Disability ( Health Burden ) ات صاب لا ا و ة ق عا لا ا) Measure of Morbidity = Disease Burden ( Methodology & Demography Physician - Epidemiologist / Khaled M. Almaz Assistant lecturer, Community Medicine Department, Aswan University hospital, Aswan, Egypt Master Degree in Public Health , October 2011 Master Degree in Internal Medicine , April 2015
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Disability ( Health Burden ) for Medical Undergraduates
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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
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
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.
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
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
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