O objeto deste estudo é a identificação de necessidades de saúde por meio de um instrumento para gestores e técnicos das áreas de planejamento e gestão em saúde. O estudo considerou o arcabouço teórico-metodológico da Saúde Coletiva e particularmente da Epidemiologia Crítica que se fundamentam na categoria reprodução social para explicar os diferentes perfis de saúde e doença de um determinado território. Objetivo: construir um instrumento de captação de necessidades de saúde para subsidiar o planejamento regional em saúde. Método: Trata-se de um estudo metodológico que foi desenvolvido em quatro etapas: Etapa 1. Uma revisão integrativa para identificar os instrumentos de levantamento de necessidades de saúde existentes; Etapa 2. Entrevistas semiestruturadas e individuais com gestores da saúde para compreender as dificuldades no levantamento de necessidades. Os dados foram gravados, transcritos e analisados através da análise de conteúdo; Etapa 3. Construção de instrumento de levantamento de necessidades de saúde para subsidiar o planejamento regional em saúde; e Etapa 4. Validação de conteúdo por comitê de especialistas, por meio da técnica Delphi e índice de validade de conteúdo. Resultados: Em relação à revisão integrativa, foram identificados 17 instrumentos de levantamento de necessidades. As 123 variáveis utilizadas para identificar necessidades foram integradas em três categorias: necessidades de reprodução social, necessidades de presença do Estado e necessidades de participação política. Em relação às entrevistas, sete gestores de saúde da região metropolitana do Espírito Santo participaram do estudo. Quatro categorias compostas por 11 temas foram analisados: (1) Compreensão do conceito de necessidades de saúde, com um tema; (2) Necessidades de reprodução social, com dois temas; (3) Necessidades de presença do Estado, com sete temas; e (4) Necessidades de participação política, com um tema. A construção do instrumento envolveu a inclusão dos resultados da revisão e das entrevistas, resultando em material composto de introdução e cinco módulos (Módulo A Identificação das classes sociais, Módulo B Reconhecimento do território, Módulo C Necessidades de reprodução social, Módulo D Necessidades de presença do Estado, e Módulo E Necessidade de participação política). A validação de conteúdo foi realizada por meio da participação de oito especialistas. Tanto a introdução, quanto os módulos apresentaram de forma geral pontuação pelo índice de validade de conteúdo maior de 0,9, o que representa clareza, pertinência e relevância adequados. Apenas um item foi classificado com baixa clareza (0,75), e dessa forma precisou ser reformulado. Outras modificações foram realizadas, a partir da sugestão dos especialistas. Conclusão: o instrumento construído tem potencialidade para identificar necessidades de saúde, a partir da captação das desigualdades sociais dos diferentes territórios. Pondera-se no entanto que o instrumento é incapaz de sozinho sensibilizar gestores e técnicos das secretarias estaduais e municipais para a utilização e análise dos dados, e portanto sua utilização deve fazer parte de processos educativos que envolvam a compreensão dos referencias teórico-metodológicos que subsidiaram a construção do instrumento. / This work takes as its object of study the health needs identification by an instrument for both managers and technicians of health planning and management areas. The study has considered the theoretical-methodological framework of Collective Health, and in particular Critical Epidemiology, which is based on the social reproduction category to explain different health-disease profiles in a given territory. Objective: to develop an instrument to assess health needs aiming at subsidizing regional planning in health. Method: This is a methodological study. This study was developed in four stages: Stage 1. An integrative literature review to identify existing instruments for health needs assessment; Stage 2. Semi-structured and individual interviews with health managers to understand difficulties in needs assessment. The data was recorded, transcribed, and analyzed by content analysis; Stage 3. Development of an instrument for health needs assessment to subsidize regional planning in health; and Stage 4. Content validation by a committee of experts, by means of the Delphi technique and content validity index. Results: In relation to the integrative review, 17 instruments for needs assessment were identified; the 123 variables used to identify needs were grouped into three categories: social reproduction needs, State presence needs, and political participation needs. In relation to the interviews, seven health managers of the metropolitan region of Espirito Santo State took part in this study. Four categories composed by 11 themes were analyzed: (1) Understanding of the health needs concept, with one theme; (2) Social reproduction needs, with two themes; (3) State presence needs, with seven themes; and (4) Political participation needs, with one theme. The instrument development included adding both literature review and the interviews findings, resulting in a material divided in introduction and five modules (Module A Identification of social classes, Module B Territory recognition, Module C Social reproduction needs, Module D State presence needs, and Module E Political participation needs). The content validation was performed by eight experts. In general the content validity index of the introduction as well as the modules was higher than 0.9, what represents adequate clarity, pertinence, and relevance. Only one item was scored as low clarity (0.75), therefore needed to be reformulated. Other modifications were made according to the experts suggestion. Conclusion: The instrument that has been developed has potential to identify health needs by analyzing social inequalities of the different territories. However, it should be considered that the instrument, by itself, is unable to raise awareness among managers and technicians of state and municipal secretaries in order to use and analyze data. Therefore, it should be used as part of educational processes that include the study of its theoretical-methodological framework.

INTRODUÇÃO: Problemas de saúde mental são responsáveis por uma morbidade significativa em todo o mundo, por sua frequência e pela associação com comorbidades físicas, níveis de incapacitação e prejuízo na qualidade de vida de portadores e cuidadores. A ocorrência de transtornos mentais comuns (TMC) é influenciada por fatores biológicos, sociais, econômicos e demográficos. O contexto social pode ter papel importante na etiologia dos transtornos mentais e na sua prevalência. OBJETIVOS: Investigar fatores de risco que contribuem para a prevalência, incidência e prognóstico de TMC em população de baixa renda da cidade de São Paulo, considerando distintos níveis contextuais: indivíduo, domicílio e setor censitário. MÉTODO: O presente estudo utilizou dados da investigação longitudinal de base populacional \"São Paulo Ageing & Health Study\" (SPAH). Os indivíduos selecionados eram residentes em domicílios em que houvesse pelo menos dois participantes do estudo com avaliação para presença de TMC, identificada pelo instrumento Self Reporting Questionaire (SRQ-20). Foram avaliadas as associações independentes entre TMC e características sociodemográficas e dos domicílios dos participantes, através de modelos de regressão logística multinível, tendo como desfechos a prevalência de TMC na inclusão e a presença de TMC em avaliação de dois anos de seguimento. RESULTADOS: Foram incluídos 2.366 indivíduos no estudo transversal, realizado no período de 2003 a 2005. A prevalência de TMC nesta amostra foi de 43%. As características individuais sexo, idade, escolaridade e ocupação estiveram associadas à prevalência de TMC. As características de domicílios aglomeração, morar com crianças, bens materiais, saneamento básico e renda familiar também se associaram à prevalência de TMC. Modelos de regressão logística multinível mostraram que parte da variância na prevalência de TMC foi associada ao nível do domicílio, com associações entre aglomeração, renda familiar e prevalência de TMC, mesmo após controle para características individuais. No estudo longitudinal foram incluídos 1.733 indivíduos, reavaliados no período de 2005 a 2007. A prevalência de TMC na avaliação de seguimento foi de 33%, sendo que 8% não apresentavam TMC na inclusão. As características individuais sexo, idade e ocupação, e a característica de domicílio renda familiar estiveram associadas à presença de TMC na avaliação de seguimento. Modelos de regressão logística multinível para os dados longitudinais mostraram que a maior parte da variância na presença de TMC foi associada ao nível do indivíduo, com associações entre sexo, faixa etária, escolaridade, ocupação e TMC, mesmo após controle para características do domicílio. O nível de domicílio também contribuiu de forma independente para a variância relacionada à presença de TMC no seguimento, com associação de efeito fixo para renda familiar, mesmo após controle para características individuais. CONCLUSÃO: Os resultados mostraram que características individuais contribuem para a maior parte da variância na prevalência, incidência e prognóstico de TMC, mas há uma associação independente com o nível domicílio, que não é explicada completamente pela renda familiar. Esses resultados indicam que características do ambiente onde as pessoas vivem contribuem para sua saúde mental, sugerindo que pesquisas futuras se concentrem nas características psicossociais de domicílios e vizinhanças para estudo de contexto social e TMC / INTRODUCTION: Mental health problems are responsible for significant morbidity worldwide, due to its high frequency and association with physical comorbidities, levels of disability and impact in quality of life of patients and caregivers. The occurrence of common mental disorders (CMD) is influenced by biological, social, economic and demographic factors. The social context may play an important role in the etiology of mental disorders and their prevalence. OBJECTIVES: To investigate risk factors associated with the prevalence, incidence and prognosis of CMD in a low income population from the city of São Paulo, considering different contextual levels: individual, household, and census tract. METHOD: The present study used data from the population-based prospective investigation \"São Paulo Ageing & Health Study\" (SPAH). The individuals selected were living in households in which there were at least two study participants with assessments for presence of TMC, identified by the instrument Self Reporting Questionnaire (SRQ-20). We assessed independent associations between CMD and the sociodemographic and households characteristics of the participants, through multilevel logistic regression models, having as outcome variables the prevalence of CMD at inclusion and the presence of TMC at the 2-year follow-up assessment. RESULTS: We included 2.366 individuals in the cross-sectional study, carried out in the period from 2003 to 2005. The prevalence of CMD in this sample was 43%. Individual characteristics sex, age, education and occupation were associated with the prevalence of CMD. The household characteristics crowding, living with children, possessions, basic sanitation and family income were also associated with the prevalence of CMD. Multilevel logistic regression models showed that part of the variance in the prevalence of CMD was associated with the household level, with associations between crowding, family income and prevalence of CMD, even after controlling for individual characteristics. In the longitudinal study, 1.733 individuals were reassessed in the period of 2005-2007. The prevalence of CMD at 2 years was 33%, with 8% in individuals without TMC at inclusion. Individual characteristics sex, age and occupation and household characteristic family income were associated with presence of CMD at follow-up. Multilevel logistic regression models for longitudinal data showed that most of the variance associated with presence of CMD was associated with the level of the individual, with associations between sex, age, education, occupation and CMD, even after controlling for household characteristics. The household level also contributed independently to the variance related to the presence of TMC at follow-up, with associated fixed effect for family income, even after controlling for individual characteristics. CONCLUSION: The results showed that individual characteristics contribute to most of the variance in the prevalence, incidence and prognosis of TMC, but there is an independent association with the household level, which is not fully explained by family income. These results indicate that characteristics of the environment where people live contribute to their mental health, suggesting that future research focus on the psychosocial characteristics of households and neighborhoods to study the social and TMC

Objetivo: Avaliar o efeito das manobras de recrutamento alveolar em desfechos clínicos de pacientes com síndrome da angústia respiratória aguda (SARA). Métodos: Busca nas bases eletrônicas MEDLINE, EMBASE, LILACS, CINAHL, CENTRAL, Scopus, and Web of Science (até Julho de 2014), sem limite de idioma, por ensaios clínicos randomizados avaliando o efeito das manobras de recrutamento alveolar versus tratamento padrão sem manobras de recrutamento em pacientes adultos com SARA. Quatro duplas de revisores avaliaram de maneira independente a elegibilidade e o risco de viés dos estudos e extraíram os dados de interesse. Realizamos metanálise dos dados por meio de modelos de efeitos aleatórios. Foi utilizada análise sequencial de trials para estabelecer limiares de significância estatística para a metanálise cumulativa considerando nosso desfecho primário (mortalidade hospitalar) para limitar o erro tipo I global por análises múltiplas. Utilizamos sistema GRADE para avaliar a qualidade da evidência. Resultados: Foram incluídos 10 ensaios clínicos randomizados (1594 pacientes, 612 eventos). O risco relativo (RR) de óbito nos pacientes tratados com manobras de recrutamento em comparação ao controle foi de 0,84 (intervalo de 95% de confiança [IC95%] 0,74-0,95; I2=0%), embora a qualidade da evidência tenha sido considerada baixa devido ao risco de viés nos estudos incluídos e à evidência indireta (ou seja, a evidência disponível não responde diretamente nosso objetivo primário, pois os pacientes no grupo experimental receberam outras intervenções ventilatórias que podem ter impactado no desfecho, além das manobras de recrutamento). Não houve diferença no risco de barotrauma (RR 1,11; IC95% 0,78-1,57; I2=0%) ou necessidade de terapia de resgate para hipoxemia (RR 0,76; IC95% 0,41-1,40; I2=56%). A maioria dos estudos não demonstrou diferenças entre os grupos nos desfechos: tempo de ventilação mecânica, tempo de internação na UTI e no hospital. A análise sequencial de ensaios clínicos demonstrou que a evidência cumulativa sobre o efeito das manobras de recrutamento na mortalidade hospitalar de pacientes com SARA é precisa quando considerado um erro tipo I de 5%, mas é imprecisa quando considerado um erro tipo I de 1%. Conclusão: A evidência atual sugere que as manobras de recrutamento alveolar reduzem o risco de óbito hospitalar em pacientes com SARA, sem aumento do risco de eventos adversos graves, entretanto, a evidência não é definitiva. Estudos adicionais são necessários para responder esta questão / Purpose: To assess the effects of alveolar recruitment maneuvers on clinical outcomes in patients with acute respiratory distress syndrome (ARDS). Methods: We searched MEDLINE, EMBASE, LILACS, CINAHL, CENTRAL, Scopus, and Web of Science (from inception to July 2014) for randomized controlled trials evaluating the effects of alveolar recruitment maneuvers versus no recruitment maneuvers in adults with ARDS. We placed no language restriction on our search. Four teams of two reviewers independently assessed eligibility and risk of bias and extracted data from the included trials. We pooled data using random-effects models. We used trial sequential analysis to establish monitoring boundaries to limit global type I error due to repetitive testing for our primary outcome (in-hospital mortality). We rated the quality of evidence using the GRADE system. Results: We included 10 trials (1594 patients, 612 events). The meta-analysis assessing the effect of alveolar recruitment maneuvers on in-hospital mortality showed a risk ratio (RR) of 0.84 (95%CI 0.74-0.95; I2=0%). However, quality of evidence was considered low due to the risk of bias in the included trials and indirectness of evidence, that is, available evidence does not address our primary outcome directly as recruitment maneuvers were usually conducted along with other ventilatory interventions that may affect the outcome of interest. There were no differences in the rates of barotrauma (RR 1.11, 95%CI 0.78-1.57; I2=0%) or need for rescue therapies (RR 0.76, 95%CI 0.41-1.40; I2=56%). Most trials found no difference between groups regarding the duration of mechanical ventilation, length of stay in ICU and in hospital. The trial sequential analysis showed that the available evidence of the effect of recruitment maneuvers on in-hospital mortality is precise when considering a type I error of 5% but not when considering a type I error of 1%. Conclusions: Although recruitment maneuvers may decrease mortality of patients with ARDS without increasing the risk for major adverse events, the current evidence is not definitive. Additional trials addressing this question may better inform clinical practice

Abstract Cardiovascular disease is currently the leading cause of mortality worldwide. Several factors contribute to its development, including increased body mass index, high blood pressure and smoking. Many genetic and behavioural determinants of these risk factors have been identified, but the interplay between them along the life course is still poorly understood. Life course epidemiology and statistical methods developed for life course studies are required to enhance understanding of the aetiologies of these risk factors for more effective prevention and treatment of cardiovascular disease. In this thesis, structural equation modelling was applied 1) to estimate the effect of variation in the fat mass and obesity-associated gene, FTO, on body mass index over the life course, 2) to identify sensitive periods of growth in influencing adult blood pressure and 3) to identify developmental changes in the effects of two confirmed genetic loci, TTC12-ANKK1-DRD2 and CHRNA5-CHRNA3-CHRNB4, affecting smoking behaviour. Additionally, pleiotropic effects of the variation in CHRNA5-CHRNA3-CHRNB4 on smoking, body mass index and blood pressure were studied. The study population was based on the Northern Finland Birth Cohort 1966 with data available from early gestation until the age of 31 years (N≈6000). The first study indicated that the effect of the FTO variant on body mass index changes over time, with strengthening of the effect by age. The results from the second study demonstrated the important role of both prenatal and postnatal growth in determining adult blood pressure. In the third study, TTC12-ANKK1-DRD2 was shown to influence the initiation of smoking, while CHRNA5-CHRNA3-CHRNB4 was associated with smoking persistence. Finally, some evidence was found for pleiotropic effects of the CHRNA5-CHRNA3-CHRNB4 gene cluster on the three traits of interest. Results from all the studies emphasised the importance of environmental and behavioural factors in determining adult metabolic profile, in addition to genetic predisposition. This study demonstrated the usefulness of life course studies in detecting age-varying genetic effects, and provided new insights into the already identified factors associated with cardiovascular disease risk. The findings also emphasise the importance of early interventions and life style guidance for long-term benefits in health. / Tiivistelmä Sydän- ja verisuonitaudit ovat maailman yleisin kuolemansyy. Useat tekijät vaikuttavat näiden tautien kehittymiseen, mukaan lukien ylipaino ja lihavuus, kohonnut verenpaine sekä tupakointi. Useita geneettisiä ja ei-geneettisiä tekijöitä on yhdistetty näihin riskitekijöihin, mutta niiden yhteisvaikutukset elämänkaaren varrella ovat vielä huonosti tunnettuja. Elämänkaariepidemiologiaa ja sitä varten kehitettyjä tilastollisia menetelmiä tarvitaan, jotta saataisiin uutta tietoa riskitekijöiden etiologioista ja voitaisiin tehokkaammin ennaltaehkäistä ja hoitaa sydän- ja verisuonitauteja. Tässä väitöskirjatyössä käytettiin rakenneyhtälömallitusta 1) estimoimaan FTO-geenin yhteyttä painoindeksiin (BMI) elämänkaaren varrella, 2) tunnistamaan kehityksellisesti tärkeitä ajanjaksoja suhteessa aikuisiän verenpaineeseen ja 3) tutkimaan kahden jo ennestään tunnistetun geneettisen lokuksen, TTC12-ANKK1-DRD2:n ja CHRNA5-CHRNA3-CHRNB4:n, vaikutusta tupakointiin eri elämänvaiheissa. Lisäksi tutkittiin CHRNA5-CHRNA3-CHRNB4:n mahdollisia pleiotrooppisia vaikutuksia tupakointiin, painoindeksiin ja verenpaineeseen. Tutkimusväestönä käytettiin Pohjois-Suomen syntymäkohorttia vuodelta 1966, joka sisältää tutkimusaineistoa varhaisraskaudesta aikuisuuteen 31 vuoden ikään saakka (N≈6000). Ensimmäinen osatyö osoitti, että FTO-geenin vaikutus painoindeksiin voimistuu iän kasvaessa. Toisen osatyön tulokset antoivat näyttöä siitä, että raskaudenaikainen ja syntymän jälkeinen kasvu ovat yhteydessä aikuisiän verenpaineeseen. Kolmannessa osatyössä osoitettiin, kuinka TTC12-ANKK1-DRD2 on yhteydessä tupakoinnin aloittamiseen, kun taas CHRNA5-CHRNA3-CHRNB4 vaikuttaa tupakointikäyttäytymisen pysyvyyteen. Viimeinen osatyö antoi näyttöä CHRNA5-CHRNA3-CHRNB4-geeniklusterin pleiotrooppisista vaikutuksista kolmeen tutkittuun fenotyyppiin. Kaikkien osatöiden tuloksissa korostui, geneettisten tekijöiden lisäksi, ei-geneettisten tekijöiden tärkeys aikuisiän metabolisen profiilin kehityksessä. Tämä työ on osoittanut elämänkaarimallituksen hyödyllisyyden, kun pyritään havaitsemaan iän mukaan vaihtelevia geneettisiä efektejä. Se on myös tuonut uutta tietoa liittyen jo aiemmin todettuihin sydän- ja verisuonitautien riskitekijöihin. Lisäksi tulokset korostavat riittävän varhaisten ehkäisytoimien ja elämäntapaohjauksen tärkeyttä pyrittäessä saavuttamaan pitkäaikaisia terveyshyötyjä.

Objectifs: Examiner les tendances temporelles, les déterminants en lien avec le design des études et la qualité des taux de réponse rapportés dans des études cas-témoins sur le cancer publiées lors des 30 dernières années. Méthodes: Une revue des études cas-témoins sur le cancer a été menée. Les critères d'inclusion étaient la publication (i) dans l’un de 15 grands périodiques ciblés et (ii) lors de quatre périodes de publication (1984-1986, 1995, 2005 et 2013) couvrant trois décennies. 370 études ont été sélectionnées et examinées. La méthodologie en lien avec le recrutement des sujets et la collecte de données, les caractéristiques de la population, les taux de participation et les raisons de la non-participation ont été extraites de ces études. Des statistiques descriptives ont été utilisées pour résumer la qualité des taux de réponse rapportés (en fonction de la quantité d’information disponible), les tendances temporelles et les déterminants des taux de réponse; des modèles de régression linéaire ont été utilisés pour analyser les tendances temporelles et les déterminants des taux de participation. Résultats: Dans l'ensemble, les qualités des taux de réponse rapportés et des raisons de non-participation étaient très faible, particulièrement chez les témoins. La participation a diminué au cours des 30 dernières années, et cette baisse est plus marquée dans les études menées après 2000. Lorsque l'on compare les taux de réponse dans les études récentes a ceux des études menées au cours de 1971 à 1980, il y a une plus grande baisse chez les témoins sélectionnés en population générale ( -17,04%, IC 95%: -23,17%, -10,91%) que chez les cas (-5,99%, IC 95%: -11,50%, -0,48%). Les déterminants statistiquement significatifs du taux de réponse chez les cas étaient: le type de cancer examiné, la localisation géographique de la population de l'étude, et le mode de collecte des données. Le seul déterminant statistiquement significatif du taux de réponse chez les témoins hospitaliers était leur localisation géographique. Le seul déterminant statistiquement significatif du taux de participation chez les témoins sélectionnés en population générale était le type de répondant (sujet uniquement ou accompagné d’une tierce personne). Conclusion: Le taux de participation dans les études cas-témoins sur le cancer semble avoir diminué au cours des 30 dernières années et cette baisse serait plus marquée dans les études récentes. Afin d'évaluer le niveau réel de non-participation et ses déterminants, ainsi que l'impact de la non-participation sur la validité des études, il est nécessaire que les études publiées utilisent une approche normalisée pour calculer leurs taux de participation et qu’elles rapportent ceux-ci de façon transparente. / Objectives: To examine the time trends, study design determinants, and quality of reporting of response rates in published case-control studies of cancer over the past 30 years. Methods: A review was conducted of case-control studies of cancer. Inclusion criteria required publications in 15 major journals, during four publication periods spanning three decades (1984-86, 1995, 2005 and 2013). 370 studies were selected and reviewed. Information on study base ascertainment, data collection methods, population characteristics, response rates, and reasons for non-participation was extracted. Quality of response rate reporting was assessed based on the amount of information reported. Descriptive statistics were used to summarize the quality of the reporting, time trends and the determinants of response rates; linear regression models were used to analyse time trends and determinants of response rates. Results: Overall, the quality of reporting of response rates and reasons for non-participation was very poor, especially for control series. Participation has declined over the past 30 years, and this decline was steeper in studies conducted after 2000. When comparing the response rates in recent studies to that in studies conducted during 1971-1980, there was a greater decline of this rate in population controls (-17.04%, 95% CI: -23.17%, -10.91%) than in cases (-5.99%, 95% CI: -11.50%, -0.48%). Statistically significant determinants of response rates among cases were: cancer type examined, location of the study population, and mode of data collection. The only statistically significant determinant of response rates among medical source controls was location of the study population. The only statistically significant determinant of response rates among population controls was type of respondent (self only or self and proxy) accepted by studies. Conclusion: Response rates in case-control studies of cancer seem to have declined and this decline has accelerated in recent studies. In order to appreciate the true level of non-participation and its determinants, as well as the impact of non-participation on validity of studies, there is a need for more transparent reporting and standardized calculation of response rates in published studies.

Leung Siu-Ngan. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2001. / Includes bibliographical references (leaves 72-74). / Abstracts in English and Chinese. / Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- Background --- p.1 / Chapter 1.2 --- Structure and Contents of Data Sets --- p.6 / Chapter 2 --- Estimation of Prevalence of Mentally Disorders --- p.10 / Chapter 2.1 --- Likelihood Function Approach --- p.10 / Chapter 2.2 --- Maximum Likelihood Estimation via EM Algorithm --- p.13 / Chapter 2.3 --- The SEM Algorithm --- p.16 / Chapter 3 --- Estimation of Lifetime Comorbidity --- p.24 / Chapter 3.1 --- What is Comorbidity? --- p.24 / Chapter 3.2 --- Likelihood Function Approach --- p.25 / Chapter 3.2.1 --- Likelihood Function Model --- p.27 / Chapter 3.2.2 --- Maximum Likelihood Estimation via EM Algorithm --- p.28 / Chapter 3.2.3 --- Odds Ratio --- p.31 / Chapter 4 --- Logistic Regression --- p.35 / Chapter 4.1 --- Imputation Method of Missing Values --- p.35 / Chapter 4.1.1 --- Hot Deck Imputation --- p.35 / Chapter 4.1.2 --- A logistic Regression Imputation Model for Dichotomous Response --- p.40 / Chapter 4.2 --- Combining Results from Different Imputed Data Sets --- p.47 / Chapter 4.3 --- Itemization on Screening --- p.60 / Chapter 4.3.1 --- Methods of Weighting on the Screening Questions --- p.61 / Chapter 4.3.2 --- Statistical Analysis --- p.62 / Chapter 5 --- Conclusion and Discussion --- p.68 / Appendix: SRQ Questionnaire --- p.69 / Bibliography --- p.72

L'objectif principal de ce travail est d’étudier en profondeur certaines techniques biostatistiques avancées en recherche évaluative en chirurgie cardiaque adulte. Les études ont été conçues pour intégrer les concepts d'analyse de survie, analyse de régression avec “propensity score”, et analyse de coûts. Le premier manuscrit évalue la survie après la réparation chirurgicale de la dissection aigüe de l’aorte ascendante. Les analyses statistiques utilisées comprennent : analyses de survie avec régression paramétrique des phases de risque et d'autres méthodes paramétriques (exponentielle, Weibull), semi-paramétriques (Cox) ou non-paramétriques (Kaplan-Meier) ; survie comparée à une cohorte appariée pour l’âge, le sexe et la race utilisant des tables de statistiques de survie gouvernementales ; modèles de régression avec “bootstrapping” et “multinomial logit model”. L'étude a démontrée que la survie s'est améliorée sur 25 ans en lien avec des changements dans les techniques chirurgicales et d’imagerie diagnostique. Le second manuscrit est axé sur les résultats des pontages coronariens isolés chez des patients ayant des antécédents d'intervention coronarienne percutanée. Les analyses statistiques utilisées comprennent : modèles de régression avec “propensity score” ; algorithme complexe d'appariement (1:3) ; analyses statistiques appropriées pour les groupes appariés (différences standardisées, “generalized estimating equations”, modèle de Cox stratifié). L'étude a démontrée que l’intervention coronarienne percutanée subie 14 jours ou plus avant la chirurgie de pontages coronariens n'est pas associée à des résultats négatifs à court ou long terme. Le troisième manuscrit évalue les conséquences financières et les changements démographiques survenant pour un centre hospitalier universitaire suite à la mise en place d'un programme de chirurgie cardiaque satellite. Les analyses statistiques utilisées comprennent : modèles de régression multivariée “two-way” ANOVA (logistique, linéaire ou ordinale) ; “propensity score” ; analyses de coûts avec modèles paramétriques Log-Normal. Des modèles d’analyse de « survie » ont également été explorés, utilisant les «coûts» au lieu du « temps » comme variable dépendante, et ont menés à des conclusions similaires. L'étude a démontrée que, après la mise en place du programme satellite, moins de patients de faible complexité étaient référés de la région du programme satellite au centre hospitalier universitaire, avec une augmentation de la charge de travail infirmier et des coûts. / The main objective of this work is to study in depth advanced biostatistical techniques in adult cardiac surgery outcome research. The studies were designed to incorporate the concepts of survival analysis, regression analysis with propensity score, and cost analysis. The first manuscript assessed survival, and cardiovascular specific mortality, following surgical repair of acute ascending aortic dissection. The statistical analyses included survival analyses with multiphase parametric hazard regression and other parametric (exponential, Weibull), semi-parametric (Cox) or non-parametric models (Kaplan Meier), comparison with the survival of a matched cohort for age, gender and race using State lifetables, and modelization with bootstrapping and multinomial logit models. The study showed that the early and late survival following surgical repair has improved progressively over 25 years in association with noticeable changes in surgical techniques and preoperative diagnostic testing. The second manuscript focused on outcomes following isolated coronary artery bypass grafting in patients with a history of percutaneous coronary intervention. The statistical analyses included multivariable regression models with propensity score, complex matching algorithm (1:3) and appropriate statistical analyses for matched groups (standardized differences, generalized estimating equations, and survival analyses with stratified proportional hazards models). The study showed that remote prior percutaneous coronary intervention more than 14 days before coronary artery bypass grafting surgery was not associated with adverse outcomes at short or long-term follow-up. The third manuscript evaluated the financial consequences and the changes in case mix that occurred at an academic medical center subsequent to the implementation of a satellite cardiac surgery program. The statistical analyses included two-way ANOVA multivariable regression models (logistic, linear or ordinal), propensity score, and cost analyses using Log-Normal parametric models. “Survival” analyses models were also explored, using “cost” instead of “time” as the outcome of interest, and led to similar conclusions. The study showed that, after implementation of the satellite cardiac surgery program, fewer patients of lower complexity came to the academic medical center from the satellite program area, with a significant increase in nursing workload and costs.

L'objectif principal de ce travail est d’étudier en profondeur certaines techniques biostatistiques avancées en recherche évaluative en chirurgie cardiaque adulte. Les études ont été conçues pour intégrer les concepts d'analyse de survie, analyse de régression avec “propensity score”, et analyse de coûts. Le premier manuscrit évalue la survie après la réparation chirurgicale de la dissection aigüe de l’aorte ascendante. Les analyses statistiques utilisées comprennent : analyses de survie avec régression paramétrique des phases de risque et d'autres méthodes paramétriques (exponentielle, Weibull), semi-paramétriques (Cox) ou non-paramétriques (Kaplan-Meier) ; survie comparée à une cohorte appariée pour l’âge, le sexe et la race utilisant des tables de statistiques de survie gouvernementales ; modèles de régression avec “bootstrapping” et “multinomial logit model”. L'étude a démontrée que la survie s'est améliorée sur 25 ans en lien avec des changements dans les techniques chirurgicales et d’imagerie diagnostique. Le second manuscrit est axé sur les résultats des pontages coronariens isolés chez des patients ayant des antécédents d'intervention coronarienne percutanée. Les analyses statistiques utilisées comprennent : modèles de régression avec “propensity score” ; algorithme complexe d'appariement (1:3) ; analyses statistiques appropriées pour les groupes appariés (différences standardisées, “generalized estimating equations”, modèle de Cox stratifié). L'étude a démontrée que l’intervention coronarienne percutanée subie 14 jours ou plus avant la chirurgie de pontages coronariens n'est pas associée à des résultats négatifs à court ou long terme. Le troisième manuscrit évalue les conséquences financières et les changements démographiques survenant pour un centre hospitalier universitaire suite à la mise en place d'un programme de chirurgie cardiaque satellite. Les analyses statistiques utilisées comprennent : modèles de régression multivariée “two-way” ANOVA (logistique, linéaire ou ordinale) ; “propensity score” ; analyses de coûts avec modèles paramétriques Log-Normal. Des modèles d’analyse de « survie » ont également été explorés, utilisant les «coûts» au lieu du « temps » comme variable dépendante, et ont menés à des conclusions similaires. L'étude a démontrée que, après la mise en place du programme satellite, moins de patients de faible complexité étaient référés de la région du programme satellite au centre hospitalier universitaire, avec une augmentation de la charge de travail infirmier et des coûts. / The main objective of this work is to study in depth advanced biostatistical techniques in adult cardiac surgery outcome research. The studies were designed to incorporate the concepts of survival analysis, regression analysis with propensity score, and cost analysis. The first manuscript assessed survival, and cardiovascular specific mortality, following surgical repair of acute ascending aortic dissection. The statistical analyses included survival analyses with multiphase parametric hazard regression and other parametric (exponential, Weibull), semi-parametric (Cox) or non-parametric models (Kaplan Meier), comparison with the survival of a matched cohort for age, gender and race using State lifetables, and modelization with bootstrapping and multinomial logit models. The study showed that the early and late survival following surgical repair has improved progressively over 25 years in association with noticeable changes in surgical techniques and preoperative diagnostic testing. The second manuscript focused on outcomes following isolated coronary artery bypass grafting in patients with a history of percutaneous coronary intervention. The statistical analyses included multivariable regression models with propensity score, complex matching algorithm (1:3) and appropriate statistical analyses for matched groups (standardized differences, generalized estimating equations, and survival analyses with stratified proportional hazards models). The study showed that remote prior percutaneous coronary intervention more than 14 days before coronary artery bypass grafting surgery was not associated with adverse outcomes at short or long-term follow-up. The third manuscript evaluated the financial consequences and the changes in case mix that occurred at an academic medical center subsequent to the implementation of a satellite cardiac surgery program. The statistical analyses included two-way ANOVA multivariable regression models (logistic, linear or ordinal), propensity score, and cost analyses using Log-Normal parametric models. “Survival” analyses models were also explored, using “cost” instead of “time” as the outcome of interest, and led to similar conclusions. The study showed that, after implementation of the satellite cardiac surgery program, fewer patients of lower complexity came to the academic medical center from the satellite program area, with a significant increase in nursing workload and costs.

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