EGJ
PART A MFPH
REVISION COURSE HANDOUT
“I couldn’t wait to get in there and tell them what I’d learned”
Stanley Hauerwas
The Hauerwas reader p25
For maximum benefit USE this handout:
Annotate, scribble, write examples
‘Read and forget; write and remember’
Page 1 of 90
EGJ
EPIDEMIOLOGY ............................................................................................. 5
Epidemiological studies: design ............................................................................................................. 6
Expressing the main result ..................................................................................................................... 6
Concepts and measures of risk ............................................................................................................. 6
Interpreting the result ............................................................................................................................ 7
Chance ................................................................................................................................................. 7
Bias ...................................................................................................................................................... 7
Confounding ........................................................................................................................................ 7
Other problems .................................................................................................................................... 7
Effect modifiers [interaction] ............................................................................................................... 8
Causation ............................................................................................................................................. 9
Putting it together – guidelines and recommendations ....................................................................... 10
Surveys .................................................................................................................................................. 11
HEALTH INFORMATION .............................................................................. 13
Routine data sources ............................................................................................................................ 14
Population ............................................................................................................................................. 14
Ad hoc censuses ................................................................................................................................. 14
Census based measures ...................................................................................................................... 15
Sickness and health ............................................................................................................................ 16
EPIDEMIOLOGY: HOW MUCH DO I NEED TO KNOW? ............................. 18
HEALTH ECONOMICS ..................................................................................................................... 20
Economic appraisal ............................................................................................................................ 21
Decision analysis ............................................................................................................................... 23
Option appraisal ................................................................................................................................. 23
SOCIAL SCIENCES ...................................................................................... 24
Sociology ................................................................................................................................................ 24
Qualitative methods .............................................................................................................................. 24
Capturing qualitative data .................................................................................................................. 24
Qualitative analysis: ........................................................................................................................... 24
Rigour in qualitative studies: ............................................................................................................. 24
Concepts of health and illness .............................................................................................................. 25
Deviance ................................................................................................................................................ 27
Variations in health .............................................................................................................................. 28
Social factors in the aetiology of illness .............................................................................................. 29
Social health....................................................................................................................................... 29
HEALTH PROMOTION ................................................................................. 30
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Strategy in health promotion ............................................................................................................... 31
Running programmes ........................................................................................................................... 32
Environment ......................................................................................................................................... 34
Health at work.................................................................................................................................... 35
Nutrition ................................................................................................................................................ 36
SCREENING ................................................................................................. 38
Quality assurance in screening ............................................................................................................ 39
ETHICS .......................................................................................................... 40
GENETICS .................................................................................................... 41
STATISTICAL METHODS ............................................................................. 43
Elementary probability theory............................................................................................................ 43
What’s this? .......................................................................................................................................... 44
Meta analysis ........................................................................................................................................ 45
Interpreting multiple regression models ............................................................................................. 46
Non statistical stuff ............................................................................................................................... 47
How would you analyse….. .................................................................................................................. 49
Parametric and non parametric .............................................................................. 49
Three famous models ......................................................................................................................... 51
COMMUNICABLE DISEASE......................................................................... 52
COMMUNICABLE DISEASE – HOW MUCH DO I NEED TO KNOW? ........ 55
ORGANISATION AND MANAGEMENT - THEORY ..................................... 57
Organisations ........................................................................................................................................ 57
Change ................................................................................................................................................... 58
Innovation .......................................................................................................................................... 58
Leadership ............................................................................................................................................. 59
Motivation ......................................................................................................................................... 59
Negotiation ........................................................................................................................................ 59
Groups ................................................................................................................................................... 60
Managing people................................................................................................................................... 61
Self management ................................................................................................................................... 61
Miscellaneous ........................................................................................................................................ 61
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EGJ
Creativity ........................................................................................................................................... 61
Delegation .......................................................................................................................................... 61
Effective communication ................................................................................................................... 61
MANAGEMENT GURUS ................................................................................................................... 63
Models................................................................................................................... 63
RUNNING HEALTH SERVICES .................................................................... 64
Funding of health services ................................................................................................................. 64
Resource allocation ............................................................................................................................ 64
Policy formulation ................................................................................................................................ 65
Funding.................................................................................................................................................. 69
Priority setting ............................................................................................................................... 69
Types of contract........................................................................................................................... 69
NHS finance systems ......................................................................................................................... 69
Monitoring ............................................................................................................................................ 70
Performance - overview ................................................................................................................ 70
Performance – evaluation of a service ............................................................................................... 70
Performance - exceptional events ...................................................................................................... 70
Governance and risk management ..................................................................................................... 70
International health care ..................................................................................................................... 71
Social policy........................................................................................................................................... 71
TIPS ON EXAM TECHNIQUE ....................................................................... 72
PREPARATION ................................................................................................................................... 72
GENERAL ............................................................................................................................................ 72
PAPER I ................................................................................................................................................ 73
PAPER IIA: critical appraisal ............................................................................................................. 80
PAPER IIB: data skills......................................................................................................................... 82
Some facts and figures .......................................................................................................................... 83
Reports / briefing papers ..................................................................................................................... 84
DATA PRACTICE: CALCULATIONS ............................................................................................. 85
Past papers – question grid .................................................................................................................. 90
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EPIDEMIOLOGY
http://www.bmj.com/epidem/ : Epidemiology for the uninitiated
NOTE – Throughout the handout anything in this typeface (Arial 10) is a direct cut-and-paste from
the syllabus
a) Epidemiology: use of routine vital and health statistics to describe the distribution of disease in
time and place and by person; numerators, denominators and populations at risk; time at risk;
methods for summarising data; incidence and prevalence including direct and indirect
standardisation, years of life lost; measures of disease burden (event-based and time-based) and
population attributable risks including identification of comparison groups appropriate to Public
Health; sources of variation, its measurement and control; common errors in epidemiological
measurement, their effect on numerator and denominator data and their avoidance; concepts and
measures of risk; the odds ratio; rate ratio and risk ratio (relative risk); association and causation;
biases; confounding, interactions, methods for assessment of effect modification; strategies to
allow / adjust for confounding in design and analysis; the design, applications, strengths and
weaknesses of descriptive studies and ecological studies; analysis of health and disease in small
areas; design, applications, strengths and weaknesses of cross-sectional, analytical studies, and
intervention studies (including randomised controlled trials); clustered data - effects on sample size
and approaches to analysis; Numbers Needed to Treat (NNTs) - calculation, interpretation,
advantages and disadvantages; time-trend analysis, time series designs; nested case-control
studies; methods of allocation in intervention studies; studies of disease prognosis.
Appropriate use of statistical methods in the analysis and interpretation of epidemiological studies,
including life-table analysis; electronic bibliographical databases and their limitations; grey
literature; evidence based medicine and policy; the hierarchy of research evidence - from well
conducted meta-analysis down to small case series, publication bias; the Cochrane Collaboration
Page 5 of 90
Epidemiological studies: design

Descriptive studies: “How much of this stuff have we got?”

Case control studies: “What caused these cases?”

Cohort studies: “What effect does this have?”

Interventions incl. RCTs
PICO
(Modelling studies)
(Systematic reviews)
Retrospective vs prospective studies: ‘Five a day’
Interventional vs observational studies: beta carotene and lung cancer, HRT and CHD
Expressing the main result
Intention to treat analysis
Concepts and measures of risk
Relative risk
Deaths per 100,000 male doctors per year from lung cancer:
smokers (>25 per day):
355
non-smokers:
14
Ratio of incidence (incidence rate ratio) =
Excess rate/ risk attributable to smoking =
Odds ratio
Population attributable “risk” (aetiologic fraction)
Number needed to treat (NNT)
Page 6 of 90
Interpreting the result
Could the result be due to




Chance?
Bias?
Confounding?
REAL effect?
Chance
P values, CIs etc – but remember Type I and Type II errors
Bias
Systematic differences in



Sample / subjects
Measuring instrument
Observer
Confounding
The ‘other explanation’
Control of confounding:
Design
Analysis
Standardisation
Residual confounding
Over-adjustment
Other problems
Ecological fallacy
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Effect modifiers [interaction]
This is a type of REALITY
Age related macular degeneration (de Jong PTVM NEJM 2006; 355: 1474 – 85)
Smokers (vs non):
Homozygous for CFH Y 402H polymorphism
Smoker AND homozygous
Odds ratio = 2.4
Odds ratio = 7.6
Odds ratio = ?
Graphically:
fluoridation of water supply more beneficial to poor than to rich.
Riley JL et al Int J Epidemiol 1999; 28: 300 –5. Jones CM et al BMJ 1997; 315: 514 – 7
Page 8 of 90
Causation
Bradford Hill criteria for causality (in order of importance):
[AB Hill. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295 - 300]
1.
2.
3.
4.
5.
strength of association
consistent in different studies
specific
temporality
biological gradient e.g. more drinks / day -> higher RR
6.
7.
8.
9.
biologically plausible
coherence
experimental evidence
analogy (if thalidomide and rubella cause foetal malformation so may other
drugs / viruses)
Mnemonic courtesy of Martin Bull:
A Statistical Cohort of Surgeons with TB Postulated the Cause to be an
Environmental Agent!
NB if picture muddy may need to think about different types of cause:
Necessary / Sufficient
Underlying / Trigger
Etc
Page 9 of 90
Uses of epidemiology (Jerry Morris):
Morris JN Uses of epidemiology Br Med J. 1955 August 13; 2(4936): 395–401
1. Historical trend
2. Community diagnosis
3. “Individual chances”
4. Operational research - how well services are working
5. Completing the clinical picture – study ALL cases
6. Identification of syndromes – ‘peptic ulcer’
7.
Clues to causes
Putting it together – guidelines and recommendations
GRADE – strong and weak recommendations
Certainty – many high quality RCTs
Importance – prevents death
Size of effect – 30% reduction in risk
Precision – narrow CI
Risks and Burdens of therapy – no adverse effect but fortnightly iv infusion
Risk of event
Costs
Values (e.g. life or comfort?)
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Surveys
Constructing the survey instrument
Construction of valid questionnaires
Validity



content
face
criterion
concurrent in concurrent test with gold standard
predictive

construct validity
Convergent/ discriminant
Reliability

Test - retest


Multiple form
Split half
Scales: should be uni-dimensional [e.g. “total SF36 score” isn’t]
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Doing the fieldwork
methods of sampling from a population
The sample
Methods of sampling and allocation
random, quasi-random,
stratified
cluster
quota
convenience
nomination / snowball
the design of documentation for recording survey data
The instrument
Typography: font size, layout, tick boxes etc
Items: ambiguous questions / double questions / leading qq
Whole thing: running order (e.g. sensitive last)
Mode: paper - computer – telephone - internet
The interview
Interviewers
Select
Train
Monitor
Respondents
Introduction – gaining consent etc
Attempts to contact (how many? Time of day?)
Use of proxy allowed?
Methods for validating observational techniques
Validation of observational techniques:
inter-observer
interviewer training
videotaping
Observer variation
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HEALTH INFORMATION
-
- Capture: how accurate? How complete?
– Coding – how fine grained?
Output: how detailed? how often? How aggregate?
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Routine data sources
Populations: conduct of censuses; collection of routine and ad hoc data; demography;
important regional and international differences in populations, in respect of age, sex,
occupation, social class, ethnicity and other characteristics; methods of population estimation
and projection; life-tables and their demographic applications; population projections; the effect
on population structure of fertility, mortality and migration; historical changes in population size
and structure and factors underlying them; the significance of demographic changes for the
health of the population and its need for health and related services; policies to address
population growth nationally and globally
Population
UK Census
Census 2011
Health question
2011: How is your health in general? Very good / good / fair/ bad/ very bad
2001: Over the last 12 months would you say your health has on the whole been good / fairly
good / not good ?
Disability question
2011: Are your day-to-day activities limited because of a health problem or disability which has
lasted, or is expected to last, at least 12 months?
2001: Do you have any long-term illness, health problem or disability which limits your daily
activities or the work you can do?
 Include problems which are due to old age
Income question – there isn’t one in the UK census!
Ad hoc censuses
Page 14 of 90
Census based measures
Deprivation scores

Jarman / Townsend score

Index of multiple deprivation IMD2000 - NOT census based: 7 domains / 33
indicators: Income, Employment, Health and disability, Education skills and
training, Barriers to housing and services, Living environment and Crime.
See http://www.communities.gov.uk/index.asp?id=1128442
Population
Estimates and projections
Historical change in population structure
1946 baby boom plus second wave
effect of economic downturn
National and international population policies
Page 15 of 90
Sickness and health
Sickness and health: sources of routine mortality and morbidity data, including primary care
data, and how they are collected and published at international, national, regional and district
levels; biases and artifacts in population data; the International Classification of Diseases and
other methods of classification of disease and medical care; rates and ratios used to measure
health status including geographical, occupational, social class and other socio-demographic
variations; routine notification and registration systems for births, deaths and specific diseases,
including cancer and other morbidity registers; pharmacoepidemiology, including use of
prescribing and Pharmacy sales data; pharmacovigilance; data linkage within and across
datasets
How collected AND PUBLISHED
 Mortality
 Hospital
Inpatient
Ambulatory – A&E, outpatient
Diagnostics – lab, radiology
 Primary care
Medical
Dental
Pharmacy
 Registers
 Surveys
Measurement surveys
Self report surveys

Non-health service: fire, police, social services department
[NB – poor definitions in non-health sources]
 Research: synthetic estimates
Page 16 of 90
Classifications:
ICD10
[OPCS4 coding for operations]
Read codes - a nomenclature not a classification
Page 17 of 90
EPIDEMIOLOGY: how much do I need to know?

Clinical features (don’t overdo this)



Time (secular trend - last 50 years, more recent)
Place
Person
age, sex, socio-economic
ethnic, occupation, familial
lifestyle

Causes & determinants
THINK ABOUT SOURCES of knowledge (e.g. ‘CHD is declining’)
==========================================================
[Infections: covered later]
Neoplasms:
*Breast
*cervix,
*colon,
*lung,
*skin (melanoma and SCC)
Metabolic, endocrine:
*Diabetes mellitus
Psychiatric:
*Schizophrenia,
*dementia
*suicide,
deliberate self harm
Nervous system:
CVD
*CHD
*stroke
Abdominal aortic aneurysm
Page 18 of 90
Respiratory
*asthma,
*chronic bronchitis
Trend summary E&W deaths 1990 – 1999 :
CHD, stroke, asthma, bronchitis: down
[smoking]
Digestive:
Caries
peptic ulcer -> Helicobacter
Perinatal
SIDS
Congenital and hereditary
Down syndrome
Injury & poisoning
Falls
Epidemiology of lifestyle
*smoking,
*alcohol,
*sexual behaviour
*diet (obesity)
*exercise
Syllabus: ‘the effects on health of different diets (e.g. the ‘Western diet’), obesity, physical activity,
alcohol, drugs, smoking, sexual behaviour and sun exposure
Page 19 of 90
HEALTH ECONOMICS
Health economics: principles of health economics (including the notions of scarcity, supply
and demand, marginal analysis, distinctions between need and demand, opportunity cost,
discounting, time horizons, margins, efficiency and equity); assessing performance; financial
resource allocation; systems of health and social care and the role of incentives to achieve
desired end-points; techniques of economic appraisal (including cost-effectiveness analysis
and modelling, cost-utility analysis, option appraisal and cost-benefit analysis, the
measurement of health benefits in terms of QALYs and related measures); marginal analysis;
decision analysis; the role of economic evaluation and priority setting in health care decision
making including the cost effectiveness of Public Health, and Public Health interventions and
involvement.
Perfect market
Elective surgery
Specialist psychiatry
Many sellers (and buyers)
Free entry (and exit)
Perfect information
Homogeneous product
No externality: I pay, someone else benefits (e.g. host purchaser / infrastructure costs)
Risk pools (Insurance systems)
1.
2.
3.
4.
Rare event
High cost
Population demand predictable
Individual's probability of demand independent
adverse selection
moral hazard
Page 20 of 90
Economic appraisal
Measurement of COST
Marginal vs unit costs (and benefits):
e.g screening interval, change in admissions
Incremental cost
Opportunity cost
Direct vs indirect
Tangible (can invoice / bill for this) vs intangible (pain, suffering etc)
Discounting



future costs
?discount future health benefits
NICE recommends 3.5% annual discount for costs and health benefits
Page 21 of 90

Cost effectiveness:
Cost minimisation – (e.g. to achieve no Hep B in drug users)
Sensitivity analysis

Cost utility:
Assess health state after treatment using Quality of Life scale e.g. EQ5D
Mobility
Selfcare
Usual activities
Pain
Anxiety / depression
Then value the utility of the health state
e.g. on a rating scale score of 0 – 100
Could use time trade off or standard gamble instead of rating scale
Disability weighting: see
Stouthard MEA et al. Disability weights for disease. Eur JPH 2000; 10: 24 – 30

Cost benefit:
Used by government to decide whether or not to go with a programme: overall cost to
society
Air pollution clean up:
cost £785m - £1100m estimate for UK
12,000 - 24,000 deaths in 1996 (COMEAP)
Do costs outweigh benefits?
May need to value life:
“Gross output”
Willingness to pay
Pay to reduce road deaths
Pay for risky occupations
Willingness to spend (e.g. for a smoke alarm)
Page 22 of 90
Decision analysis
Economic appraisal plus sensitivity analysis
May also involve decision tree
www.diabetic-retinopathy.screening.nhs.uk
Also Richardson WS et al JAMA 1995; 273: 1292 - 5
Option appraisal
Where should paediatric cardiac surgery take place?
Efficiency: generally about getting the most out of your resources
Cost efficiency –
no money wasted
Technical efficiency – no inputs wasted i.e. no kit, staff, standing idle
[Doesn’t work when you’re comparing different mixes of inputs and outputs cf
option appraisals]
Allocative efficiency – can’t give A more without taking from B i.e. no surplus
OR
Technical – do CABG as cheaply as possible
Allocative – allocate funds for anti-smoking (achieves more /
more efficient CHD reduction)
Equity
vertical: greater resource for greater need
horizontal: equal resource for equal need
Equality - of what?



Equal spend per person
Equal spend for equal need
Equal spend for equal benefit
Page 23 of 90
SOCIAL SCIENCES
Sociology
‘study of individuals in groups and social formations’ (Lawson and Garrod) includes
institutions
Organisations and management
Social identity – age class gender race
Family and friendship
Power and class (Marxism?)
Work including professions and status
Norms and deviance, discrimination
Social welfare, education etc
Qualitative methods
The principles of qualitative methods including semi-structured and in-depth interviewing, focus
groups, action research, participant observation, and their contribution to public health research
and policy; their appropriate use, analysis and presentation; the ethical issues which may arise;
validity, reliability and generalisability; common errors and their avoidance; strengths and
weaknesses.
Capturing qualitative data
ethnography
long interview
diary
analysis of documents and images
Qualitative analysis:
grounded approaches
semiotics (symbolism)
discourse analysis / repertoires
Rigour in qualitative studies:
Researchers' perspective (e.g. feminist)
Full description of fieldwork method
Subject selection
Recording (e.g. tape plus transcription)
Main results
Exceptions noted (e.g. help seeking and masculinity)
Verbatim quotes
Page 24 of 90
Concepts of health, wellbeing and illness and aetiology of illness: the theoretical
perspectives and methods of enquiry of the sciences concerned with human behaviour; illness
as a social role; concepts of health and wellbeing; concepts of primary and secondary
deviance; stigma and how to tackle it; impairment, disability and handicap; social and structural
iatrogenesis; role of medicine in society; explanations for various social patterns and
experiences of illness (including differences of gender, ethnicity, employment status, age and
social stratification); the role of social, cultural, psychological and family relationship factors in
the aetiology of illness and disease; social capital and social epidemiology.
Health care: different approaches to health care (including self-care, family care, community
care, self-help groups); hospitals as social institutions; professions, professionalisation and
professional conflicts; the role of clinical autonomy in the provision of health care; behaviour in
response to illness and treatments; psychology of decision-making in health behaviour.
Epilepsy ‘from a sociological perspective’ ?
Ageing . inequalities .
Concepts of health and illness
Culture and health beliefs: (your culture = your rules on how to eat / drink / heal etc)
Cultural beliefs about the body
Shape: beautiful baby competitions
Size: bodybuilding
Clothing: white coat
Surface: no hat = catch cold
Anatomy: circumcision
Physiology: no concept of brain death = no transplants (Japan 1997)
Culture and diet
Junk food
Moslem / Hindu / Jewish
"Plain" food
Spraying mercury (Cuba, Dominica, Puerto Rico)
Ayurvedic and Chinese medicine (lead, mercury, arsenic)
Page 25 of 90
Mildred Blaxter on lay concepts of health (mostly age related):
Health and lifestyles London: Routledge 1990 Table 3.1
May include community values (‘Healthy Hawaiian’)
Kleinman on how people do health care (think cold, headache, backpain)
Illness as a social role (Parsons)
Iatrogenesis (Illich) www.planetpapers.com/Assets/3621.php
Clinical – adverse effects of drugs
Social – childbirth as a clinical event
Structural or cultural - “stripping away from human culture of ways of coping with pain,
birth and death and their replacement by a sanitised technological medical intervention”
Colpo d’aria
“Oh, the dreaded Colpo d’Aria! If you’ve suffered a Colpo d’Aria you’ve been struck by
some moving air, most probably chilly air, and most probably on your chest or
perhaps the back of your neck. If you live in Italy, it can be deadly; ask any Italian!
I’ve heard Colpo d’Aria blamed for everything from stiff muscles, to inner ear
infections, chest colds and even heart attacks. I have not yet heard anyone say that a
Colpo d’Aria caused his cancer, but that, and gum disease, are about the only illnesses
for which a stiff breeze has not been held responsible.
Fortunately there is some good treatment available should you fall victim to an evil air
current. The first thing you want to do is go to the pharmacy and get a bastone di
zolfo, a stick of sulphur.”
Page 26 of 90
Health care
Professions
According to Freidson (1970), a profession
1.
2.
3.
4.
controls entrance into the ranks;
professional expertise is not a commercial property;
control of practice is exercised by professional colleagues; and
the primary mechanism for quality control is personal responsibility and
integrity.
Related to autonomy in clinical practice
Hospitals as social institutions: LS and acute (Goffman on asylums)
Asylum
Prison
Factory
Business
University
City
Deviance
Implications of labelling behaviour for organic and psychiatric disease
Illness as deviance and doctor as agent of social control: ?smoking, homosexuality, alcohol
Primary and secondary deviance
Stigma
Disability and handicap
e.g. Intellectual impairment > learning disability > mental handicap
Handicap pejorative in US
WHO now suggests ‘abilities’ and ‘participation’
Page 27 of 90
Variations in health
Explanations for socio-economic patterning of ill health
Current, early life or life-course:
 Lifestyle
 Material
 Drift
 Psycho-social stress
Explanations for area differences:

Composition
the type of people who live there
social capital?

Physical
climate
facilities (food supply, health services etc)
Page 28 of 90
Social factors in the aetiology of illness
Social health
Social breakdown as a cause of illness
Durkheim – anomie (lack of rules / order) and suicide rates
Effect of divorce on health
Kawachi on census measures of frgamentation
Income inequality (Wilkinson)
e.g. Brazil / Cuba: Brazil higher MEAN income but more inequality / worse
infant mortality
Social capital: a social construct:




Existence of community networks
Participation in networks (civic engagement)
Having a local identity and sense of solidarity
Having norms of trust and reciprocal help and support
Stress at work: Whitehall II cohort (Marmot)


effort / reward
demand / control
[NB rewards not just money – cf Maslow]
[low control at home predicts CHD in F but not M]
Equality, equity and policy: concepts of need and social justice; priorities and rationing;
balancing equity and efficiency; consumerism and community participation; prioritisation
frameworks and equity of service provision; public access to information; user and carer
involvement in service planning; problems of policy implementation; principal approaches to
policy formation; appreciation of concepts of power, interests and ideology; inequalities in the
distribution of health and health care and its access, including inequalities relating to social
class, gender, culture and ethnicity, and their causes; health and social effects of migration,
and the health effects of international trade; global influences on health and social policy;
critical analysis of investment in health improvement, and the part played by economic
development and global organisations
Page 29 of 90
HEALTH PROMOTION
Principles and practice of health promotion: collective and individual responsibilities for
health, both physical and mental; interaction between, genetics and the environment (including
social, political, economic, physical and personal factors) as determinants of health, including
mental health; ideological dilemmas and policy assumptions underlying different approaches to
health promotion; the prevention paradox; health education and other methods of influencing
personal life-styles which affect health; appropriate settings for health promotion (e.g. schools,
the workplace); the value of models in explaining and predicting health-related behaviour; risk
behaviour in health and the effect of interventions in influencing health related behaviour in
professionals, patients and the public; theory and practice of communication with regard to
heath education; the role of legislative, fiscal and other social policy measures in the promotion
of health; methods of development and implementation of health promotion programmes;
community development methods; partnerships; evaluation of health promotion, public health
or public policy interventions; international initiatives in health promotion; opportunities for
learning from international experience.
Disease prevention, models of behaviour change: evaluation of preventative actions,
including the evidence base for early interventions on children and families, support for social
and emotional development; pre-determinants of health including the effect of social cohesion
on health outcomes; approaches to individual behaviour change including economic and other
incentives; the role social marketing; involvement of the general public in health programs and
their effects on health care; concepts of deprivation and its effect on health of children and
adults; the benefits and means of community development, including the roles and cultures of
partner organisations; health impact assessment of social and other policies; the role of
strategic partnerships and the added value of organisations working together; the role of setting
targets and goals .
Page 30 of 90
Strategy in health promotion
Health promotion framework
 Legislative
Fiscal: tax (e.g. tobacco) or subsidy (e.g. free school fruit)
Legal
 Health service:
Health authority
Hospital
Primary care (Med, Den, Pharm)
 Other players
Voluntary
District councils (Environmental health, housing, leisure)
County (schools, transport)
Others: police?
Use this for: smoking – diet – exercise – alcohol - IVdrugs – falls - teen pregnancy
Social marketing – four ‘P’s aimed at ‘social good’
‘Product’ (or ‘proposition’) - brand / message / desired behaviour
Place (setting) - school, workplace , home
Promotion - e.g. paid adverts, free publicity, giveaways
Price - free / subsidised
Includes concepts of
consumer focus
market segmentation
http://www.stir.ac.uk/media/schools/management/documents/Am-I.pdf
Page 31 of 90
Running programmes
Models of health behaviour
 Becker and Maiman Health beliefs model
 Social learning
 Locus of Control: Internal / external
 Prochaska & DiClemente 1984 stages of change
Susan Michie Behaviour Change Wheel
Page 32 of 90
Development, implementation and evaluation of health promotion

Karelia [Heartbeat Wales]

The ASSIST study

SureStart evaluations
Early intervention
Preschool day care in deprived populations – 1960s onwards
(Cochrane review – 8 studies, all USA)
Perry Pre School project / Head Start (USA);
Sure Start http://www.bmj.com/cgi/reprint_abr/332/7556/1476
Parenting programmes (Sarah Stewart-Brown)
Parenting skills for teenage mums (Cochrane review – 4 studies)
Page 33 of 90
Environment
Environmental determinants of disease; risk and hazard; the effects of global warming and climate
change; principles of sustainability; methods for monitoring and control of environmental hazards
including: food and water safety; atmospheric pollution and other toxic hazards, noise, and ionising and
electromagnetic radiation; the use of legislation in environmental control; health impact assessment for
environmental pollution; transport policies;
Monitoring of :



Food
Water
Air
Smoke, SO2, NO2, ozone; radiation; cigarettes
http://www.advisorybodies.doh.gov.uk/comeap/state.htm
Smoke: London smog: 500 microgm / m3; = ten times current
Radiation: http://www.hpa.org.uk/radiation/
Bq
Gy
Sv
general population limit:
5 mSv / yr
UK exposure
2.6 mSv / yr
of which 50% Radon, further 35% natural.
97% of artificial exposure is medical
10 weeks in Cornwall = 50 Chest X ray = 250 hours long haul = 1 mSv
CT of chest = 8mSv
Non-ionising radiation
Power lines and cancer http://www.mcw.edu/gcrc/cop/powerlines-cancer-FAQ/toc.html
Acute episodes:
Mercury contamination:
Bhopal
Goiania
Emergency planning: PLAN – PREPARE – RESPOND – RECOVER - RECORD
Page 34 of 90
The health problems associated with poor housing and home conditions, inadequate water supplies,
flooding, poor sanitation and water pollution
Physical health
Damp housing
Overcrowding and TB – slum clearance and the MoH
Shanty towns and typhus
Mental health
Social health
Evidence based housing interventions:
Pest control
Keeping the house dry and removing mould
Radon
Smoke-free
Lead control
Smoke alarms
Swimming pool fencing
Preset water temperature
Housing RCTs – heating and insulation (NZ); poor vs rich neighbourhoods (Chicago)
Water supply and sanitation
Global warming – see document on DH airpollution website
Sustainability
Health at work
appreciation of factors affecting health and safety at work (including the control of substances hazardous
to health); occupation and health;
Occupational hazards in the NHS – biol and chem.
Famous occupational diseases
Radiation workers
Coal miners
Furniture makers in High Wycombe
Wool sorters disease
Page 35 of 90
Nutrition
principles of nutrition, nutritional surveillance and assessment in specific populations including its short
and long term effects; the influence of malnutrition in disease aetiology, pregnancy, and in growth and
development; markers of nutritional status, nutrition and food; the basis for nutritional interventions and
assessment of their impact; social, behavioural and other determinants of the choice of diet; Dietary
Reference Values (DRVs), current dietary goals, recommendations, guidelines and the evidence for
them; the effects on health of different diets (e.g. “Western” diet)
Methods
Diary – record or weighed
FFQ
Blood measurements
Studies
Clinical observation
Ecological – 7 countries, InterSalt
Whole diet - Mediterranean
Intervention
component – Beta-carotene, DASH
whole diet – Atkins etc
Classic deficiency diseases
Pellagra
Goitre and cretinism
Vitamin A, iron, zinc – third world
Food fortification
Iodised salt
Folate (USA)
‘Western diet’
Total energy (calorie intake)
Fat
Fibre (non starch polysaccharide)
Salt
Page 36 of 90
Current dietary goals and recommendations:
Whole population
2500 kcal = 10,000 kJ; <35% as fat, <11% added sugar
'5-a-day' (400 grams of fruit and veg / 18 grams of fibre)
Salt – 6gms as salt ( c.2gm as sodium )
but see http://www.nhlbi.nih.gov/health/prof/heart/hbp/salt_up2.htm
Subgroups
pregnant women: soft cheese, liver, folate
Vitamins and cancer: beta-carotene, alpha tocopherol
Beta carotene: protective in observational, harmful in intervention
Determinants of choice of diet:
People eat food not components!
Chinese diet
Mediterranean diet
Western diet
Pryer JA et al. Dietary patterns among a national random sample of British adults. J Epidemiol
Community Health 2001 Jan;55(1):29-37 e.g. among men the most prevalent diet group was
"beer and convenience food" (34% of the male population)
Page 37 of 90
SCREENING
Diagnosis and Screening: principles, methods, applications and organisation of screening for
early detection, prevention, treatment and control of disease; statistical aspects of screening
tests, including knowledge of and ability to calculate, sensitivity, specificity, positive and
negative predictive values, and the use of ROC curves; differences between screening and diagnostic tests, case finding; likelihood ratios; pre and post test probability; ethical economic,
legal and social aspects of screening; the principles of informed choice; planning, operation
and evaluation of screening programmes; the evidence basis needed for developing screening
policies and implementing screening programmes, including established programmes such as
breast and cervix and those currently in development, being piloted or subject to major
research activity, current examples (amongst others) being colon cancer, chlamydia screening
and certain antenatal / neonatal screening tests; ethical, social and legal implications of a
genetic screening test.
Wilson criteria:
The disease
Importance, natural history, does early intervention make any difference?
The test
Specificity and sensitivity, acceptable
The programme
Ethics, economics, logistics
Special biasses in cancer screening
length bias
lead time bias
Screening tests and Bayes theorem
Page 38 of 90
Quality assurance in screening
Invite
Screen
Confirm
Treat
Population health outcome
UK National www.nsc.nhs.uk or http://libraries.nelh.nhs.uk/screening/ **
Antenatal
Neonatal – PKU, MCADD, sickle, hearing
Childhood
Cancer: http://www.cancerscreening.nhs.uk
Breast
Cervix
Colorectal: 50-69 once in 2yrs, FOB
Chlamydia
Occupational
Bladder cancer – in UK organised by HSE
Assessing test performance
Receiver operating characteristic [ROC] curve
Page 39 of 90
ETHICS




Harm (maleficence)
Good (beneficence)
Self (autonomy - make your own decisions about yourself)
Others - justice
Two types of justice
Greatest good for greatest number (Jeremy Bentham c1800– utilitarian)
Greatest benefit for least advantaged (John Rawls 1971– social justice)
e.g. ethics of
forcing people to wear seat belts (saves life but doesn’t respect autonomy)
genetic testing (parent vs rights of child)
giving life saving blood to a child Jehovah’s witness
NB in exam
1. don’t give a personal opinion (“so I think we should / shouldn’t do this”) – just set out
the issues under each of the four headings
2. if you have strong religious views on e.g. abortion which you feel you have to express
say “Christians / Muslims believe that…” not “I think that….”
the ethics and etiquette of epidemiological research.
Helsinki declaration www.wma.net
Caldicott principles – not law, “data transfer must be justified”
Data protection act
Human Rights Act – right to privacy
Page 40 of 90
GENETICS
elementary human genetics; inherited causes of disease in populations; basic genomic concepts
including patterns of inheritance, penetrance, genotype/phenotype differences, polygenetic disorders,
gene-environment interactions and the role of genes in health and disease; ætiology, distribution and
control of disease in relatives; elementary molecular biology as related to genetic epidemiology and
microbiology.
Understanding of basic issues and terminology in the design, conduct, analysis and interpretation
of population-based genetic association studies, including twin studies, linkage and association
studies.
http://www.phgu.org.uk/pages/edu_resources.htm
Mendel
dominant
recessive
sex-linked
'Polymorphism' vs 'mutation'
Non Mendelian inheritance




multi-gene (hypertension)
variable penetrance – haemochromatosis: abnormal gene but variable disease
state
variable expression (how much gene product is made from the DNA: same gene
- mild vs severe disease)
one versus two genes
Multiple allele
Need to know what % of disease attributable to each specific mutation:
Gene frequency in different populations e.g. Cystic fibrosis
Burden of disease
BrCa1
Page 41 of 90
Evidence for genetic basis of common diseases: e.g. hypertension, schizophrenia:

twin studies
Lichtenstein et al. Environmental and heritable factors in the causation of cancer NEJM
Jul13,2000: 343;78-85.

gene identification studies
(AJPH 2009;99:480-486)
Monozygotic
Dizygotic
Siblings
r
0.83
0.65
0.51
Neither
186
280
716
One
31
65
248
Both
31
33
102
Gene – environment (susceptibility)
Smoking and CFH Y402H gene leading to AMD
PKU
Page 42 of 90
STATISTICAL METHODS
Fuller treatment including calculations etc
http://bmj.bmjjournals.com/collections/statsbk/ this is the entire text of “Statistics at square
one”
elementary probability theory; methods for the quantification of uncertainty; estimation of confidence
intervals; independence of events; conditional probability; standard statistical distributions (e.g. Normal,
Poisson and binomial) and their uses; sampling distributions; principles of making inferences from a
sample to a population; measures of location and dispersion and their appropriate uses; graphical
methods in statistics; hypothesis testing; type I and II errors; problems of multiple comparisons;
parametric and non-parametric tests for comparing two or more groups; sample size and statistical
power; regression and correlation; the appropriate use, objectives, and value of multiple linear
regression, multiple logistic regression, principles of life-tables and Cox regression. Comparisons of
survival rates; heterogeneity; funnel plots; the role of Bayes' theorem.
systematic reviews, methods for combining data from several studies, and meta-analysis;
You may be required to calculate:
Standard Error and Confidence Interval (CI) of a proportion and of a difference in proportions, Chi
Square for a 2 X 2 table, McNemar's test, standardisation - direct and indirect, weighted averages, CI
and standard errors for means
Elementary probability theory
Probability of BOTH / AND -> multiply the probabilities
Only works if the two events are independent
So if observation shows the two events happen together more often than that – then the events are NOT
independent
probability of appendicitis AND Down's syndrome
probability of being a case of D&V AND eating egg sandwich
probability of cot death in first child AND second child
Application to calculation of ‘expected’ chi-square
Probability of EITHER / OR -> add the probabilities
Must be exclusive (i.e. can't both happen)
probability of either fatal or non-fatal stroke
Page 43 of 90
What’s this?
Descriptive statistics
Displays
Use a system to analyse them:
1. This is a scattergram [type of display] showing data for life expectancy and
deprivation [data plotted] in health authorities in England [units of analysis].
2. The obvious feature is a close inverse relationship (but formal analysis is
needed).
3. We interpret this to mean that life expectancy decreases as deprivation
increases (but more information is needed before we can conclude this is a causal
relationship).





Bar chart
Histogram
Scattergrams
Pie chart
Box and whisker plot
 Survival curves:
 Hazard function
 Kaplan Meier product limit (because product of probabilities
so far)
 [BMJ 5 Dec 1998 p 1572]
 (e.g.cancer by stage)
 conditions for this (e.g. median survival time estimate):
 censored = non-censored for survival
 early = late
 event happens at time specified (<> OP follow up )
 Systematic review plots:
 Forest
 Funnel
Page 44 of 90
Meta analysis
NB meta analysis not the same as SYSTEMATIC REVIEW
Sole purpose of meta-analysis = increased precision of effect estimate
nonstatistical aspects
e.g. comparability, quality of studies
weighting
Heterogeneity
 commonsense e.g. jet lag and shift work
 statistical
Bias detectable in funnel plot (odds ratio vs suspect factor):
Publication bias:
Location,
English language,
Citation,
Multiple publication
Page 45 of 90
Interpreting multiple regression models
Many predictors of one outcome
MODELS – goodness of fit
Three main types:

Logistic
outcome is a yes / no e.g. dead / alive at 5yrs

Survival
outcome is a time to an event e.g. death, relapse

Linear
outcome is a number e.g. area rate of disease

(Poisson
outcome is a count e.g. number of deaths)
Result is given as



Logistic – odds ratio
Survival – hazard ratio
Linear – regression coefficient
“No effect”



Odds ratio = 1
Hazard ratio = 1
Regression coefficient = 0
means no effect
ditto
ditto
Assumptions:
Logistic – effect of predictor same throughout range i.e. one number captures it all
Survival – curves 'parallel' i.e. proportion of hazard same throughout follow up
Linear – linear, independent, equally weighted
So not valid for:

Survival – surgery (high early mortality) versus medical (continuous loss)

Linear – area analyses (spatial autocorrelation), time series (serial autocorrelation)
Page 46 of 90
Non statistical stuff
STUDY DESIGN
Making inferences from a sample to a population: generalisation
Random samples
Representative samples
Sample size:
 effect size [incorporates variability]
 significance level for testing [usually two sided 5%]
 power of study to detect difference [usually 80%]
e.g.
‘Based on an estimated cumulative incidence of injuries requiring medical attention of
35% in the first two years of life, a study of 800 participants (400 intervention: 400
control) would have over 80% power to detect a risk ratio of 0.7 at the 0.05 level of
significance, allowing for a 10% loss to follow up.’
Type I and Type II errors
Type I – multiple testing
Type II – study power too small - “Two is too small” [Lisa Wilkins]
Hypothesis testing [P values etc] vs estimation [95% CIs]
Transformations
5 reasons to transform data:
1. make variance equal
2. make linear
3. make Gaussian / Normal – you can then plug in to a whole load of
powerful theory
4. other simplification (e.g geometric mean?)
5. presentation of results
Very Large G/Nomes Seem Pathetic
A note on “regression to the mean”
All about things which VARY e.g. blood pressure
If you select “top 10” of a variable, next time you measure they won’t be the top 10.
Page 47 of 90
Page 48 of 90
How would you analyse…..
Focus on the type of problem:
A: GROUPS OF PEOPLE
“Please put me in a 2 x 2 table”
Percentage in one group / column too high (e.g. higher %age of chicken eaters fell ill)?
====> chisquared test
[More than two columns – perhaps chisquared for trend]
2. “Is one group of
People }
towns }
Numbers}
bigger}
wiser }
different from}
the other one?”
Analysis of variance (ANOVA):
 one way: e.g. blood pressure mean in different racial groups
 two way: e.g. blood pressure mean by sex in different racial groups
Special case of this is :
t test - model for difference in means,
Validity assumptions: what you’re measuring is (1) Normally distributed and (2) has
same variance in populations from which groups / sample drawn (may not know this for
sure and have to use the samples to guess) and (3) measurements are independent of
each other
Non parametric version: Mann Whitney U test etc [e.g. SF36]
3. Matched pairs – McNemar’s chisquared test for discordant pairs
[McNemar’s statistic: (A-B)2 / A+B : same ‘how often that big’ i.e. distribution as chisquared]
Parametric and non parametric
 Parametric:
“IF we can assume that in these people [blood pressure] is Normally distributed,
THEN this is a very odd [low P] result…...”
 Non parametric:
“………But it isn’t so odd if [blood pressure] isn’t Normally distributed”
So: parametric tests more powerful [likely to produce low P / declare significant] provided
assumptions justified.
Page 49 of 90
B: ASSOCIATION i.e. “PLEASE PUT ME ON A SCATTERGRAM”
Pearson product moment [= least squares] - parametric
Spearmann rank correlation – non parametric
Multiple regression
[Cronbach’s alpha – for agreement between raters e.g. reading a mammogram]
C: SURVIVAL
Cox proportionate hazards model - parametric
Log rank – non parametric
D. TIME SERIES
Simple stuff:
Inspect the graph: trend, seasonality
Annual totals: up or down?
Moving average to smooth out
Predictive models e.g. does daily up and down of particulates in air predict daily up and down
of hospital admissions?
Serial correlation: auto regressive (AR) to cope with serial correlation
Moving average (MA) to smooth bumps
Hence ARMA or ARIMA models – too advanced for Part A!
Scales
Nominal
Ordinal
Interval
Ratio
Kappa – measure of agreement for nominal scales e.g. do two judges put observations into same
categories?
Page 50 of 90
Three famous models
These all function by converting numbers into probabilities
(i.e they are probability density functions)
You have to specify some things about the model (cf "what scale is this model
aircrcaft?")
To model:


Toss up (yes / no event): binomial function (specify expected proportion of yes/no)
Count (whole number): Poisson function (specify mean / expected number for thing you
are modelling)

Rate (e.g. age standardised death rate): Normal Gaussian function (specify mean and sd
of the thing you are modelling)
NB admissions are a count, bed days are not
Europeans (n=149)
Punjabi Sikh (n=151)
doi: 10.1093/ije/dyr101
SBP
DBP
140 (sd 17)
82 (sd 10)
144 (sd 17)
82 (sd 8)
Page 51 of 90
COMMUNICABLE DISEASE
definitions (incubation, communicability and latent period; susceptibility, immunity, and herd immunity);
surveillance - national and international -, its evaluation and use; methods of control; the design,
evaluation, and management of immunisation programmes; choices in developing an immunisation
strategy; the steps in outbreak investigation including the use of relevant epidemiological methods;
emergency preparedness and response to natural and man-made disasters; knowledge of natural
history, clinical presentation, methods of diagnosis and control of infections of local and international
Public Health importance (including emerging diseases and those with consequencies for effective
control); organisation of infection control; a basic understanding of the biological basis, strengths and
weaknesses of routine and reference microbiological techniques (see also 2d); international
aspects of communicable disease control including Port Health.
epidemic theory (effective and basic reproduction numbers, epidemic thresholds) and techniques for
infectious disease data (construction and use of epidemic curves, generation numbers, exceptional
reporting and identification of significant clusters);
================================================================
Surveillance
(NB this is an information activity)
notification
laboratory reporting
GP spotter schemes (e.g. flu)
NHSDirect
British Paediatric Surveillance Unit (e.g. SSPE, HUS, paed HIV)
Purpose of surveillance – POWER! (Thanks to Anj Saha)
Priorities for resource allocation
Outbreaks detected early
Warning system
Evaluate effectiveness of interventions
Risk groups characterised
Special arrangements: AIDS, leprosy
Enhanced surveillance, salivary diagnosis
Page 52 of 90
Disease control
Surveillance
How is it spreading? Risk groups?
Basic science for new diseases e.g Ebola, MERSCoV
Diagnosis
Diagnostic techniques
Access to diagnosis
Screening
Treatment
Access to health services
Compliance with treatment
Prevention
Specific - imm & vacc programmes
General – sewage / enough food / good housing etc
Contacts
Identification and management of contacts
Immunisation: Green book, Joint Committee on Vaccination and Immunisation
Hepatitis B control:
1.
2.
3.
4.
5.
6.
Surveillance
Screening blood products & organ donations
Sterilisation of sharps inc non-medical (eg tattoos)
Safe disposal of Sharps
Stab! ie vaccinate risk groups
Safe sex &needle exchange education
Page 53 of 90
Epidemiology in outbreak investigation and control: Galbraith
PROCESS AND TASKS
 Confirm facts
 Immediate measures : to contain / treat illness
 Case definition - > case finding: Full extent in time and place
 active
 enhanced surveillance
 Descriptive epidemiology: e.g. all babies / ethnics / swimmers
 Hypothesis: usually mode of spread, sometimes cause
 Test hypothesis
 Action: e.g. Broad St pump
[Media handling - usually not for Part A]
Molecular epidemiology:
e.g. whole genome sequencing for TB control
Management of contacts, other methods of interrupting transmission: role of contact
immunisation
Methods of disposal of clinical waste, disinfection and sterilisation
Infection control in the hospital (including MRSA)
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/
PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4064682&chk=Vqjhyn
International aspects: WHO
Emergency planning (SARS, pandemic influenza):
 Plan
 Prepare (stockpiles etc) and Prevent (vaccinate)
 Respond
 Recover (from the event including psychological care)
 Record
Page 54 of 90
Communicable disease – how much do I need to know?
AgORMICS and PIDQUICS
1. Clinical – one line only
2. Agent: Is it virus / bacteria / protozoa etc;
How do you diagnose it?
3. Occurrence in named country
(e.g. winter epidemics / sporadic / imported cases only)
4. Reservoir
5. Mode of transmission:
(parenteral / faecal-oral / something else),
6. Incubation (omit unless you’re sure)
7. Communicability (e.g. communicable while still excreting in stool)
8. Susceptibility and resistance (e.g. infection confers resistance)
or: (exam comments Jan 99): Identification, Causative Organism, incidence,
reservoirs, how transmitted
2. Control: prevention, control of case: isolation, disinfection, quarantine, immunisation,
contacts, specific measures, [PIDQUICS], ? epidemic measures
http://www.hpa.org.uk/infections/topics_az/list.htm
Food poisoning:
Salmonella (enteritidisPT4)
Shigella
Campylobacter
Cryptosporidiosis
Listeria
E coli 0157
Typhoid
Cholera
Meningitis:
Meningococcus
Haemophilus
Pneumonias
Pneumococcus
Legionnaires
TB**
Mantoux, γ interferon tests etc
Viral fevers
Ebola
Lassa
Dengue
Page 55 of 90
Hepatitis
A
B
C
Immunisable
D: inc cutaneous
P
[T]
polio: OPV vs IPV
[M]
M inc SSPE
R
HIB
Sexual:
Chlamydia
Gonorrhoea
Syphilis
HIV
SARS and other corona viruses
Herpes
Influenza: vaccine, treatments, surveillance
Rabies
Lyme disease
Q fever
Plague – Madagascar
Giardiasis
Head lice
Scabies
Toxocara
Toxoplasma
Malaria
Page 56 of 90
ORGANISATION AND MANAGEMENT - theory
Internal and external organisational structures environments; evaluating internal resources and
organisational capabilities; identifying and managing internal and external stakeholder interests;
structuring and managing inter-organisational (network) relationships, including intersectoral work,
collaborative working practices and partnerships; social networks and communities of interest; assessing
the impact of Political, economic, socio-cultural, environmental and other external influences
Motivation, creativity and innovation in individuals, and its relationship to group and team dynamics;
barriers to, and stimulation of, creativity and innovation (e.g. by brainstorming); learning with individuals
from differing professional backgrounds; personal management skills (e.g. managing: time, stress,
difficult people, meetings); the effective manager; principles of leadership and delegation; principles of
negotiation and influencing; principles, theories and methods of effective communication (written and
oral) in general, and in a management context. Interactions between managers, doctors and others; the
theoretical and practical aspects of power and authority, role and conflict; professional accountability clinical governance, performance and appraisal; behaviour change in individuals and organisations.
Organisations
Describing an organisation:
Some common structures:



Divisional
Functional teams
Matrix
Handy on styles
Page 57 of 90
Management and Change: management models and theories associated with motivation and
leadership and change management, and their application to practical situations and problems; critical
evaluation of a range of principles and frameworks for managing change; an understanding of the issues
underpinning the design and implementation of performance management against goals and objectives
Change
Gleicher’s formula:
Dissatisfaction x vision x first steps > resistance
Susan Michie Behaviour Change Wheel (again)
Force field analysis (Lewin)
PEST
SWOT (Ansoff)
Innovation
Innovators 5% >> Early Adopters 20% >> Late adopters >>> Laggards
Innovators: High SES and “cosmopolitan”
Innovations will spread quickly if:





Relative advantage
Compatibility
Simplicity
Can Trial
Observable benefit
Red Cabbage Sounds Too Organic!
Page 58 of 90
Leadership
Theories about leadership:
1. Trait - [intelligence, self confidence, persistence, etc - also charisma] – the hero
2. Skills – US military [knowledge, problem solving, social judgement]
3. Contingency: (Fiedler) “best fit” between leader, led, task
Public health leaders (Day et al):
Mentor
Shape
Network
Know
Advocate
Microscopic sheep need kingsize armbands
Motivation
Maslow
McGregor
Social power (French and Raven 1959)
Expert:
Legitimate:
Reward:
Referent:
Coercive:
technical
obligations
pay etc
makes me feel valued
make life difficult for
Negotiation
(Fisher and Ury: Harvard Negotiation Project “Getting to Yes”)




Separate the problem from the people (not “He doesn’t understand”)
Focus on interests not positions (‘family friendly’ not ‘home at 3.30pm’)
Invent options (e.g. crèche, school taxi service, etc etc)
Objective criteria (e.g. meets requirements of Care for the Family Charter)

Work on BATNA
Page 59 of 90
Groups
Adair: group needs, task needs, individual needs: - NB ALL THREE must be met
Belbin roles





Plant (ideas)
Resource investigator
Team worker (hugs everyone)
Completer / finisher
Specialist (technical expertise)
Etc
Forming – storming – norming – performing (Tuckman)
Polite hello – big rows about basics – consensus – on with the task
Page 60 of 90
Managing people
Job design
Selection
Appraisal
Self management
Assertiveness
Time management
Delegation
Miscellaneous
Creativity
Group
Brainstorm
Time out
Knowledge management
Personal
Play
Mind map
Art
Delegation
 Explain
 Train
 Monitor
 Praise
“Delegate responsibilities not tasks”
Effective communication
Written
Customer focussed
Short words – short sentences
Technical language appropriate to readership
Spoken
Remember non verbal aspects
Two way!
Page 61 of 90
www.leadershipacademy.nhs.uk
Personal qualities
Integrity
CPD
Manage self
Self awareness
Work with others
Develop networks
Build relationships
Encourage contribution
Work within teams
Manage services
Planning
Manage resources
Manage people
Manage performance
Improve services
Patient safety
Critically evaluate
Encourage innovation
Facilitate transformation
Set direction
Identify context
Apply evidence
Make decisions
Evaluate impact
Create vision
Develop vision
Influence vision of wider healthcare system
Communicate the vision
Embody the vision
Deliver the strategy
Frame the strategy
Develop the strategy
Implement the strategy
Embed the strategy
Page 62 of 90
MANAGEMENT GURUS
Models
Taylor: “Scientific management” c. 1910 - the one best way to do things
e.g. doctor to patient in A&E
Fayol: 1910 / 1950 – 5 tasks of management:

Plan, Organise, Co-ordinate, Command, Control
Mayo: c.1930 – Hawthorne experiments – social processes at work
i.e. morale matters!
Mintzberg: c.1975 – what managers do (mostly muddle through)



Interpersonal - figurehead, leader, liaison
Informational- monitor, disseminate, spokesman
Decisional – entrepreneur, disturbance handler, resource allocator, negotiator
Motivation:
McGregor: X (lazy) and Y (great people)
Maslow: Hierarchy of Needs [NB once a want is satisfied it is no longer important]
Mayo: see above
Herzberg: 1959 Motivation to work –


Satisfaction = Motivators – achivement, recognition, career progress etc
Dissatisfaction = ‘hygiene’ factors – status, salary, work conditions, company policy
Page 63 of 90
RUNNING HEALTH SERVICES
c) Approaches to the assessment of health care needs, utilisation and outcomes, and the
evaluation of health and health care: the uses of epidemiology and other methods in defining
health service needs and in policy development; participatory needs assessment; formulation and
interpretation of measures of utilisation and performance; measures of supply and demand; study
design for assessing effectiveness, efficiency and acceptability of services including measures of
structure, process, service quality, and outcome of health care; measures of health status, quality
of life and health care; population health outcome indicators; deprivation measures; principles of
evaluation, including quality assessment and quality assurance; equity in health care; clinical audit;
confidential enquiry processes; the use of Delphi methods; economic evaluation (see also 4.d);
appropriateness and adequacy of services and their acceptability to consumers and providers;
epidemiological basis for preventive strategies; health and environmental impact assessment.
Funding of health services
Taxation – general or hypothecated
Insurance – personal or ‘social’
Personal savings (‘provident’)
Patients belong as:
Citizens (e.g. NHS)
Employees (e.g. armed forces)
Customers (e.g. HMO)
NB Most countries have all of these – key issue is which one dominates
International comparisons: USA, Germany
Resource allocation



Population size
Age
Morbidity – proxy by mortality (SMR) and LLSI (Census)
Page 64 of 90
Policy and strategy development and implementation: differences between policy and
strategy, and the impact of policies on health; principles underpinning the development of
policy options and the strategy for their delivery; stakeholder engagement in policy developing,
including its facilitation and consideration of possible obstacles; implementation and evaluation
of policies including the relevant concepts of power, interests and ideology; strategy
communication and strategy implementation in relation to health care; theories of strategic
planning; analysis, in a theoretical context of the effects of policies on health; major national
and global policies relevant to public health; health service development and planning; methods
of organising and funding health services and their relative merits, focusing particularly on
international comparisons and their history;
Health and social service quality risk management; principles underlying the development of
clinical guidelines, clinical effectiveness and quality standards, and their application in health
and social care; integrated care pathways; public and patient involvement in health service
planning; professional accountability, clinical governance, performance and apprasial; historical
development of personal health services and of public health.
Policy formulation
Central policy: Power, ideology in health policy formation




Ideology e.g. centralise or localise, competition or planning, consumerism vs
technical (maternity services)
Special interests e.g. professional, commercial (tobacco, drugs)
Data e.g. Euro data on cancer survival
Expert advice e.g. vCJD, SARS, flu policy
Local policy: Consumer and community participation


Focus groups, opinion polls etc
Citizen’s jury


GP as proxy for local public
Non executives on local Boards
Page 65 of 90
HOW COMMISSIONING WORKS
PLAN
Assess need
Does need exist? (Effectiveness)
Write specification
Procure capacity
Number work
FUND
Prioritisation
Fair decisions (Theories of justice)
Contract type
MONITOR
Overview
Service
Event
Page 66 of 90
Use of information for health service planning and evaluation; specification and uses of
information systems; common measures of health service provision and usage; the uses of
mathematical modeling techniques in health service planning; indices of needs for and outcome
of services; the strengths, uses, interpretation and limitations of routine health information; use
of information technology in the processing and analysis of health services information and in
support of the provision of health care; principles of information governance
Planning
Need = ability to benefit (Stevens)
Need / demand / supply : Bradshaw
Symptoms not the same as need (stoical patients)
Assessing needs for a population (e.g. immigrants)



Physical health:
Public health programmes:
Imm and vac
Screening
Lifestyle
Primary care: medical (e.g. skin / foot problems) dental, pharmacy
Specialist (same as anyone else)
Mental health: e.g. depression / anxiety / post traumatic etc
Social health: e.g. keep groups together, language culture etc
Joint strategic needs assessment
Asset based needs assessment
Assessing needs for a specific condition or service (e.g. arthritis, ECMO)

Epidemiological
Definition
Numbers
absolute e.g. incidence
marginal e.g. waiting times
norms
How do we meet the need now? (e.g. admit to orthopaedic bed)
Does this work? (e.g. how many get back to work?)
Other ways to meet the need (e.g. out patient physio, home exercise)

Comparative
Neighbouring services

Corporate
Government policy
Page 67 of 90
Stakeholder views
Page 68 of 90
Funding
Priority setting
Government policies
Local opinion
Economic evaluation
Strength of evidence
Justice



Bentham
Rawls
Procedural
Procedural justice and IFRs
Types of contract
Block / capitation
Tariff / item of service
Finance, management accounting and relevant theoretical approaches: the linkages
between demographic information and health service information - its public health
interpretation and relationship to financial costs; budgetary preparation, financial allocation,
contracts and service commissioning; methods for audit of health care spending.
NHS finance systems
Budget reports usually show:
Pay (staff salaries)
Non Pay (e.g. drugs and equipment)
Spend:
year-to-date
forecast to year end
Separate recurrent from non-recurrent (e.g. buying a piece of equipment)
Non-recurrent = ‘capital’ spending
Page 69 of 90
Monitoring
Performance - overview
Outcome framework for NHS in England – 5 ‘domains’



Effective
o Prevent premature death
o Good QoL for long term conditions
o Recovery from acute episodes
Good experience
Safe
Quality outcomes framework (QOF) for GPs
http://www.qof.ic.nhs.uk/
Performance – evaluation of a service
Donabedian: process, structure, outcome
 structure e.g. beds, opening hours, staff qualifications and numbers etc.,
 process e.g. number of admissions. Operations
 outcome
Performance - exceptional events



Confidential enquiries
Sentinel audit
Untoward incident – ‘never’ events
Root cause analysis – active errors and latent errors
=========================================================
Governance and risk management


How serious?
How likely?
Risks to:




Patients
Staff
Buildings & equipment
Reputation
Page 70 of 90
migration, and the health effects of international trade; international influences on health and social
policy; critical analysis of investment in health improvement, and the part played by economic
development and global organisations
International health care
Infections e.g. SARS
People going abroad for treatment
Tourists
People retiring e.g. to Spain
Immigrants
Border issues
Social policy
“role of state in relation to welfare of citizens”
SHEESH






Social security
Housing
Education
Employment
Social services
Health
Michael Hill Understanding social policy 6th ed Oxford: Blackwell 2000.
A good read.
Page 71 of 90
TIPS ON EXAM TECHNIQUE
PREPARATION
You MUST get enough sleep for the five days before the exam.
Dement WC. The promise of sleep. London: Macmillan 2001
Book diary time for revision, but Benedict Carey (‘How we learn’) says that following a routine
of same time, same place may not be optimal. It’s ok to potter, mull things over etc.
Always quickly revise what you did yesterday – that’s an important aid to memory. (Ideally do
it again a week later too.)
Don’t just read passively - test yourself.
Buy a watch or clock with a big face; analog not digital.
GENERAL
1. WATCH YOUR TIMING!
Paper IA: 25 minutes per qq: 5 minutes to plan; 20 minutes to write.
When allowed to open the paper, write down the start time opposite each question:;
10.00; 10.25; 10.50;
11.15; 11.40; 12.05
Paper IB: slightly less; allow 20 minutes per qq. 3 to plan, 17 to write.
Start times: 2.00; 2.20;
2.40; 3.00
If you’ve gone over the allotted time on a question - or part of a question –
STOP WRITING AND MOVE ON!
Paper IIA: The exam assumes you will take 50 minutes to read the article for critical appraisal.
You can then allow one minute per 1% of marks i.e. 40 minutes for 40% of the marks. Again:
If you’ve gone over the allotted time on a question - or part of a question –
STOP WRITING AND MOVE ON!
Paper IIB: 5 questions in 90 minutes = 18 minutes per question.
2. HEADINGS
You must structure your answer. The easy way to do this is to use headings: two per page.
Page 72 of 90
No headings needed if the question is broken down into many parts.
3. EXAMPLES
Give examples: name authors ; cite studies
If the example is implicit in the question (e.g. ‘discuss screening for colorectal cancer’) stick to
that, don’t wander off
If the example is not implicit in the question (e.g. ‘discuss quality assurance in screening
programmes), use a wide variety of examples’
4. CRITIQUE
Explain everything: Say ‘because…’ ‘hence’ ‘and so’ as often as possible!
Give both sides of any argument: ‘on the one hand...’ ‘on the other hand’
Point out any limitations e.g. of data sources, problems with somebody’s theory etc etc
5. AMOUNT
You will need to write about 250 words every ten minutes i.e. about 2-3 sides of A4 for
a 20 minute answer when practising (The exam answer paper has very wide margins so you will
cover more paper.)
PAPER I
If you can't think of a better structure:
For short questions e.g. "write short notes on":
 What is it? (definition if possible but if not talk around it)
 What do people use it for? – give an example
 Something in favour
 Something against
and, if time allows:
 Current issues in.....
OR for more social / management questions:



Definitions and subcategories of the problem
How to tackle the problem
How to prevent the problem
Page 73 of 90
General frameworks
Mind map:
Method:






Underline the key word in the question
Construct mind map of anything that comes to mind
Fill out mind map with names / data / case studies
Add in some topical examples
Number main areas of map to give the order for your main paragraphs
Always start with points on definitions
Basic roles of public health:





Health improvement e.g. lifestyle programmes
Health protection e.g. vaccination programme, outbreak response
Health services e.g. screening programmes, commissioning
Health intelligence e.g. surveillance of trends etc
[Academic – R&D] e.g. basic research
Page 74 of 90
Epidemiology
1. If ‘describe the ep of’:
 Time [secular trends - 50year, more recent]
 Place [UK, Euro, world]
 Person
 age / sex / soc cl
 ethnic / occupations / lifestyles
 familial / genetic
 any other famous facts?
FILL OUT the answer by thinking about the quality of study / data (e.g. ascertainment)
2. If ‘cause’ or ‘association’: Bradford Hill framework
3. 'What is the evidence?' or 'How would you study…?'
Consider evidence from:
Descriptive: time trend, spatial, people affected: do they fit the hypothesis?
Surveys
Case - control
Cohorts
Interventions
Remember studies in special groups e.g. high risk, occupational
Evaluation
If "how would you evaluate…" mention Donabedian then
 structure e.g. beds, opening hours, staff qualifications and numbers etc.,
 process e.g. number of admissions. operations
 outcome e.g. survival, quality of life
If "assess the performance of..."
Could use Donabedian, may need to consider performance framework:
Health improvement
public health
Fair Access
equity
Appropriate Delivery of effective health care
EBM
Patient / carer experience
complaints/survey
Outcome of NHS care
audit
Page 75 of 90
Needs assessment
If “assess the health needs of …" a group e.g. immigrants



Physical health:
Public health programmes:
Hygiene – food water shelter
Imm & Vacc
Screening
Lifestyle programmes
Primary care: medical (e.g. skin / foot problems) dental, pharmacy
Specialist (same as anyone else)
Mental health: e.g. depression / anxiety / post traumatic etc
Social health: e.g. keep groups together, language culture etc
If “assess the needs for" a condition e.g. arthritis

Epidemiological
Definition
Numbers (absolute e.g. incidence or marginal e.g. waiting times)
How do we meet the need now? (e.g. admit to orthopaedic bed)
Does this work? (e.g. how many get back to work?)
Other ways to meet the need (e.g. out patient phsyio, home exercise)

Comparative
Royal College norms or standards
Neighbouring services

Corporate
Government policy
Stakeholder views
Page 76 of 90
Communicable disease / environmental health
Mention TASKS and MANAGEMENT PROCESS to achieve them
TASKS
Outbreak framework if possible
 Confirm facts
 Immediate measures : to contain / treat illness
 Case definitionS : definite, possible, probable
 Case finding: FULL EXTENT in time and place
 active
 enhanced surveillance
 Descriptive epidemiology: e.g. all babies / ethnics / swimmers
 Hypothesis: usually mode of spread, sometimes cause
 Test hypothesis
 Action: e.g. Broad St pump
MANAGEMENT PROCESS
OB plan, multiagency team, press releases etc
Similar can work for acute chemical exposure
Page 77 of 90
Health information
Always consider all of (even if only to say “not much use”):






Mortality
Hospital: Inpatient, OPD / A&E, lab
Primary care: Medical, [dental], prescribing, NHS Direct
Register: e.g. cancer
Surveys
Non-health: fire, police, social services etc
Health promotion and disease prevention
Again TASKS and MANAGEMENT PROCESS
Health promotion framework:
 Legislative
Fiscal tax or subsidy
Bans
 Health service:
Local policy
Hospitals (treatment but also as a major local employer)
Primary care
 Local:
Schools
Leisure
Others e.g. transport, policy, voluntary groups etc
Page 78 of 90
Short notes e.g. statistics, economics
What is it?
When would you use it? –give an example (preferably real, if not make a hypothetical)
Something good / useful
Something tricky / difficult
[Hot topics]
Sociology / social policy / management
Basic requirement is to match theories with facts.
Use one of the theories (see above: e.g. Maslow, Handy) as a way of describing how the world
works.
Remember the big picture e.g. other agencies to involve in any practical problem:
 UP: Department of Health involvement; Colleges; GMC?
 SIDEWAYS: Colleagues in your organisation, neighbours (e.g.hospitals)
 DOWN: GPs, public
Social policy
Use the SHEESH headings, one paragraph about each:
Social security (disability benefit, pensions etc)
Housing
Employment
Education
Social service
Health
Ethics
Use the headings, one paragraph about each:
Good - how can this do good to the patient
Harm - how might this do harm to the patient
Autonomy (let people decide for themselves)
Justice (fairness to other people)
Page 79 of 90
PAPER IIA: critical appraisal
50 minutes to read the paper; 10 minutes for each 10% of the marks
40% of marks = 40 minute answer so PLAN the answer fully.
Do NOT read the paper from beginning to end.
Just read: the title - the last para of introduction - the first para of discussion - the last
para of discussion:
This gives you 90% of what you need in 2 minutes!
Now go back and hunt out details – still don’t try to read everything: just hunt for the
answers to the headings below.
The research question: what were they trying to prove? Is it an important problem?
The subjects: e.g. patients / resident population – who was excluded?
The method
Design – RCT / case control / systematic review
Execution – e.g. response rate / groups balanced
What instrument used to measure outcome – sensitive / accurate etc
The intervention: what did they intend to do? e.g. 6 visits per month
Comparator – placebo? Usual care? What?
Fidelity of intervention – what did they achieve? e.g. 20% of group dropped out
Main result: what did they find? e.g. 36% reduction in disease
Could this be due to
Chance- what is the P value / confidence interval?
Type I error – how many P tests?
Type II error – was study power specified?
Bias – intervention and control handled differently Confounding – other explanations
Truth!
Page 80 of 90
For a full critical appraisal include discussion and applicability as follows but this
isn’t needed the question asks for ‘strengths and limitations’
Discussion
Restate Main result – comment: is this effect big / small / trivial?
What is already known about this topic – use your general public
health knowledge
What this study adds
Limitations of this study – based on everything so far!
What does it mean for me?
Applicability – were the research subjects like my population?
Place (e.g. urban/rural) Culture (e.g. USA / UK) Setting (e.g. primary / secondary
care)
Can it be scaled up – how intensive was it - Cost ? Sustainability? Staff
required?
For each section you consider 

Give strengths and weaknesses
Say ‘because…’ a lot!
Page 81 of 90
PAPER IIB: data skills
Reading graphs etc: – Data content – obvious features – possible interpretation
A general approach to reading tables




Size (using common sense: high or low e.g. smoking rates all above 60%?)
Spread (highest and lowest; spread out or clumped together?)
Trend (is the Table in some order?)
Variation by Gender / Age / Practitioners / Spatial (GAPS)
Interpretation: ABC E
Artefacts:
Blip:
Category:


Error e.g. typing mistake
coding


P values / confidence intervals etc
Consistency – time (blip?), sex (male AND female affected?) etc


Primary into secondary
Health / social care
Epidemiology of underlying disease or its risk factors
LA Name
Wigan
Salford
Allerdale
Lancaster
Liverpool
Carlisle
Barrow-in-Furness
Ribble Valley
Crewe and Nantwich
Chester
South Lakeland
Macclesfield
SMR CIRCULATORY CHD Admissions Angiography
DISEASE I00 - I99
(SAR) I20 - I25
(SAR) K63
126
113
121
108
120
88
117
87
116
124
113
104
108
97
107
72
105
98
99
76
97
77
96
73
IMD 2004
103
85
97
89
140
66
112
62
58
69
81
68
Health Inequalities (2005). North West Public Health Observatory. www.nwpho.org.uk/information”
Page 82 of 90
29.3
38.2
22.9
22.3
49.8
22.2
33.0
10.3
17.1
17.0
12.0
11.2
Some facts and figures
Basic facts and figures (England) for 250,000 people : all VERY approximate – designed for
ease of remembering!
250,000 people
15% over 65
15% under 16
Smokers 20% of ADULT population; obese also 20% of adult popn
25 people HIV positive (more in London)
40 teenage (under 18) conceptions
-------------------------------------------------------------------------Deaths per year: 2500 (1 in 100)
= births per year!
CHD under 75yr :
Lung cancer
Bowel cancer
Breast cancer
Suicide
RTA
Cancer of cervix
200
150
75
50 deaths (100 cases / registrations)
50
20
5
Pregnancy with congenital anomaly:
Congenital heart disease: 10 (5 per 1000 births each)
Down syndrome, NTD, cerebral palsy: 5 each (1 per 1000)
-----------------------------------------------------------------------Screening: 1 or 2 cases per 1000 screened (breast: 12 cases / 1 per month)
-----------------------------------------------------------------------GP consults
1,250,000 per year
OP attendances
200,000 per year (of which 60 new, 140 old)
A&E attendance
75,000 per year
Hospital admissions: 50,000 per year
Emergency 40 / day; Elective 60 / day
AMI, stroke, O/D, pneumonia: each 1 or 2 per day / 400 per year
Hip replacement 4 per week = 200 per year
People with schizophrenia (point prevalence 1 in 1000): 250
-------------------------------------------------------------------------Hospital docs 350; 100 consultant, 250 junior
GPs n = 250+ (list size c. 1800)
Attendances = 20% of popn every 2 weeks
NHS Dentists n = 125
Money: about £1000 per head = £250m for 250,000 people
£125m hospital; £25m GP drugs
Page 83 of 90
Reports / briefing papers
"Write a report / briefing paper":
 Purpose: one sentence ‘The aim of this briefing is to …’
 Background
Scientific – ‘What is already known about this topic’
Policy: any government policies / NICE guidelines / NSFs?
 This data / report ‘What this study / data adds’
NB NO TECHNICAL TERMS – e.g. death not mortality, illness not morbidity
etc etc, don’t quote P values or CIs
 Implementation
Likely views of:
Consultants
GPs
Public / patients
Any ethical issues?
Requirements for
more staff
equipment
buildings
Cost and cost per QALY (or similar)
 Conclusion and recommendation
_____________________________________________________________________
Page 84 of 90
DATA PRACTICE: CALCULATIONS
1. Here is an extract from Doll’s data on death rates in British doctors followed for 35
years (BMJ 1992; 305 p1523)
Death rate per 100,000 men per year, age standardised by cigarettes smoked per day
0
1-14
15-24
25 or more
Lung cancer
14
100
182
327
IHD
526
752
825
956
Chronic bronchitis 9
77
93
180
Suicide
25
29
32
60
For each of the four conditions, calculate the excess risk associated with being a heavy
(25 or more) smoker rather than a non smoker.
2. Patients with breast cancer were randomised to receive trastuzumab or placebo. After a
median of 23.5 months follow up, 59 of the 1703 patients receiving trastuzumab had died,
compared to 90 of 1698 patients receiving placebo. [Lancet 2007; 369: 29 – 36]
a. What is the relative risk reduction?
b. What is the absolute risk reduction?
c. What is the Number Needed to Treat?
3. Here are some numbers: 5, 6, 8, 9, 12, 15, 22
Calculate Mean, Median, Variance, Standard deviation.
[Variance is a measure of dispersion – how far each number is from the mean, but to stop the postive cancelling out
the negative, square them all before adding up. Obviously you also need to divide by however many numbers
you’ve got (N). Or is it N-1 – we will cover this on the course]
Now suppose this was a sample of patients with trigeminal neuralgia, and the scores are, say,
pain scores. What is the standard error on your estimate of the true mean?
4. In a trial of medication review intended to reduce admissions to hospital of old people,
the number of emergency hospital admissions in the intervention and control groups
were as follows (http://www.bmj.com/cgi/reprint_abr/330/7486/293)
[weighted average]
0
Intervention 253
Control
281
Number of admissions
1
2
3
113
34
10
99
26
5
4
3
3
5
1
0
6
1
0
a.
Calculate the mean number of admissions per person in (a) the intervention and
(b) the control group.
b.
Would a t test be an appropriate way to judge whether the difference in mean
admissions per person is due to chance?
Page 85 of 90
5. Average survival after a diagnosis of glioma (a brain cancer) is 6 months. A new drug
increases median survival by one month. Standard treatment costs £1000. Treatment
with the new drug, including extra monitoring costs, is £6000. The quality of life on
treatment is estimated at 50% of full quality. [Data adapted from NICE appraisal of
temozolamide]
a. What is the incremental cost per life year gained?
b. What is the cost per QALY?
6. In a randomised controlled trial of screening for abdominal aortic aneurysm in men
aged 64 – 73, 6333 men were invited for screening (of whom 77% attended) and 6306
were controls. Twenty four men in the screened group were referred for surgery. After a
mean of 52 months follow up, nine men in the screened group and 27 in the control
group had died from abdominal aortic aneurysm. Survival was greater in the group
invited for screening (P = 0.003 on the log rank test). (BMJ 2 Apr 05 p750)
A Cox proportional hazards regression analysis of the same data showed that the hazard ratio
for the screened group, compared to the unscreened group, was 0.33 (95% confidence interval
0.16 to 0.71).
a. Explain what is meant by ‘P = 0.003’ and ‘95% CI 0.16 to 0.71’ .
b. How do you interpret this result?
Standard Error and Confidence Interval (CI) of a proportion and of a difference in proportions, Chi
Square for a 2 X 2 table, McNemar's test, standardisation - direct and indirect
7. National league tables for elective repair of abdominal aortic aneurysm were published
on 28 June 2013. Average post operative mortality in the whole data set was 2.2%.
Surgeon A was reported as having ‘ten times the average mortality rate’ based on the 9
operations he performed. Surgeon C had a mortality rate of 5% based on 20 operations.
[confidence interval on a proportion and difference in proportions]
a. Is either surgeon’s post-operative death rate significantly different from the national
average?
b. Is the difference between surgeons A and C due to chance?
c. What else might account for the difference?
8. In an outbreak of vomiting at a school, 49 / 250 children who ate cucumber fell ill, and 4
/ 124 who did not eat cucumber fell ill. (Aldous et al JECH 1994; 48: 41 – 45.)
[chi square]
a. Is there a statistically significant association between eating cucumber and falling ill?
Page 86 of 90
9. Last year, the maternity service at a local hospital delivered 3000 babies. Of these, 280
were low birth weight (1500-2499gms) and 20 very low birth weight (<1500gms). There
were 4 still births and 21 further perinatal deaths. Local obstetricians say that they deliver
more low birth weight babies than the national average. In national data (courtesy of Dr
Imogen Stephens), birth weight specific PNMR for England Wales and Northern Ireland in
2009 was as follows:
Bwt
<1500 gms
1500 - 2499 gm
2500 or more
PNMR
269
26
2.4
Does birth weight explain the high PNMR at the local hospital? Could the ratio of observed
deaths to expected be due to chance?
[indirect standardisation, confidence interval on an SMR]
10. In an audit study, two radiologists, Dr Able and Dr Baker, both read the same set of 648
mammograms and decide whether a cancer is present. The results are shown below:
For a given mammogram:
B says yes
B says no
A says yes
12
9
A says no
3
624
a. Is there evidence that A is saying yes (or B saying no) too often? (i.e. is the difference
between A and B’s judgements due to chance?
[Nemar’s test]
11. Among 37 100 people screened for colorectal cancer in Finland, 806 people tested positive
for faecal occult blood of whom 65 were found to have cancer at colonoscopy. Of the people
who screened negative, 32 were subsequently found to have cancer.
(BMJ 2008; 337: a2261)
Calculate the sensitivity, specificity and positive likelihood ratio of screening by faecal
occult blood in this population. What are the pre-test odds of a person having cancer? What
are the post-test odds in someone who is screen-positive?
12. The following data are from a study, carried out in Uganda in 1959, of serum cholesterol
among African and Asian people. (IJE 2012; 41: 1221 – 5)
Serum cholesterol (mg per 100 ml):
mean and standard deviation
Age in years African
n
Asian
n
12
166 [40]
96 206 [46]
120
20
134 [28]
101 218 [49]
104
40
145 [43]
120 248 [52]
130
Page 87 of 90
a. Calculate the standard error on the estimate of mean serum cholesterol among
(i) 40 year old Africans and (ii) 40 year old Asians.
b. What statistical test would be appropriate to help you decide whether the
difference in cholesterol gain between the two groups is likely to be due to
chance?
(For interest only – 248 mg/dl = 6.4 mmol/l)
13. In national mortality data for England and Wales, there were 567 deaths from diabetes
mellitus in men aged 15 – 64 years old, out of a total of 52 586 deaths in this age group. A
special research study showed that the equivalent figures for Punjabi males in this age group
were 19 deaths from diabetes among 591 total deaths.
[adapted from Balarajan R et al BMJ 1984 289 1185 -7]
a. Calculate the proportional mortality ratio.
b. Give three possible reasons for your finding.
14. In the following table of data, calculate (a) crude and (b) directly age-standardised mortality
per 100 000.
Age band
15-24
25-34
35-44
45-54
55-64
Our population
15 000
20 000
12 000
10 000
5 000
Our deaths
3
5
2
4
5
Standard popn
10 000
10 000
10 000
10 000
10 000
Bonus question on next page.
Page 88 of 90
Bonus questions!
15. The age standardised mortality rate in England is 138 per 100,000 and in Scotland it is 196
per 100,000. The percentage of problem drug users in England and Scotland is 1.07% and
1.84% respectively; and their SMR is 1244 i.e. mortality rate is 12.44 times that of the
general population. (BMJ 2008:337:a478)
a. What is the excess mortality per 100,000 in Scotland compared to England?
b. What proportion of the excess is due to problem drug use?
16. Here are some blood pressure data from the MRFIT trial (Lancet 1994; 344: 104)
Systolic BP
N
CHD death rate*
Per 10,000 person years
<110
21,379
9.8
110 – 119
66,080
11.1
120 – 129
98,834
12.9
130 – 139
79,304
17.0
140 – 149
44,388
22.8
150 – 159
21,477
30.5
160 – 169
9308
34.0
170 – 179
4013
47.6
180 or more
3191
57.2
 adjusted for age, serum cholesterol, smoking, medicated diabetes and income:
average of 11.6 years follow up
a. Calculate excess deaths due to high blood pressure.
b. What percentage of the total excess deaths are in people whose systolic blood
pressure is 160 or more?
c. What percentage of the total excess deaths is in people whose blood pressure is
in the range 110 – 129?
Page 89 of 90
Past papers – question grid
Critical appraisals
Jun 15 – Suicide after prison release (cohort)
Jan 15 – Telephone coaching plus matched controls (edited)
Jun14 – Surgical safety checklist
Jan 14 – RCT of education on antibiotic prescribing
Jun 13 – Whitehall II on diabetes social inequality
Jan 13 – Before / after menu labelling
Jun 12 – systematic review salt and hypertension
Jan 12 – intervention at a suicide bridge
Jun11 – effect of intervention on falls
Jan 11 – RCT (prostate cancer screening)
Jun 15
Jan 15
Jun 14
Jan 14
1. Sys review Cluster
2. Heterogeneity Crossover
3. Funnel plot ITT
Variance / se
What test?
COPD outcome Asthma admission
Efficacy.
Prev / inc
Ecological
Time series
Why variation Effectiveness Direct / indirect studies
How audit?
Per protocol / ITTFocus / inter
Complex
Grey
Cluster trial
Heterogen
Non randomised Funnel
Qual res:
1.methods
2. str / wknss
Study design
Confounding
Traffic / schools Focus group
Angina survey Person-time
Variables
Delphi method
P values
and CI
Correlation
Survival
Outlier
Health impact <16 accident
Assessmnt
strategy
(waste incinrtr)
CVD strategy
Genes – CF and Flooding
Cancer
Or drought
Nominal
Ordinal
Interval
Ratio
Olympics
Chlamydia
1.epi
2.control
Increase MMR Ep and control: Harm reduction Fire on industrialVTEC
uptake
Meningo
(IDU)
estate
HPV
Measles
Res care
D&V OB
Diabetes –
Secondary
prevention
Sampling
Qq design
Ca cervix
screening
1.Popn growth Admin data
2. control
uses
policies
Jun 13
Jan 13
Africa
travel advice
Fertility measuresCancer registers Monitoring healthJnformation
System;
governance
Quality of 1 care
Jun 12
Jan 12
Sample
Size
AAA screening Hep B
Scabies
Screening
theory PPV
etc
Jun 11
Jan 11
Hep C:
Burden
Risk factors
Confidentiality Direct ASR
in survey and (elderly
record linkage accidents)
Record linkage Cancer
registration
Local survey
method
Outcome
indicator
Surgical
outlier
Assess mental
health needs
Labelling and
genetic
screening
Vaccine
uptake
CUA
CBA CEA
Response of
Health services Unemployment: Opportunity costBiobank ethics Opportunity costC/E thresholds Prog budget
Hlthcare org to ‘econ perspective’
effects
QALY
and social
Direct/indirect
& marginal
Fee for case vs
causes
Rationing
Average/marginal
analysis
capitation
Opp cost
QALY
Time horizon
Causing own
illness
Org change
Power and
Authority /
Explosion
Spend and
outcomes
Governance
Ageing policy Strategy
and
development
implementation
Involving
public
Guidelines:
Change
Mgt tool
Minimising
risk
Clinical errors
Conflict and
resolution
HS funding
Leadership
Delegation
Functional
Matrix
Project mgt
Targets
1. Data for
Health at work Surveys as
neonatal mort PMR
health info
2. SMR vs DSR
Alcohol:
soc, pol, econ
Falls info
Prescribing measures
Registers
Safety monitorin
Health services Marginal analysisPublic involvement
Alc
Formulate and Social norms
‘sociol perspectieSupply/demand
minimum price implement policy
Obesity strategy Sustainable
devel
Change / svc
Motivation
reconfiguration theories
Systems and
RTA in
adolescents
Page 90 of 90