Course notes: Part I MFPHM revision - Edmund Jessop
Part A MFPH
revision COURSE handout
“I couldn’t wait to get in there and tell them what I’d learned”
Stanley Hauerwas
The Hauerwas reader p25
For maximum benefit -
USE this handout:
Annotate, scribble, write examples
‘Read and forget; write and remember’
EPIDEMIOLOGY 5
Epidemiological studies: design 6
Expressing the main result 6
Concepts and measures of risk 6
Interpreting the result 7
Chance 7
Bias 7
Confounding 7
Other problems 7
Effect modifiers [interaction] 8
Causation 9
Putting it together – guidelines and recommendations 10
Hierarchy of evidence 10
Surveys 11
HEALTH INFORMATION 13
Routine data sources 13
Population 13
Ad hoc censuses 14
Census based measures 14
Routine statistics 14
Epidemiology: how much do I need to know? 16
HEALTH ECONOMICS 18
Economic appraisal 19
Decision analysis 21
Option appraisal 21
SOCIAL SCIENCES 22
Sociology 22
Qualitative methods 22
Capturing qualitative data 22
Qualitative analysis: 22
Rigour in qualitative studies: 22
Concepts of health and illness 23
Deviance 25
Variations in health 26
Social factors in the aetiology of illness 27
Social health 27
HEALTH PROMOTION 28
Strategy in health promotion 29
Running programmes 30
Environment 32
Health at work 33
Nutrition 34
SCREENING 36
Quality assurance in screening 37
ETHICS 38
GENETICS 39
STATISTICAL METHODS 40
Elementary probability theory 40
What’s this? 41
Meta analysis 42
Interpreting multiple regression models 43
Non statistical stuff 44
How would you analyse….. 45
Parametric and non parametric 45
Three famous models 47
COMMUNICABLE DISEASE 48
Communicable disease – how much do I need to know? 51
ORGANISATION AND MANAGEMENT - theory 53
Organisations 53
Change 54
Innovation 54
Leadership 55
Motivation 55
Negotiation 55
Groups 56
Within the group 56
Between groups 56
Managing people 57
Self management 57
Miscellaneous 57
Creativity 57
Delegation 57
Effective communication 57
MANAGEMENT GURUS 58
Models 58
Running health services 59
Funding of health services 59
Resource allocation 59
Policy formulation 60
HOW COMMISSIONING WORKS 61
Planning 62
Funding 63
Priority setting 63
Types of contract 63
NHS finance systems 63
Monitoring 64
Performance - overview 64
Performance – evaluation of a service 64
Performance - exceptional events 64
Governance and risk management 64
International health care 65
Social policy 65
TIPS ON EXAM TECHNIQUE 66
PREPARATION 66
GENERAL 66
PAPER I 67
PAPER IIA: strengths and weaknesses 74
PAPER IIB: data skills 75
Some facts and figures 76
Reports / briefing papers 77
DATA PRACTICE: CALCULATIONS 78
Past papers – question grid 83
EPIDEMIOLOGY
: Epidemiology for the uninitiated
NOTE – Throughout the handout anything in this typeface (Arial 10) is a direct cut-and-paste from the syllabus
a) Epidemiology: use of routine vital and health statistics to describe the distribution of disease in time and place and by person; numerators, denominators and populations at risk; time at risk; methods for summarising data; incidence and prevalence including direct and indirect standardisation, years of life lost; measures of disease burden (event-based and time-based) and population attributable risks including identification of comparison groups appropriate to Public Health; sources of variation, its measurement and control; common errors in epidemiological measurement, their effect on numerator and denominator data and their avoidance; concepts and measures of risk; the odds ratio; rate ratio and risk ratio (relative risk); association and causation; biases; confounding, interactions, methods for assessment of effect modification; strategies to allow / adjust for confounding in design and analysis; the design, applications, strengths and weaknesses of descriptive studies and ecological studies; analysis of health and disease in small areas; design, applications, strengths and weaknesses of cross-sectional, analytical studies, and intervention studies (including randomised controlled trials); clustered data - effects on sample size and approaches to analysis; Numbers Needed to Treat (NNTs) - calculation, interpretation, advantages and disadvantages; time-trend analysis, time series designs; nested case-control studies; methods of allocation in intervention studies; studies of disease prognosis.
Appropriate use of statistical methods in the analysis and interpretation of epidemiological studies, including life-table analysis; electronic bibliographical databases and their limitations; grey literature; evidence based medicine and policy; the hierarchy of research evidence - from well conducted meta-analysis down to small case series, publication bias; the Cochrane Collaboration
1 Epidemiological studies: design
• Descriptive studies: “How much of this stuff have we got?”
• Case control studies: “What caused these cases?”
• Cohort studies: “What effect does this have?”
• Interventions incl. RCTs
PICO
(Modelling studies)
(Systematic reviews)
Retrospective vs prospective studies: ‘Five a day’
Interventional vs observational studies: beta carotene and lung cancer, HRT and CHD
2 Expressing the main result
Intention to treat analysis
2 Concepts and measures of risk
Relative risk
Absolute risk
Deaths per 100,000 male doctors per year from lung cancer:
smokers (>25 per day): 327
non-smokers: 14
Ratio of incidence (incidence rate ratio) =
Absolute risk difference =
(Excess rate/ risk attributable to smoking = )
Population attributable “risk” (aetiologic fraction)
Odds ratio
Number needed to treat (NNT)
3
3 Interpreting the result
Could the result be due to
• Chance?
• Bias?
• Confounding?
• REAL effect?
1 Chance
P values, CIs etc – but remember Type I and Type II errors
2 Bias
Systematic differences in
• Sample / subjects
• Measuring instrument
• Observer
3 Confounding
The ‘other explanation’
Control of confounding:
Design
Analysis
Standardisation
Residual confounding
Over-adjustment
4 Other problems
Ecological fallacy
5 Effect modifiers [interaction]
This is a type of REALITY
Age related macular degeneration (de Jong PTVM NEJM 2006; 355: 1474 – 85)
Smokers (vs non): Odds ratio = 2.4
Homozygous for CFH Y 402H polymorphism Odds ratio = 7.6
Smoker AND homozygous Odds ratio = ?
Graphically:
fluoridation of water supply more beneficial to poor than to rich.
Riley JL et al Int J Epidemiol 1999; 28: 300 –5. Jones CM et al BMJ 1997; 315: 514 – 7
[pic]
6
7 Causation
Bradford Hill criteria for causality (in order of importance):
[AB Hill. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295 - 300]
1. strength of association
2. consistent in different studies
3. specific
4. temporality
5. biological gradient e.g. more drinks / day -> higher RR
6. biologically plausible
7. coherence
8. experimental evidence
9. analogy (if thalidomide and rubella cause foetal malformation so may other drugs / viruses)
Mnemonic courtesy of Martin Bull:
A Statistical Cohort of Surgeons with TB Postulated the Cause to be an Environmental Agent!
NB if picture muddy may need to think about different types of cause:
Necessary / Sufficient
Underlying / Trigger
Etc
8
9
10
11
Uses of epidemiology (Jerry Morris):
Morris JN Uses of epidemiology Br Med J. 1955 August 13; 2(4936): 395–401
1. Historical trend
2. Community diagnosis
3. “Individual chances”
4. Operational research - how well services are working
5. Completing the clinical picture – study ALL cases
6. Identification of syndromes – ‘peptic ulcer’, ‘frailty’
7. Clues to causes
12 Putting it together – guidelines and recommendations
GRADE – strong and weak recommendations
Importance – prevents death
Size of effect – 30% reduction in risk
Precision – narrow CI
Certainty – many high quality RCTs
Risks and Burdens of therapy – no adverse effect but fortnightly iv infusion
Risk of event
Costs
Values (e.g. life or comfort?)
AGREE – quality of guidelines
13 Hierarchy of evidence
NB ‘Cultures of evidence’
4 Surveys
Constructing the survey instrument
Construction of valid questionnaires
Validity
• content
• face
• criterion
concurrent
predictive
• construct validity
Convergent/ discriminant
Reliability
‘degree to which measurement is free from measurement error’
• Test - retest
• Multiple form
• Split half
Scales:
• should be uni-dimensional
• some instruments have domains
o [e.g. “total SF36 score” is wrong]
Doing the fieldwork
methods of sampling from a population
The sample
Methods of sampling and allocation
random, quasi-random,
stratified
cluster
quota
convenience
nomination / snowball
the design of documentation for recording survey data
The instrument
Typography: font size, layout, tick boxes etc
Items: ambiguous questions / double questions / leading qq
Whole thing: running order (e.g. sensitive last)
Mode: paper - computer – telephone - internet
The interview
Interviewers
Select
Train
Monitor
Respondents
Introduction – gaining consent etc
Attempts to contact (how many? Time of day?)
Use of proxy allowed?
Methods for validating observational techniques
Validation of observational techniques:
inter-observer
interviewer training
videotaping
Observer variation
HEALTH INFORMATION
- Capture: how accurate? How complete?
– Coding – how fine grained?
- Output: how detailed? how often? How aggregate?
Routine data sources
Populations: conduct of censuses; collection of routine and ad hoc data; demography; important regional and international differences in populations, in respect of age, sex, occupation, social class, ethnicity and other characteristics; methods of population estimation and projection; life-tables and their demographic applications; population projections; the effect on population structure of fertility, mortality and migration; historical changes in population size and structure and factors underlying them; the significance of demographic changes for the health of the population and its need for health and related services; policies to address population growth nationally and globally
Sickness and health: sources of routine mortality and morbidity data, including primary care data, and how they are collected and published at international, national, regional and district levels; biases and artifacts in population data; the International Classification of Diseases and other methods of classification of disease and medical care; rates and ratios used to measure health status including geographical, occupational, social class and other socio-demographic variations; routine notification and registration systems for births, deaths and specific diseases, including cancer and other morbidity registers; pharmacoepidemiology, including use of prescribing and Pharmacy sales data; pharmacovigilance; data linkage within and across datasets
2 Population
UK Census
Census 2011
Health question
2011: How is your health in general? Very good / good / fair/ bad/ very bad
2001: Over the last 12 months would you say your health has on the whole been good / fairly good / not good ?
Disability question
2011: Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months?
2001: Do you have any long-term illness, health problem or disability which limits your daily activities or the work you can do?
• Include problems which are due to old age
Income question – there isn’t one in the UK census!
1
2 Ad hoc censuses
3
4 Census based measures
Deprivation scores
• Jarman / Townsend score
• Index of multiple deprivation IMD2000 - NOT census based: 7 domains / 33 indicators: Income, Employment, Health and disability, Education skills and training, Barriers to housing and services, Living environment and Crime. See
Population
Estimates and projections
Historical change in population structure
1946 baby boom plus second wave
effect of economic downturn
3 Routine statistics
• Mortality
• Hospital
Inpatient
Ambulatory – A&E, outpatient
Diagnostics – lab, radiology
• Primary care
Medical
Dental
Pharmacy
• Registers
• Surveys
Measurement surveys
Self report surveys
• Non-health service: fire, police, social services department
[NB – poor definitions in non-health sources]
• Research: synthetic estimates
Classifications:
ICD10
[OPCS4 coding for operations]
Read codes - a nomenclature not a classification
Epidemiology: how much do I need to know?
• Clinical features (don’t overdo this)
• Time (secular trend - last 50 years, more recent)
• Place
• Person
age, sex, socio-economic
ethnic, occupation, familial
lifestyle
• Causes & determinants
THINK ABOUT SOURCES of knowledge (e.g. ‘CHD is declining’)
==========================================================
[Infections: covered later]
Neoplasms:
*Breast
*cervix,
*colon,
*lung,
*skin (melanoma and SCC)
Metabolic, endocrine:
*Diabetes mellitus
Psychiatric:
*Schizophrenia,
*dementia
*suicide,
deliberate self harm
Nervous system:
CVD
*CHD
*stroke
Abdominal aortic aneurysm
Respiratory
*asthma,
*chronic bronchitis
Trend summary E&W deaths 1990 – 1999 :
CHD, stroke, asthma, bronchitis: down [smoking]
Digestive:
Caries
peptic ulcer -> Helicobacter
Perinatal
SIDS
Congenital and hereditary
Down syndrome
Injury & poisoning
Falls
Epidemiology of lifestyle
*smoking,
*alcohol,
*sexual behaviour
*diet (obesity)
*exercise
Syllabus: ‘the effects on health of different diets (e.g. the ‘Western diet’), obesity, physical activity, alcohol, drugs, smoking, sexual behaviour and sun exposure
1 HEALTH ECONOMICS
Health economics: principles of health economics (including the notions of scarcity, supply and demand, marginal analysis, distinctions between need and demand, opportunity cost, discounting, time horizons, margins, efficiency and equity); assessing performance; financial resource allocation; systems of health and social care and the role of incentives to achieve desired end-points; techniques of economic appraisal (including cost-effectiveness analysis and modelling, cost-utility analysis, option appraisal and cost-benefit analysis, the measurement of health benefits in terms of QALYs and related measures); marginal analysis; decision analysis; the role of economic evaluation and priority setting in health care decision making including the cost effectiveness of Public Health, and Public Health interventions and involvement.
Perfect market
| |Elective surgery |Specialist psychiatry |
|Many sellers (and buyers) | | |
|Free entry (and exit) | | |
|Perfect information | | |
|Homogeneous product | | |
No externality: I pay, someone else benefits (e.g. host purchaser / infrastructure costs)
Risk pools (Insurance systems)
1. Rare event
2. High cost
3. Population demand predictable
4. Individual's probability of demand independent
adverse selection
moral hazard
1 Economic appraisal
Measurement of COST
Marginal vs unit costs (and benefits):
e.g screening interval, change in admissions
Incremental cost
Opportunity cost
Direct vs indirect
Tangible (can invoice / bill for this) vs intangible (pain, suffering etc)
Discounting
• future costs
• ?discount future health benefits
• NICE recommends 3.5% annual discount for costs and health benefits
• Cost effectiveness:
Cost minimisation – (e.g. to achieve no Hep B in drug users)
Sensitivity analysis
• Cost utility:
Step 1: Assess health state after treatment using Quality of Life scale e.g. EQ5D
Step 2: Place a value (utility) on that health state
(e.g. on a rating scale score of 0 – 100)
Could use time trade off or standard gamble instead of rating scale
Disability weighting: see
Stouthard MEA et al. Disability weights for disease. Eur JPH 2000; 10: 24 – 30
• Cost benefit:
Used by government to decide whether or not to go with a programme: overall cost to society
Air pollution clean up:
cost £785m - £1100m estimate for UK
12,000 - 24,000 deaths in 1996 (COMEAP)
Do costs outweigh benefits?
May need to value life:
“Gross output”
Willingness to pay
Pay to reduce road deaths
Pay for risky occupations
Willingness to spend (e.g. for a smoke alarm)
2 Decision analysis
Economic appraisal plus sensitivity analysis
May also involve decision tree
diabetic-retinopathy.screening.nhs.uk
Also Richardson WS et al JAMA 1995; 273: 1292 - 5
3
4
5
6 Option appraisal
Where should paediatric cardiac surgery take place?
Efficiency: generally about getting the most out of your resources
Cost efficiency – no money wasted
Technical efficiency – no inputs wasted i.e. no kit, staff, standing idle
[Doesn’t work when you’re comparing different mixes of inputs and outputs
cf option appraisals]
Allocative efficiency – can’t give A more without taking from B i.e. no surplus
OR Technical – do CABG as cheaply as possible
Allocative – allocate funds for anti-smoking (achieves more / more efficient CHD reduction)
Equity
vertical: greater resource for greater need
horizontal: equal resource for equal need
Equality - of what?
• Equal spend per person
• Equal spend for equal need
• Equal spend for equal benefit
SOCIAL SCIENCES
1 Sociology
‘study of individuals in groups and social formations’ (Lawson and Garrod) includes institutions
Organisations and management
Social identity – age class gender race
Family and friendship
Power and class (Marxism?)
Work including professions and status
Norms and deviance, discrimination
Social welfare, education etc
2 Qualitative methods
The principles of qualitative methods including semi-structured and in-depth interviewing, focus groups, action research, participant observation, and their contribution to public health research and policy; their appropriate use, analysis and presentation; the ethical issues which may arise; validity, reliability and generalisability; common errors and their avoidance; strengths and weaknesses.
1 Capturing qualitative data
ethnography
long interview
diary
analysis of documents and images
2 Qualitative analysis:
grounded approaches
semiotics (symbolism)
discourse analysis / repertoires
3 Rigour in qualitative studies:
Researchers' perspective (e.g. feminist)
Full description of fieldwork method
Subject selection
Recording (e.g. tape plus transcription)
Main results
Verbatim quotes
Exceptions noted (e.g. help seeking and masculinity)
Concepts of health, wellbeing and illness and aetiology of illness: the theoretical perspectives and methods of enquiry of the sciences concerned with human behaviour; illness as a social role; concepts of health and wellbeing; concepts of primary and secondary deviance; stigma and how to tackle it; impairment, disability and handicap; social and structural iatrogenesis; role of medicine in society; explanations for various social patterns and experiences of illness (including differences of gender, ethnicity, employment status, age and social stratification); the role of social, cultural, psychological and family relationship factors in the aetiology of illness and disease; social capital and social epidemiology.
Health care: different approaches to health care (including self-care, family care, community care, self-help groups); hospitals as social institutions; professions, professionalisation and professional conflicts; the role of clinical autonomy in the provision of health care; behaviour in response to illness and treatments; psychology of decision-making in health behaviour.
Epilepsy ‘from a sociological perspective’ ?
3 Concepts of health and illness
Culture and health beliefs: (your culture = your rules on how to eat / drink / etc)
Cultural beliefs about the body
Shape: beautiful baby competitions
Size: bodybuilding
Clothing: white coat
Surface: no hat = catch cold
Anatomy: circumcision
Physiology: no concept of brain death = no transplants (Japan 1997)
Culture and diet
Junk food
Moslem / Hindu / Jewish
"Plain" food
Spraying mercury (Cuba, Dominica, Puerto Rico)
Ayurvedic and Chinese medicine (lead, mercury, arsenic)
Mildred Blaxter on lay concepts of health (mostly age related):
Health and lifestyles London: Routledge 1990 Table 3.1
May include community values (‘Healthy Hawaiian’)
Kleinman on how people do health care (think cold, headache, backpain)
Zola – triggers to seeking professional help
Illness as a social role (Parsons)
Iatrogenesis (Illich) Assets/3621.php
Clinical – adverse effects of drugs
Social – childbirth as a clinical event
Structural or cultural - “stripping away from human culture of ways of coping with pain, birth and death and their replacement by a sanitised technological medical intervention”
Colpo d’aria
“Oh, the dreaded Colpo d’Aria! If you’ve suffered a Colpo d’Aria you’ve been struck by some moving air, most probably chilly air, and most probably on your chest or perhaps the back of your neck. If you live in Italy, it can be deadly; ask any Italian! I’ve heard Colpo d’Aria blamed for everything from stiff muscles, to inner ear infections, chest colds and even heart attacks. I have not yet heard anyone say that a Colpo d’Aria caused his cancer, but that, and gum disease, are about the only illnesses for which a stiff breeze has not been held responsible.
Fortunately there is some good treatment available should you fall victim to an evil air current. The first thing you want to do is go to the pharmacy and get a bastone di zolfo, a stick of sulphur.”
Sociology of health care
Professions
According to Freidson (1970), a profession
1. controls entrance into the ranks;
2. professional expertise is not a commercial property;
3. control of practice is exercised by professional colleagues; and
4. the primary mechanism for quality control is personal responsibility and integrity.
Related to autonomy in clinical practice
Hospitals as social institutions: LS and acute (Goffman on asylums)
Asylum
Prison
Factory
Business
University
City
4 Deviance
Implications of labelling behaviour for organic and psychiatric disease
Illness as deviance and doctor as agent of social control: ?smoking, homosexuality, alcohol, obesity?
Primary and secondary deviance
Stigma
Disability and handicap
e.g. Intellectual impairment > learning disability > mental handicap
Handicap pejorative in US
WHO now suggests ‘abilities’ and ‘participation’
5 Variations in health
Explanations for socio-economic patterning of ill health
Current, early life or life-course:
• Lifestyle
• Material
• Drift
• Psycho-social stress
Explanations for area differences:
• Composition
the type of people who live there
social capital?
• Physical
climate
facilities (food supply, health services etc)
6 Social factors in the aetiology of illness
1 Social health
Social breakdown as a cause of illness
Durkheim – anomie (lack of rules / order) and suicide rates
Effect of divorce on health
Kawachi on census measures of fragmentation
Income inequality (Wilkinson)
e.g. Brazil / Cuba:
Brazil higher MEAN income but more inequality / worse infant mortality
Social capital: a social construct:
• Existence of community networks
• Participation in networks (civic engagement)
• Having a local identity and sense of solidarity
• Having norms of trust and reciprocal help and support
Equality, equity and policy: concepts of need and social justice; priorities and rationing; balancing equity and efficiency; consumerism and community participation; prioritisation frameworks and equity of service provision; public access to information; user and carer involvement in service planning; problems of policy implementation; principal approaches to policy formation; appreciation of concepts of power, interests and ideology; inequalities in the distribution of health and health care and its access, including inequalities relating to social class, gender, culture and ethnicity, and their causes; health and social effects of migration, and the health effects of international trade; global influences on health and social policy; critical analysis of investment in health improvement, and the part played by economic development and global organisations
HEALTH §
Principles and practice of health promotion: collective and individual responsibilities for health, both physical and mental; interaction between, genetics and the environment (including social, political, economic, physical and personal factors) as determinants of health, including mental health; ideological dilemmas and policy assumptions underlying different approaches to health promotion; the prevention paradox; health education and other methods of influencing personal life-styles which affect health; appropriate settings for health promotion (e.g. schools, the workplace); the value of models in explaining and predicting health-related behaviour; risk behaviour in health and the effect of interventions in influencing health related behaviour in professionals, patients and the public; theory and practice of communication with regard to heath education; the role of legislative, fiscal and other social policy measures in the promotion of health; methods of development and implementation of health promotion programmes; community development methods; partnerships; evaluation of health promotion, public health or public policy interventions; international initiatives in health promotion; opportunities for learning from international experience.
Disease prevention, models of behaviour change: evaluation of preventative actions, including the evidence base for early interventions on children and families, support for social and emotional development; pre-determinants of health including the effect of social cohesion on health outcomes; approaches to individual behaviour change including economic and other incentives; the role social marketing; involvement of the general public in health programs and their effects on health care; concepts of deprivation and its effect on health of children and adults; the benefits and means of community development, including the roles and cultures of partner organisations; health impact assessment of social and other policies; the role of strategic partnerships and the added value of organisations working together; the role of setting targets and goals .
1 Strategy in health promotion
Health promotion framework
• Legislative
Fiscal: tax (e.g. tobacco) or subsidy (e.g. free school fruit)
Legal
• Health service:
Health authority
Hospital
Primary care (Med, Den, Pharm)
• Other players
Voluntary
District councils (Environmental health, housing, leisure)
County (schools, transport)
Others: police?
Use this for: smoking – diet – exercise – alcohol - IVdrugs – falls - teen pregnancy
Social marketing – four ‘P’s aimed at ‘social good’
‘Product’ (or ‘proposition’) - brand / message / desired behaviour
Place (setting) - school, workplace , home
Promotion - e.g. paid adverts, free publicity, giveaways
Price - free / subsidised
Includes concepts of
consumer focus
market segmentation
2 Running programmes
Models of health behaviour
• Becker and Maiman Health beliefs model
• Social learning
• Locus of Control: Internal / external
• Prochaska & DiClemente 1984 stages of change
Susan Michie Behaviour Change Wheel
Development, implementation and evaluation of health promotion
• Karelia [Heartbeat Wales]
• The ASSIST study
• SureStart evaluations
Early intervention
Preschool day care in deprived populations – 1960s onwards
(Cochrane review – 8 studies, all USA)
Perry Pre School project / Head Start (USA);
Sure Start
Parenting programmes (Sarah Stewart-Brown)
Parenting skills for teenage mums (Cochrane review – 4 studies)
3
4 Environment
Environmental determinants of disease; risk and hazard; the effects of global warming and climate change; principles of sustainability; methods for monitoring and control of environmental hazards including: food and water safety; atmospheric pollution and other toxic hazards, noise, and ionising and electromagnetic radiation; the use of legislation in environmental control; health impact assessment for environmental pollution; transport policies;
Monitoring of :
• Food
• Water
• Air
Smoke, SO2, NO2, ozone; radiation; cigarettes
Smoke: London smog: 500 microgm / m3; = ten times current
Radiation:
Bq
Gy
Sv
general population limit: 5 mSv / yr
UK exposure 2.6 mSv / yr
of which 50% Radon, further 35% natural.
97% of artificial exposure is medical
10 weeks in Cornwall = 50 Chest X ray = 250 hours long haul = 1 mSv
CT of chest = 8mSv
Non-ionising radiation
Power lines and cancer
Acute episodes:
Mercury contamination:
Bhopal
Goiania
Emergency planning: PLAN – PREPARE – RESPOND – RECOVER - RECORD
The health problems associated with poor housing and home conditions, inadequate water supplies, flooding, poor sanitation and water pollution
Physical health
Damp housing
Overcrowding and TB – slum clearance and the MoH
Shanty towns and typhus
Mental health
Social health
Evidence based housing interventions:
Pest control
Keeping the house dry and removing mould
Radon
Smoke-free
Lead control
Smoke alarms
Swimming pool fencing
Preset water temperature
Housing RCTs – heating and insulation (NZ); poor vs rich neighbourhoods (Chicago)
Water supply and sanitation
Sustainability
1
2
3 Health at work
appreciation of factors affecting health and safety at work (including the control of substances hazardous to health); occupation and health;
Occupational hazards in the NHS – biol and chem.
Famous occupational diseases
Radiation workers
Coal miners
Furniture makers in High Wycombe
Wool sorters disease
5 Nutrition
principles of nutrition, nutritional surveillance and assessment in specific populations including its short and long term effects; the influence of malnutrition in disease aetiology, pregnancy, and in growth and development; markers of nutritional status, nutrition and food; the basis for nutritional interventions and assessment of their impact; social, behavioural and other determinants of the choice of diet; Dietary Reference Values (DRVs), current dietary goals, recommendations, guidelines and the evidence for them; the effects on health of different diets (e.g. “Western” diet)
Methods
Diary – record or weighed
FFQ
Blood measurements
Studies
Clinical observation
Ecological – 7 countries, InterSalt
Whole diet - Mediterranean
Intervention
component – Beta-carotene, DASH
whole diet – Atkins etc
Classic deficiency diseases
Pellagra
Goitre and cretinism
Vitamin A, iron, zinc – third world
Food fortification
Iodised salt
Folate (USA)
‘Western diet’
Total energy (calorie intake)
Fat
Fibre (non starch polysaccharide)
Salt
Current dietary goals and recommendations:
Whole population
2500 kcal = 10,000 kJ; chisquared test
[More than two columns – perhaps chisquared for trend]
People } bigger}
2. “Is one group of towns } wiser } the other one?”
Numbers} different from}
Analysis of variance (ANOVA):
• one way: e.g. blood pressure mean in different racial groups
• two way: e.g. blood pressure mean by sex in different racial groups
Special case of this is :
t test - model for difference in means,
Validity assumptions: what you’re measuring is (1) Normally distributed and (2) has same variance in populations from which groups / sample drawn (may not know this for sure and have to use the samples to guess) and (3) measurements are independent of each other
Non parametric version: Mann Whitney U test etc [e.g. SF36]
3. Matched pairs – McNemar’s chisquared test for discordant pairs
[McNemar’s statistic: (A-B)2 / A+B : same ‘how often that big’ i.e. distribution as chi-squared]
1 Parametric and non parametric
• Parametric:
“IF we can assume that in these people [blood pressure] is Normally distributed,
THEN this is a very odd [low P] result…...”
• Non parametric:
“………But it isn’t so odd if [blood pressure] isn’t Normally distributed”
So: parametric tests more powerful [likely to produce low P / declare significant] provided assumptions justified.
B: ASSOCIATION i.e. “PLEASE PUT ME ON A SCATTERGRAM”
Pearson product moment [= least squares] - parametric
Spearmann rank correlation – non parametric
Multiple regression
[Cronbach’s alpha for internal consistency of e.g. a questionnaire
kappa statistic for agreement between raters e.g. reading a mammogram]
C: SURVIVAL
Cox proportionate hazards model - parametric
Log rank – non parametric
D. TIME SERIES
Simple stuff:
Inspect the graph: trend, seasonality
Annual totals: up or down?
Moving average to smooth out
Predictive models e.g. does daily up and down of particulates in air predict daily up and down of hospital admissions?
Serial correlation: auto regressive (AR) to cope with serial correlation
Moving average (MA) to smooth bumps
Hence ARMA or ARIMA models – too advanced for Part A!
Scales
Nominal
Ordinal
Interval
Ratio
Kappa – measure of agreement for nominal scales e.g. do two judges put observations into same categories?
2 Three famous models
These all function by converting numbers into probabilities
(i.e they are probability density functions)
You have to specify some things about the model (cf "what scale is this model aircrcaft?")
To model:
• Toss up (yes / no event): binomial function (specify expected proportion of yes/no)
• Count (whole number): Poisson function (specify mean / expected number for thing you are modelling)
NB admissions are a count, bed days are not
• Rate (e.g. age standardised death rate): Normal Gaussian function (specify mean and sd of the thing you are modelling)
doi: 10.1093/ije/dyr101
SBP DBP
Europeans (n=149) 140 (sd 17) 82 (sd 10)
Punjabi Sikh (n=151) 144 (sd 17) 82 (sd 8)
COMMUNICABLE DISEASE
definitions (incubation, communicability and latent period; susceptibility, immunity, and herd immunity); surveillance - national and international -, its evaluation and use; methods of control; the design, evaluation, and management of immunisation programmes; choices in developing an immunisation strategy; the steps in outbreak investigation including the use of relevant epidemiological methods; emergency preparedness and response to natural and man-made disasters; knowledge of natural history, clinical presentation, methods of diagnosis and control of infections of local and international Public Health importance (including emerging diseases and those with consequencies for effective control); organisation of infection control; a basic understanding of the biological basis, strengths and weaknesses of routine and reference microbiological techniques (see also 2d); international aspects of communicable disease control including Port Health.
epidemic theory (effective and basic reproduction numbers, epidemic thresholds) and techniques for infectious disease data (construction and use of epidemic curves, generation numbers, exceptional reporting and identification of significant clusters);
================================================================
Surveillance
(NB this is an information activity)
High quality surveillance is:
Accurate
Complete
Timely
Cost-effective
(Anything else?)
Purpose of surveillance – POWER! (Thanks to Anj Saha)
Priorities for resource allocation
Outbreaks detected early
Warning system
Evaluate effectiveness of interventions
Risk groups characterised
Special arrangements: AIDS, leprosy
Enhanced surveillance, salivary diagnosis
Disease control
Surveillance
How is it spreading?
Any risk groups?
Basic science for new diseases e.g Ebola, MERSCoV
Diagnosis
Diagnostic techniques
Access to diagnosis
Screening
Treatment
Access to health services
Compliance with treatment
Prevention
Specific - imm & vacc programmes
General – sewage / enough food / good housing etc
Contacts
Identification and management of contacts
Hepatitis B control:
1. Surveillance
2. Screening blood products & organ donations
3. Sterilisation of sharps inc non-medical (eg tattoos)
4. Safe disposal of Sharps
5. Stab! ie vaccinate risk groups
6. Safe sex &needle exchange education
Epidemiology in outbreak investigation and control: Galbraith
PROCESS AND TASKS
• Confirm facts
• Immediate measures : to contain / treat illness
• Case definition - > case finding: Full extent in time and place
• active
• enhanced surveillance
• Descriptive epidemiology: e.g. all babies / ethnics / swimmers
• Hypothesis: usually mode of spread, sometimes cause
• Test hypothesis
• Action: e.g. Broad St pump
[Media handling - usually not for Part A]
Molecular epidemiology:
e.g. whole genome sequencing for TB control
Emergency planning (SARS, pandemic influenza):
• Plan
• Prepare (stockpiles etc) and Prevent (vaccinate)
• Respond
• Recover (from the event including psychological care)
• Record
Communicable disease – how much do I need to know?
AgORMICS and PIDQUICS
1. Clinical – one line only
2. Agent: Is it virus / bacteria / protozoa etc;
How do you diagnose it?
3. Occurrence in named country
(e.g. winter epidemics / sporadic / imported cases only)
4. Reservoir
5. Mode of transmission:
(parenteral / faecal-oral / something else),
6. Incubation (omit unless you’re sure)
7. Communicability (e.g. communicable while still excreting in stool)
8. Susceptibility and resistance (e.g. infection confers resistance)
or: (exam comments Jan 99): Identification, Causative Organism, incidence, reservoirs, how transmitted
2. Control: prevention, control of case: isolation, disinfection, quarantine, immunisation, contacts, specific measures, [PIDQUICS], ? epidemic measures
Food poisoning:
Salmonella (enteritidisPT4)
Shigella
Campylobacter
Cryptosporidiosis
Listeria
E coli 0157
Typhoid
Cholera
Meningitis:
Meningococcus
Haemophilus
Pneumonias
Pneumococcus
Legionnaires
TB** Mantoux, γ interferon tests etc
Viral fevers Ebola, Lassa
Dengue
Zika
Hepatitis
A
B
C
Immunisable
D: inc cutaneous
P
[T]
polio: OPV vs IPV
[M]
M inc SSPE
R
HIB
Sexual:
Chlamydia
Gonorrhoea
Syphilis
HIV
SARS and other corona viruses
Herpes
Influenza: vaccine, treatments, surveillance
Rabies
Lyme disease
Q fever
Plague – Madagascar
Giardiasis
Head lice
Scabies
Toxocara
Toxoplasma
Malaria
ORGANISATION AND MANAGEMENT - theory
Internal and external organisational structures environments; evaluating internal resources and organisational capabilities; identifying and managing internal and external stakeholder interests; structuring and managing inter-organisational (network) relationships, including intersectoral work, collaborative working practices and partnerships; social networks and communities of interest; assessing the impact of Political, economic, socio-cultural, environmental and other external influences
Motivation, creativity and innovation in individuals, and its relationship to group and team dynamics; barriers to, and stimulation of, creativity and innovation (e.g. by brainstorming); learning with individuals from differing professional backgrounds; personal management skills (e.g. managing: time, stress, difficult people, meetings); the effective manager; principles of leadership and delegation; principles of negotiation and influencing; principles, theories and methods of effective communication (written and oral) in general, and in a management context. Interactions between managers, doctors and others; the theoretical and practical aspects of power and authority, role and conflict; professional accountability - clinical governance, performance and appraisal; behaviour change in individuals and organisations.
1 Organisations
Describing an organisation:
7 S
Some common Structures:
• Divisional
• Functional teams
• Matrix
Handy on Styles
Culture
Management and Change: management models and theories associated with motivation and leadership and change management, and their application to practical situations and problems; critical evaluation of a range of principles and frameworks for managing change; an understanding of the issues underpinning the design and implementation of performance management against goals and objectives
2 Change
Gleicher’s formula:
Dissatisfaction x vision x first steps > resistance
Susan Michie Behaviour Change Wheel
PEST
SWOT (Ansoff)
1
2
3 Innovation
Innovators: High SES and “cosmopolitan” (Coleman)
2.5% innovators > 13.5% early adopters > 68% majority > 16% laggards
Network theory
Cliques and hierarchies (Newton)
Innovations will spread quickly (Ryan & Gross, Iowa) if:
• Relative advantage
• Compatibility
• Simplicity
• Can Trial
• Observable benefit
Red Cabbage Sounds Too Organic!
3 Leadership
Theories about leadership:
1. Trait - [intelligence, self confidence, persistence, etc - also charisma] – the hero
2. Skills – US military [knowledge, problem solving, social judgement]
3. Contingency: “best fit” between leader, led, task
Public health leaders (Day et al):
Mentor
Shape
Network
Know
Advocate
Microscopic sheep need kingsize armbands
1 Motivation
Maslow
McGregor
Social power (French and Raven 1959)
Expert: technical
Legitimate: obligations
Reward: pay etc
Referent: makes me feel valued
Coercive: make life difficult for
2 Negotiation
(Fisher and Ury: Harvard Negotiation Project “Getting to Yes”)
• Separate the problem from the people (not “He doesn’t understand”)
• Focus on interests not positions (‘family friendly’ not ‘home at 3.30pm’)
• Invent options (e.g. crèche, school taxi service, etc etc)
• Objective criteria (e.g. meets requirements of Care for the Family Charter)
• Work on BATNA
4 Groups
1 Within the group
Adair: group needs, task needs, individual needs: - NB ALL THREE must be met
Belbin roles
Plant (ideas)
• Resource investigator
• Team worker (hugs everyone)
• Completer / finisher
• Specialist (technical expertise)
• Etc
Tuckman: Forming – storming – norming – performing
Polite hello – big rows about basics – consensus – on with the task
2 Between groups
Lingard’s concepts of ownership and trade
Managing people
Job design
Selection
Appraisal
6 Self management
Assertiveness
Time management
Delegation
7 Miscellaneous
1 Creativity
Group
Brainstorm
Time out
Knowledge management
Personal
Play
Mind map
Art
2 Delegation
• Explain
• Train
• Monitor
• Praise
“Delegate responsibilities not tasks”
3 Effective communication
Written
Customer focussed
Short words – short sentences
Technical language appropriate to readership
Spoken
Remember non verbal aspects
Two way!
8 MANAGEMENT GURUS
1 Models
Taylor: “Scientific management” c. 1910 - the one best way to do things
e.g. doctor to patient in A&E
Fayol: 1910 / 1950 – 5 tasks of management:
• Plan, Organise, Co-ordinate, Command, Control
Mayo: c.1930 – Hawthorne experiments – social processes at work
i.e. morale matters!
Mintzberg: c.1975 – what managers do (mostly muddle through)
• Interpersonal - figurehead, leader, liaison
• Informational- monitor, disseminate, spokesman
• Decisional – entrepreneur, disturbance handler, resource allocator, negotiator
Motivation:
McGregor: X (lazy) and Y (great people)
Maslow: Hierarchy of Needs [NB once a want is satisfied it is no longer important]
Mayo: see above
Herzberg: 1959 Motivation to work –
• Satisfaction = Motivators – achivement, recognition, career progress etc
• Dissatisfaction = ‘hygiene’ factors – status, salary, work conditions, company policy
Running health services
c) Approaches to the assessment of health care needs, utilisation and outcomes, and the evaluation of health and health care: the uses of epidemiology and other methods in defining health service needs and in policy development; participatory needs assessment; formulation and interpretation of measures of utilisation and performance; measures of supply and demand; study design for assessing effectiveness, efficiency and acceptability of services including measures of structure, process, service quality, and outcome of health care; measures of health status, quality of life and health care; population health outcome indicators; deprivation measures; principles of evaluation, including quality assessment and quality assurance; equity in health care; clinical audit; confidential enquiry processes; the use of Delphi methods; economic evaluation (see also 4.d); appropriateness and adequacy of services and their acceptability to consumers and providers; epidemiological basis for preventive strategies; health and environmental impact assessment.
1 Funding of health services
Taxation – general or hypothecated
Insurance – personal or ‘social’
Personal savings (‘provident’)
Patients belong as:
Citizens (e.g. NHS)
Employees (e.g. armed forces)
Customers (e.g. HMO)
NB Most countries have all of these – key issue is which one dominates
International comparisons: USA, Germany
2 Resource allocation
• Population size
• Age
• Morbidity – proxy by mortality (SMR) and LLSI (Census)
Policy and strategy development and implementation: differences between policy and strategy, and the impact of policies on health; principles underpinning the development of policy options and the strategy for their delivery; stakeholder engagement in policy developing, including its facilitation and consideration of possible obstacles; implementation and evaluation of policies including the relevant concepts of power, interests and ideology; strategy communication and strategy implementation in relation to health care; theories of strategic planning; analysis, in a theoretical context of the effects of policies on health; major national and global policies relevant to public health; health service development and planning; methods of organising and funding health services and their relative merits, focusing particularly on international comparisons and their history;
Health and social service quality risk management; principles underlying the development of clinical guidelines, clinical effectiveness and quality standards, and their application in health and social care; integrated care pathways; public and patient involvement in health service planning; professional accountability, clinical governance, performance and apprasial; historical development of personal health services and of public health.
2 Policy formulation
Central policy: Power, ideology in health policy formation
• Ideology e.g. centralise or localise, competition or planning, consumerism vs technical (maternity services)
• Special interests e.g. professional, commercial (tobacco, drugs)
• Data e.g. Euro data on cancer survival
• Expert advice e.g. vCJD, SARS, flu policy
Local policy: Consumer and community participation
• Focus groups, opinion polls etc
• Citizen’s jury
• GP as proxy for local public
• Non executives on local Boards
John Kingdon framework for policy development
3 streams:
Problem stream
Proposals stream
Political stream
Need to align to provide a policy window
Lindblom Muddling through – rational incrementalism
HOW COMMISSIONING WORKS
PLAN
Assess need
Does proposal meet the need? (Evidence review)
Write specification
Procure capacity
Number work
FUND
Prioritisation
Fair decisions (Theories of justice)
Contract type
MONITOR
Overview
Service
Event
Use of information for health service planning and evaluation; specification and uses of information systems; common measures of health service provision and usage; the uses of mathematical modeling techniques in health service planning; indices of needs for and outcome of services; the strengths, uses, interpretation and limitations of routine health information; use of information technology in the processing and analysis of health services information and in support of the provision of health care; principles of information governance
3 Planning
Need = ability to benefit (Stevens)
Need / demand / supply : Bradshaw
Symptoms not the same as need (stoical patients)
Assessing needs for a population (e.g. immigrants)
• Physical health:
Public health programmes:
Imm and vac
Screening
Lifestyle
Primary care
Medical
Dental
Pharmacy
Specialist (same as anyone else)
• Mental health: e.g. depression / anxiety / post traumatic etc
• Social health: e.g. keep groups together, language culture etc
Joint strategic needs assessment
Asset based needs assessment
Planning capacity – numbers
Assessing needs for a specific condition or service (e.g. arthritis, ECMO)
• Epidemiological
Definition
Numbers
absolute e.g. incidence
marginal e.g. waiting times
norms
Model of care
• Comparative
Neighbouring services
• “Corporate need”
Government policy
Stakeholder views
4 Funding
1 Priority setting
Government policies
Local opinion
Economic evaluation
Strength of evidence
Justice
• Bentham
• Rawls
• Procedural
Procedural justice and IFRs
2 Types of contract
Block / capitation
Tariff / item of service
Finance, management accounting and relevant theoretical approaches: the linkages between demographic information and health service information - its public health interpretation and relationship to financial costs; budgetary preparation, financial allocation, contracts and service commissioning; methods for audit of health care spending.
2 NHS finance systems
Budget reports usually show:
Pay (staff salaries)
Non Pay (e.g. drugs and equipment)
Spend:
year-to-date
forecast to year end
Separate recurrent from non-recurrent (e.g. buying a piece of equipment)
Non-recurrent = ‘capital’ spending
5 Monitoring
1
1 Performance - overview
Outcome framework for NHS in England – 5 ‘domains’
• Effective
o Prevent premature death
o Good QoL for long term conditions
o Recovery from acute episodes
• Good experience
• Safe
Quality outcomes framework (QOF) for GPs
2 Performance – evaluation of a service
Donabedian: process, structure, outcome
• structure e.g. beds, opening hours, staff qualifications and numbers etc.,
• process e.g. number of admissions. Operations
• outcome
3
4 Performance - exceptional events
• Confidential enquiries
• Sentinel audit
• Untoward incident – ‘never’ events
Root cause analysis – active errors and latent errors
=========================================================
5 Governance and risk management
• How serious?
• How likely?
Risks to:
• Patients
• Staff
• Buildings & equipment
• Reputation
migration, and the health effects of international trade; international influences on health and social policy; critical analysis of investment in health improvement, and the part played by economic development and global organisations
6 International health care
Infections e.g. SARS
People going abroad for treatment
Tourists
People retiring e.g. to Spain
Immigrants
Border issues
7 Social policy
“role of state in relation to welfare of citizens”
SHEESH
• Social security
• Housing
• Education
• Employment
• Social services
• Health
Michael Hill Understanding social policy 6th ed Oxford: Blackwell 2000.
A good read.
TIPS ON EXAM TECHNIQUE
1
2 PREPARATION
You MUST get enough sleep for the five days before the exam.
Dement WC. The promise of sleep. London: Macmillan 2001
Book diary time for revision, but Benedict Carey (‘How we learn’) says that following a routine of same time, same place may not be optimal. It’s ok to potter, mull things over etc.
Always quickly revise what you did yesterday – that’s an important aid to memory. (Ideally do it again a week later too.)
Don’t just read passively - test yourself.
Buy a watch or clock with a big face; analog not digital.
3 GENERAL
1. WATCH YOUR TIMING!
Paper IA and IB: 25 minutes per qq: 5 minutes to plan; 20 minutes to write.
When allowed to open the paper, write down the start time opposite each question:;
10.00; 10.25; 10.50; 11.15; 11.40; 12.05
2.00; 2.25; 2.50; 3.15
If you’ve gone over the allotted time on a question - or part of a question –
STOP WRITING AND MOVE ON!
Paper IIA: The exam assumes you will take 50 minutes to read the article. You can then allow one minute per 1% of marks i.e. 40 minutes for 40% of the marks. Again:
If you’ve gone over the allotted time on a question - or part of a question –
STOP WRITING AND MOVE ON!
Paper IIB: 5 questions in 90 minutes = 18 minutes per question.
2. HEADINGS
You must structure your answer. The easy way to do this is to use headings: two per page.
No headings needed if, as if often the case nowadays, the question is broken down into many parts.
3. EXAMPLES
Give examples: name authors ; cite studies
Rule #1: If the example is implicit in the question (e.g. ‘discuss screening for colorectal cancer’) stick to that, don’t wander off
Rule #2: If the example is not implicit in the question (e.g. ‘discuss quality assurance in screening programmes), use a wide variety of examples
4. CRITIQUE
Explain everything: Say ‘because…’ ‘hence’ ‘and so’ as often as possible!
Give both sides of any argument: ‘on the one hand...’ ‘on the other hand’
Point out any limitations e.g. of data sources, problems with somebody’s theory etc etc
5. AMOUNT
You need to write about 250 words every ten minutes i.e. about 2-3 sides of A4 for a 20 minute answer when practising (The exam answer paper has very wide margins so you will cover more paper.)
4 PAPER I
If you can't think of a better structure:
For short questions e.g. "write short notes on":
• What is it? (definition if possible but if not talk around it)
• What do people use it for? – give an example
• Something in favour
• Something against
and, if time allows:
• Current issues in.....
OR for more social / management questions:
• Definitions and subcategories of the problem
• How to tackle the problem
• How to prevent the problem
General frameworks
Mind map:
Method:
• Underline the key word in the question
• Construct mind map of anything that comes to mind
• Fill out mind map with names / data / case studies
• Add in some topical examples
• Number main areas of map to give the order for your main paragraphs
• Always start with points on definitions
Basic roles of public health:
• Health improvement e.g. lifestyle programmes
• Health protection e.g. vaccination programme, outbreak response
• Health services e.g. screening programmes, commissioning
• Health intelligence e.g. surveillance of trends etc
• [Academic – R&D] e.g. basic research
Epidemiology
1. If ‘describe the ep of’:
• Time [secular trends - 50year, more recent]
• Place [UK, Euro, world]
• Person
• age / sex / soc cl
• ethnic / occupations / lifestyles
• familial / genetic
• any other famous facts?
FILL OUT the answer by thinking about the quality of study / data (e.g. ascertainment)
2. If ‘cause’ or ‘association’: Bradford Hill framework
3. 'What is the evidence?' or 'How would you study…?'
Consider evidence from:
Descriptive: time trend, spatial, people affected: do they fit the hypothesis?
Surveys
Case - control
Cohorts
Interventions
Remember studies in special groups e.g. high risk, occupational
Evaluation
If "how would you evaluate…" mention Donabedian then
• structure e.g. beds, opening hours, staff qualifications and numbers etc.,
• process e.g. number of admissions. operations
• outcome e.g. survival, quality of life
If "assess the performance of..."
Could use Donabedian, may need to consider performance framework:
Health improvement public health
Fair Access equity
Appropriate Delivery of effective health care EBM
Patient / carer experience complaints/survey
Outcome of NHS care audit
Needs assessment
If “assess the health needs of …" a group e.g. immigrants
• Physical health:
Public health programmes:
Hygiene – food water shelter
Imm & Vacc
Screening
Lifestyle programmes
Primary care: medical (e.g. skin / foot problems) dental, pharmacy
Specialist (same as anyone else)
• Mental health: e.g. depression / anxiety / post traumatic etc
• Social health: e.g. keep groups together, language culture etc
If “assess the needs for" a condition e.g. arthritis
• Epidemiological
Definition
Numbers (absolute e.g. incidence or marginal e.g. waiting times)
How do we meet the need now? (e.g. admit to orthopaedic bed)
Does this work? (e.g. how many get back to work?)
Other ways to meet the need (e.g. out patient phsyio, home exercise)
• Comparative
Royal College norms or standards
Neighbouring services
• Corporate
Government policy
Stakeholder views
Communicable disease / environmental health
Mention TASKS and MANAGEMENT PROCESS to achieve them
TASKS
Outbreak framework if possible
• Confirm facts
• Immediate measures : to contain / treat illness
• Case definitionS : definite, possible, probable
• Case finding: FULL EXTENT in time and place
• active
• enhanced surveillance
• Descriptive epidemiology: e.g. all babies / ethnics / swimmers
• Hypothesis: usually mode of spread, sometimes cause
• Test hypothesis
• Action: e.g. Broad St pump
MANAGEMENT PROCESS
OB plan, multiagency team, press releases etc
Similar can work for acute chemical exposure
Health information
Always consider all of (even if only to say “not much use”):
• Mortality
• Hospital: Inpatient, OPD / A&E, lab
• Primary care: Medical, [dental], prescribing, NHS Direct
• Register: e.g. cancer
• Surveys
• Non-health: fire, police, social services etc
Health promotion and disease prevention
Again TASKS and MANAGEMENT PROCESS
Health promotion framework:
• Legislative
Fiscal tax or subsidy
Bans
• Health service:
Local policy
Hospitals (treatment but also as a major local employer)
Primary care
• Local:
Schools
Leisure
Others e.g. transport, policy, voluntary groups etc
Short notes e.g. statistics, economics
What is it?
When would you use it? –give an example (preferably real, if not make a hypothetical)
Something good / useful
Something tricky / difficult
[Hot topics]
Sociology / social policy / management
Basic requirement is to match theories with facts.
Use one of the theories (see above: e.g. Maslow, Handy) as a way of describing how the world works.
Remember the big picture e.g. other agencies to involve in any practical problem:
• UP: Department of Health involvement; Colleges; GMC?
• SIDEWAYS: Colleagues in your organisation, neighbours (e.g.hospitals)
• DOWN: GPs, public
Social policy
Use the SHEESH headings, one paragraph about each:
Social security (disability benefit, pensions etc)
Housing
Employment
Education
Social service
Health
Ethics
Use the headings, one paragraph about each:
Good - how can this do good to the patient
Harm - how might this do harm to the patient
Autonomy (let people decide for themselves)
Justice (fairness to other people)
5 PAPER IIA: strengths and weaknesses
50 minutes to read the paper; 10 minutes for each 10% of the marks
Top tips:
1. ‘Strengths and weakness’ is only 40% of marks: remember the other 60%
2. It takes 30 minutes to write 600 words so take 10 minutes to PLAN the S&W answer fully
3. Say ‘… because’ a lot!
Technique is in two stages:
1. assemble material – see below
2. group into findings, strengths and weaknesses
Strengths and weakness – the task is to deliver 600 words on strengths and weakness, or 300 words on each. That’s two sentences ( = 25 words) of strengths and same again on weaknesses on each of the following 12 headings:
1. AIM
POPULATION
2. Main study population
3. Exclusions
METHOD
4. Design
5. Execution
6. Instrument
INTERVENTION
7. Design
8. Fidelity
RESULT
9. Big?
10. Chance (Type I and II errors)
11. Bias
12. Confounding
6 PAPER IIB: data skills
Reading graphs etc: – Data content – obvious features – possible interpretation
A general approach to reading tables
• Size (using common sense: high or low e.g. smoking rates all above 60%?)
• Spread (highest and lowest; spread out or clumped together?)
• Trend (is the Table in some order?)
• Variation by Gender / Age / Practitioners / Spatial (GAPS)
Interpretation: ABC E
Artefacts:
• Error e.g. typing mistake
• coding
Blip:
• P values / confidence intervals etc
• Consistency – time (blip?), sex (male AND female affected?) etc
Category:
• Primary into secondary
• Health / social care
Epidemiology of underlying disease or its risk factors
|LA Name |SMR CIRCULATORY DISEASE I00 - |CHD Admissions (SAR) I20|Angiography (SAR) K63 |IMD 2004 |
| |I99 |- I25 | | |
|Wigan |126 |113 |103 |29.3 |
|Salford |121 |108 |85 |38.2 |
|Allerdale |120 |88 |97 |22.9 |
|Lancaster |117 |87 |89 |22.3 |
|Liverpool |116 |124 |140 |49.8 |
|Carlisle |113 |104 |66 |22.2 |
|Barrow-in-Furness |108 |97 |112 |33.0 |
|Ribble Valley |107 |72 |62 |10.3 |
|Crewe and Nantwich |105 |98 |58 |17.1 |
|Chester |99 |76 |69 |17.0 |
|South Lakeland |97 |77 |81 |12.0 |
|Macclesfield |96 |73 |68 |11.2 |
| | | | | |
|Health Inequalities (2005). North West Public Health Observatory. .uk/information” |
| | | | | |
7 Some facts and figures
Basic facts and figures (England) for 250,000 people : all VERY approximate – designed for ease of remembering!
250,000 people
15% over 65
15% under 16
Smokers 20% of ADULT population; obese also 20% of adult popn
25 people HIV positive (more in London)
40 teenage (under 18) conceptions
--------------------------------------------------------------------------
Deaths per year: 2500 (1 in 100) = births per year!
CHD under 75yr : 200
Lung cancer 150
Bowel cancer 75
Breast cancer 50 deaths (100 cases / registrations)
Suicide 50
RTA 20
Cancer of cervix 5
Pregnancy with congenital anomaly:
Congenital heart disease: 10 (5 per 1000 births each)
Down syndrome, NTD, cerebral palsy: 5 each (1 per 1000)
------------------------------------------------------------------------
Screening: 1 or 2 cases per 1000 screened (breast: 12 cases / 1 per month)
------------------------------------------------------------------------
GP consults 1,250,000 per year
OP attendances 200,000 per year (of which 60 new, 140 old)
A&E attendance 75,000 per year
Hospital admissions: 50,000 per year
Emergency 40 / day; Elective 60 / day
AMI, stroke, O/D, pneumonia: each 1 or 2 per day / 400 per year
Hip replacement 4 per week = 200 per year
People with schizophrenia (point prevalence 1 in 1000): 250
--------------------------------------------------------------------------
Hospital docs 350; 100 consultant, 250 junior
GPs n = 250+ (list size c. 1800)
Attendances = 20% of popn every 2 weeks
NHS Dentists n = 125
Money: about £1000 per head = £250m for 250,000 people
£125m hospital; £25m GP drugs
8 Reports / briefing papers
"Write a report / briefing paper":
• Purpose: one sentence ‘The aim of this briefing is to …’
• Background
Scientific – ‘What is already known about this topic’
Policy: any government policies / NICE guidelines / NSFs?
• This data / report ‘What this study / data adds’
NB NO TECHNICAL TERMS – e.g. death not mortality, illness not morbidity etc etc, don’t quote P values or CIs
• Implementation
Likely views of:
Consultants
GPs
Public / patients
Any ethical issues?
Requirements for
more staff
equipment
buildings
Cost and cost per QALY (or similar)
• Conclusion and recommendation
_____________________________________________________________________
9 DATA PRACTICE: CALCULATIONS
1. Here is an extract from Doll’s data on death rates in British doctors followed for 35 years (BMJ 1992; 305 p1523)
Death rate per 100,000 men per year, age standardised by cigarettes smoked per day
| |0 |1-14 |15-24 |25 or more |
|Lung cancer |14 |100 |182 |327 |
|IHD |526 |752 |825 |956 |
|Chronic bronchitis |9 |77 |93 |180 |
|Suicide |25 |29 |32 |60 |
For each of the four conditions, calculate the excess risk associated with being a heavy (25 or more) smoker rather than a non smoker.
2. Patients with breast cancer were randomised to receive trastuzumab or placebo. After a median of 23.5 months follow up, 59 of the 1703 patients receiving trastuzumab had died, compared to 90 of 1698 patients receiving placebo. [Lancet 2007; 369: 29 – 36]
a. What is the relative risk reduction?
b. What is the absolute risk reduction?
c. What is the Number Needed to Treat?
3. I have invented a new scale for quality of life, and obtained scores from seven Part A MFPH students, which are as follows: 5, 6, 8, 9, 12, 15, 22.
a. What is the mean score in these seven students?
b. If we take that mean as an estimate of the mean score among all Part A students, what is the standard error of the estimate?
4. In a trial of medication review intended to reduce admissions to hospital of old people, the number of emergency hospital admissions in the intervention and control groups were as follows ()
[weighted average]
Number of admissions
| |0 |1 |2 |3 |4 |5 |6 |
|Intervention |253 |113 |34 |10 |3 |1 |1 |
|Control |281 |99 |26 |5 |3 |0 |0 |
a. Calculate the mean number of admissions per person in (a) the intervention and (b) the control group.
b. Would a t test be an appropriate way to judge whether the difference in mean admissions per person is due to chance?
5. In patients over 65 with newly diagnosed glioblastoma, the median overall survival was longer with radiotherapy plus temozolomide than with radiotherapy alone (9.3 months vs. 7.6 months; hazard ratio for death, 0.67; 95% confidence interval [CI], 0.56 to 0.80; P ................
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