Service quality determinants that affect the service users' commitment to hospitals

99 Pages·2013·6.47 MB·English

Volume 1 / Number 2 / 2013
Balkan Journal of Health Science
Editorial board Sadržaj / Table of Contents
Editor-in-chief prof. dr Mensura Kudumovic
Statistical tests for medical waste management ..............42
Technical Editor B. Sc. Eldin Huremovic Dusanka Stojanovic, Mensura Kudumovic, Vesna Aleksic
Mirza Basic Maric
Service quality determinants that affect the servic
Members users’ commitment to hospitals .........................................52
Prof. dr Zmago Turk Mahmut Akbolat, Oguz Isik
(Slovenia),
Expression of low molecular weight proteins in
Prof. dr Budimka Novakovic different age groups of the renal failure patients ............57
Nadeem Sheikh, Zunera Fayyaz, Hina Anjum,
(Serbia),
Asma W. Qureshi, Javaid Iqbal
Prof. dr Camil Sukic
Environmental protection and sustainable
(Serbia),
development ........................................................................63
Prof. dr Bekim Fetaji Ibro Skenderovic, Becir Kalac, Isat Skenderovic
(Macedonia),
Anesthesia for endovascular repair toracic and
abdominalis aortic aneurysm (our experience) ..............69
Prof. dr Aleksandar Dzakula
Ermina Mujicic, Mirsad Kacila, Amel Hadzimehmedagic,
(Croatia),
Faida Kucukalic, Slavenka Straus
Prof. dr Dzenana Gaco
Radiologic findings of non-occupational Asbestos
(Bosnia and Herzegovina),
exposure and its relationship to respiratory function
Prof. dr Gordana Manic disorders: A study in southeast Turkey ...........................72
(Bosnia and Herzegovina). Ozlem Abakay, Cengizhan Sezgi, Abdurrahman Abakay,
Mustafa Ayhan, Askeri Karakus
Therapy of hirsute ..............................................................80
Address: Sarajevo Aida Dervisevic
Hamdije Kresevljakovica 7A
Level of burnout in caregivers working in residential
Bosnia and Herzegovina homes and factors affecting burnout ...............................83
Hasan Huseyin Eker, Cuneyt Unsal, Aclan Ozder,
Turgut Sahinoz, Merve Kocaakman, Perihan Karadelioglu
E-mail: [email protected]
Pharmacological agents for postoperative analgesia......91
Web page: http://www.drunpp.ba/bjhs.html
Meldijana Omerbegovic
Mitral valve prolapse in University of
Sarajevo students ................................................................98
Published by DRUNPP, Sarajevo
Pozderac Zana, Azra Durak-Nalbatinic
Volume 1 Number 2, 2013
Diagnosis and treatment of traumatic hemothorax .....108
ISSN 2303-4092
Slobodan Milisavljevic, Stanko Mrvic, Dragan Stojkovic,
Sefcet Hajrovic, Dubravka Golubovic, Marko Spasic
Balkan Journal of Health Science is indexed in:
Central nervous system agents to control food
intake and energy balance ............................................. 121
Makbule Gezmen Karadag, Duygu Turkozu
The effects of story writing learning and painting
upon the third grade primary school students
creative power ..................................................................130
Marzieh Gholamitooranposhti
Instruction for Authors ...................................................138
Balkan Journal of Health Science
Statistical tests for medical waste management
Dusanka Stojanovic1, Mensura Kudumovic2, Vesna Aleksic Maric1
1 University of Banja Luka, Faculty of Economics Banja Luka, Bosnia and Herzegovina,
2 University of Sarajevo, Faculty of Medicine Sarajevo, Bosnia and Herzegovina.
Abstract use of cleaner technologies for sterilization or de-
contamination of infectious medical waste. Paper
Every organization has a medical problem with
proposes statistical tests of risk assessment for the
certainty disposal of medical waste harmful to the
purpose of obtaining good results in the field of
environment. This paper describes the issues and
environmental protection. The definition of risk
the possibility of improving safety management
phrases: possible variants of action (alternative)
systems security risks in the area of medical wa-
and possible (uncertain) achievement, indicating
ste. Risk management is the process of risk iden-
uncertainty. The risk can be discussed only in the
tification, risk assessment and take certain steps to
context of a specific alternative. [2]
reduce the risk to some extent. This paper descri-
The risk does not mean a safe performing a
bes the basic goals and ideas of the risk manage-
negative effect on the estimated negative effects
ment process in medical dumps, method of enfor-
whose realization is uncertain.
cement, and the typical problems that arise in this
Risk analysis in this case is very heavy, making
area. Risk management is the process of risk iden-
it difficult following five factors:
tification, risk assessment and steps taken to redu-
1. uncertainty related to the definition of the
ce the risk to a certain level. This work provides
problem,
the basis for the development of an effective risk
2. difficulties that arise when evaluating the
management program, containing definitions and
facts,
the practical guidance necessary for assessing and
3. complexity disclosure of relevant values,
mitigating risk in the system of medical landfills.
4. unpredictable behavior of participants in the
Key words: statistics, absolute risk reduction,
process, and
relative risk reduction, medical waste
5. inconsistence of the evaluation process.
Introduction At the outset it will introduce the basic con-
cepts that are often used in the work. In Table 1
The reform of the healthcare system in our co-
are given concise definitions of the main concepts
untry is aimed at improving the quality of health
in the field of risk management taken from the
services, both in the state, and private sector health
ISO / IEC 14971st Definitions of adverse effect
care. An important element in improving the qua-
and hazard taken from ISO / IEC Guide 51:1999,
lity of health services is adequate disposal of me-
definition 3.1 and 3.5.
dical waste, which is in accordance with national
The term hazard is the basis of most of the meth-
legislation as well as the basic principles of pro-
odology for assessing and controlling risks. How-
fessional practice of medical waste management,
ever, its definition is the cause of many disputes and
prevention of communicable diseases and health
ambiguities in the process of forming a list of known
promotion. The objectives of this paper is to initia-
and foreseeable hazards. Primarily this is due to the
te the idea of reducing the amount of waste that is
fact that almost every situation or event in a device
generated in the institutions providing health care,
or system can be declared potential cause harmful
especially the separation of waste at the main ca-
effects. It should be noted that certain hazard can
tegories in the place of creation, the proper packa-
have one, but several potential causes.
ging of the same, marking and disposal, separation
of recyclables from waste, recycling, as and the
42 Volume 1 / Number 2 / 2013
Balkan Journal of Health Science
Table 1. Definitions cooperation with the administration of health in-
stitutions on such matters . Basically, there are the
Term Definition
following two types of medical waste:
Certainty Absence of unacceptable risk
- Non-hazardous waste (waste that does not
The combination of probability
Risk
have the characteristics of hazardous waste
and severity of adverse effects
and is similar to the waste generated in
Hazard Potential cause adverse effects
households)
Injury, damage or any danger to
Adverse
- Hazardous wastes (which in its origin,
the patient, operator, equipment or
consequences
the environment composition or concentration of hazardous
substances may cause danger to the
Identification of as many hazards
Risk Analysis and their likelihood and severity environment and human health, and has
of harmful effects that cause one of the least hazardous characteristics
defined by special regulations, including the
The process of reducing the risk of
changes to the design, installation packaging in which the hazardous waste is
Risk Control
of protective measures or giving or has been packed).
warnings
Estimated remaining (residual) The European Commission is still in 1994. The
Evaluation of
risk and decision on its defined comprehensive European Waste Catalogue
risk
admissibility to introduce common terminology throughout the
countries of the European community and enhance
the management of waste (Council Directive no.
1. Medical waste
2000/532/EC). Basically, in the European Waste
There are several definitions of medical waste Catalogue, waste is defined based on the following
that are considered acceptable when categorizing three criteria [3]:
and classification medical waste generated in health 1. Origin of the waste that is defining the industry
care facilities. Under medical waste includes all the or sector from which encourages waste (the
waste generated in health care facilities (public or first two digits - the health sector - 18).
private), medical research centers and laboratories. 2. Process where waste is generated (the other
It is a heterogeneous mixture of waste, while 10- two figures - waste generated in the provision
25% is hazardous waste risk to human health and of health services in maternity hospitals, the
the environment. According to the Law on Waste diagnosis, treatment or prevention of disease
(Draft Law on Waste Management of Bosnia and in humans - 18 01).
Herzegovina) waste is defined as any substance or 3. Type of waste (third pair of digits - non-
object included in the European Waste Catalogue, infectious wastes - wastes whose collection
which the owner discards or intends or has to reject, and 03). According to the European Waste
in accordance with the law. Waste originating from Catalogue, each type of waste has its own
medical institutions only one part of the medical classification number or code that consists
waste and still be graded in different categories. An of 6 digits (for example, 18 01 03).
important area of work of professionals responsi-
ble for handling and disposal of medical waste is a Classification of medical waste according to
risk assessment, provision of preventive measures the European Waste Catalogue [9]:
to protect employees. This applies primarily to the 1. Pathoanatomically waste: a recognizable
health sector, consumers of health services, as well body parts, placenta…
as environmental protection. [7] 2. Infectious waste: bandages, swabs, sharps,
For good waste management practices is crucial waste from dialysis Infected blood
to health workers and associates know exactly what 3. Municipal waste: regular rubbish, waste from
is expected of them in connection with the classifi- the kitchen,….
cation of waste, to be motivated and properly trai- 4. Hazardous waste: radioactive waste,
ned for these activities, and that they have adequate pharmaceutical agents, chemicals and others.
Volume 1 / Number 2 / 2013 43
Balkan Journal of Health Science
2. International legislation treatment, storage, transport), the system records
the principles of legal and financial responsibilities
2.1 EU directives
generator waste inspection system that will provide
Basically waste management policy in the
effective law enforcement and criminal provisions.
European Union are set out in the Resolution of
the Council of Europe’s waste management stra-
tegy (97/C76/01) which is based on the Waste 3. The current situation in the country in
Framework Directive (75/442/EEC) and other terms of medical waste management
regulations on waste management in the EU.
Medical waste in health care institutions in Bosnia
It was found five basic principles:
and Herzegovina is created in uneven amounts, de-
- hierarchy of waste management,
pending on the type of facility, number of beds, types
- viable disposal facilities,
of diseases and conditions which are disposed of, and
- best available technology,
the types of services in health care facilities provide.
- vicinity of waste disposal and
Disposal of various categories of medical waste in
- producer responsibility.
Bosnia and Herzegovina to the 2008th he performed
in different ways in different health institutions. The
Alongside these are pursued, the following
Ministry of Health of Bosnia and Herzegovina’s
principles: a common definition of waste in all
2007th The specific activity began to introduce a uni-
Member States, encouraging cleaner production
form system of medical waste management, and in
and use of clean products, promoting the use of
particular the category of infectious medical waste.
economic instruments, regulation of transportati-
Certain categories of medical waste can be a signi-
on of waste, as well as environmental protection
ficant threat to the health of employees in health
and the internal market. [10]
care facilities, and beyond.
2.1.1 Basel Convention In addition to health risks that result from direct
Basel Convention on the Control of Transbo- contact, medical waste can have irreversible indirect
undary Movements of Hazardous Wastes and their health effects through contamination of waterways
Disposal (1989) is one of the most internationally and soil during the treatment and final disposal and
accepted legal acts in the field of hazardous waste air pollution through emissions of highly toxic ga-
management. In our country, in force since 1999th ses when insineracije. It has been proven that there
year, among other things regulates the transboun- is no method of waste treatment or disposal which
dary movement and disposal of medical waste (as completely eliminates the risks of medical waste
hazardous waste). The agreement was signed by carries for the population or the environment.
over 100 countries that have accepted the princi-
3.1 Conditions in the dumps
ple that the only legitimate transport hazardous
On dumps in Bosnia and Herzegovina is not
waste exports from countries that do not have the
done separating medical from other types of wa-
facilities or qualified personnel for reliable waste
ste. The current practice of mixing medical waste
disposal, in countries that have facilities and pro-
with municipal waste in landfills with inadequate
fessional staff.
system work, can also lead to the rapid spread of
2.1.2 Customizing international legislation infectious diseases, transmission of microorgani-
Existing legislation does not cover all aspects of sms through the air (such as microorganisms be-
medical waste management and make recommen- come due to air emissions through smoldering wa-
dations for the treatment of specific waste streams, ste). The spread of infection through direct contact
which represents the medical waste. It is essential employees at dumps and other visitors who are not
to its compliance with the European directives and aware of the risks, and collect and landfill waste,
international standards, which includes a clear de- as well as by animals and birds (vector) that by
finition of hazardous medical waste and its various landfill roam in search of food, it is also one of
categories, the introduction of integrated manage- the identified routes of infection . Most landfills in
ment (segregation, collection, storage, handling, Bosnia and Herzegovina are not sanitary landfills,
44 Volume 1 / Number 2 / 2013
Balkan Journal of Health Science
and on them are still buried waste daily, or further of different decisions and analysis which are obta-
treated. This practice is present in sanitary landfills. ined using the method of risk assessment in order
Many landfills have arranged access, and they also to achieve security in the work. Risk assessment
often leads to the uncontrolled burning of waste. relating to dangerous activities is the process by
which risk is determined based on the probability
3.2 Conditions associated with the formation
that there is an accident and the potential risks to
of infectious medical waste
human life and health, as well as the environment.
In hospitals across Bosnia and Herzegovi-
The basic elements of risk assessment, the proba-
na, there are over 40,000 beds with an approxi-
bility and the consequences. Only risk that can be
mate number of about 10 million hospital days.
managed is an acceptable risk - the risk that impli-
The average bed occupancy is 65% per annum.
es that the possible effects on human health and
According to the data from the health sector, the-
material goods are within acceptable. Under the
re is an additional 1700 beds, which are found in
legislation, both in the domain of health and medi-
military hospitals and private clinics. On the basis
cine, environmental protection, there is a need for
of these data, an estimate was made quantities of
the development of risk assessment by all entiti-
medical waste generated in health care facilities.
es engaged in waste management. It is necessary
According to estimates of the World Health Orga-
also that among the various departments there is
nization, in hospitals in Bosnia and Herzegovina
constant collaboration of experts involved in wa-
is produced on average 1.2 kg of medical waste
ste management. Risk is a combination of threats,
per hospital bed per day. This quantity is proporti-
assess the severity and probability (the degree to
onal to the quantity and average, which is valid for
which it is likely) that these threats be realized.
the countries of Eastern Europe. [11]
Therefore, risk assessment is a process in which:
- Identify hazards;
3.3 Quantities of infectious medical waste
- Identify and assess threats that are associated
It is estimated that all health institutions in Bo-
with it;
snia and Herzegovina annually produce about 5
- Assess risks;
tons. Approximately one ton of waste may be con-
- Estimated the importance of risk in the
sidered hazardous waste. Improper handling of me-
circumstances discussed.
dical waste can be a significant factor in the spread
and transmission of infectious diseases. Introducing
4.1. Basic steps in the risk assessment
a system of infectious medical waste management
In making those risk assessments are underta-
in Bosnia and Herzegovina is of great importance
ken following five steps:
for improving the health of the population of Bo-
Step No.1: Identify hazards;
snia and Herzegovina, as well as improving the qu-
Step No. 2: Determine who / what might be da-
ality of health services. Activities of the Ministry
maged / injured and how;
of Health and Ministry of Environment and Spatial
Step No. 3: Assess the risks and decide whether
Planning of Bosnia and Herzegovina on the intro-
existing preventive measures, adequate or should
duction of management systems infectious medical
take additional measures;
waste, in a unique way at all by administrative dis-
Step No. 4: Record the findings and results of
tricts in the state health institutions and the private
the assessment;
sector mode a primarily significantly reducing the
Step No. 5: Check made estimates and revise
amount of creating infectious medical waste.
them if necessary.
4.2 Risk assessment and decide whether the
4. Risk Assessment
existing precautions are adequate or need to
Categories of medical waste as defined Euro- take additional measures
pean waste catalog and defined in this study ai- Quantitative risk assessment can be obtained by
med at defining the basic setup procedures for risk determining the probability of unfolding for each
assessment [6]. Risk assessment is a combination hazard, and then multiplying the values obtained

Volume 1 / Number 2 / 2013 45
Balkan Journal of Health Science
with the measure of the seriousness of the likely Table 3. shows the simplest way to combine
consequences. These factors can be expressed qu- these parameters.
antitatively (numerical values) or qualitative (des- Table 3. contains a graph that helps you make
criptive), as noted in the following text [4].ISO decisions about risk acceptability. White areas in
14971:2000 applies to risk man agement, a group of the table are low-risk areas. All risks under him
ISO 9000 specifies the properties that a good de- are considered acceptable and does not require
velopment process must meet. Table 2. shows the taking any measures. Right up there is a high-
distribution of risk in accordance with IEC 61508- risk area. All the risks in it objectionable and ap-
5, which defines four classes of risk in relation to plication protection at the landfill is only possible
acceptance: when it is appropriate measures to eliminate or
Table 2. Class of risk with respect to the accepta- shift in the central area of ALARP (As Low As
bility of [3] Reasonably Possible) risk - the area colored yel-
low. It is in this area takes most of the decisions
Class of risk Interpretation
regarding the risks. The basic principle is that
Unacceptable
any risk down to the bottom right corner until
Undesirable and acceptable only
it is practicable and while the costs proportion-
if the reduction is impractical or
ate drawn using one word, reasonable. Also, it
costs are disproportionately large in
is necessary to devote much attention to the fact
relation to the improvement.
that the introduction of measures to increase the
Acceptable if the costs exceed the
safety of landfill, it also increases the complex-
gains improvements.
ity of which in most cases have a negative impact
Negligible
on the general level of reliability and security.
The decision on what is reasonable and what is
The following example is taken from IEC 60601-
not, is the key to the whole process. In itself in-
1-4. It defines six levels of probability of harmful
cludes cost of implementation measures for risk
consequences, in order from lowest to highest:
reduction, the amount of the reduction and the re-
- Extremely amazing
sulting benefits. Often the decision is subjective
- Amazing
and therefore recommends that it adopt an inter-
- Rare
disciplinary team with multiple perspectives on
- Occasional
the same problem. When deciding to be taken and
- Likely
the following guidelines:
- Frequent
- Regulations and instructions of the
It also defines four levels of harmful effects: competent authority
- catastrophic - more dead or seriously injured - Discussions and agreements with project
- critical - one or several dead or seriously partners
injured - International Standards
- limit - possible injury - Laws and legal acts.
- negligible - possible minor or no injuries
Table 3. Parameters of the acceptability of risk [3]
The probability of harmful consequences Weight adverse effects
I II III IV
Disastrous Critical Limit Negligible
A - Frequent I-A II-A III-A IV-A
B - Likely I-B II-B III-B IV-B
C - Occasional I-C II-C III-C IV-C
D - Rare I-D II-D III-D IV-D
E - Incredible I-E II-E III-E IV-E
F- Extremely incredible I-F II-F III-F
46 Volume 1 / Number 2 / 2013
Balkan Journal of Health Science
5. Evaluation of risk 5.1 The odds ratio: calculation, use and
interpretation
After the assessment, each risk in the system
The odds ratio ( OR) is one of the few statistics
must be evaluated in order to establish his eligi-
that have become increasingly important in IT re-
bility and possible measures for its reduction.
search and decision-making. Since this test sample
Evaluation of the risk out of the strictly technical
size is particularly useful because the researcher
framework, as it possesses and its legal and ethical
offers clear and direct information about which
aspects. Her goal is to find a balance between the
approach to protection has the best prospects for
gains that the product offering, pricing and risk,
the benefit of the medical depot. Commonly, the
to the satisfaction of users, the development team
data consist of values for each pair of conditions
and other stakeholders. In the context of medical
and outcomes and are presented in table format.
waste in the first place in all safety considerations
The most commonly occurring form of tables 2 ×
comes the human factor. Like in previous areas of
2, although possibly larger tables. Since it is easy
risk management or evaluation there is no unified
to calculate,
methodology. The process further complicated by
the fact that the decision to put one at risk, other
OR = (a × d) / (b × c)
risks in a new perspective and affects their eli-
gibility, therefore it is necessary to pay attention
OR can be calculated manually on the spot, if
to the order in which they handle the risks [9].
necessary, to determine the odds that a particular
After the implementation phase of identifying and
event for the medical depot at risk for this event.
evaluating risks, access to its reduction for which
In addition to assisting informational employees in
there is an almost unlimited range of options. The
decisions about care, since it provides simple infor-
optimal approach is generally already looming in
mation that you and the workers at the landfill can
the analysis of the problem, but it is often neces-
understand and thus to participate in decisions about
sary compromises due to economic, technical and
the security that will be based on the prospects of
time requirements for its implementation. As a
success of applied protection. OR is an indirect me-
rule, chooses the simplest method, which reduces
asure, which we will explain in detail in the section
the risk to an acceptable level. There are a number
on the interpretation of the statistical test. [1]
of statistical tests that can help in making deci-
sions about the selection of interventions to pro- Calculating the odds ratio
tect medical depot, drawing conclusions about the The calculation of the odds ratio is quite sim-
effects of the various contingency] certain events ple. The formula is as follows:
in situations related to the protection of medical
landfills. One of the tests that are commonly en-
The odds ratio =
countered is the odds ratio (Odds Ratio, OR). The

odds ratio is estimated whether the odds of a par-
ticular event or outcome the same for both groups
where XY1 a chance of doing tested for Group 1 and
of respondents landfills in the overall medical
XY2 a chance of doing tested for Group 2 Another
examination dumps a larger region. Explained in
way of presenting the formula is tabular form:
more detail, with OR to measure the ratio seems to
Table 4.
be an event or result occur, and it seems that this
event will follow. IT perspective, it often means Standard A new type of
that the researcher measures the ratio seems to be protection sophisticated
landfill protection in landfills
to develop a pollution or perform totally pollution
due to a failure or virus infection from the dump Event a b
and it seems that the infection or total pollution No events c d
will not occur.
The odds ratio = (a/b)/(c/d) or
The odds ratio = (a × d)/(b × c)
Volume 1 / Number 2 / 2013 47
Balkan Journal of Health Science
OR is often used to determine the effect size And how do you interpret the other results for
difference between the two treatments (treatment the OR: If OR is 1.00, meaning that it is equally
- use of a particular type of care at the landfill). likely to dump both groups appear to be very dan-
Take for example the protection of landfill infec- gerous. OR greater than 1 indicates that it is more
ted dangerous virus type 1. Although the rate of likely that the landfill first group (in this case the
infection of the landfill in the range of 25% to dump to standard care) play event (disaster) than in
47%, assuming that the test group dumps in the other groups of landfills. OR less than 1 means that
framework of the medical depot one region de- it is less likely that the event will occur in the first
struction rate 38% with standard care. However, group surveyed landfills. However, the OR values
developed new sophisticated methods of protec- less than 1.00 can not be directly interpreted. OR
tion against infection and contamination. The does not work that speaks about the extent to which
question is: what are the odds that the landfill will the less likely that the event will occur in the first
have an effect on the environment and if the appli- group of landfills. It is important to put in the first
cation of new sophisticated methods of protection column group that is expected to have more chan-
compared with standard methods applied? OR a ces to play the event. Not worth trying to determine
way that can be compared if the odds given equal how accurately less likely that the first group of the
outcomes for two different groups. OR is the ratio earliest occurrence compared to other groups. If the
of the following two ratios: the ratio of standard odds of the first group, in which the event occurred,
care and new sophisticated protection in a group a small group of other layout, to be replaced of the
of landfills totally damage the environment and table so that the second group occurs in the first co-
the ratio of standard care and new protection for lumn, and the first to the second. You will then be
groups of landfills that have not had the impact on able to interpret a statistically significant difference
the environment. According to the values in Table because it will be the team moving to calculate how
4, is calculated as follows: many more times at the event in the second group
Table 5 than the first [1].
A new type of sophi- If you replace the columns in the above exam-
Standard pro-
sticated protection ple, the OR will amount
tection landfill
in landfills
Event 152 17 (5/22) / (45/28) = (0.2273 / 1.607) = 0.14
No events 262 103
As you can see, it does not tell us that in a group
The odds ratio = (a/b)/(c/d) = of landfill protected new methods were 0.14 times
= (152/17)/(262/103) = 8,94/2,41 = 3,71 fewer cases of disasters - the devastating effects
of landfill on the environment, but at the surveyed
The formula can be expressed as (a × d)/(b × c), landfills protected by standard methods. In fact,
and the result is the same: this procedure gives a result that can only be inter-
preted in the following way “seems to be the first
The odds ratio = (152 × 103)/ (17 × 248) = group to perform an event smaller than it looks to
= (15656/4216) = 3,71. be at the event to perform other groups.” To what
extent are the exact odds in the first group smaller
OR calculation result can be interpreted as than it looks in the other groups is not known. [13]
follows: in a group of landfills that have been pro-
tected by standard methods, totally destroying the 5.2 Relative risk and relative risk reduction
environment was 3.71 times higher than in the Compared to the ARR, the relative risk - RR
group of landfills that are protected by the new implies an entirely different view of risk. He carri-
sophisticated methods. Based on these results, the ed the risk of infection from the landfill have pro-
researcher should conclude and suggest that all the tections groups in relation to the risk of landfill
dumps diagnosed with type 1 virus provides a new group that is not protected. Since this is a test to
type of protection (to abandon the standard care). determine the relative risk, it may not be quite so
48 Volume 1 / Number 2 / 2013
Balkan Journal of Health Science
clearly and simply explained as a test to determine baseline risk, so does the RRR, but much slower
the absolute risk reduction. However, determining in comparison with the ARR (again, assuming that
the relative risk gives us a different perspective on the risk of protected landfill approximately con-
the value of care in relation to not use adequate stant) (Table 6).
protection. RR is calculated as follows: Table 6. The effect of primary risk in a relatively
reduced risk
RR = risk groups with the applied protection /
Baseline Risk Treated Risk ARR RRR
risk groups with inadequate protection
48% 31% 17% 35.4%
55% 31% 24% 43.6%
For example, a 31.6% site to be infected
65% 31% 34% 52.3%
and not applied for protection, and a 16.4% be-
75% 31% 44% 58.7%
ing infected although taken adequate protection.
85% 31% 54% 63.5%
As we know ARR in protected landfill is 15.2.
95% 31% 64% 67.4%
Another way to describe this situation is that
the 68.4% of landfills remain uninfested though It is clear that the low value of the initial risk,
not protected, while 83.6% of landfills remain RRR is much higher than ARR, but at higher val-
non-infected if they were adequately protected: ues of primary risk ARR approaching RRR. Due
to the sensitivity of RRR to the baseline risk is
RR = 0,316 / 0,164 = 1.93 important for the researcher to take into account
both the statistical test (ARR and RRR) in order
This result can be explained by the sedentary: to estimate the reduction in risk to which you can
The risk of infection is unprotected is 1.93 multi- apply to get some protection or early application
plied by the risk of infection in spite of adequate of certain occupational groups landfills. It is also
protection. important to remember that every single landfill
However, this is not the same as a percentage may or may not benefit from a particular interven-
of risk-reduction provided adequate protection. tion. These statistical tests provide assessment for
Statistical test that provides information about re- groups of landfills, and not for each individual
ducing risk in relation to the fact that the protecti- landfill. It should be remembered that the con-
on is applied or not, is called relative risk reduc- cept of “no significant difference” in the majority
tion – RRR. RRR is calculated by the following of statistical tests compared to the difference is 0,
formula: and it is generally measured variable means. OR at
the situation is different. The term “no significant
RRR = AAR / Baseline Risk difference” in the statistical test means a value of
1 Therefore, when CI - Confidence Interval in-
Therefore, the RRR in our example (for the cludes the value of 1, the researcher will immedi-
landfill on which the protection is applied): ately know that the odds are examined outcomes
the same for both (or all) of the group of applied
RRR = 15.2% / 31.6% = 41.8% protection standard (and more sophisticated), even
if it fails to examine statistical significance. Great
RRR expresses the extent to which protection importance ratio seems to lie in the fact that it is
reduces the risk of danger to the landfill, com- easy to calculate, very easy to interpret and pro-
pared to the natural risk, or the risk of landfills vides conclusions that can bring IT decisions. Fur-
that are not protected at all. It can be interpreted thermore, sometimes in certain situations helps
as follows: adequate protection will reduce risk IT managers that can explain the odds of one
in older landfills to 48.1%, compared to the risk outcome, and what else. If you know what their
to the same landfill in case the term does not use chances of achieving the desired result of protec-
protection. On the determination of RRR which tion, executives at medical waste management can
affects his interpretation seems more complicated more easily decide on the acceptance or rejection
than determining the ARR. How to increase the of costly care. Many managers want to participate
Volume 1 / Number 2 / 2013 49