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PubMed2005

Integrated population-based surveillance of noncommunicable diseases: the Pakistan model.

The escalating burden of noncommunicable diseases (NCDs) worldwide warrants an urgent public health response. Resource constraints and other factors necessitate an integrated and concerted approach to the range of NCDs. A necessary prerequisite for effective planning, implementation, and evaluation of NCD prevention programs is access to reliable and timely information on mortality, morbidity, risk factors, and their socioeconomic determinants. However, there is limited experience in the setting up of integrated NCD surveillance models in low-resource settings. As part of the National Action Plan for the Prevention and Control of NCDs in Pakistan, an integrated, systematic, and sustainable population-based NCD surveillance system is being established, and will be maintained and expanded over time. This is a common population surveillance mechanism for all NCDs (with the exception of cancer). The model includes population surveillance of main risk factors that predict many NCDs and combines modules on population surveillance of injuries, mental health, and stroke. In addition, the model has been adapted for program evaluation; this will enable it to track implementation processes using appropriate indicators, facilitating an assessment of how interventions work and which components contribute most to success. This paper outlines the first activity in this sequential process, including its merits and limitations.

Adolescent↗
PubMed1995

Guidelines for interpretation of some common indicators of residency program performance.

OBJECTIVE: To provide national norms for indicators of residency-training program quality and information on their reproducibility. PARTICIPANTS: The 364 residency-training programs that had 4 or more candidates take the 1989 to 1991 certifying examination in internal medicine for the first time. DESIGN: Within each residency, program directors' ratings of medical knowledge, certifying examination scores, and certification status (pass or fail) were available for each candidate from 1989 to 1991. Means of these data were calculated for each program for each year of the study. To provide a way of comparing an individual program with all other programs, percentiles are reported for each year. To assess the precision of the measures, generalizability theory was applied and confidence intervals for all data are reported for programs of various size (1 to 25 residents taking the examination) and over the years (1 to 3). RESULTS: Over the 3 years of the study, knowledge ratings, certification rates, and composite scores declined slightly. The correlations between program ratings of medical knowledge and the composite scores ranged from .47 to .60 and certification rates ranged from .44 to .55. The confidence intervals around all of the program performance indicators are relatively large and are affected most by the number of residents in the program. There is little variability across the years. CONCLUSIONS: In smaller programs the precision of the performance indicators is poor; in programs with only a few residents they are virtually meaningless. On the positive side, programs are relatively stable and aggregating indicators over years is a reasonable way to increase their precision in assessing program performance. If the goal of program evaluation is to identify programs at the extremes, especially those at the low end, then such data may help guide program directors and educators.

Clinical Competence↗
PubMed1986

Electrophysiologic and antiarrhythmic efficacy of oral sotalol for sustained ventricular tachyarrhythmias: evaluation by programmed stimulation and ambulatory electrocardiogram.

Programmed ventricular stimulation and ambulatory electrocardiography were performed both before and during oral sotalol therapy in 39 patients with ventricular tachyarrhythmia inducible by programmed stimulation (sustained ventricular tachycardia [n = 31], ventricular fibrillation [n = 3], nonsustained ventricular tachycardia [n = 5]). Oral sotalol was started at 80 mg twice daily and the dose thereafter was then gradually increased until a mean daily dose of 300 mg (range 160-480) was reached. In 12 of 34 patients with inducible sustained ventricular tachycardia or fibrillation the arrhythmia was suppressed; in 19 patients it was not and in 3 the spontaneous arrhythmia recurred. Reproducibly inducible nonsustained ventricular tachycardia was suppressed by sotalol in all five patients with this arrhythmia. Thus, a favorable electrophysiologic response was obtained in 17 (44%) of 39 patients. Arrhythmia suppression correlated with the type of arrhythmia (unsustained or sustained) induced during the control period (p less than 0.05), and nonresponders had a higher incidence of previously ineffective drug trials (p less than 0.05). In 22 patients treated long term with sotalol suppression of arrhythmia inducibility on programmed stimulation predicted freedom from recurrences (16 of 17), whereas continued inducibility indicated drug failure (5 of 5) (p less than 0.005). Serial ambulatory electrocardiograms performed in 37 of the 39 patients did not correlate with the results of electrophysiologic testing. For the patients on long-term treatment, invasive testing was superior to electrocardiographic monitoring in predicting outcome. These data indicate that in daily doses of 160 to 480 mg oral sotalol is a very useful agent in patients presenting with sustained ventricular tachycardia or fibrillation, and its efficacy is fairly well predicted by programmed stimulation.

Adult↗
PubMed1988

Left ventricular hypertrophy and ventricular dysrhythmic risk in hypertensive patients: evaluation by programmed electrical stimulation.

Left ventricular hypertrophy in hypertensive patients is associated with an increased prevalence of ventricular arrhythmias. Twelve patients with left ventricular hypertrophy assessed by M-mode echocardiography and 12 without left ventricular hypertrophy underwent an electrophysiological study with programmed electrical stimulation. The patients with left ventricular hypertrophy had a prolonged infranodal conduction time which correlated closely with left ventricular mass (r = 0.71; P less than 0.001). Programmed electrical stimulation initiated more intraventricular re-entry and unsustained ventricular tachycardia in the group with left ventricular hypertrophy than in the control group, although sustained ventricular tachycardia was never induced. We conclude that ventricular vulnerability is increased in hypertensive patients with left ventricular hypertrophy, especially in those who show electrocardiographic evidence of left ventricular hypertrophy.

Arrhythmias, Cardiac↗
PubMed2006

Strengthening the case for disease management effectiveness: un-hiding the hidden bias.

As is the case with most health care program evaluations, disease management (DM) programs typically follow an observational study design, indicating that randomization to treatment or control was not performed. The foremost limitation of observational studies, compared to randomized studies, is that the only biases that can be controlled for are those associated with observed variables. Hidden bias refers to all those unobserved covariates that may distort the conclusions of the study. This paper introduces a sensitivity analysis that is used to determine the magnitude of hidden bias necessary to alter the conclusion that a DM program intervention was indeed effective.

Bias↗