Ebook Bài giảng Thống kê y tế: Phần 2

SE(p) co the dtfdc tfdc ltfdng bdi V p(l-p)/n Mot cach tong quat 95% khoang tin cay cd the dtfdc tmh nhtf tfdc ltfdng ± 1,96 SE(tfdc ltfdng) Bai tap Mot can bo dinh dtfdng mong muon de tfdc ltfdng mtic tieu thu keo hang tu&n cua cac tre em d mot ltia tuoi nhat dinh mot vting nao dd Sau thiet ke mot phtfdng an cho phep xac dinh mtic tieu thu keo cua mot dtfa tre mot tu&n, tien hanh dieu tra thti va thay rang lech chuan cua viec tieu thu keo mot tuan vao khoang 3ounce (1,5kg) Anh ta can nhac l&y mot mau ngau nhien gom 25 tre hoac 100 tre hoac la lay mot mau 625 tre hoac lay mot mau 2500 tre lam dieu tra chinh - Lfdc ltfdng sai so chuan va sai so' ldn nhat tin cay 95% - Sai so trung binh mau cho moi mot cd mau bon cd mau tren Trong mot mau ngau nhien gom 150 hoc sinh gai ltfa tuoi 14 phat hien thay 38 hoc sinh gai mac benh can thi c&n dtfdc dieu tri a/ Hay tfdc ltfdng ti le hoc sinh gai cua tuoi quin the mac benh can thi can dtfdc dieu tri b/ Hay tfdc ltfdng 90%, 95% va 99% cac khoang tin cay doi vdi ti le that cac hoc sinh gai ltfa tuoi 14 quan the bi mac benh can thi c&n dtfdc dieu tri Bdi 6: CAC PHEP KIEM DINH CO Y NGHIA N am dtfdc bdi 6, hgc vien co k h a nang: - Hieu dtfdc tinh hdp ly cua phep kiem dinh theo nghia tong quat; - Xac dinh dtfdc gia thiet khong; - Tinh dtfdc sai so' chu&n cua trung binh m lu va ty le m&u; - Tinh dtfdc lech chu^n va giai thich dtfdc tam quan cua no doi vdi trung binh mau hoac ty le mau; - Stf dung khoang tin cay doi vdi trung binh quan the hoac ty le de suy dien ket qua cua cac phep kiem dinh 66 O bai chung ta co mot mau cac quan sat ve mot bien nao do, chung ta se so sanh no vdi mot chuan cho trtfdc Gia thiet rang da biet phudng sai cua quan the, dieu ma tren thtfc te khong the biet Vi du: Nghien ciiu nguy cd mac benh co lien quan tdi mot nghe nghiep nhat dinh Lay mot mau ngau nhien gom 20 ngtfdi dan ong tuoi ttf 30-39 Trung binh huyet ap tam thu tinh dudc la 141,4 mmHg Gia stf rang cac kinh nghiem trUdc day cho biet quan the ldn trung binh huyet ap tam thu doi vdi dan ong thuoc nhom tuoi la (.i = 133.2 mmHg vdi lech chuan =15,1 mmHg Hoi stf tang huyet ap cd lien quan tdi nghe nghiep khong? De tra ldi cho cau hoi nay, trUdc het ta dat gia thiet rang: Khong cd stf tang huyet ap tam thu doi vdi nghe Mau 20 ngtfdi la mau ngau nhien tu: toan bo quan the dan ong thuoc liia tuoi 30-39 tuoi Ta biet rang gia tri trung binh cua mau se tuan theo luat phan pho'i chuan vdi gia tri trung binh ji = 133,2 mmHg va lech chuan la : 8/ V n = 15,1/ V 20 = 3,38 mmHg Do lech chuan tat nhien cung la sai so chuan cua g ia tri, trung binh Chung ta da biet ve phan phoi chuan cua dai ltfdng ngau nhien X vi vay cac gia tri trung binh mau nam ngoai gidi han 133,2 ± 1,96 x 3,38 nghia la ngoai khoang ttf 126,6 den 139,8 no chi xuat hien vdi xac suat la 5% Ta thay gia tri trung binh mau cua chung ta la 141,4 mmHg Nam ngoai khoang vay cd the suy dieu gi? - Hoac la (1): Gia thiet rang khong cd stf tang huyet ap tam thu vdi nghe la dung va trung binh mau ma ldn, ddn thuan la stf chon mau khong may man va chi xuat hien vdi xac suat la 5% - Hoac la (2): Gia thiet rang khong cd sU tang huyet ap tam thu vdi nghe la sai Ta khong the noi chac chan dtfdc hai dieu tren cai nao la dung Nhtfng de dieu mot dung thi xac suat lai qua be chi xuat hien vdi xac suat la 5% nen chung ta khong tin no xay vi vay buoc ta phai cong nhan dieu hai Nhu vay, chung ta ket, luan rang cd sU tang Huyet ap tam thu d nhtfng ngtfdi dan ong lam nghe vdi mtfc sai l&m nho hdn 5% Ly luan kieu diidc goi la ph ep kiem dinh co y nghia Bay gid ta thtf xem gia tri trung binh mau cd nam ngoai khoang trung binh qiu\n the (.i va lech chuan khong De khang dinh dtfdc dieu ta dua gia thiet Ho 67 - Neu x khong nam khoang (i ± 1,96 5/ V"n" thi: t = I ~x - jj I/ 5/V n > 1,96 Ta noi stf khac biet giiia va n la co y nghia thong ke vdi xac suat sai lim la a < 5% - Neu 11 I >2,58 thi stf khac biet co y nghia thong ke vdi xac su&'t sai lam la a 30) Chon mot mau de quan sat ta tinh dudc gia tri trung binh m&u X Qua m&u ta muon biet: Co the chap nhan gia thuyet Ho cho rang mau dudc chon tu: tong the cd trung binh khong? Ta co quy tac thtfc h an h sau Muon so sanh mot so trung binh "x quan sat tren n trUdng hdp vdi mot so trung binh ly thuyet p., ta dua tren ty so: Trong S la lech tieu chuan cua quan the (dd biet) So sanh gia tri tuyet doi cua t va ta (trong bang tinh san cua Laplace) Neu I t | < 1,96: Su khac khong cd y nghia thong ke (vdi mUc y nghia a > 0.05) Neu | t | > 1,96 : Su khac cd y nghia vdi mUc y nghia a < 0.05 Neu I t | > 2,58 thi a < 0,01 Neu I t | > 3,29 thi a < 0,001 Tri so ly thuyet thudng la mot tri so trung binh ma ngUdi ta du dinh se dat dudc (trong ludng trung binh cua mot vien thuoc, mot chai thuoc nude v.v ) hoac cac tieu chuan ludng xet nghiem, cac hang so sinh vat hoc v.v da dudc xac dinh Nhung cong thUc tren cd chUa lech tieu chu&n chUa biet \i vav thuc hanh chung ta phai thay bang lech tieu chuan mau s Chung ta dua tren ty so": Xt = _s Vn Trong do: s la lech tieu chu^n mau 72 M au nho n < : Cong thUc tinh giong mau ldn, S Vn nhung day ta phai tim bac tu do: k = n - Sau ta so sanh | t | thuc nghiem vdi ta ly thuyet bang tinh san cua Stiudon - Fiso (bang gia tri tdi han t) Neu | t | ^ ta sU khac co y nghia thong ke ( mUc y nghia a tra bang cac gia tri tdi han t) Neu | t | < ta sU khac khong cd y nghia thong ke PhifOng phap so sanh tvfng cap tri so : Dd la phudng phap theo doi d cac thdi diem khac tren cung mot doi tUdng De so sanh hieu qua cua hai cach tac dong khac tren cung mot doi tUdng nghien cUu NgUdi ta thudng dung thii nghiem thuoc xem tac dung cua thuoc trUdc va sau dung C) day ta khong so sanh tri so" cua mau khac ma so sanh tUng cap tri so’ tren cung mot ddn vi nghien cUu Ta ap dung phudng phap so sanh mot tri so trung binh vdi mot tri so" ly thuyet (x =0 ) tren cd sd gia thuyet Ho (2 mau bat ky du sai khac nhung van cung mot tong the) O day tUng cap tri so lai rut tU mot ddn vi nghien cUu, vi vay ta phai so sanh tUng cap mot Chenh lech cua tifng cap cd the la so am hoac dudng TU tong cac hieu cua cac cap ta tinh dUdc tri so" trung binh thuc nghiem Sau dd ta dem so sanh vdi tri so" ly thuyet la t= jt - (X = ) Tn a L a p b a n g d e tinh x thuc n gh iem \ Cac :ri so" TrUdc thi nghiem(a) Sau thi nghiem(b) b - a (x, (1) ni (2) x.n (1) x (2) x2 ,n, (4) = (3) x (1) I x,n, I x2 ,n, 73 b T in h p h tid n g sai : Khong cd tan so": s = n —1 n Co t&n so : Sau tra bang, tim ta ly thuyet (bang gia tri tdi han cua t) Bac tu k = n - Neu 11| < ta Su khac biet khong co y nghia thong ke , a >0,05 Neu 11| > ta Su khac biet co y nghia thong ke So sanh hai so trung binh quan sat 2.1 Mau ldn n > 30 , n2 >30 Quan sat hai mau, mau co so ddn vi mau n! , gia tri trung binh x 1; phudng sai s] mau cd so" ddn vi mau n2 , gia tri trung binh x2 , phudng sai s Q u i t a c : Muon so sanh hai so" trung binh quan- x1 va "x2 quan sat tren nt va n2 trUdng hdp, ta dua tren ti so": Gia tri 11| tinh dudc, so vdi gia tri t ly thuyet ,bang Laplace Neu 11|> 1,96 sU khac cd y nghia a < 0,05 Neu 11| > 2,58 thi a < 0,01 Neu I tl > 3,29 thi a < 0,001 2.2 M au nho n xa : Su khac cd y nghia vdi mtic y nghia a < 0.05 Neu I t f > xa/2 : Su khac cd y nghia thong ke, mtic y nghia < a < 0.05 Neu I t I < x a /2 : Su khac khong cd y nghia thong ke C a c h t in h xa: s]t{n^,a) + s]t(ni t,a) xa = -s;+s; s ' A n , - ^ a/ 2) + xa/ = s ’ + si N eu c a c b ie n X v a Xo_ c o p h u d n g s a i la n h u n h a u : Muon so sanh hai so" trung binhxl va"x2 quan sat tren nj va n2 trUdng hdp ta dua tren ty so": •X , - X f 11 s — + — In, nJ 75 S31 S34- S35, S39- S41.-S44 S46 S49- S51 S54- S56, S59S61, S64- S 6 S69- S71, S74S76, S79- S81, S84- S , S89- S91 S94- S96, S99, T00-T01, T06- T07, T09, T i l , T13- T14 282 Hau qua mot vat la xam nhap vao mot lo tu nhien Effects of foreign body entering through natural orifice T15-T19 283 Bong va sU an mon T20-T32 Burnss and corrosions 284 Nhiem doc thuoc va cac chat sinh hoc T36- T50 Poisoning by drugs and biological substances 285 Tac hai cua cac chat doc co nguon goc chu yeu khong T51- T65 phai thuoc Toxic effects of substances chiefly nonmedical as to 286 source Cac hoi chiing dieu tri sai T74 Maltreatment syndromes 287 Hau qua cua cac nguyen nhan ben ngoai khac va khong xac dinh Other and unspecified effects of external causes 288 T33- T35, T 6 - T73, T75-T78 Mot so bien chung sdm cua chan thudng va bien chiing T79-T88 cua cham soc ngoai khoa va y hoc, khong xep o' ndi khac Certain early complications complications of surgical medical of and trauma care, and not elsewhere classified 289 Di chiing cua cac thudng ton chan thudng, ngo doc va T90-T98 hau qua khac nguyen nhan ben ngoai Sequalae of injuries, of poisoning and of other consequences of external causes 171 CHL/dNG XX: NGUYEN NHAN BEN NGOAI CUA BENH TAT VA TU CUNG 290 Tai nan giao thong yo i V I Transport accident 291 Tai nan nguyen nhan siic khoe cd hoc va khong co y \V20 - W64 Exposure to inanimate mechhnical forces 292 Tai nan chet duo'i chet chim W - W84 Accident drowing and submersion 293 Tai nan dong dien, biic xa, nhiet va ap luc khong W85 -W99 cao Eposure electric current, radiation and extreme ambian air temperature and pressure 294 Tai nan khoi, lua va ngon liia X00 ■ ■X09 Exposure to smoke, fire and flame 295 Tai nan hdi nong, nong X10 ■ ■X19 Contact with head and hot 296 Tai nan do,tiep xuc vdi dong vat va cay co chat doc X20 •X29 Contact with venomous animals and plants 297 Tai nan doc chat X40 - X49 Accident poisoning by and exposure 298 Tu tii - Intentional self - harm X60 - X84 299 Bao luc - Assault X r> -Y09 300 Tai bien thuoc va sinh ph&m dieu tri y jU - Y59 Drugs medicament and bilogical substances causing adverse effect in therapeutic use 301 Tai nan rui ro dieu tri noi, ngoai khoa cho ngUdi ygg - Y69 benh Misadventure to patients during surgical and medical care 302 Tai nan dung thiet bi chan doan va dieu tri Y70 - Y82 Medical device associated with adverse accident in diagnostic and therapeutic use 303 Cac yeu to' bo trd nguyen nhan gay benh tat tu vong da phan loai Supplementary factors related to cause of morbidity and mortality classified elsewhere 172 yqq - Y98 CHUONG XXI: CAC YEU TO ANH HUONG DEN SLTC KHOE NGUOI KHAM NGHIEM VA DIEU TRA 304 NgUdi co tiep xuc vdi cac dich vii y te va cac kham ZOO- Z01 nghiem khac Person encoutenng health services tor examination and investigation 305 Nhiem ( HIV) khong co trieu chung Asymptomatic Z21 human immunodeficiency virus ( HIV) infection status 306 Nhung ngUdi co nguv cd lien quan tien cac benh truyen Z20 Z22- 7/29 nhiem Other persons with potential health hazards related to communicable diseases 307 Quan ly cac bien phap tranh thai Z30 Contraceptive management 308 Giam sat thai va phat hien trudc sinh Z34- Z36 Antenatal screening and other supervision of pregnancy 309 Tre de song phan theo noi sinh Z3S Liveborn infants according to place of birth 310 Cham soc va kham nghiem sau de Z39 Postpartum care and examination 311 Nhung nguoi ma y te phai chain soc vdi nhung ly dac Z40- Zn4 biet Persons encoutenng health services for specific procedures and health care 312 XliUng ngudi can den cac dich vu y te vi nhung lv khac Z31- Z33 Z37, Z55- Z99 Person encoutenng health services for other reasons 173 CAC QUI TAC VA Hl/CfNG DAN MA HOA TU VONG Cac thong ke tti vong la mot nhting nguon thong tin chfnh ve r-uc khoe va d nhieu nUdc la nhting loai dti kien v te dang tin cay nhat Nguyen n han tti vong Nam 1967 Hoi nghi Y te The gicii lan thti 20 da dinh nghia cac nguyvn nhan tti vong de dua vao giay chting nhan y te ve nguyen nhan tti vong la: "Moi benh, tinh trang hoac tdn thudng da dan den hoac tham gia van tti vong va cac hoan canh tai nan hoac bao lUc da gay non cac ton thudng do" Dinh nghia nh&m bao dam rang moi thong tin co lion quan dudc ghi lai va ngtfdi xac nhan khong dtfdc chon mot vai tinh trang benh de ghi va loai bo cac tinh trang khac Dinh nghia khong bao gom cac trieu chting hoac hinh thtic chet, nhu suy tim hoac suy ho hap Khi chi co mot nguyen nhan tti vong dtfdc ghi lai, nguyen nhan dtfo'e chon de lap bang tti vong Khi co nhieu nguyen nhan tti vong dtfdc ghi, viec ltfa chon phai phu hdp vdi cac quy tac dudi day Cac quy tac dtfa tren khai niem ve nguyen nhan dau tien cua tti vong Nguyen n h an dau tien cua tti vong Hoi nghi quoc te stia doi lan thti nhat tri rang nguyen nhan tti vong de lap bang ban dSu dudc chi dinh la nguyen nhan dau tien cua' tti vong Tti quan diem de phong tti vong can thiet phai cat dtit day chuyen cac sU kien hoac tac dong dieu tri d mot thdi diem nao Muc tieu hien htfu nhat ctia y te cong dong la ngan chan nguyen nhan tac dong da gay day chuyen Vi muc dich nguyen nhan cd ban dau tien cua tti vong elude dinh nghia la: a Benh hoac ton thtfdng da md dau cho chuoi cac stf kien benh ly dan true tiep den ttf vong hoac la: b Cac hoan canh tai nan hoac bao luc hoac tai nan da gay ton thudng 'b e t ngtfdi Mau quoc te ve giav chting nhan cua y te ve nguyen n han tti vong Nguyen tac tren cd the dudc ap dung thong nhat bang cach sti dung mau sriay chting nhan cua y te theo ldi khuven cua Hoi nghi the gidi Dd la trach nhiem cua nha chuyen mon y te da ky giav chting nhan tti vong de chi ro nhting tinh trang benh ly da dan den tti vong 171 Gi&'y chiing nh&n cua y te dtfdi day nham lam cho viec ltfa chon nguyen nhan tu vong dAu tien dtfdc de dang co ghi hai hoac nhieu nguyen nhan mAu QUOC TE VE CHlTNG NHAN CUA Y TE VE NGUYEN NHAN TU VONG Nguyen nhan ttf vong Khoang cach thdi gian ttf bat dAu qua trinh benh ly cho tdi tut vong I B e n h hoac tin h tra n g (a) Trtfc tiep dan tdi ttf vong Do (Hoac la hau qua cua) Cac nguyen nhan trtfdc (b) Cac tinh trang benh, neu co Da dAn den nguyen nhan tren Do (Hoac la hau qua cua) Nguyen nhan dAu tien Cua ttf vong dtfng d cuoi (c) Do (Hoac la hau qua cua) (d) II Cac tin h tr a n g b e n h Co y nghia khac gop phan vao tii vong, nhtfng khong co lien quan vdi benh hoac tinh trang da gay tii vong + Dieu khong co nghia la hinh thtfc chet nhtf suy tim, suy ho hap No co nghia la benh, tdn thtfdng hoac bien chtfng da gay ttf vong PhAn I cua giay chtfng nhan la cua cac benh co lien quan den chuoi cac stf kien dan trtfc tiep den ttf vong va phan II la cua cac tinh trang khong lien quan nhtfng tham gia vao ttf vong Nam 1990 Hoi nghi Y te The gidi lAn thtf 43 co khuyen nghi r&ng c&n cac ntfdc co the them mot dong ntfa (d) phan I cua giay chtfng nhan Tuy nhien cac ntfdc co the ap dung hoac tiep tuc dung mot giay chtfng nhan chi co dong phan I dong thtf khong can thiet 175 Tinh trang dtfdc ghi d dong cuoi cua phan I cua giay chtfng nhan tn.: nguyen nhan dau tien cua ttf vong dtfdc dung de lap bang De phan biet eiua _ kha nang, ttf ngti nguyen nhan cd ban dau tien (originating antecedent 'MU dtfdc dung gan cho chinh tinh trang d dong cuoi phan I cua giay chtfng n h a n v < Tu nguyen nhan dau tien cua ttf vong (underlying cause) se dtfdc dune le x tc dinh nguyen nhan dtfdc chon de lap bang Neu chi co mot mat xich chuoi cac stf kien thi ghi d dong I la du Neu co nhieu mat xich, thi nguyen nhan trtfc tiep dtfdc ghi d (a) va nguyen nhan cd ban trtfdc dtfdc ghi sau d dong (b) hoac tren dong (b) va (c) Mot vi du va giay chtfng nhan ttf vong vdi btfdc chuoi cac stf kien dan trtfc tiep den ttf vong la: (a) Nghen mach phoi (b) Gay xtfdng benh ly (c) Carcinom thu phat xtfOng dtii (d) Carcinom vu Phan I la cua bat ke tinh trang co y nghia nao khac da gop phan vao hau qua chet ngtfdi nhtfng khong lien quan den benh hoac tinh trang trtfc tiep gay ttf vong Sau cac ttf "do (hoac la hau qua cua)" xuat hien tren giay chtfng nhan bao gom khong chi nguyen nhan trtfc tiep hoac qua trinh benh ly ma ca nguyen nhan gian tiep, vi du mot tinh trang trudc co khuynh hudng dan den nguyen nhan trtfc tiep lam ton hai den cac mo hoac htf hai den chtfc nang, ca sau mot thdi gian dai Ltfu y rang khoang cach thdi gian gan dung (phut, gid, tuan thang hoac nam) ttf bat dau cua moi tinh trang benh va chet giup cho bac si ghi giay chtfng nhan thiet lap lai chuoi cac stf kien da dan den ttf vong va no cung co ich sau viec htfdng dan ngtfdi ma hoa chon ma sd thich hdp Nam 1990 Hoi nghi Y te The gidi da khuyen rang cac ntfdc co the coi bao gom ca tren giay chtfng nhan ttf vong nhtfng van de ve thai san thong thtfdng va thai san vong mot nam trtfdc chet Phtfdng thtfc chpn nguyen nhan ttf vong dau tien de lap bang ttf vong Khi chi cd mot nguyen nhan ttf vong dtfdc bao cao, nguyen nhan r .v ijdc dtfng de lap bang Khi co nhieu nguyen nhan ttf vong dtfdc bao cao bu v > ã}Đ chon nguyen nhan dau tien la xac dinh nguven nhan cd ban trtfdc gh |,no- 176 cuoi cung cua phan I tren giay chiing nhan bang cach ap dung nguyen ly chung hoac cac quy tac lua chon 1,2.3 Trong mot vai trtfdng hdp, phan loai quoc te benh tat cho phep nguyen nhan cd ban dtfdc thay the bang mot nguyen nhan thich hop de dien ta nguyen nhan cd ban viec lap bang Vi du co mot so loai phoi hdp cac tinh trang hoac co the la cac ly dich te hoc de uu tien cho cac tinh trang khac tren giay chtfng nhan Do bu'dc tiep sau la xac dinh xem co the ap dung mot hoac nhieu quy tac siia ddi A den F lien quan den cac tinh huong tren Ma so ket qua co dudc de lap bang la ma so cua nguyen nhan dau tien Khi nguyen nhan cd ban ban dau cua tu vong la mot ton thudng hoac la ket qua cua mot nguyen nhan ben ngoai dtfdc xep d chudng XIX cac hoan canh dan den tinh trang dtfdc chon la nguyen nhan dau tien de lap bang va dtfdc ma hoa d V01-Y89 Ma so cho ton thudng hoac hau qua co the dudc sii dung nhtf ma so them Cac quy tac ltfa chon nguyen nhan cO ban dau tien a Q ua tr in h lien tuc: Ttf ngtf qua trinh lien tuc (chuoi) dudc gan cho hai hay nhieu tinh trang benh dudc dua vao o dong ke tiep o' phan I Moi tinji trang cd mot nguyen nhan dtfdc chap nhan gan o dong tren no Vi du 1: I (a) Chay mau gian tinh mach thtfc quan (b) Tang huyet ap ciia (c) Sd gan (d) Viem gan B Neu cd nhieu nguyen nhan tii vong mot dong cua giay chtfng nhan thi co the cd nhieu qua trinh lien tuc dtfdc bao cao Vi du 2: (a) Hon me (b) Nhoi mau cd tim va tai bien mach mau nao (c) Ytfa xd dong mach Tang huyet ap Cac qua trinh lien tuc la: Vua xd dong mach (dan den) nhoi mau cd tim (dan den) hon me Vila xd dong mach (dan den) tai bien mach mau nao (dan den) hon me Cao huyet ap (dan den) nhoi mau cd tim (dan den) hon me Cao huyet ap (dan den) tai bien mach mau nao (dan den) hon me 177 b N guyen ly ch u n g : Khi nhieu tinh trang dtfdc ghi giay chtfng nhan, chon tinh tranc dtfdc ghi mot minh d dong cuoi ph^n I, chi nao no co kha nang lam xay moi tinh trang da xay d tren no c Cac quy tac lUa chon: Quy tac 1: Neu nguyen ly chung khong ap dung va co ghi mot qua trinh lien tuc dan den tinh trang dtfdc ghi dau tien tren giay chtfng nhan, thi chon nguyen nhan dau tien cua qua trinh Neu co nhieu qua trinh lien tuc d&n den tinh trang dtfdc ghi dau tien, thi chon nguyen nhan d&u tien cua qua trinh dtfdc ghi trtfdc tien Quy tac 2: Neu khong ghi mot qua trinh lien tuc nao dan den tinh trang dtfdc ghi d&u tien tren giay chtfng nhan thi chon tinh trang dtfdc neu dau tien Quy tac 3: Neu tinh trang benh dtfdc chon theo nguyen ly chung hay theo quy tac quy tac hoac hien nhien la mot hau qua trtfc tiep cua mot tinh trang benh khac da dtfdc neu len d phftn I va ph&n II, thi chon tinh trang benh nguyen phat Mot so nhan xet ve cac quy tac ltfa chpn Trong mot giay chtfng nhan dtfdc dien dung cach, thi nguyen nhan d&u tien dtfdc ghi mot minh d dong cuoi cua phan I va cac tinh trang neu co, dtfdc coi nhtf la mot qua trinh lien tuc cua nguyen nhan d4u tien se dtfdc ghi tren o, moi tinh trang benh va mot dong theo trat ttf nguyen nhan tien len Vi du 3: I (a) U re - huyet (b) Than tf ntfdc (c) Bi tieu tien (d) Phi dai tuyen tien liet Giay chtfng nhan dtfdc dien thich hdp, vi the nguyen ly chung dtfdc ap dung Tuy nhien, ca neu giay chtfng nhan khong dtfdc dien thich hop thi nguyen ly chung vln co the ap dung mien la tinh trang benh dtfdc ghi mot minh d dong cuoi cung cua phan I, co the dan den tat ca cac tinh trang benh d tren no tham chi mac du cac tinh trang benh dtfdc ghi tren no khong dtfdc ghi theo trat ttf nguyen nhan dung dan 178 Vi du 4: I (a) Di can toan the (b) Viem phe quan - phdi (c) Ung thu phoi Nguyen ly chung khong ap dung co nhieu tinh trang benh dtfdc ghi d dong cuoi cua phan I, neu tinh trang benh ddn le se dtfdc ghi khong the dan toi cac tinh trang benh da dtfdc ghi tren no Htfdng dan viec chap nhan cac qua trinh lien tuc khac dtfdc dua cuoi cac quy tac, nhtfng can chu y rang ban tUdng thuat cua ngUdi chtfng nhan y te chi phan anh mot quan niem thong bao ve cac tinh trang benh da den tu vong va ve moi quan he vdi cua chung Khi nguyen ly chung khong dtfdc ap dung, ngtfdi chtfng nhan hay co gang lam sang to hdn, bdi vi cac quy tac ltfa chon phan nao doc doan va khong phai bao gid cung co the dan den mot stf ltfa chon thoa man ve nguyen nhan dau tien Dtf khong co dtfdc viec lam sang to them thi van phai ap dung cac quy tac ltfa chon Quy tac chi dtfdc ap dung co mot qua trinh lien tuc dtfdc ghi ket thuc bang tinh trang da dtfdc ghi dau tien tren giay chtfng nhan Neu mot qua trinh nhu vay khong co thi ap dung quy tac va chon tinh trang benh dudc ghi dau tien Tinh trang benh dudc chon theo cac quy tac tren co the la mot hau qua hien nhien cua mot tinh trang benh khac khong dtfdc ghi theo moi quan he nguyen nhan dung dan vdi no phan II hoac tren cung mot dong cua phan I Neu nhu vay ap dung quy tac va chon tinh trang benh cd ban dau tien Tuy nhien no chi dudc ap dung khong co mdi nghi ngd gi ve moi quan he nguyen nhan gitfa hai tinh trang benh Quy tac 3: Cac hau qua trtfc tiep dtfdc coi la cua mot tinh trang benh khac Sarcom Kaposi, u Burkitt va bat ky u tan sinh (neoplasm) ac tinh khac cua mo lympho, tao mau va cd lien quan, dtfdc xep d C46 hoac C81-C96 deu dtfdc coi la hau qua trUc tiep cua benh HIV d ndi ma no dtfdc bao cao Khong cd stf thtfa nhan nao nhu vay ddi vdi cac loai khac cua u tan sinh ac tinh Bat ky benh nhiem khuan nao cd the xep vao: A00-B19, B 25-B 49 B58-B 64, B99 hoac J - J deu dtfdc coi la hau qua trtfc tiep cua benh HIV dtfdc bao cao Mot sd bien chtfng sau md (viem phdi), (moi loai), chav mau, viem tac tinh mach, mach huyet khoi, nhiem khuan huyet ngtfng tim suy than 179 (cap), viem phe quan phdi, xep phoi va nhoi mau co the dtfdc coi nhu la hau qua trtfc tiep cua mot phau thuat, tru! phi cuoc md dtfdc tien hanh I tuan hoac laii hdn trudc chet Viem phdi va viem phe quan phoi co the dtfdc chap nhan la bien chung cua moi benh Dac biet viem phe quan phdi dtfdc coi nhtf la mot hau qua hien nhien cua cac benh lam hao mon (nhtf u tan sinh ac tinh va suy dinh dtfdng) va cac benh gay nen liet (nhtf cac tdn thtfdng nao hoac song, chay mau nao hoac huyet khoi va viem xam cap) cung nhu la cac benh lay truyen va cac tdn thudng quan Moi benh dtfdc mo ta hoac neu la "nghen mach" co the dtfdc coi la hau qua trtfc tiep cua huyet khoi tinh mach, viem tinh mach hoac viem tinh mach huyet khoi, benh van tim, rung nhi, stf sinh de hoac bat ky phau thuat nao Moi benh dtfdc mo ta nhtf la thtf phat se dtfdc coi nhtf la hau qua trtfc tiep cua nguyen nhan nguyen phat co kha nang nhat da dtfdc ghi tren giay chung nhan Thieu mau thtf phat va khong dac hieu, suy dinh dtfdng, gay det hoac suy mon co the dtfdc coi la hau qua cua moi u tan sinh ac tinh Moi viem than - be than co the dtfdc coi la hau qua cua tac tiet nieu ttf cac tinh trang benh nhtf phi dai tuyen tien liet hoac hep nieu quan Hoi chtfng than co the dtfdc coi la hau qua cua moi nhiem khuan lien cau (sot tinh hong nhiet, dau hong lien c&u khuan ) Mat ntfdc co the dtfdc coi la hau qua cua moi benh nhiem khuan ruot Mot cuoc mo tren mot cd quan da biet co the dtfdc coi la hau qua true tiep cua moi tinh trang benh phai mo (nhu u ac ti'nh hoac ton thtfdng) cua chinh cd quan da dtfdc bao cao dau tren giay chtfng nhan Stia doi nguyen n h an dtfOc chon Nguyen nhan ttf vong dtfdc chon khong nhat thiet la tinh trang co l'ch nhat va cung cap thong tin nhat cho viec lap bang Vi du, neu tuoi gia hoac mot benh tong quat nao nhu tang huyet ap hoac xd vtfa dong mach dtfdc chon no se kem htfu l'ch hdn la neu mot bieu hien hoac ket qua hoac benh dtfdc chon Doi can siia doi viec ltfa chon cho phu hdp vdi cac yeu cau cua viec phan loai hoac ia doi vdi mot ma so ddn cho hoac nhieu nguyen nhan hon cung dtfdc bao cao ket hop hoac la tfu tien cho mot nguyen nhan dac biet dtfdc bao cao cung vca vai tinh trang benh khac 180 Cac quy tac stfa cloi sau day nham cai tien htfu l'ch va chinh xac cua so lieu tii vong va co the dtfdc ap dung sau viec ltfa chon nguyen nhan cd ban Cac qua trinh lien quan lan cua viec lua chon va sua doi da dtfdc tach rieng cho sang sua hdn Mot so" quy tac siia doi doi hoi viec ap dung cac quy tac ltfa chon sau chung khong kho khan doi vdi nhiing ngtfdi ma hoa co kinh nghiem nhung quan de xuyen suot qua trinh ltfa chon, stfa doi va neu can ltfa chon lai Cac quy tac stia doi Quy tac A: Tuoi gia va cac trang thai benh khong xac dinh ro: Khi nguyen nhan dtfdc chon, dtfdc xep vao chtfdng XVIII (cac trieu chtfng, dau hieu va phat hien lam sang va xet nghiem bat thtfdng, khong xep d ndi khac) trtf R (hoi chtfng chet tre em dot ngot) va mot tinh trang benh dtfdc xep d ndi khac ngoai R00-R94 hoac R96-R99 dtfdc bao cao tren giay chtfng nhan, viec chon lai nguyen nhan ttf vong dtfdc cdi nhtf la tinh trang benh dtfdc xep d chtfdng XVIII khong dudc bao cao, trtf phi neu no lam thay doi viec ma hoa Quy tac B : Cac tinh trang benh khong quan trong: Khi nguyen nhan dtfdc chon la mot tinh trang benh khong quan khong chac la gay nen ttf vong va mot tinh trang benh tr§m hdn dtfdc bao cao, chon lai nguyen nhan cd ban coi nhtf tinh trang benh khong quan da khong dtfdc neu len Neu ttf vong la ket qua cua phan tfng ngtfdc lai cua viec dieu tri benh khong quan thi chon phan tfng ngUdc lai Quy tac C: Viec phoi hdp: Khi nguyen nhan dtfdc chon, dtfdc ket hdp viec phan loai hoac cac chu thich de stf dung viec ma hoa nguyen nhan cd ban cua ttf vong vdi mot hoac nhieu tinh trang benh khac tren giay chtfng nhan, hay ma hoa stf phoi hdp Chi ma hoa stf phoi hdp moi quan he nguyen nhan dung d&n dtfdc xac dinh hoac co the dtfdc suy dien ttf viec ap dung cac quy tfic ltfa chon Khi co mau thuln stf phoi hdp, hay phdi hdp v i tinh trang benh se dude chon neu nguyen nhan dune chon ban diu khong dudc bao cao Hay lam bat ky stf phoi hdp nao co the ap dung dtfdc 181 Quy tac D: Tfnh dac hieu: Khi nguyen nhan dtfdc chon mo ta mot tinh trang benh vcli cac ttf chung chung va mot ttf khac cung cap thong tin chinh xac hdn ve vi tri hoac ban chat cua tinh trang benh dtfdc bao cao tren giay chung nhan, thi tfu tien dtfng ttf co nhieu thong tin hdn Quy t ic thtfdng ap dung ttf chung chung trd nen mot tinh ttf xac dinh cho ttf chinh xac Quy tac E: Giai doan sdm va giai doan muon cua benh: Khi nguyen nhan dtfdc chon la mot giai doan sdm cua mot benh va tren giay chtfng nhan co bao cao mot giai doan muon hon cua cung benh do, hay ma hoa giai doan muon Quy tac khong ap dung cho mot hinh thtfc "man tinh" dtfdc bao cao nhtf la mot the "cap tinh", trtf viec phan loai dtfa cac chi dan dac biet cho tac dung Quy tac F: Di chtfng: Khi nguyen nhan dtfdc chon la mot hinh thtfc sdm cua mot tinh trang benh ma viec phan loai cung cap mot muc "di chtfng cua " rieng biet, va co chtfng ctf rang chet xay cac hieu qua lai cua tinh trang benh hdn la ttf cac hieu qua cua giai doan hoat tinh cua no, hay ma hoa vao muc "di chtfng cua " Cac muc "di chtfng cua " la cac loai sau: Cl (NK + KSV) B90-B94 E64-E68 G09 169 097 va Y85-Y89 CIV (Noi tiet CIV IX XV: Chtfa XX (Nguyen dinh dtfdng va (He than (Tuan) de, sau de ben ngoai chuyen hoa) kinh) cua benh tat va ttf vong 182 MUC LUC Trang Ldi noi dau Thong ke y te Bai Cac phan phoi tan so' Bai Do thi, bieu thong ke y te 13 Bai Phep vi tri va bien thien 35 Bai Xac suat cac luat phan phoi xac suat cua dai ltfdng ngau nhien 44 Bai Cac phan phoi mau va cac khoang tin cay 60 Bai Cac phep kiem dinh co y nghia 6 Bai Kiem dinh gia thuyet thong ke 70 Bai Lien he ttfdng quan va hoi qui 8 Bai Phudng phap tieu chuan hoa 101 Bai 10 Thong ke tinh hinh mac benh cua nhan dan 107 Bai 11 Bo chi so thong ke y te cd ban 112 Bang phan phoi F 138 Bang gia tri tdi han cua T va X 139 Phu luc: Phan loai thong ke quoc te cac benh tat va cac qui tac htfdng dan ma hoa ttf vong 140 183 NHA XUAT BAN Y HOC BAI GIANG THONG KE Y TE Chiu trach nhiem xuat ban: B S NGUYEN VAN CU Bien tap: DANG TH E VINH Stia ban in: T H E VINH Trinh bay bia: DOAN VUONG In 500 cuon, kho 19x27 tai Cong ty In Tong hop Ha Xoi - 67 Pho Due Chir.h Giay chap nhan dang ky ke hoach X B so: 900 C X B cap 21 thang 12 n a m 1996 In xong va nop luu chieu thang 12-1997