outcome research 1 introduction [email protected]. edu.tw
TRANSCRIPT
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Aims:Aims:• To equip students with basic
methodology and skills of clinical and preventive outcome research
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RulesRules– Students: graduate students of the College of Publi
c Health (CPH), NTU– Credit: elective, 2 credits (2 hours/week)– Time: 10:10-12:00am, Tuesday, 1st semester– Place: Room 205, New Site of CPH– Instructor: Wei-Chu Chie/Kuo-Liong Chien– Language: English/Chinese– Evaluation: class performance 10%, oral presentati
on 20%, written report 70%
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Date Topic
09/16 Introduction
09/23* Research design and statistical methods (1) experimental
09/30 Research design and statistical methods (2) observational
10/07 Sources of data/ethical concerns
10/14 Outcomes/instruments selection
10/21 Primary endpoint: survival
10/28* Surrogate endpoints
11/04 Quality of life/utility
11/11 Satisfaction
11/18 Outcome evaluation of screening
11/25* Outcome evaluation of drug therapy
12/02* Outcome evaluation of clinical procedures
12/09 Outcome evaluation of immunization
12/16 Outcome evaluation of health promotion
12/23 Application in evidence-based medicine
12/30 Students’ presentation
01/06 Students’ presentation* Dr. KL Chien
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Outcome: Outcome: importance/rationaleimportance/rationale
• Impossible to ask how you grow, ask not what you harvest 只問耕耘不問收穫 in preventive and clinical medicine
• Location of outcome– in health care policy management– in clinical epidemiology & evidence-based
medicine
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Health care Health care policy/managementpolicy/management
• Structure• Process• Outcome
– Donnabedian, 1966
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Clinical epidemiologyClinical epidemiology• The science of making predictions
about individual patients by counting clinical events in similar patients, using strong scientific methods for studies of groups of patients to ensure that the predictions are accurate.– Fletcher, et al. 1996
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Clinical epidemiologyClinical epidemiology• The study of variation in the outcome
of illness and of the reasons for that variation:
• observation• inference
– Weiss, 1996
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Background of outcome Background of outcome research developmentresearch development
• Health as basic human right• Rising health care cost/movements
of cost containment• Managed care
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Definition of an “outcome”Definition of an “outcome”• The end result of care, or a
measurable change in the health status or behavior of patients.– Harris, 1991
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Health outcomes in clinical Health outcomes in clinical epidemiologyepidemiology
• Death• Disease• Discomfort• Disability• Dissatisfaction
– Fletcher et al., 1996
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DeathDeath• A bad outcome if “untimely”
– Fletcher et al., 1996
• The final endpoint– insensitive sometimes– too late in preventive medicine
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DiseaseDisease• A set of symptoms, physical signs,
and laboratory abnormalities– more objective?– surrogate endpoints– definition of “normal”
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DiscomfortDiscomfort• Symptoms such as pain, nausea,
itching, and tinnitus– part of health status– part of quality of life– more subjective– usually needs measurement
instruments: questionnaires or scales
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DisabilityDisability• Impaired ability to go about usual
activities at home, work, or recreation– goal of tertiary prevention– specific definition and assessment tools– special domain of health status or
quality of life
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DissatisfactionDissatisfaction• Emotional reaction to disease and its
care, such as sadness or anger– more subjective– part of quality of life– part of service satisfaction– more likely to be used in management
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Outcomes in outcome Outcomes in outcome managementmanagement
• Clinical• Functional• Financial• Perceptual
– Hegyvary, 1991
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Clinical outcomeClinical outcome• The patient’s response to medical
and nursing intervention– wound healing, mobility– weight gain, body temperature– blood pressure, heart rate, blood sugar,
peak expiratory flow
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Functional outcomeFunctional outcome• The patient’s maintenance or
improvement of physical functioning– specific: self-catheterization, …– global: overall sense of well-being– independent living skills: ADL, …– part of quality of life: specific and global
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Financial outcomeFinancial outcome• Outcome achieved with the most
efficient use of resources– direct cost– approximate cost: length of stay,
frequency of ER visits– indirect cost– for cost-effectiveness analysis
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Perceptual outcomePerceptual outcome• The patient’s satisfaction with
outcomes, care received, and providers– new attention– more in management
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Outcome of health education and Outcome of health education and health care interventionhealth care intervention
• Health behaviors• Self-efficacy• Health status• Health care utilization
– Chronic diseases self-management program– Lorig et al., 1996
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Health behaviorsHealth behaviors– Primary prevention:
• Exercise, diet, smoking, alcohol, …• Stress coping, injury prevention, ...• Immunization and chemoprophylaxis
– Secondary prevention: screening• cancer• cardiovascular, …
– Tertiary prevention• compliance, disease management and
self-care
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Self-efficacySelf-efficacy• Confidence to perform certain
behaviors– health behaviors– disease management– compliance and self-care– community participation
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Health statusHealth status• Well-being• Disability
– physical– mental– social
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Health care utilizationHealth care utilization• Visits
– regular clinics: physical, mental– emergency– alternative medicine
• Hospital stays• Outpatient surgeries
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Multidisciplinary approachesMultidisciplinary approaches• Teamwork
– Key caregivers: nurses– Physicians of different clinical specialties– Management specialties– Statisticians– Epidemiologists
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BenchmarkingBenchmarking• Best practice• Comparison
– between similar organizations or units– between the present outcome and the
benchmark
• Management purposes
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Process of outcome Process of outcome management/researchmanagement/research
– Identifying the patient outcome– building the team– selecting the instrument– measuring the patient outcome– analyzing the data– summarizing the findings– applying the findings to practice– planning future patient outcomes
projects
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Outline of the courseOutline of the course• Research design• Data source• Instrument selection and
measurement• Different outcomes• Different procedures• Application to Evidence-based
medicine