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Population Studies in Cardiothoracic Surgery in SA. Anthony Linegar MBChB., FC(Cardio)SA., Ph.D. Registrars’ Symposium Bloemfontein, June 2011. Faculty.

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Presentation on theme: "Population Studies in Cardiothoracic Surgery in SA. Anthony Linegar MBChB., FC(Cardio)SA., Ph.D. Registrars’ Symposium Bloemfontein, June 2011. Faculty."— Presentation transcript:

1 Population Studies in Cardiothoracic Surgery in SA. Anthony Linegar MBChB., FC(Cardio)SA., Ph.D. Registrars’ Symposium Bloemfontein, June 2011. Faculty of Health Sciences Dept. Cardiothoracic Surgery University Free State

2 What is population health?... Refers to health status and health status inequities of populations and subgroups over time. Populations not individuals are the focus of action. Rapidly evolving, multidisciplinary science that includes:- Kindig D, Stoddart G. Am J Public Health. 2003 Mar;93(3):380-3. Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine Health outcomes -Measurement - Analysis (Dependant variable ) Health determinants -Patterns (in-dependant variable) Policies & Interventions

3 Why population studies / health service research? Establishes the facts (need, population, specialty) Positions the specialty within historical and current health care context

4 Why population studies / health service research? Illuminates weaknesses and strengths in the system Strategic planning in health care delivery and in individual career planning. How to translate research evidence into health care policy.

5 Health service research looks at effectiveness of health care. Depends on the specific research question, Method to be used:- Observational (cohort, case-control, cross section,) Experimental trials (randomised, non-randomised) Relationship association and causative

6 Cohort study – follow up study Observational Not randomised Identify a group who all share specific characteristics (alcohol consumption > 7 units per day) but healthy subjects Follow for pre-selected outcome (cirrhosis) Compare to population outside the cohort (control)

7 Case control Observational Not randomised Select patients with a disease (lung ca) as the starting point Select patients without the disease Then measure exposures that might have a causal relationship (smoking) Selection is prone to bias Not able to establish a cause: effect but establishes an associative relationship

8 Cross section study Assess the whole of a population Disease and exposure are measured simultaneously in a population Snap shot of disease prevalence and characteristics at one point in time. Cause and effect are not certain as it may not be clear which came first as they are not chronologically studied

9 Randomisation Starting point is one group split into 2 and therefore supposed to be as similar as possible Split created by random process Blinded Double blinded Therapeutic intervention applied to one group and comparisons made on outcomes of the two groups

10 Terminology Epidemiology investigates distribution and determinants of disease Health economics studies the financing of health care systems, quantifies the value of service provided, models decision making, attempts to influence the application of available resources. Operational research

11 What measures do we use? Crude incidence Incidence = new cases per year / population x 100,000 (time based definition) ASIR Standardisation – adjustment to remove effect of differences in a composite population This minimises erroneous comparisons. Mortality rates crude = deaths per year/ population X 100,000

12 Measures continued Prevalence is not expressed per unit time = total cases at one point in time / population this is not a rate. Clinical activity Performance gap

13 Why population studies / health service research? Informs about:- burden of disease service delivery performance gap Burden of disease in community Clinical activity within the burden of disease Research activity Clinical governance Linegar AG, 2008

14 A word on literature reviews - sources MEDLINE via search engine PUBMED; 16 million citations since 1950 OVID EMBASE CINAHL Cochrane Library for clinical trials and systematic reviews. African database (Africa-Wide:NiPad) SA non-reviewed journals

15 A word on literature reviews Simple review Bias; selection; exclusion; incomplete; sample size inadequate; lacks relevance; needs a great deal of explanation. Value determined by the research question and the aim of the literature review.

16 A word on literature review Systematic review Starts with a predetermined aim and a clear and reproducible method, limitations are noted Duplication by another researcher should reveal the same results – reproducible Analysis of results requires meta-analysis

17 Study example in Rheumatic HD, Congenital HD, Thoracic surgery. 1.Research question 2.Aim of the study 3.Objectives of the study 4.Method

18 Example 1.Research question based on a hypothesis - the performance gap in TSY in CSA 2.Aim - to design a model 3.Objectives - Qt burden of disease - Qt clinical activity - Qt performance gap 4.Method - define the population - define the time period of the study - quantitative burden of disease study - Mixed methods

19 Health study in CSA Mixed methods study – Performance gap in TS Aim to create a model for the development of thoracic surgery 2004-2006 Population 5.2 million (HDI 121 st ) 86% dependant on state health care provision One department CTS (Bloemfontein) - 3 consultants, 4 registrars - 8 bed ICU and 22 ward beds

20 Method burden of disease Burden of disease in community Inflammatory lung disease Pleuro-pulm TB Lung Carcinoma Oesophagus Carcinoma Thoracic Trauma National health statistics Cancer registry Mortality data MRC BOD, Unit

21 Method clinical activity Clinical activity Big 5 thoracic diseases Universitas Hospital Departmental stats, theatre records General Surgery 7 Regional hospitals Gen surg, Int Med, Paed, Trauma Private sector – Insurance industry ICD10, operation codes.

22 Method academic productivity Academic productivity Systematic review SA thoracic surgery literature 1955 – 2008 Interdisciplinary interactions Curriculum Teaching and training methods Records, Filing, database Linegar, Smit, Goldstraw, Van Zyl SA Med J 2009; 99:592-594

23 Methodology Burden of disease in community Clinical activity within the burden of disease Research activity Demographics CIR, ASIR Disease specific Mortality Data Stats SA, HST, MRC National Cancer Registry Publications (large series over finite time period) Departmental statistics Regional and tertiary hospitals Private CT Surgeons statistics Private medical aids ICD 10 codes Operation codes Other disciplines (Gen Surg) No. of surgeons (WTE) Systematic review all publications

24 The next step - implementation

25 The ATLAS Project: Premise for analysis. Qt Size of population and Burden of Disease / 100,000 Incidence ~Prevalence ~ Mortality Resectability / Operability 10 – 20% Calculate required number of lung resections

26 Atlas project: results The top ten causes of cancer mortality in SA (persons) (Bradshaw et al., 2003). RankCause of deathNumber of deaths% of cancer deaths 1 Cancer of Lung Trachea Bronchus 717317.2 % 2 Cancer of Oesophagus580313.9% 3Cervix cancer34248.2% 4Breast cancer30627.3% 5Liver cancer26926.5% 6Colo-rectal cancer24465.9% 7Prostate cancer24115.8% 8Stomach cancer23655.7% 9Pancreas cancer15303.7% 10Mouth and Oro-pharynx cancer14643.5% All Cancer deaths41691100%

27 Annual SA mortality: MRC vs Stats SA Stats SA 2005. 34%

28 Age Standardised death rates in SA. Cause specific mortality rates in SA and FS 2000 (Bradshaw et al., 2003). Cause of death Age std death rate / 100 000 population SA Number of deaths SA (pop = 45m) Number of deaths FS (pop = 2.9 m) Estimated number of deaths for Central SA (pop = 4.6 m)* HIV/AIDS349.9165 8591179616130 TB83.529 80324223849 Homicide72.532 48513273342 LRTI64.822 09722492987 COPD49.312 4737372272 Road traffic accident4318 4468111982 Lung cancer26.471733691217 Oesophagus cancer20.95803258963

29 The ATLAS Project: Burden of disease based on ASDR. 26.4 per 100,000 in 48m – 50 m population 12672 – 13200 deaths per annum Actual recorded deaths 2008 = 7131 713 - 1320 operations/ annum (10% resect) 1426 – 2640 operations/ annum (20% resect)

30 Clinical activity: lung resections Table 5.3 Operations performed during 2006 at teaching hospitals in SA. ABCDEFG Total operations2684631186190413dna210 Pneumonectomy (all pathologies) 71119821dna15 Pneumonectomy (lung cancer) 0nk40ndadna0 Lobectomy (all pathologies) 1626691523dna11 Lobectomy (lung cancer) 7nk103dna 0 Bullectomy1274514dna0 Pleurectomy2271120dna0 Lung reduction00000dna0 Open drain empyema502758dna0 Decortication25517246dna23 Fenestration (Eloesser)00007dna2 Thoraco-myoplasty10024dna1 Oesophageal stent29155000dna10 Oesophagectomy311432dna2 Benign oesophageal00000dna0 Mediastinoscopy1415301929dna6 Mediastinal mass43029dna0 Trauma operations9116210dna0 Sympathectomy00010dna0 Thoracic outlet00000dna0

31 Private sector lung resections 2005 SA2006 SA All DrsCTSAll DrsCTS Admissions12092811357328 Admissions per 100,0003094210 Lung resections25 2321 Scale up Medscheme and Discovery data to represent the whole private population = 38-45 cases per annum

32 The performance gap Burden = 713 – 1320 operations required per annum in state and private in SA Operations for lung cancer done annually = 20 – 30 in 7 University Hospitals = 45 resections in private Total resections = 65 – 75 per annum Performance gap for SA as a whole 1 : 10 to 1 : 20

33 What does this mean? Clinical service provision 90% to 95% of expected resections are not done As a complete resection provides the only chance of potential cure for these patients Most potentially curable patients are not adequately treated

34 Task 1.Design a study plan in your region to explore the following - Rheumatic HD - Congenital HD - Thoracic surgery with respect to burden of disease; service provision; identify possible solution pathways 2.Bring results to next annual meeting

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