result of premature

mortality and disability is a composite indicator that incorporates mortality and morbidity into a

single number.

Both DALYs and Heal Y are measuring disease burden on disability.

Life expectancy (Survival Rate)

---------------Morbidity statistics :

To assess the frequency of the diseaseDisease Burden

( years of potential life lost )DALYs : Disability-adjusted life year QALYs : Quality-adjusted life years

Types of Disease Burden

DALYsQALYsHALE

Indicators of HealthDisability Indicators:

Sullivan's index , HALE (Health Adjusted Life Expectancy) , DALY (Disability Adjusted Life Year).

===============Sullivan's index is a expectation of life free from disability.HALE is the equivalent number of years in full health that a newborn can

expected to live based on the current rates of ill health and mortality. DALY expresses the years of life lost to premature death and years lived

with disability adjusted for the severity of disability.

Health ExpectanciesHealth expectancies measure years of life gained or years of improved quality of life. In this group of measures, among others, Following Measures are classified:1. Active life expectancy (ALE),2. Disability-free life expectancy (DFLE),3. Disability-adjusted life expectancy (DALE),4. Healthy adjusted life expectancy (HALE),5. Quality adjusted life expectancy (QALE).

Health GapsHealth gaps measure lost years of full health in comparison with some ‘ideal’ health status or accepted standard. In this group of measures among others,Following Measures (indicators) are classified:1. Potential years of life lost (PYLL),2. Healthy years of life lost (HYLL),3. Quality adjusted life years (QALY),4. Disability adjusted life years (DALY).

Both approaches use Time and multiply number of years lived (or, not lived in case of premature death) by the “quality” of those years. The process of adjustment of the years of healthy life lived is called “quality adjustment” (expressed as QALYs) The process of adjustment of the years of healthy life lost is called “disability adjustment” (expressed as DALYs) .

It means that QALYs represent a gain which should be maximized,

DALYs represent a loss which should be minimized. In the QALY approach the quality is weighted (sometimes called

“utility”, as it is the case of cost-utility analyses) on a Scale

from 1 indicating perfect health and the highest quality of life, to 0 indicating no quality of life and is synonymous to death.

In the DALY approach the Scale goes in opposite way: a Disability weighted zero indicates perfect health (no disability), and weighted 1 indicates death.

The Disability weighting is the most difficult and controversial part of the DALY approach .

DALYs

DALYs

Calculation of DALYsDisability-Adjusted Life Year

(DALY) conceptThe DALY measure is the sum of both dimensions / components just described :-

The Sum of the YLLs and the YLDs (4,10,11,15-19) :

DALY = YLL + YLDDALY = disability adjusted life yearsYLL = years of life lost due to premature deathYLD = years lost due to disability

Calculating DALYs.At the end the YLLs and the YLDs are summed up according to Equation 4.

The sum of the YLLs and the YLDs (4,10,11,15-19) :

DALY = YLL + YLDFor the woman from Example 8 the DALYs are calculated as follows:DALY = 33.99 + 10.50 = 44.49The burden of disease in this case in terms of DALYs is 44.49 years.

QALYs

QALYs

QALYs

Quality Administration

Quality Assurance of Medical Practice

QUALITY OF HEALTH CARE

What is Quality?

“The quality of technical care consists in the application of medical

science and technology in a manner that maximizes its benefit to

health without correspondingly increasing risks. The most

comprehensive and perhaps the simplest definition of quality is that

used by advocates of Total Quality Management: “Do the right thing,

right, the first time.”

Components of Quality

1. Effectiveness

2. Efficiency

3. Technical ~2ornpeence

4. Safety

S. Accessibility

6. Interpersonal Relations

7. Continuity

8. Amenities

Effectiveness: doing "right" things, i.e. setting right

targets to achieve an overall goal

Efficiency: doing things in the most economical

way (good input to output ratio)

Cost EffectivenessCost-effectiveness analysis (CEA) is a form of Economic Analysis that compares the Relative Costs and Outcomes (Effects) of different courses of action. Cost-effectiveness analysis is distinct from cost–benefit analysis, which assigns a monetary value to the Measure of Effect.

The most commonly used Outcome Measure is Quality-Adjusted Life Years (QALY).A special case of CEA is Cost–Utility Analysis , where the

Measure of Effect in terms of years of full health lived, using a measure :

1. Quality-Adjusted Life Years. 2. Disability-Adjusted Life Years.

Cost-Effectiveness is typically expressed as an incremental cost-effectiveness ratio (ICER), the ratio of change in costs to the change in effects.

A complete compilation of Cost-Utility Analyses in the peer reviewed medical literature is available from the Cost-Effectiveness Analysis Registry website.

التكلفة فعالية CEAتحليل التكاليف بين المقارنة أساس على يقوم والذي االقتصادي، التحليل أشكال من

. ) العمل ) خطط من أكثر أو باثنتين الخاصة الصلة ذات التأثيرات النتائج وبين يعين والذي والفائدة، التكلفة تحليل عن التكلفة فعالية تحليل مفهوم ويختلف

. المتّبع التأثير مقياس على النقدية القيمة ما الحاالت وعادةً في الصحية، الخدمات مجال في التكلفة فعالية تحليل يُستخدم

. يتم عام، وبشكل الصحي الوضع على التأثيرات معرفة فيها يصعب عن التي التعبيرالمكاسب إلى المقام فيها يرمز الناتجة النسبة إن حيث من التكلفة فعالية تحليل

سنوات ) المبكرة، الوالدة حاالت تفادي الحياة، سنوات القياس عن الناتجة الصحية) بالرؤية الصحية التمتع بالمكاسب المرتبطة التكلفة البسط .ويمثل

الجودة ويعد حيث من الحياة سنوات النتيجة.. QALYمقياس مقياس هو. اإلطار هذا في شيوعًا أكثر بشكل المستخدم

القول يمكن الوقت، نفس لتحليل وفي مماثل التكلفة فائدة تحليل إن . التكلفة فعالية

Cost Efficiency (Cost Optimality)In the context of Parallel Computer Algorithms, refers to a

Measure of how Effectively Parallel Computing can be used to solve a particular problem.

A Parallel Algorithm is considered Cost Efficient if its Asymptotic Running Time multiplied by the number of processing units involved in the computation is comparable to the Running Time of the best sequential Algorithm.

For example, an Algorithm that can be solved in time using the best known sequential Algorithm and in a Parallel Computer with processors will be considered Cost Efficient.

) المثالية ) التكلفة أو الكفاءة أو الفعالية كلفةالمتوازية • الحو�اسيب خوارزميات مجال� فيمدى • قياس إلى المتوازية فعاليةيشير مشكلة الحوسبة حل أجل من

معينة. الوقت • كان إذا التكلفة حيث من فعالة أنها متوازية خو�ارزمية تعتبر

المشاركة المعالجة وحدات من عدد في مض�روبا للتشغيل المقارب. تسلسلية خو�ارزمية أفضل تشغيل مدة تعادل الحساب في

،المثال سبيل المدة على في حلها يمكن التي للخوارزمية سينظرO(n) معروفة متسلسلة خوارزمية أفضل كمبيوتر و باستخدام في

معالجات مع التكلفة O(p) mبالتوازي حيث من ...كفعالة

Cost–Benefit Analysis (CBA) = Benefit–Cost Analysis (BCA)

1. It is a systematic approach to estimating the strengths and weaknesses of alternatives (for example in transactions, activities, functional business requirements);

2. It is used to determine options that provide the best approach to achieve benefits while preserving savings.

3. The CBA is also defined as a systematic process for calculating and comparing benefits and costs of a decision, policy (with particular regard to government policy) or (in general) project.

والفائدة التكلفة CBA / BCAتحليلسياسة • أو قرار أو مشروع وتكاليف فوائد حساب خاللها من يمكن منهجية عملية عن عبارة

. )" بينها )" والمقارنة ما المشروع حكومية: والفائدة التكلفة لتحليل غرضان وهناك

1.) / ( / ، الجدوى التبرير سليًما اتخاذه تم الذي القرار االستثمار كان إذا ما تحديد

2. . هذه وتُبنى المشروعات بين المقارنة في عليه االعتماد يمكن أساس توفيرفي خيار لكل المتوقعة اإلجمالية التكلفة بين المقارنة أساس على العملية

تفوق الفوائد كانت إذا ما لمعرفة المتوقعة، اإلجمالية الفوائد مقابل. كمية وبأي التكاليف،

Study Designs

used in

Outcomes Research

in

Quality Assurance of Medical Practice

1. Randomized control trials

2. Cross-sectional studies

3. cohort studies

4. Meta-analysis

5. Systematic reviews

SPSS Program

Minitab Program

( used Mainly in Quality Administration )

Epidemiological Science of

Disability ( Health Burden )

Working Definitions &

Operational Definitions of

Impairment , Disability , Handicap

Definitions1. Working definitions of Impairment , Disability , Handicap

The WHO ; World Health Organization’s International Classification of Impairments, Disabilities and Handicaps provide a consistent terminology and a classification system.

These concepts lead to the concept of dependency on other people or service providers.

Impairment :

“in the context of health experience, impairment is any loss or

abnormality of psychological, physiological or anatomical

structure or function”. It represents deviation from some

norms in the individual’s biomedical status. While impairment

is concerned with biological function, disability is concerned

with activities expected of the person or the body.

Disability :

‘in the context of health experience, a disability is any

restriction or lack in ability (resulting from an

impairment) to perform an activity in the manner or

within range considered normal for a human being’.

Functional Handicap :

It represents the social consequences of Impairments or Disabilities.

It is thus a social phenomenon and a relative concept.

‘In the context of health experience, a Handicap is a

disadvantage for a given individual resulting from an

Impairment or a Disability that limits or prevents the fulfillment

of a role that is normal- depending on age, sex and social and

cultural factors- for that individual’.

Dependency :

is defined as “a state in which an individual is

reliant upon other(s) for assistance in meeting a

recognized need”.

2. Operational definitions of Disability

Operational definitions of Disability, on the whole, concentrate upon 1. Activities of daily living (ADL), 2. Instrumental activities of daily living (IADL)

1-Activities of daily living (ADL):

The term ‘activities of daily living' includes

activities that are basic to daily life, such as

bathing, dressing, feeding, continence, transfer

from bed and chair and toileting.

2- Instrumental activities of daily living (IADL)

The scope was broadened with IADL concept, which

incorporates measures of more complex adaptive or

self-maintaining functions such as housekeeping and

grocery shopping, i.e. doing heavy housework, light

housework, cooking, transportation and marketing.

The emerging concept of ‘preclinical disability’ focuses on identifying stages in the natural history of functional loss that precede the onset of overt ADL or IADL dependencies.

This phenomenon has been measured in terms of adaptive modification in the performance of common tasks such as doing heavy housework and walking up and down stairs.

In addition to screening and care planning for individual patients.

Conceptual Framework for Disability

The following map demonstrates the current understanding of interactions between the dimensions of ICIDH-2.

Health condition

•Function and disability are seen as an interaction or complex relationship

between the health and the contextual factors (i.e., environmental and personal

factors).

•There is a dynamic interaction among these factors.

•Interventions at one element level have the potential to modify other

related elements.

•The interaction works in two directions; even the presence of a disability

may modify the health condition itself.

3- Models of Functioning and Disability

Models of Functioning

Models of Disability

A- Medical models

The medical model views disability as a personal problem, directly caused

by disease, trauma or other health condition, which requires medical care

provided in the form of individual treatment by professionals.

Medical care is viewed as the main issue, and at the end, the principal

response of the political level is that of modifying or reforming health care

policy.

B- Social modelsThe social model of disability, on the other hand, sees the issue mainly as socially

created, as a matter of the full integration of individuals into society.

Disability is not an attribute of an individual, but rather a complex collection of

conditions, many of which are created by the social environment.

Hence, the management of the problem requires social action, and it is a collective

responsibility of society at large to make the environmental modifications necessary

for the full participation of people with disabilities in all areas of social life and at

political level it becomes a question of human rights.

Exposure &

Causes&

Risk Factors

Factors that may affect the future proportion of the Disabled Persons in

the world

I- Change in the age composition of the general population.

II- Change in the pattern of morbidity and mortality.

III- Change in the extent of health services.

IV-Increase in the urbanization and industrialization.

Underlying causes of Disability

A number of chronic conditions have been found to be strongly

related to disability, these include heart disease (especially

myocardial infarction, angina, congestive heart failure),

osteoarthritis (especially arthritis of the keens), hip fracture, stroke,

chronic obstructive pulmonary disease, visual impairment, hearing

impairment, depression.

The co-occurrence of multiple chronic conditions,

or comorbidity is common in older population.

Cross-sectional studies have demonstrated that with an

increasing number of chronic diseases there is a stepwise

increase in disability in ADLs, IADLs and mobility.

Risk factors and Disability1. Age2. Sex3. Socio-Economic Status (SES)4. Lifestyle factor as a predictor of Disability5. Body Mass Index (BMI)6. Skeletal Muscle Mass cut points7. Foot pain and Disability8. Drug Abuse (illicit drugs)9. Race

Statistics1. Survival Analysis Statistical Tests2. Hospital Statistics

1– Survival Analysis Statistical Tests

Survival analysis & Survival Time in Statistical Tests

Usually asked from Medical Physicians in Oncological department whatever chemotherapeutic medical oncology or surgical oncology or radiothrapeutic medical oncology.

Oncology is a medical department in faculty of medicine concerned with (tumour specially Malignancy not benign ) diseases.

Survival Analysis is widely used in the bio-sciences to quantify survivorship in a population under study. The statistical programs includes three widely used tests :- 1. Kaplan-Meier (product-limit) Estimator 2. Cox Proportional Hazards Model 3. Weibull Fit.

Regression & Survival Analysis• Kaplan Meier Regression : if deal with one factor i.e.: one

predictor>>> Called : Simple Regression

• Cox regression : if deal with more than one factors i.e. more than one predictors

>> Factors called in SPSS program : Covariate/s.Covariate/s : Quantitative or Qualitative Variable/s.

2– Hospital Statisticsالخدمات مراكز في الطبي االحصاء

الصحية

Used in :-

1. Health Care Administration (Hospital Administration)

2. Medical Statistics

Used in :-

1. Health Care Administration (Hospital Administration)

2. Medical Statistics

Types of Hospital Statistics Vital statistics :

Births & Deaths Patients statistics

Demographic dataAdministrative data : Stay , mode of Treatment , Discharge Utilization statistics

Bed use & Patient Movement StreamNumber of patients , Visits , lab & radiology InvestigationsBed use : Occupancy , Turnover , Stay

Rates in Hospital Statistics

Average inpatient census = No. of patients / total duration in days

Bed occupancy rate : Total No. of inpatients days in a given period * 100

= -------------------------------------------------- No. of available staffed beds * No. of days in this period

Bed overload rate : = No. of days when the bed occupancy is 100 %

Bed underloading rate : = No. of days when the bed occupancy is 60 % or less in a duration (days)

Bed turnover rate : No. of In-patients in a specific period = ---------------------------------------------- No. of beds in the same period

In-patients : Patients treated in Health Care are services ( Hospital Stay = with Admission ) until improvement of health status.Out-patients : 1. Patients treated in Health Care are services ( Hospital ) = but without admission2. Patients treated in Clinic Office

Bed Vacancy Rate : Vacancy Rate in a specific duration = 100 % - Occupancy Rate in this duration

Net Bed Vacancy Rate = 100 – Highest Occupancy Rate

Length of Hospital Stay :

Calculated for each patient after discharge from hospital

Refers to the No. of calendar days from the day of patient

admission to the day of discharge

Length of stay : = date of discharge – date of admission

Total length stay :

is the sum of all stay days

Refers to No. of days of care provided to patients

1. Discharged

2. Died

3. The discharge days.

Average length of stay :

Total Length of Stay for a given period = -------------------------------------------------- Total No. of discharge (including deaths)

,,,, for the same period

To calculate the average length of stay for the hospital or for every departments :

Step 1 : length of stay (for every department) = date of discharge – date of admissionStep 2 : Total length stay = summation of all length of stayStep 3 : Average length of stay = Total length stay / total No. of discharge (including deaths)

Hospital Death Rates

( Hospital Mortality Rates )

Hospital death rates :1. Gross death rate2. Net death rate3. Neonatal death rate4. Maternal mortality rate5. Fetal death rate6. Still – Birth rate7. Postoperative death rate8. Post anaesthetic death rate

Gross death rate : Total No. of Inpatients deaths for a given period * 100

= -------------------------------------------------------

Total No. of discharges ;

including : adult , child , new-born deaths

(for the same period)

Net death rate :Exclude < 48 hoursTo not count deaths to the hospital ( infection control diseased

inpatient : got infection after hospital admission by 48 hours) Is a debatable issue

Hospital acquired infection :

Total No. of infections for a given period * 100

= --------------------------------------------------------

Total No. of discharges (including deaths)

for the same period

Specific : Postoperative Infection Rate

( Infection Control Administration )

Consultation rate :

Refers to the No. of all consultations for patients

It is a Measure of Hospital Use and Quality of Care

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