CHAPTER 4

Measuring &
Interpreting Morbidity
Steven T. Fleming & F. Douglas Scutchfield

Presentasi Kelompok : Anandito Birowo, dr. I Putu

Nanda Ariesta Putra & dr. Robert MD

M ATA K U L I A H : M A N A J E M E N E P I D E M I O L O G I
D O S E N P E N G A M P U : P R O F. D R . A R L E T T E S U Z Y P U S PA
P E RT I W I , D R G . , S P. K G A , S U B S P. A I B K ( K ) , M . P S I , F S C D A , F I A D H
Population
• Epidemiology = the study of the
distribution and determinants of disease in
human populations.
A population science and therefore be
distinguished from clinical medicine, which has a
focus on the diagnosis and treatment of individual
patients.
• Population = a group of people with at
least one distinguishing characteristic.
Population Health
• Multiple determinants of health, the outcomes of health,
or both. (Kindig & Stoddart, 2003)
• The health of a population as measured by health status
indicators and as influenced by social, economic, and
physical environments, personal health practices,
individual capacity and coping skills, human biology, early
childhood development, and health services. (Dunn &
Hayes, 1999)
Population Health Planning
• Kindig, Asada & Booske (2008) developed a model of population health
planning => relates the medical care, individual behavior, social environment,
physical environment, and genetic determinants of health to population health
outcomes that include mortality and health-related quality of life (QOL), which
is determined by the burden of morbidity.
• McDowell, Spasoff & Kristjansson (2004) distinguish
among four types of population health measures :
Descriptive, Predictive/Prognostic, Analytical,
Evaluation.
• The measurement of morbidity or disease is an
important for population health, and critically
important for descriptive and prognostic applications.
Definition of Disease
Disease
• An interruption, cessation or disorder of body functions, systems or
organs. (Merrill, 2016)
• Almost any departure from perfect health. (Weiss & Koepsell, 2014)

Morbidity
• Any departure, subjective or objective, from a state of physiological
or psychological well-being. (Porta, 2014) — a definition that
includes disease and illness
Classification of Diseases
Transmission : airborne (influenza), vector-borne
(malaria), intestinal discharge (cholera)
Source : microorganism (plague), inanimate
sources (radiation, noise).
Body system (nervous, circulatory, respiratory,
digestive systems etc)  International
Classification of Diseases (ICD) ; ICD-10-CM
classifies diseases into more than 65,000 categories
Natural History of Disease

Definition: Course of a disease over time from onset to resolution

Two Aspects of
Natural History

Process by which disease occurs

Process of disease progression—movement from one stage to another
o Prepathogenesis phase = exposure to the agent occurs (before the disease process begins)
 Susceptibility phase = period during which the host may be particularly susceptible to
the agent, because of low resistance, poor nutrition, or other factors.
 Adaptation phase = the host is successful in resisting disease
o Pathogenesis phase = the development of disease, with the early phase happening before
symptoms occur.
o Incubation period (infectious) / Induction or latency period (noninfectious) = period
between exposure and onset of symptoms
Two Points of
Disease

Clinical horizon: The point at which signs and symptoms make a

disease detectable.
Mosby (2009) : the line of demarcation pre-clinical and clinical phases.
Critical point: The moment in the progression of a disease before
which treatment is more effective and after which major or severe
consequences occur.
Celentano and Szklo (2018) : a point in the natural history before which
treatment is more effective and/or less difficult to administer
For a screening program to be effective, the clinical
horizon must occur before the critical point : We must be
able to detect disease at a point in its natural history
before major consequences occur.
If the critical point occurs before the clinical horizon :
serious consequences occur before the disease can be
detected, so screening is ineffective.
Characteristic Natural History
of Diseases
Acute disease : relatively severe, treatable
disease of short duration, with an outcome of
either recovery or death.
Chronic disease : typically less severe and of
longer duration, and it often does not conclude
with complete recovery but rather progressive
disability.
Subacute disease : intermediate in both
severity and duration.
Sources of Morbidity Data
Communicable disease reports
oCDC’s Morbidity and Mortality Weekly Report
oPhysicians/labs  public health departments  CDC
oSome notifiable diseases/life-threatening diseases,
reported directly to CDC :
• Botulism/cholera/rabies, etc.: report by phone
immediately
• Hepatitis A/malaria/measles: report within 1 day
• AIDS/mumps/Lyme disease: report within 7 days
Clinical records/hospital records
oRegulations protect the confidentiality.
oViewed by some as biased.
Financial claims from patient
encounters
oAs such are driven by financial incentives .
oThe diagnoses associated may be those that
maximize reimbursement rather than those
that are most clinically relevant.
Morbidity registries (e.g., cancer registry)
Surveys of disease and health
oNational Health Interview Survey
oHealth and Nutrition Survey
oNational Hospital Discharge Survey
oNational Notifiable Disease Surveillance System
oNational Nursing Home Survey
oNational Ambulatory Medicare Care Survey
Measuring Morbidity
Ratio
• Obtained by dividing one independent number by another

Proportion
• Measure where the numerator is a subset of the denominator

Rates
• Includes (1) frequency of the event in the numerator(x), (2)population at risk
in the denominator (y) and time which the event occurred, Usually expressed
as some factor of 10(k). X/Y x k
EXAMPLE
Suppose that during 2020 there were 12.000 heart disease
death in Kentucky, and the population at risk in Kentucky
was 4.400.000, expressed as a rate per 100.000 :

12.000/4.400.000 x 100.000 =
273 per 100.000
Prevalence & Incidence
Prevalence
• Measures cases of disease in a defined
population and period
• Point Prevalence
• Proportion of people in a population who
have a particular disease or condition at a
particular point in time
• Rates as shown in the foregoing equation
• Period Prevalence
• Measures number of people with particular
disease during some period and expresses
this figure as either a proportion and rates
Incidence
• Cumulative Incidence
• Examines the number of members of a cohort
who have developed disease over a defined
period
• Incidence Density / Incidence Rate
• Measures how many new cases of a given
disease occur in a defined population that is
at risk over a certain period and is calculated
by dividing the cumulative incidence by a
measure of person-time
Exclude Criteria
1. People who died during previous period
2. If the disease is a chronic disease, people who develop the
disease are no longer at risk of incident disease
3. People who died within the time frame expressed by the
measure may be at the risk for only part of the period
4. Some measures pertain only to certain population
5. Some people may take steps that remove them from the at
risk population
EXAMPLES
In 2015, newly diagnosed cases numbered 1.53 million, but estimated 23.6 M
people were living with diabetes melitus (DM). Estimated US Population, 18 and
older = 247 M
Incidence Rate

1.53 M/247 M x 1000 = 6.19/1000

Prevalence Rate

23.6 M/247 M x 1000 = 95.5/1000

Prevalence and incidence are related by duration.
This relationship is specified as :
• Prevalence (P) = Incidence (I) x Duration (D)
• Duration (D) = prevalence (P) / Incidence (I)
EXAMPLES
Assume that the incidence rate of lung cancer is 610.8 per 100.000
and the prevalence rate is 306 per 100.000
Average survival of lung cancer patients is ……….. ??

306 / 610.8 = 0.5 year = 6 months

Relationship Between
Incidence and Prevalence
PRACTICES
PRACTICES
•Which summarizes the
occurrence of a
particular disease (say,
gonorrhea) among 1000
collage students.
•Gonorrhea often recurs,
so we can specify the
time window between
episodes (say, one
month)
What was Incidence Rate during
2020 ?

8 per 1.000

What was Period Prevalence

during 2020 ?

11 per 1.000
What was Point Prevalence
on July 15 2020 ?

5 per 1.000
Case Study 4.1. Epidemiologic Investigation
of Congestive Heart Failure
An Epidemiologic investigation that began on
January 1 2020, identified a population of
1.000 people among whom four were found
to have congestive heart failure on this date.
During the year of the study, six additional
new cases were found. Among the 10 cases,
there were seven deaths during the year.
There were no deaths among the remaining
990 people.
What was the point prevalence
on January 1 2020 ?

4 per 1.000

What was the point prevalence

on 31 July 2020 ?

7/(1000-3) x 1.000
7/997 x 1.000
7.02 per 1000
 What was the point
prevalence on October 31
2020 ?

6/(1000-4) x 1.000
6/996 x 1.000
6.02 per 1.000

What was the

cumulative Incidence
during 2020 ?

6/(1000-4-(7/2)) x 1.000
6/992,5 x 1.000
6.05 per 1.000
What was the incidence
density during 2020 ?

6/(990+1,5) x 1000
6.05 per 1000 person-years
 What was the mortality
rate during 2020 ?

7 per 1000

What was the case fatality

rate during 2020 ?

7/10 = 70%
Screening
Identification of unrecognized disease or defect by the application
of tests, examinations, or other procedures that can be applied
rapidly and inexpensively to populations. (Valanis, 1999)

• Screening Test : performed on healthy

individuals to identify disease before
symptoms occur
• Diagnostic Test : performed on patients
with symptoms to identify disease.
Two measures of the quality of a test
•Validity : a measure, such as a screening test, represents a
particular phenomenon
•Realibility : measure of consistency. Reliable screening
tests yield the same results regardless of the number of
times they are repeated.
•Sensitivity : proportion of those who have the disease and
test positive (True sick) -> Good for screening
•Specificity : proportion of those who do not have the
disease and test negative (True well) -> Good for diagnostic
•The positive predictive value (PPV) is the proportion of
those who test positive and who actually have the disease.
•The negative predictive value (NPV) is the proportion of
those who test negative and who actually do not have the
disease
The sensitivity is calculated by dividing a, by a + c
The specificity is calculated by dividing d, by b + d
Example
Sensitivity = 15/40 = 37.5%

Specificity = 34/40 = 85%

PPV = 15/21=
= 71.4%71.4%

NPV = 34/59 = 57.6%

Case Study 4.2.
Breast Cancer Screening
This case study evaluates the changes in test characteristics for breast
cancer screening, with the first stage being magnetic resonance imaging
(MRI) and the second stage being core needle biopsy (CNB).

a. Assume sensitivity of 92 percent and specificity of 70 percent

for MRI and sensitivity of 87 percent and specificity of 98
percent for CNB.
b. Assume that the prevalence of breast cancer among women
aged 20–40 is 0.2 percent, among all women aged 20 and
older is 2 percent, and among women with symptoms is 10
percent.
1. How successful is the MRI in identifying women with breast
cancer?
2. How successful is the MRI in ruling out women without breast
cancer?
3. Of all those without breast cancer, what percentage will
incorrectly test positive (false positives) with the MRI?
4. How would you calculate and interpret the PPV for a sample of
100,000 women aged 20 and older?
5. How would you calculate and interpret the PPV for a sample of
women aged 20–40?
6. How would you calculate and interpret the PPV for a sample of
100,000 women with symptoms?
7. What is the relationship between prevalence of disease and PPV?
1.The MRI would identify 92 percent of women with breast cancer.
2. The MRI would rule out 70 percent of women without breast cancer.
3. 100% – 70% = 30%, i.e., 30 percent would incorrectly test positive for breast cancer.
4.
A good screening program
• High specificity and sensitivity
• Simplicity, cost, safety, patient
acceptability
• Disease should be serious
enough
• Test detects disease at earlier
stage
•Treatment if screen positive
easier/more effective than treatment
after symptoms
• Available treatment is acceptable to
patients
• Prevalence of disease should be high
in population to be screened
• Follow-up diagnostic/treatment
available for patients who test positive
Summary
A model of population health planning is determined by the burden of morbidity or
disease.
Each disease has a characteristic natural history from onset to resolution.
For a screening program to be effective, the clinical horizon (when the disease can be
detected) must occur before the critical point (the point after which severe
consequences occur) .
The burden of morbidity can be expressed by rates: prevalence and incidence.
As prevalence of disease increases, the PPV of a test (the proportion of those who test
positive and who actually have the disease) will increase.
Validity and reliability measure the quality of a test .
Thank You !