1. Measurement and Finance H Edu 5100

2. Quantitative perspectives The size and demographic characteristics of the population The direct measures of health and ill health in a population Use of services

3. Census data Every 10 years Textbook numbers  1996 = 79.9% of lived in MSAs  1980 = 78%  1960 = 63%

4. Census data Textbook numbers  1998 = 48.9% male (49.1% in 2000 census) 87.3% non-Black (87.7% in 2000 census) 35.2 = median age (35.3 in 2000 census) 12.7% was 65 and over (12.4% in 2000) (80.2% lived in MSA from 2000 census)

5. Why? What do these data tell us? Why do we need them?

6. Epidemiology The study of how and why diseases are distributed in the population… Why some get sick and some don’t

7. Some key words… Study Distribution Determinants Health-related states Populations Control

8. 1/2 1 = numerator 2= denominator

9. Rate Denominator = 1,000 or 10,000 Base Comparisons

10. Rate Denominator = population at risk Numerator = the events The population at risk has to be all of the people or things that the numerator could have happened to

11. Remember… The numerator has to have all the events you’re measuring The denominator must include exactly the number that the numerator’s event could have happened to Rates with the same base can be compared

12. Definitions Risk = the probability of an unfavorable event. Risk factors = factors associated with an increased risk of acquiring disease

13. Try this… There are more drownings in Los Angeles each year than in Las Vegas. Los Angeles must have a less adequate swimming instruction program.

14. Los Angeles What’s the population at risk? Los Angeles has a much larger population at risk. Las Vegas is in the desert, reduces the population exposed to the risk of drowning.

15. Do this on your own… A new and puzzling disease has become epidemic in the Midwest. It is significant that 80 percent of those affected live within a mile of a railroad track. It is therefore obvious that railroads must be somehow related to the disease…

16. What sounds best? We reduced the rate from 2/1000 to 1/1000 We reduced the rate from 20/10,000 to 10/10,000 We reduced the rate from 2,000/2,000,000 to 1,000/1,000,000

17. Check-off list Establish a problem exists Confirm the homogeneity of the events Collect all the events Characterize the events

18. Characterizing events PersonPlaceTime SexResidenceYear Occupation Season AgeEventsDay, etc. Economic group Anatomic siteOnset Immunization status Geographic site Duration of an activity

19. Check-off list (cont) Look for patterns and trends Formulate an hypothesis Test the hypothesis Write up results

20. Epidemic Curves Endemic = whenever diseases are regularly and continuously present Epidemic = the occurrence of disease that clearly exceeds normal expectancy. Pandemic = epidemic that has gone international

21. Pneumonia and influenza

22. Respiratory Insuficiency

23. Viral Hepatitis

24. Malaria in Bakersfield, CA

25. You figure it out

26. Incidence and prevalence Prevalence = how many people have a disease at any one moment. Incidence = how many incidents of the disease are just starting. The new cases.

27. Illness Among 20 People Figure V-1

28. 20 More

29. The Anteater

30. Anteater At dinner 3,126 red and 5,210 black ants 3 red to 5 black ratio (not rate) Prevailing ratio in the area is 9 red and 10 black. For every 10 black ants along Random Path, 9 red ants could come to dinner, but only 6 do.

31. Ant Queens What are the odds of each ant being dinner? Does this mean we’ll have to move? Can I handle the loss with a few more eggs and if so, how many more eggs?

32. Ant Queens Both queens kept track of the next 1,000 ants to graduate from the nursery. By the end of the season, the ultimate fate of each was known.

33. Red Ant Queen Grim Reaper visited in forms such as birds, careless feet, being sat upon, etc. Anteater accounted for 400

34. Black Ant Queen 500 ended up as dinner

35. Direct comparison Red ants have 80 percent of the risk that black ants have… (400/1000 vs 500/1000) The anteater could know this…

36. Retrospective and Prospective Retrospective (case control) = begin after the fact and look back Prospective (cohort) = start with a condition in question and watch it over a period of time to see what happens

37. See if you understand… The smoking histories of all patients entering a hospital with cold sores who enter the same hospital Retrospective

38. See if you understand… The physical examination records of all incoming freshmen class of 1928 at U.C. are examined to see if their recorded height and weight are related to their chance of developing coronary heart disease by 1968. Prospective

39. See if you understand… All the mothers of Grass Valley who delivered a baby in 1970 are interviewed to see if the number of colds they had during their pregnancy is related to any defects apparent at birth in their infant. Retrospective

40. See if you understand… A whole town is examined and all who are judged to be well are questioned extensively about their diet to see whether or not their eating habits will predict their risk of developing subsequent bowel cancer. Prospective

41. See if you understand… All the patients being discharged from one hospital in NYC with a diagnosis of myocardial infarction (heart attack) are characterized by certain demographic variables and compared to NYC population to see if any of these characteristics are determinants of survival from a heart attack there. Retrospective

42. Cause and Association Association = relationships which may exist between the occurrence of one thing (like a risk factor) and the occurrence of another (like a disease). Causality …

43. Causality If you have “it” and the “disease” is more likely to occur, and When you take “it” away, the “disease” is less likely to occur, then “it” is considered a cause of the “disease.”

44. Five basic criteria… Consistency Strength Specificity Time relationship Coherence

45. Practice 1 During the previous year, nine residents of a community died from the same type of cancer. List some of the reasons that might justify an investigation.

46. Practice 1 ideas Determine how many cases to expect Research Control and prevention Why people died Training Politics Legal concerns

47. Practice 2 During August, a county health department received reports of 12 new cases of tuberculosis and 12 new cases of aseptic meningitis. Tuberculosis does not have a seasonal distribution; however, aseptic meningitis, which is caused primarily by an infection, is highly seasonal, and peaks from August-October. What additional information is needed to determine whether either of these groups of cases is an outbreak?

48. Practice 2 ideas How many diseases usually occur

49. Practice 3 You are called to help investigate a cluster of 17 men who developed leukemia in a community. Some of them worked as electrical repair men, and others were ham operators. Which study design would you choose to investigate a possible association between exposure to electromagnetic fields and leukemia?

50. Practice 3 ideas Case-control Compare the 17 people already identified with the control Were they exposed to the same electromagnetic fields

51. Practice 4 The manager of a grocery store has reported a rash illness among the store’s workers. What type of study would you use to determine the source of the outbreak? Why? What is the appropriate measure of association? Review the table on exposure to celery and calculate the measure of association and interpret your results.

52. Practice 4 table Total workers Cases Exposed5625 Non- exposed 705

53. Practice 4 table Total workers CasesAttack rate Exposed562525/56 = 44.6% Non- exposed 7055/70 = 7.1%

54. Practice 4 table Total workers CasesAttack rate Exposed562525/56 = 44.6% Non- exposed 7055/70 = 7.1% Relative risk 44.6/7.1 = 6.3

55. Practice 4 ideas Cohort study Relative risk … attack rate for workers exposed to celery divided by the attack rate for those who were not exposed. Attack rate for exposed = 25/56 or 44.6% Attack rate for non-exposed = 5/70 or 7.1% Relative risk = 44.6/7.1=6.3 Compare other vegetables and fruits Look for significance

56. Vital Statistics Births Deaths Fetal deaths Marriages Divorces

57. Infant Mortality

58. Infant Mortality Rates CountryRate per 1,000 live births Sweden2.77 Japan3.28 Finland3.59 Germany4.20 Australia4.76 Canada4.82 United Kingdom5.22 United States6.63 Afghanistan165.96 Source: http://www.geographyiq.com/ranking/ranking_Infant_Mortality_Rate_aall.htm

59. Infant Mortality Rate Utah = 5.3 deaths per 1,000 live births

60. Morbidity = sickness & disease State health department data

61. Health status & health-related behaviors

62. Causes of death in the U.S. 2001 RankNumberPercent of total deaths Rate 1 2 3 4 5 6 7 8 9 10 11 12 13 14 All Causes Diseases of heart Malignant neoplasm Cerebrovascular diseases Chronic lower respiratory diseases Accidents Diabetes mellitus Influenza and pneumonia Alzheimer’s disease Nephritis Septicemia Intentional self-harm (suicide) Chronic liver disease Assault (homicide) Essential hypertension 2,416,425 700,142 553,768 163,538 123,013 101,537 71,372 62,034 53,852 39,480 32,238 30,622 27,035 20,308 19,250 100.0 29.0 22.9 6.8 5.1 4.2 3.0 2.6 2.2 1.6 1.3 1.1 0.8 848.5 245.8 194.4 57.4 43.2 35.7 25.1 21.8 18.9 13.9 11.3 10.8 9.5 7.1 6.8

63. Causes of death in the U.S. 1900 RankNumberPercent of total deaths Rate 1 2 3 4 5 6 7 8 9 10 All Causes Pneumonia Tuberculosis Diarrhea, enteritis, ulceration of the intestines Diseases of the heart Intracranial lesions of vascular origin Nephritis All accidents Cancer and other malignant tumors Senility Diphtheria 343,217 40,362 38,820 28,491 27,427 21,353 17,699 14,429 12,769 10,015 8,056 100.0 11.8 11.3 8.3 8.0 6.2 5.2 4.2 3.7 2.9 2.3 72.3 64.0 50.2 40.3 38.3 31.7 25.9 22.9 17.9 14.4

64. Healthy People 2010

65. Use of health care services Hospital discharge data Health department data

66. Sources and Uses of Health Care Funds 192919652002 Total health spending (millions)$3,656$41,012$1,545,900 Adjusted for inflation (2002 $$)32,400192,3001,545,900 Per capita (adjusted)3059625,427 As a % of GDP3.5%5.7%14.7% % Paid by Self (out-of-pocket)81%44%15% Third parties19%56%85% Government13%25%45% Private insurance< 1%25%35% Philanthropy, other6% 5%

67. Flow of funds Exchange Two-party transaction Derived demand

68. Role of Government

69. Sources Shift to third-party payment Payments are made from…

70. Income and ethnicity as determinants of mortality (1996 data) Mortality rate Income CategoryWhiteBlack < $9,9990.918%1.234% $10,000 - $14,9990.840%1.123% $15,000 - $19,9990.706%0.899% $20,000 – $24,9990.660%0.867% $25,000 - $29,9990.591%0.603% $30,000 +0.542%****

71. Use of funds Intensity of services Hospitals Nursing homes Doctors, nurses and other health care workers Drugs Administration Public health Research