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238 Cards in this Set
- Front
- Back
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What is public health? (week1 pop health)
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Improving the health of populations through community intervention.
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What is "American Medicine"? (week1)
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Diagnosing, treating, or preventing disease in individuals through medical intervention.
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What are some of the differences between public health and medicine? (week1 pop health)
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Public health focuses on: the population, wellness model, health promotion, interdependence, beneficence as public good, social marketing and health communication, incentives for universal health care.
Medicine focuses on: the individual, disease model, preventive medicine, independence, beneficence as individual good, interpersonal communication, incentives for care of uninsured |
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What does population health involve? (week1 pop health)
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Population health involves defining and measuring the health of populations, with focus on factors that determine health and the policies and programs that influence those determinants.
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How does population health differ from public health? (week1 pop health)
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Population health focuses on major determinants such as medical care, education, and income, which remain outside of public health authority and responsibility.
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How does population health differ from medicine? (week1 pop health)
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Population health:
1) pays attention to populations, 2)emphasizes health policy, and 3)focuses on the broad definition of health rather than disease. |
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What are some failures of public health and medicine leading to a call to population health? (week1 pop health)
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Medical error, health inequities, cost of and access to healthcare, difficulty managing the explosion of medical knowledge and technologies, limitations of biomedical model, limited effectiveness of large scale preventive programs, impatience of the public and young professionals with the current state of affairs
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What are the tools of population health? (week1 pop health)
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Epidemiology, Biostats, Health Policy, Health Behavior, Environmental Health, Health Services Research, Quality Improvement, Community Participatory Research, Genetic Epidemiology, Health Informatics
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What is epidemiology? (week1 epi)
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The study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to control of health problems.
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What are the applications of epidemiology? (week1 epi)
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1) Measure frequency of disease
2) Study distribution of disease 3) Evaluate determinants of disease |
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What are the 2 basic assumptions of epidemiology? (week1 epi)
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1) Diseases do NOT occur at random
2) Human disease has causal and preventive factors that can be identified |
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What is the definition of prevalence? (week1 epi)
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Prevalence is the proportion of those with a particular disease at a particular point in time and can be thought of as the probability that someone selected at random has disease. (# with disease at particular time/total population at that time)
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What is the definition of incidence? (week1 epi)
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Incidence is the measure of NEW cases of disease which occur in a pouplation at risk during a specified period of obeservation.
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What is the relationship between incidence and prevalence? (week1 epi)
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Prevalence is approximately equal to (Incidence) X (Duration of Disease).
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What is cumulative incidence? (week1 epi)
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The proportion of the population who experience an event during a stated period of time. Commonly used to describe risk, but requires a closed population. Defined as (New cases of disease during observation)/(population at risk of disease at start of observation)
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What is incidence rate? (week1 epi)
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Incidence rate provides a measure of how quickly something is happening. Defined as (# of new cases of disease)/(the sum of person and time at risk in population). Always measured in units of time^-1.
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What is Mortality? (week1 epi)
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Special type of incidence defined as (Total number of deaths)/(Total population)
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What is Case Fatality? (week1 epi)
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Special type of incidence defined as (Deaths due to particular disease)/(Number of persons with disease)
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What is Proportionate Mortality? (week1 epi)
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Special type of incidence defined as (Deaths due to particular disease)/(Total number of deaths).
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What is the Process of Epidemiology? (week1 epi)
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1) Observe the possible influence of a particular factor on the occurrence of disease
2) Formulate and test a hypothesis 3) Asses validity of any observed associations 4) Make inference about role of factor in causing the disease |
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What is the difference between "classical" and clinical epidemiology? (week1 epi)
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Classical epi was the study of variation in occurrence of disease and the reason for that variation.
Clinical epi is the study of variation in the outcomeof disease and the reasons for that variation. |
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What are social determinants of health? (week1 social determinants)
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Social determinants of health are the economic and social conditions that influence the health of individuals and communities.
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What is the definition of poverty? (week1 social determinants)
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Poverty is the extent to which people do without resources.
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What are the different ways to be rich or poor? (week1 social determinants)
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One can be rich or poor in following ways:
Financial, Emotional, Mental, Spiritual, Physical, Support System, Relationships |
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What is perceived stress? (week1 social determinants)
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Perceived stress is the cognitive perception of imbalance between the demands placed on an individual and the individual's capability to respond to these demands at a reasonable cost.
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What is the Demand-Capability Balance? (week1 social determinants)
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The Demand-Capability Balance refers to increased demands and limited capability or low demand and high capability situations that can lead to unfavorable outcomes, and a broadening of perspective is necessary to balance the two.
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What is homeostasis? (week1 social determinants)
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Homeostasis is the foundation of biologic existence, namely the tendency of any system to maintain current state of being through a complex system of automatic feedback loops, checks and balances, i.e. stability in normal physiological states in an organism.
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What is allostasis? (week1 social determinants)
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Allostasis is a dynamic regulatory process through which the body maintains stability through change in various physiological systems in response to internal and external demands.
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What are the systems included in allostasis? (week1 social determinants)
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ANS, Hypothalamic pituitary axis, cardiovascular, metabolic, immune
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What is allostatic load? (week1 social determinants)
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Allostatic load is the prolonged or maladaptive response to internal or external stimuli.
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What is the cost of allostasis? (week1 social determinants)
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Wear and tear on the body chronically, a broad range of chronic conditions, and distress
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What is the protection-versus-damage paradox of allostatic load? (week1 social determinants)
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Cortisol and epinephrine help mobilize energy in acute stress and normally boost immune system BUT if their secretion is not regulated, they can promote fat deposition, insulin resistance, hypertension, immunosuppression, damage to nerve cells, etc.
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What are primary mediators in allostatic load? (week1 social determinants)
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Primary mediators regulate events at the cellular level (primary effects), i.e. action of enzymes and receptors, leading to secondary outcomes
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What are secondary outcomes in allostatic load and how are these related to tertiary outcomes? (week1 social determinants)
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Secondary outcomes manifest @ the level of tissues and organs (ex. Abnormal metabolism, cardiovascular disease, obesity, hypertension, high cholesterol). Tertiary outcomes are disease endpoints resulting from secondary outcomes.
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What are Health Disparities? (8/1M Health Disparity)
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Differences in health-related outcomes by race, gender, socioeconomic status or other grouping
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What's the difference b/w a health inequality and a health inequity? (8/1M Health Disparity)
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Inequalities are differences in rates of death or disease, inequities are differences we deem morally wrong.
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What's the difference b/w a racial disparity and a racial bias in healthcare (8/1M Health Disparity)
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A disparity is due to racial inequalities and is a shortfall due to health system factors, a bias is when the disparity is not due to health system factors.
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What are some consequences of health disparities? (8/1M Health Disparity)
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Increased patient mortality, increased healthcare costs…
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List 3 examples of health disparities in the medical literature (8/1M Health Disparity)
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1) African Americans have a considerably higher mortality rate than other races 2) The poor have a much higher mortality rate than the rich 3) Hispanics have >2x the uninsured rate of Whites
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How do we reduce health disparities? Seriously…tell me… (8/1M Health Disparity)
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Recognize they're prevalent, understand and address factors that predispose to health disparities, reduce racial disparities.
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What is a cohort study? (8/2T Epi)
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Study in which a group or groups of individuals with unknown outcomes are selected based on the presence or absence of exposure to a specified risk factor. The groups are then followed over a period of time to assess the occurrence of the specified outcome.
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What are the two types of a cohort study? (8/2T Epi)
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Retrospective: Exposure already happened. Prospective: Groups assembled in the present and tracked over time for outcomes.
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What are common biases with cohort studies? (8/2T Epi)
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Performance bias, observation bias, membership bias, loss to follow-up (major source of bias)
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What is relative risk? (8/2T Epi)
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RR=Incidence of disease in group exposed to risk factor/incidence of disease in group not exposed to risk factor *Measures likelihood of developing disease in exposed group relative to unexposed group
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What is risk difference? (8/2T Epi)
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RD=(Incidence of disease in group exposed - Incidence of disease in group not exposed)
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What is the number needed to treat? (8/2T Epi)
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NNT=1/Absolute Risk Difference) *number of pts who need to be treated to achieve one additional favorable outcome or avoid one unfavorable outcome
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What are some advantages of a cohort study? (8/2T Epi)
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Good for rare exposures, can examine multiple effects of a single exposure, can establish a temporal relationship, can directly determine incidence of disease, and can determine the relative risk and risk difference.
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What are some limitations of a cohort study? (8/2T Epi)
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Poor for rare outcomes, relatively expensive and time consuming, requires ongoing availability of subjects and records, may be seriously affected by losses to follow-up.
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cases vs control (8/5F Epi)
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cases: individuals with disease or outcome of disease. Controls: Individuals similar to the cases
in all aspects except for the absence of the disease or outcome of interest |
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case control definition (8/5F Epi)
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A type of observational epidemiologic
study in which subjects are selected on the basis of whether they do (cases) or do not (controls) have a particular disease or outcome of interest. The cases and controls are then compared with respect to the proportion having a history of a prior exposure or characteristic of interest. |
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featurs of case control studies (8/5F Epi)
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• Observational and not experimental
• Disease status is determined first, then past exposure is ascertained • Extremely susceptible to bias |
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situations that favor case control studies (8/5F Epi)
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• Diseases with long latency
• Rare diseases • Diseases where the exact etiologic exposures are not known • Hypothesis generation in early stages of study of particular disease or outcome |
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definition of outcome (8/5F Epi)
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Needs to be as homogenous as possible. Similar disease entities can have very different risk factors.
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definition of cases (8/5F Epi)
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Can be influenced by bias. For example, uterine vs cervical cancer being two different names for the same disease depending on the patients SES in the 1940's. Also, having a consistent method of classification is very important.
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types of cases: prevalent vs incident (8/5F Epi)
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Prevalent
– Existing cases – May bias towards less severe disease – Obscures temporal association Prevalence (Incidence) x (Duration of disease) Incident – Newly diagnosed cases – More accurately represents population – Decreases available sample size |
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selection of controls in case control studies (8/5F Epi)
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• Controls should be those individuals
who would have been selected as cases had they developed the disease • Sources of controls same as for cases – Hospitalized patients – Co-workers, friends – Family members, relatives, spouses – General population |
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proportion of controls for case control study (8/5F Epi)
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Generally a 1:1 ratio is fine. The power will go up with more controls, however after 4:1 this effect ceases.
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Types of Bias that can affect Case Control studies (8/5F Epi)
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Selection Bias, Recall Bias, Performance Bias
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How to prevent recall bias in case control studies (8/5F Epi)
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• Blinding
• Equal treatment of case and control groups – i.e., limiting performance bias • Using medical records or other objective measures of exposure |
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Relative Risk calculation and Case Control (8/5F Epi)
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• It is not possible to calculate the
incidence of disease in the presence or absence of exposure; • Therefore it is not possible to calculate the RR in a case-control study. |
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Calculating Odds Ratio (8/5F Epi)
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First: The odds of exposure among cases and controls must be calculated. Odds= 1/1-p Where p is the probability. Probability is calculated as the number of outcomes over the total (so cases or controls). Second: The odds ratio = odds of exposure among cases/odd of exposure among controls.
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Interpreting the odds ratio (8/5F Epi)
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OR = 1: No association
OR > 1: Exposure is associated with an increased risk of disease OR < 1: Exposure is associated with an decreased risk of disease |
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Advantages of Case Control Studies (8/5F Epi)
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• Good design for rare outcomes or
diseases with a long latency period • Can examine multiple potential causes of a single disease • Relatively quick and inexpensive • No excess risk to participants |
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Limitations of case control studies (8/5F Epi)
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• Poor design for rare exposures
• Cannot directly compare the incidence of disease in the case and control groups • Difficult to determine temporal relationship of exposure and disease • Particularly susceptible to Bias |
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Define Association - 2 definitions (7/28H Epi)
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1. The statistical dependence between two variables
2. The degree to which the rate of disease among persons with a specific exposure is either higher or lower than the rate of disease among persons with out the exposure. |
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Define Cause (7/28H Epi)
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An act of event which initiates or permits, alone or in combination with other causes, a sequence of events resulting in an effect.
Examples: HIV and AIDS, Smoking and Lung Cancer |
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Give 4 possible explanations for an observed statistical association (7/28H Epi)
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1. Chance
2. Bias 3. Confounding 4. True Association |
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How is chance generally assessed? (7/28H Epi)
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Using the p-value. A p-value of less than 0.05 would indicate that there is a less than 5% probability the observed findings are due to chance
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Define Bias - 2 definitions (7/28H Epi)
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A systematic error in the way individuals are selected or in the way data is collected or reported
2. A tendency (intentional or unintentional) to inappropriately or unfairly favor one or more of the groups or interventions being evaluated. |
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Define Selection Bias (7/28H Epi)
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Groups of exposed and unexposed subjects differ systematically in a way which effects the outcome. An example here would be not selecting the subjects at random.
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Define Recall Bias (7/28H Epi)
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Differential recall of events
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Define Performance Bias (7/28H Epi)
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Systematic difference in provision of care or in the application of an intervention
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Define Confounding (7/28H Epi)
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The presence or an additional factor that is: Associated with the exposure and independently affects the risk of developing the disease or outcome.
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Explain what confounding can lead to and how it can be controlled. (7/28H Epi)
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Confounding can lead to the observation of differences when they do not exist. This can be controlled by randomization, matching, restriction, stratification, and multivariate analysis.
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List 5 criteria to judge the presence of a cause-effect relationship. (7/28H Epi)
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Strength of association, consistency of association, temporal relationship, dose-response gradient, biological plausibility
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How is the strength of association measured? (7/28H Epi)
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Measured using the relative risk (cohort or RCT), absolute risk, or odds ratio (case-control). NOT the p-value.
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Define Consistency of Association (7/28H Epi)
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The repetitive demonstration, by different investigators using different methods in different populations, of an association between exposure to the putative cause and the outcome of interest.
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Define Temporal Relationship (7/28H Epi)
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The cause should come before the effect. Data from RCTs and Cohort studies provide the most direct evidence.
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Define Dose-Response Gradient (7/28H Epi)
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An increase or decrease in the exposure should lead to a corresponding change in the associated outcome. Does not prove or disprove causation.
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Define Biological Plausibility (7/28H Epi)
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A known or postulated biologic mechanism explains how the exposure might reasonably alter the risk of developing the disease or outcome.
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What is a medical error? (8/8M Medical Error)
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Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim
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What is an adverse event? (8/8M Medical Error)
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An injury caused by medical management rather than the underlying condition of the patient
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What is a near miss, aka a close call? (8/8M Medical Error)
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An event or situation that could have resulted in an accident, injury, or illness, but did not either by chance or through timely intervention.
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What is a sentinel event? (8/8M Medical Error)
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An unexpected occurrence or variation involving death or serious physical or psychological injury or risk
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Does our current error model blame the individual or the system? (8/8M Medical Error)
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Individual
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What is an active failure? (8/8M Medical Error)
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Failures which are often attributed to the actions of visible operators of the system end (sharp end), human errors
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What is a latent failure? (8/8M Medical Error)
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Failures which may lie dormant within a system and do not in themselves cause an accident (blunt end), i.e. bad handwriting, look-alike meds
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What is the swiss cheese concept of safety? (8/8M Medical Error)
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Many defenses have to fail ("line up") at just the right time for an accident to occur.
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Describe the person approach to error management. (8/8M Medical Error)
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Focuses on individuals, blames and threatens individual with disciplinary measures and litigation
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Describe the system appraoch to error management. (8/8M Medical Error)
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Focuses on the conditions under which individuals work (hazards), builds defenses to avert errors or mitigate their effects and creates better systems
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What are human factors that contribute to error? (8/8M Medical Error)
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environmental, organisational and job factors, and human and individual characteristics which influence behavior at work in a way that can affect health and safety
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What is human factors engineering? (8/8M Medical Error)
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Designing systems devices, software, and tools to fit human capabilities and limitations. Using methods to gather data on the hidden needs of the human element and unexpected interactions between the system and the human element. Make it easy to do the right thing and hard to do the wrong thing.
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Why is the systems approach better than the individual approach? (8/8M Medical Error)
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Humans are fallible and errors are to be expected. We'll always have moments of forgetfulness or inattention, and blaming people has little to no effect on future fallibility. Best remedy is to create a better defense/system with fewer latent conditions.
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What is the purpose of using permuted blocks of random sizes? (8/8M Journal Club)
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To reduce predictability
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What condition about the treatments allow RCT to work well? (8/8M Journal Club)
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One treatment has to be not apparently better than the other
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How is concealing allocation assignment different than blinding? (8/8M Journal Club)
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Concealing the allocation assignment is only keeping the exact sequence of randomization a secret. Study intervention was not blinded, since it's difficult to blind the clinicians giving the treatment.
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Why was the study terminated early? (8/8M Journal Club)
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There was a finding w/ already enough power showing that the treatment was harming the patients
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How would you compute the relative risk? (8/8M Journal Club)
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Divide (risk in treated) over (risk in controls)
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What is the limitation of the study? (8/8M Journal Club)
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Study intervention was not blinded
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What is the "diagnostic process"? (7/18M Epi)
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Chief Complaint (Main concern), Early generation of hypothesis ("working diagnosis"), Additional data gathering, Revision of diagnosis
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What are the reasons for obtaining a diagnostic test? (7/18M Epi)
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To confirm ("rule in") a diagnosis, to exclude ("Rule out") a diagnosis, to detect a clinically silent condition, to determine the extent of disease, and to monitor disease process
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What are the qualities of a perfect test? (7/18M Epi)
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Is abnormal (positive) among all who have the disease of interest, is normal among those who don't have the disease, produces the same result every time it is measure, is available at no cost or risk (*does not exist)
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Why is a t-test not clinically useful? (7/18M Epi)
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It compares the differences in average values between samples in relationship to their spread. It is NOT decision oriented (p-value is not helpful in deciding whether the test should be used). ALSO-if the sample size is big enough, differences will be significant, even if it isn't.
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What is the "Gold Standard"? (7/18M Epi)
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The test criterion used unequivocally to define the presence of a condition or disease of interest.
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What is a true positive? (7/18M Epi)
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Test indicates disease is present in an individual known to have the disease by the gold standard.
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What is a true negative? (7/18M Epi)
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Test indicates disease is absent in an individual known not to have disease (determined by Gold standard).
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What is a false positive? (7/18M Epi)
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Test indicates disease is presnet in an individual known not to have disease, as determined by the gold standard.
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What is a false negative? (7/18M Epi)
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Test indicates disease is absent in an individual known to have disease, as determined by gold standard.
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What is sensitivity? (7/18M Epi)
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The true positive rate, or the proportion of patients with the target disorder who have a positive test result. Tells us: among those who have the disease how many times does the test say they have the disease? Equal to the TP/(TP+FN)
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What are the costs of False negative errors? (7/18M Epi)
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Risk of missing treatable disease, missed opportunities for counseling, false reassurance
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What is specificity? (7/18M Epi)
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The true negative rate, or the proportion of patients without the target disorder who have a negative test result. This equals TN/(FP+TN).
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What are the costs of false positive errors? (7/18M Epi)
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Risks/Costs of additional testing, risks/costs of inappropriate treatment, effects of inappropriate diagnostic labels (worry/lost work), discrimination in obtaining insurance
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What are the limitations of sensitivity and specificity? (7/18M Epi)
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They are intrinsic (the same throughout different populations), and you must have prior knowledge of disease to determine these values. These aren't helpful clinically, but more so in research developing tests.
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What is positive predictive value? (7/18M Epi)
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Proportion of patients with a positive test who have the target disorder. This answers the question-among those the test says have the disease, how many acutally have the disease? Equals TP/(TP+FP)
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What is negative predictive value? (7/18M Epi)
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Proptorton of patients with a negative test who are free of the target disorder. This answers the question-among those the test says do not have disease, how many actually do not have disease? Equals TN/(TN+FN)
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How is health care shifting (who is it shifting towards?) (7/20W US Health System)
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THE PATIENT. Ethical proactice patterns are patient oriented, medical liability is patient oriented, even payment is becoming increasingly patient oriented (Did the patient improve? Was there harm done?) This is different from the past.
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How is compensation changing? (7/20W US Health System)
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You get paid for what you are worth, not for what it costs. Example: in medicare, fee schedule is based on what the physicians do, and not the amount of work involved
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What are concerns about relationships with insurance companies? (7/20W US Health System)
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Insurance companies are intermediaries, and are thrust into the middle of problems.
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What is an issue with the socialization of physicians? (7/20W US Health System)
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In health care today, muliple people are working together to do something, yet physicians are told they are "lone agents"with the ability to diagnose, prescribe, admit, and discharge. It is hard to share these rights! It is hard to move to a team model! But it is better if errors require multiple people (swiss cheese model-trying to design it that holes don't align)
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What should health care reform encompass? (7/20W US Health System)
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Wee need to be more coordinated, more accountable, and more at risk collectively. We need to work more closely together and use information technology. We will always need more PCPs than we have. We need to extend primary, secondary, and tertiary care as close to the patients as possible. We need to incorporate strategic planning, and have accountable governance and leadership. We also need to move away from volume to value (move away from fee-for service)
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What is the barbell theory of health care? (7/20W US Health System)
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We spend a lot of money in the early and late stages of life.
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What is patient-centered integrated care? (7/20W US Health System)
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You can't go from being individuals expecting to make a change and go at it alone. We need to go from "cowboys to pit crews".
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Why is a common information technology system important? (7/20W US Health System)
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We need to enable and improve patient care to get better patient outcomes. This allows us to turn data into information, not just HAVE data.
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Have we seen health reform yet? (7/20W US Health System)
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NO. We have seen insurance reform, not health reform yet. We have seen the extension of coverage, offering of stability and security, but not disease management, greater care coordination, or superior outcomes.
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What is the Commonwealth survey? (7/20W US Health System)
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Evaluates performance of US health care system as compared to others. We don't rank well. We spend a lot.
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What does it mean to look "upstream"? (7/20W US Health System)
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Look beyond the here and now. For example, right now, in advertising, all we see is "if only you do X, you will be Y", or "if you eat "light food" you will be healthier. We need to look at economic, political and social foces, BEYOND individuals into what is going on in the community and family
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What are the consequences of a fragmented approach? (7/20W US Health System)
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Innefficiency, inequality, commodization, commericalization.
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What is clinical intelligence? (7/20W US Health System)
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How we transform data into information.
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How can health information technology improve health care? (7/20W US Health System)
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It can allow us to move to a more system-based population care, without changing the doctor-patient relationship. It can give physicians the opportunity to work as a team and make providing care more efficient. It can ultimately decrease the cost of providing care
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How do we (as future phsyicians) encompass bioethics in our future careers? (7/20W US Health System)
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Never be done learning, know personal responsibilities, know institutional responsibilities, know community responsibilities, and know what national needs are. Try to make the biggest impact in your community and with your patient.
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What is primary prevention? (7/29M Epi)
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Screening asymptomatic people who are healthy.
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What is secondary prevention? (7/29M Epi)
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Screening those with known risk factors.
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What is tertiary prevention? (7/29M Epi)
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Screening to prevent complications in people with disease.
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List factors that should influence your decision on whether or not to screen. (7/29M Epi)
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1. Disease must have a significant effect on the quality/quantity of life. 2. The frequency of the disease must be sufficient to justify the cost and risk of screening. 3. Tests must be available at reasonable cost and risk to detect the disease in the asymptomatic phase. 4. Acceptable methods of treatment must be available. 5. The disease must have an asymptomatic phase during which treatment yields a result superior to that obtained by delaying treatment until symptoms appear.
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What is lead time bias? (7/29M Epi)
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erroneous inference of reduced mortality resulting merely from earlier detection of disease, not from greater effectiveness of early treatment.
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What is length time bias? (7/29M Epi)
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erroneous inference of reduced mortality associated with screening caused by the disproportionate detection of less aggressive disease among screened patients.
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What is spectrum bias? (7/29M Epi)
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Biases that may occur in the studies of evaluation of screening interventions (selection bias, length bias, lead time bias, etc.)
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What is verification bias? (7/29M Epi)
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occurs when a study selectively includes patients for disease verificaton/exclusion by gold standard testing, based on positive or negative results of preliminary testing
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List 5 criteria used to determine if an association can be considered cause. (7/29M Epi)
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1. Strength of Association 2. Consistency of Association 3. Temporal Relationship 4. Dose-Response Relationship 5. Biologic Plausability
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What is chance? (7/29M Epi)
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luck of the draw, generally assessed by the p-value
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What Is bias? (7/29M Epi)
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systematic errors in the way individuals are selected or in the way data is collected/reported--a tendency to unfairly favor one or more of the groups/interventions being evaluated (types: selection bias, recall bias, performance bias)
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What is confounding? (7/29M Epi)
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the presence of an additional factor that is associated with the exposure, but independently affects the risk of developing the disease or outcome
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What is the relationship between sample and population? (7/29M Epi)
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population (N) is the whole collection of units from which a sample may be drawn. Sample (n) is a selected subset of the population. Populations are too large to study, so if a sample is selected correctly it will be representative of the population and we can use data from the sample to make estimates and inferences about the population
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How can selection affect precision and accuracy? (7/29M Epi)
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random selection and large sample size will increase precision and accuracy
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What is a randomized control trial? (7/29M Epi)
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A comparative study of the effect of 2 or more interventions on a given outcome, in which exposure to a particular intervention is determined by random chance.
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What is a cohort study? (7/29M Epi)
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participants are selected based on an exposure of interest and followed forward in time to measure occrrence of an outcome. This is a prospective study design
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What is a case-control study? (7/29M Epi)
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participands are selected on the basis of an outcome of interest and then asked about prior exposure. This is a retrospective study design
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What are strengths/limitations of cohort study? (7/29M Epi)
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Strengths: good to use when exposure is rare, can examine multiple outcomes of a single exposure, able to establish a temporal relationship between exposure and outcome, minimizes bias in the ascertainment of exposure, allows direct measurement of the inceidence of disease in the exposed/unexposed groups, able to calculate the relative risk directly. Limitations: less useful for the evaluation of rare diseases, expensive and time consuming, losses to follow-up can affect results
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What are strengths/limitations of case-control study? (7/29M Epi)
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Strengths: quick/inexpensive, good for study of diseases with long latency periods, optimal for evaluation of rare diseases, can examine multiple etiologic factors for one disease. Limitations: Difficulty with the evaluation of rare exposures, cannot directly compute the inceidence of disease in the exposed/non-exposed groups, temporal relationship between exposure and disease may be difficult to determine, particularly prone to selection and recall bias
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What are strengths/limitations of RCT? (7/29M Epi)
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Strengths: can provide the strongest and most direct evidence upon which to make a judgment about a cause-effect relationship. Randomization makes study groups comparable, eliminating biases. Limitations: not all questions can be subjected to RCT, tend to be time-consuming and expensive
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what is lead time bias and how it can be avoided (7/25M Biostat)
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erroneous inference of reduced mortality resulting merely from EARLIER DETECTION of disease, and not from greater effectiveness of early treatment. Avoid by proper RCT or examining age/sex-specific disease mortality rate (rather than survival time)
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what is length [time] bias and how it can be avoided (7/25M Biostat)
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erroneous inference of reduced mortality resulting from the disproportionate detection of indolent (less aggressive) disease among screened patients. Avoid by proper RCT, examine age/sex-specific disease mortality rate (rather than survival time), or stratify outcomes of screened and unscreened by pathologic “markers” or aggressiveness
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what characteristics of disease make it suitible for screening (7/25M Biostat)
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1. disease must have significant effect on quantity or quality of life 2. frequency of disease must be sufficient 3. tests must be available at reasonable cost and risk to detect the disease in the asymptomatic phase 4. acceptable methods of treatment must be available 5. disease must have an asymptomatic phase during which treatment yields a result superior to that obtained by delaying treatment until symptoms appear
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what are the consequences of true positives in screening? (7/25M Biostat)
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labeling, treatment in pre-symptomatic phase causes more harm than benefit, diagnostic toolkit has outstripped our therapeutic toolkit
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what are the consequences of false positives in screening? (7/25M Biostat)
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cost/pain/risk of follow-up tests and initiation of Rx, unnecessary anxiety or mental anguish, medico-legal consequences of complications
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Describe the CRITICAL POINT (7/25M Biostat)
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biologic onset → early diagnosis possible → usual clinical diagnosis → outcome:
●before early diagnosis possible – too early; false reassurance ●between early diagnosis possible and usual clinical diagnosis – CRITICAL POINT: screening potentially valuable ●between usual clinical diagnosis and outcome – no advantage over waiting for signs and symptoms |
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What are the reasons not to screen? (7/25M Biostat)
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●low prevalence (pretest probability): on the order of 0.1 – 1%
●imperfect specificity: generates lots of false positives |
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What are the classifications of screening? (7/25M Biostat)
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• Primary: asymptomatic persons who are “healthy”
• Secondary: persons with known risk factors • Tertiary: preventing complications in persons with disease |
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What does screening entail, and why is it done? (7/25M Biostat)
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• What: Immunizations, counseling, screening
• Why: population based improvement in outcomes associated with their use may be larger than therapies targeted to smaller groups |
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What are the principles for medical ethics? (7/22F Bioethics)
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Justice
Autonomy Beneficence Non-malfiecense |
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Describe the case of the God Committee (7/22F Bioethics)
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Made it unnecessary to reoperate perpetually and to allow multiple dialysis to occur by inventing a permanent indwelling shunt (permanent shunt between artery and vein) a spigot. Indefinitely extending the life of people with kidney failure. Established a dialysis unit (17 slot) (1960)
Can only pick 1/50 applicants Established an admissions and policy committee (est. 1961 Swedish Hospital) Doctors alone can't make the decision, no longer purely a medical issue e.g. Qualities adjusted life years (QUALYs), dependents Put together a cross section a society Minister Lawyer Housewife Labor leader State government official Banker Surgeon Two physician advisors Getting support from the community by forming non medical criteria for selection No children No >45 years old No other complicating disease No one psychologically incapable of undergoing the treatment No persons not from Washington State (NO CHANCE - WRONG TO LEAVE THIS TO A GAME OF CHANCE) Social worth criteria A man's contributions to society should determine Age/sex Martial status, number of dependent Income/net worth Emotional stability and capacity to accept treatment (criteria to implement bias) Educational background Occupation Past performance and future potential Submit references Scribner went talking about his new treatment Reporter of LIFE magazine asked "how do you chose who gets dialysis?" "Seattle God Committee" Scribner got SLAMMED Group reported that the committee "always agreed." The one time in US history that the government SOLVED THE PROBLEM (LOL) Congress passed legislation that any person needing dialysis will get dialysis |
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Describe the case of Julie (7/22F Bioethics)
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Case of Julie
39 yo Takes a whole bottle of extra strength Tylenol Fulmative liver failure Asks to be put on waitlist for a liver txp Should she be allowed to be listed? Nasty divorce Lost her job Uses weed Uses cocaine alcoholic Daughter of known drug dealer IS a convicted drug dealer |
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Other cases? (7/22F Bioethics)
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1. Patient is bleeding is leg, take wrist vessel to leg, however wrist will have slight disability
Patient doesn't care about leg but doesn't want wrist touched (that's value laden) Reason why informed consent is so important (autonomy) 2. Patient has gangrenous leg and needs to amputate or die Patient wasn't lacking capacity and wants to "die whole" Niece is sick and didn't check on him and feel guilty and feels she's killed him |
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Why is "ethics" inseparably linked to medical practice? (7/22F Bioethics)
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It's not just God Committee, not just Julie, there are value laden decisions are throughout medicine. These decisions are value laden (not purely medical)
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In SPIN and SNOUT, what does SPIN stand for? (7/25M Epi)
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It means if the SPecificity of a test is high, then a positive test rules IN the diagnosis.
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In SPIN and SNOUT, what does SNOUT stand for? (7/25M Epi)
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It means if the SeNsitivity of a test is high, then a negative test rules OUT the diagnosis.
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What are the three types of preventive interventions? (7/25M Epi)
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Immunization, counseling, and screening.
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Define primary, secondary, and tertiary preventitive services. (7/25M Epi)
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Primary-Asymptomatic persons who are "Healthy", Secondary-Persons with known risk factors (e.g. family history of disease), Tertiary-Preventing complications in persons with disease
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What is the critical point for screening? (7/25M Epi)
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It is a point in between Early Diagnosis and Usual Clinical Diagnosis. Screening is potentially valuable in this time zone.
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How come you may not recommend screening even at the cirtical point? (7/25M Epi)
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Screening for low-prevelance disease have many false positives that can lead to additional testing and/or unnecessary anxiety (also medico-legal complications and intiation of unnecessary drugs).
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What are possible adverse consequences of true positives while screening? (7/25M Epi)
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They can create problems if labeling or treatment in the pre-sympotmatic phase causes more harm than benefit. (e.g. gene tests for Huntington's disease). Expected Benefit needs to be greater than expected harm.
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What is lead time bias? (7/25M Epi)
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The erroneous inference of reduced mortality resulting merely from earlier detection of the disease, not from the greater effectiveness of early treatment. Just cause you find it earlier, the disease is known to be present for a longer time in patients.
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What are good ways to avoid lead time bias? (7/25M Epi)
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Perform proper RCT for screening tests, use age & gender specific mortality rates.
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What is length bias? (7/25M Epi)
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The erroneous inference of reduced mortality associated with screening caused by the disproportionate detection of indolent (less aggressive) disease among screened patients.
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What are good ways to avoid length bias? (7/25M Epi)
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Perform proper RCT for screening tests, use age & gender specific mortality rates, and stratify outcomes of screened and unscreened by pathologic "markers" of aggressiveness
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T/F: A randomized control trial is the weakest study design. (8/1M Epi)
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F
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What is an RCT? (8/1M Epi)
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A comparative study of the effect of 2+ interventions on a given outcome, in which exposure to a particular intervention is determined by ranom chance.
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What are other names for RCTs? (8/1M Epi)
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Clinical trial, experimental study, controlled trial, gold standard trial, intervention trial
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What is the source population of an RCT? (8/1M Epi)
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A group interested in (that may benefit from) a given intervnetion
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Describe the prototyp/timeline for an RCT: (8/1M Epi)
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Source population -> eligiblity -> consent to participate -> randomization with intervention -> observe outcome
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A what point in an RCT does the randomization occur? (8/1M Epi)
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The experimental intervention
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List 5 situations that favor RCT: (8/1M Epi)
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(1.) Equipose -- legitimate uncertainity about effect of outcome; (2.) Exposure of interest is modifiable behavior and people reqlinquish control (ie. smoking vs. cholesterol level); (3.) Treament not already accepted; (4.) Effects small to moderate size; (5.) Outcome of interest is resonably common
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List 5 components of an RCT: (8/1M Epi)
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Assignment, Assessment, Analysis, Interpretation, Extrapolation
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Selection must be based on what 3 factors: (8/1M Epi)
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(1) Inclusion high risk individuals, (2) Exclusions should be reasonable, (3) Maximize generalizability
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A study population is formalized from what 2 previous populations? (8/1M Epi)
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(1) Reference population (removing non-participants), (2) Experimental population (removing those excluded)
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Define randominzation (8/1M Epi)
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The same known probability of receiving each of the possible treatments
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What are the advantages of randomization? (8/1M Epi)
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(1) Assigned treatment group is unknown in advance, (2) Groups comporable for all variables except intervention (incl. known/unknown), (3) Confounding and bias reduced or eliminated, (4) Readers have more confidence in association results
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What bias may arise from RCT? (8/1M Epi)
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Performance bias
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What is performance bias? (8/1M Epi)
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A bias if intervention groups are treated differently/preferentially to one another
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What is the role of blinding (incl. for researchers and patients)? (8/1M Epi)
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Prevents measurement bias (skew analysis with your ideas), premature drop-out, and unwanted co-interventions (ie. performance bias)
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Who can be blinded? (8/1M Epi)
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Study subject, person assessing outcome, study investigators, statistician
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Who constitutes "double-blinding" (8/1M Epi)
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Study subjects + person assessing outcome
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T/F: Accounting for all subjects entered in the study for the analysis can minize bias of the results. (8/1M Epi)
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T
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What is the "intent to treat" analysis? (8/1M Epi)
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Subjects are analyzed in the group to which they were randomized, regardless of what treatment they actually received (ie.pt received self-tx or if study made mistake)
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What is the less popular outcome analysis and why is it good and bad? (8/1M Epi)
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Treatment actually received -- Advantage for studying efficacy, Disadvantage --> bias results
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Why is intent-to-treat a good outcome analysis? (8/1M Epi)
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Preverses the benefits of randomization; Underestimates the true effect of intervention (if have a significant result, more confident it's truly significant)
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Power has to do with what characteristic of a study? (8/1M Epi)
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Study size
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Define power. (8/1M Epi)
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Power -- the ability to detect a difference
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How do you calculate power? (8/1M Epi)
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1 - b ; b = Type II error
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What is a Type I error? What 2x2 cell box does it correspond with? What is another name for it? (8/1M Epi)
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Error when you falsely reject a true null hypothesis. False positive. (alpha; corresponds with p-value)
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What is a Type II error? What 2x2 cell box does it correspond with? What is another name for it? (8/1M Epi)
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Error when you fail to reject a false null. False negative. (beta; corresponds with power)
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What is the external validity/generalizability of a study? (8/1M Epi)
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The ability to extrapolate the study's results to a broader population.
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Is a RCT retrospective or prospective? (8/1M Epi)
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Prospective.
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What bias is eliminated by a study being prospective? (8/1M Epi)
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Recall bias minimized.
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Which dtudy is the best a reducing bias/confounding factors? (8/1M Epi)
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RCT
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T/F: Relative Risk of exposure can be assessed in an RCT. (8/1M Epi)
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T
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What are 3 disadvantages to an RCT? (8/1M Epi)
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Expensive; Difficult to excute well; Not good for all situations (ethical issues in inducing exposure; uncommon outcomes)
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What study provides the most direct and strongest evidence to determine a causal relationship? (8/1M Epi)
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RCT
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How is generalizability determined? (8/1M Epi)
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Based on inclusion/exclusion criteria.
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What are two unique features of an RCT? (8/1M Epi)
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Exposure is assigned; randomization occurs to minimize bias and confounding
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What are 2 advantages of RCT? (8/1M Epi)
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Minimizes bias/confounding; strongest way to show an association (even causation)
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What are the types of data you can expect to see? (7/18M Biostat)
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Numerical or character (everything else)
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What are the types of numerical data? (7/18M Biostat)
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Nominal, Ordinal, Interval, Ratio. Basically anything you can perform a mathematical operation on is numerical. Do not include patient numbers or dates.
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What are common descriptive statistics? (7/18M Biostat)
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N (overall/population total), n (subset or sample total), %, Mode (value with the greatest frequency), Mean and standard deviation (central tendency and variation measures)
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What is the most comon type of distribution? (7/18M Biostat)
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Most are "normal" or bell-shaped
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How do you calculate Standard Deviation? (7/18M Biostat)
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[Sum of (variation about the mean)^2]/sample size
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What is the relationship between standard deviation and variance? (7/18M Biostat)
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SD = (variance)^(1/2); SD^2 = variance
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How do variance, SD, and SE change as a function of sample size? (7/18M Biostat)
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As sample increases variance, SD, and SE decrease
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What is an interquartile range? (7/18M Biostat)
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25th-75th percentile difference
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When should you use median and IQR? (7/18M Biostat)
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skewed data
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What is the effect of extreme values? (7/18M Biostat)
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skew the mean; so median is a much better measure of central tendency than mean.
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What statistics should you report for a normal distribution? (7/18M Biostat)
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mean and standard deviation or standard error
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What is a probability? (7/18M Biostat)
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The likelihood of an outcome as expressed as a value between 0 and 1. Assumes that each event is independent. All possible values of probability must add up to 1.
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How are probability distributions standardized? (7/18M Biostat)
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Have an area equal to 1.0
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What is a t-test? (7/18M Biostat)
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compares two means of independent groups, collected identically. T= (mean1 - mean2)/variance expression. The test statistic is checked along a t-distribution chart, and we obtain a p-value based on its relationship to identified critical values for the sample size.
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What does a p-value tell us? (7/18M Biostat)
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The p-value reflects the test statistic result, which allows us to make inferences on whether our null hypothesis is valid or not. Reject the hypothesis if p is less than some critical value (i.e. 0.05). It tells us the likelihood of obtaining even a greater effect meausre had we been ablet o repeat data collection of the same sample size and variation seen.
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What are the limitations of a p-value? (7/18M Biostat)
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Does not tell us how good or bad the data collection process was, if we used the best statistical test to challenge our null hyptohesis, if our sample truly reflects our underlying population.
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What makes a test statistic increase? (7/18M Biostat)
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the difference (or effect) increases, the sample size increases, the variation in the data decreases
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What makes a test statistic decrease? (7/18M Biostat)
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There is very little difference or the effect is small, sample size is small relative to variation, variation in the data is large
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What is lifeskills training? (7/21H lifeskills)
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A youth development approach to substance reduction
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What skills are emphasized in lifeskills training? (7/21H lifeskills)
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Resisting peer pressures, developing self-esteem, efective anxiety coping skills, enhance cognitive and behavioral competency to reduce and prevent health risk behaviors, increase knowledge of immediate consequence of substance abuse
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Is prevention succesful? (7/21H lifeskills)
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Yes! 15 diseases cause 56% of medical expenses, and each of these diseases could be benefitted by prevention. BUT, we only spend 4% of the 1.7 trillion dollars spent on healthcare on prevention
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What is primary prevention? (7/21H lifeskills)
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It covers all activities designed to reduce the instances of an illness in a population and thus to reduce the risk of new cases appearing regardless of risk factors. i.e. upstream or universal preention
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What is secondary prevention? (7/21H lifeskills)
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Activities aimed at reducing the prevalence of an illness in a population and thus to reduce its duration. Involves early screening. i.e. selective prevention
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What is tertiary prevention? (7/21H lifeskills)
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Aims to reduce the incidence of chronic incapacity or recurrences in a population, and thus to reduce the functional consequences of an illness. i.e. indicated prevention and down-stresm prevention. E.g. bariatric surgery
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What is the prevention paradox? (7/21H lifeskills)
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Many interventions that aim to improve health have relatively small influences and perceptible benefits on the health of most people. For one person to benefit, many people have ot change their behavior, even though they receive no benefit or even suffer from the change.
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When is lifeskills training most effective? (7/21H lifeskills)
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When healthcare personnel or peer educators conduct it rather than the teacher. It is based on skills and interaction, not content
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What to teens usually identify as their biggest health concern? (7/21H lifeskills)
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stress
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