1. 12 June 2004Clinical algorithms in public health1 Seminar on “Intelligent data analysis and data mining – Application in medicine” Research on poisonings in children: public health perspective for the development of clinical algorithms by Dr Sergio Pièche

2. 12 June 2004Clinical algorithms in public health2 Developing clinical algorithms in public health The problem The target Principles Research

3. 12 June 2004Clinical algorithms in public health3 The problem Developing clinical algorithms in public health: The problem Injuries Mortality: causing deaths Morbidity: burden of the condition Age group at risk Costs: hospital and primary health care Likely impact of interventions

4. 12 June 2004Clinical algorithms in public health4 The target Developing clinical algorithms in public health: The target Health providers at primary health care level: –Health background: doctors, medical assistants, nurses, other health workers –Type of facility: equipment, supply, access to referral facility

5. 12 June 2004Clinical algorithms in public health5 Principles Developing clinical algorithms in public health: Principles Safe and effective guidelines:  Sensitive and specific clinical signs  Minimum number of clinical signs  Requiring simple skills to be used  Standard and simple assess-classify-treat system  Possible to teach and learn  Minimum number of essential drugs  Best care possible for severe cases Safe and effective guidelines:  Sensitive and specific clinical signs  Minimum number of clinical signs  Requiring simple skills to be used  Standard and simple assess-classify-treat system  Possible to teach and learn  Minimum number of essential drugs  Best care possible for severe cases

6. 12 June 2004Clinical algorithms in public health6 Clinical algorithm ASSESSMENT : signs CLASSIFICATION: for action TREATMENT: the action Danger signsSEVERE Referral: pre-referral treatment Other signsMODERATE Treatment (follow-up needed) Other signs or no signs MILDHome care

7. 12 June 2004Clinical algorithms in public health7 Research Developing clinical algorithms in public health: Research Hydrocarbon poisoning Organophosphate poisoning

8. 12 June 2004Clinical algorithms in public health8 Research on poisoning: prospective study Developing clinical algorithms in public health: Research on poisoning: prospective study Clinical predictors of severity of accidental poisoning from hydrocarbons and organophosphates in children below 5 years old

9. 12 June 2004Clinical algorithms in public health9 Research on poisoning: aim Developing clinical algorithms in public health: Research on poisoning: aim …to develop an algorithm for the outpatient management of children with hydrocarbon and organophosphate poisonings at primary health care facilities in developing countries.

10. 12 June 2004Clinical algorithms in public health10 Research steps Developing clinical algorithms in public health: Research steps Derivation of clinical decision rule (factors with predictive power) Prospective validation of the algorithm in different settings Provider performance analysis Impact

11. 12 June 2004Clinical algorithms in public health11 Research approach Developing clinical algorithms in public health: Research approach Identification and standard definition of signs and symptoms Gold standards for diagnoses Definition of outcomes Observer variability and bias Procedures (protocol and instruments; training, supervision)

12. 12 June 2004Clinical algorithms in public health12 Research methodology - 1 Developing clinical algorithms in public health: Research methodology - 1 Enrolment Children 2 to 59 months old History: unintentional exposure to hydrocarbons or organophosphates Acute exposure Seen within 48 hours of exposure to poison New cases

13. 12 June 2004Clinical algorithms in public health13 Research methodology - 2 Developing clinical algorithms in public health: Research methodology - 2 Procedures All children admitted for at least 48 hours post- exposure irrespective of severity (written consent and free admission) Examined by study physician + investigations upon admission Followed up at 6, 12, 24, 48 hours post-exposure No delay or interference with quality care

14. 12 June 2004Clinical algorithms in public health14 Follow-up Post-exposure OPD/ER 6 hours Follow-up 12 hours Follow-up 24 hours Follow-up 48 hours Follow-up Discharge / death Cl. exam. (Lab tests; X-ray) Intermediate outcomes Final outcome

15. 12 June 2004Clinical algorithms in public health15 E.g. Hydrocarbon poisoning Respiratory signs: cough, fast breathing,etc Vomiting … Chemical pneumonitis Outcome Bacterial pneumonia Severity

16. 12 June 2004Clinical algorithms in public health16 Research methodology - 3 Developing clinical algorithms in public health: Research methodology - 3 Sample size To detect the overall association and prediction of common symptoms and signs with poisoning severity and outcome To account in the analysis for stratification of cases in sub-groups based on time of exposure to poison

17. 12 June 2004Clinical algorithms in public health17 Key questions Which common clinical signs and symptoms best predict poisoning severity and outcome? How long is the safe clinical observation period before sending home a child who has been exposed to hydrocarbons or organophosphates?

18. 12 June 2004Clinical algorithms in public health18 Research: Analysis Developing clinical algorithms in public health: Research: Analysis Chi-square statistics or Fisher exact test, risk differences, risk ratios, odds ratios Multivariate logistics regression - incl. stepwise techniques Data mining techniques to be considered Sensitivity, specificity, predictive accuracy

19. 12 June 2004Clinical algorithms in public health19 Data analysis: The challenge!