Introductory course on Field Epidemiology Prof.Dr.Pirom Kamol - Ratanakul June 27, 2006 09.00 -...
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Transcript of Introductory course on Field Epidemiology Prof.Dr.Pirom Kamol - Ratanakul June 27, 2006 09.00 -...
Introductory course on Field EpidemiologyIntroductory course on Field Epidemiology
Prof.Dr.Pirom Kamol - RatanakulProf.Dr.Pirom Kamol - RatanakulJune 27, 2006 09.00 - 12.00 a.mJune 27, 2006 09.00 - 12.00 a.m..
EXPERIMENTALEXPERIMENTALSTUDYSTUDY
RESEARCHRESEARCH
A STUDY IN SEARCH FOR A STUDY IN SEARCH FOR FACTSFACTS
OR OR NEW KNOWLEDGENEW KNOWLEDGE USING THE RELIABLE USING THE RELIABLE
AND VALID METHODOLOGYAND VALID METHODOLOGY
DESIGN METHODOLOGYSTATISTICS
VALIDITY
RESULT ERROR(เท็จ)
True Value(จรงิ)+
RANDOM(NOISE)
SYSTEMATIC(BIAS)
Drug ANOYES
IMPROVEMENT Improvement Rate
Drug B
10 10 20 1020 = 50 %
5 15 20 20 = 25 %5
Drug A LOOKS TWICE AS GOOD
Drug ANOYES
IMPROVEMENT Improvement Rate
Drug B
500 500 1,000 5001,000 = 50 %
Drug A ONLY MARGINALLY BETTER
450 550 1,000 1,000 = 45 %450
BUT x2 = 5.01 AND P < .05
Drug ANOYES
IMPROVEMENT Improvement Rate
Drug B
10 10 20 1020 = 50 %
5 15 20 20 = 25 %5
Drug A LOOKS TWICE AS GOOD
BUT x2 = 2.67 AND P > .05
WEIGHT IN (Lb.)
200
201
202
203
204
205
1 2 3 4 5
DAYS ON TREATMENT
0
30
100
130
200
250
1 2 3 4
DAYS ON TREATMENT
Wt (1b)
SUPPRESS THE ZERO
esearch design
esearch methodology
tatistics
RESEARCHDESIGN
HYPOTHESIS
Expected Relationship between 2 (or more) Variables
CAUSEDETERMINEINFLUENCE
INDEPENDENTVARIABLES
DEPENDENTVARIABLE
CLEAR VALUE-FREE SPECIFICTESTABLE
c AVAILBLE METHODS
INDEPENDENTVARIABLE
DEPENDENTVARIABLE
เหตุExposure
(Risk Factor)
ผลOutcome
INTERVENTION OUTCOME
X - sectional
Cohort(Prospective)
Case-control(Retrospective)
ClinicalResearch
Experimental
Assign Exposure
Natural Exp.
Laboratory
Animal
Human
Descriptive
Analytical
X-sectional
Longitudinal
Observational
NO comparison group
Comparisongroup
O+
(CASE)O-
(CONTROL)
E ORETROSPECTIVEEXPOSURES
E1
E1
E1
.
.
.
EE OOPROSPECTIVEPROSPECTIVE
OOUUTTCCOOMMEESS
OO11
OO22
OO33EE++ PROSPECTIVEPROSPECTIVE
EE-- PROSPECTIVEPROSPECTIVE
COHORTCOHORT
X-SECTIONALX-SECTIONAL
SAMPLESAMPLE
EE OO
PRESENT SITUATIONPRESENT SITUATION
X-XECTX-XECT
RETROSPECTIVERETROSPECTIVECASE-CONTROLCASE-CONTROLE OE O
PROSPECTIVEPROSPECTIVECOHORTCOHORT E OE O
(Natural E)(Natural E)
EXPERIMENTALEXPERIMENTAL E OE O (Assign E)(Assign E)
RETROSPECTIVE PROSPECTIVERETROSPECTIVE PROSPECTIVEE
O
PAST FUTUREPAST FUTURE
PRESENTPRESENT
EE--
EE++
O-
(Control)
O+
(Case)
OUTCOMEOUTCOME
EXPOSUREEXPOSURE
EXPOSUREEXPOSURERISK FACTORSRISK FACTORS
OUTCOMEOUTCOMEEFFECTEFFECT
PastPast Present SituationPresent Situation FutureFuture
Cross - sectionalCross - sectional
Case – ControlCase – Control(Retrospective)(Retrospective)
CohortCohort(Prospective)(Prospective)
ASSIGN EXPOSURE or INTERVENTION ?ASSIGN EXPOSURE or INTERVENTION ?
RETROSPECTIVERETROSPECTIVECASE-CONTROLCASE-CONTROL
PROSPECTIVEPROSPECTIVECOHORTCOHORT
CROSS-CROSS-SECTIONALSECTIONAL
E OE O E OE O E/OE/O
START FROM “O” or “E” ?START FROM “O” or “E” ?
ANALYTICANALYTIC DESCRIPTIVEDESCRIPTIVE
CAMPARISON GROUP ?CAMPARISON GROUP ?YES NOYES NO
OBSERVATIONALOBSERVATIONALEXPERIMENTALEXPERIMENTAL
YESYES NONOOBSERVEOBSERVE
RESEARCH QUESTION (S)
BURDEN OF ILLNESS
EFFICACY
ETIOLOGY ORCAUSATION
EFFECTIVENESS
EFFICIENCYIMPLEMENTATION
ทกุข์
สมุทัย
นิโรธ
มรรค
Natural Hx. Diagnostic test
RESEARCH METHODOLOGY
Population & Sample INTERVENTION Outcome Measurement
TARGET POP.
POPULATIONto be
SAMPLED
Sampling Technique
SAMPLE
N = ?
Allocation
EXPERIMENTIntervention
CONTROLStandard Placebo
OUTCOMEMEASUREMENT
Primary OutcomeSecondary Outcome
1
2
3
BURDENNATURAL HISTORYDIAGNOSTIC TEST
CAUSATIONTHERAPY?
EXISTING DATACRITICAL APPRAISAL
VALIDITY / APPLICABILITY
YES NORESEARCH
ORIGINAL DO IT BETTER
ME TOO !
LEVEL OF SCIENTIFIC WORK
METHODOLOGY & STATISTICS
RESEARCH DESIGN
GOOD QUESTION ?
NO YESREQUIRED RESEARCH ?
YESNORESEARCH DESIGN ?
Pop. Intervention MeasurementRESEARCH METHODOLOGY
STATISTICS ?
WHAT IS A CLINICAL TRIAL?
Assign intervention techniques
Prospective study Follow forward in time From a well-defined pt. (baseline)
Contain a “CONTROL GROUP”
Comparable to the exp.gr. in every wayComparable to the exp.gr. in every wayexcept for the intervention being studiedexcept for the intervention being studied
Randomized assigning subjects to control & exp.gr.
IDEAL CLINICAL TRIAL
RANDOMIZED DOUBLE-BLINDRANDOMIZED DOUBLE-BLINDCLINICAL TRIAL (RCT)CLINICAL TRIAL (RCT)
PHASE OF CLINICAL TRIALSPHASE OF CLINICAL TRIALS
PHASE I :PHASE I :PHASE 2 :PHASE 2 :PHASE 3 :PHASE 3 :PHASE 4 :PHASE 4 :PHASE 5 :PHASE 5 :
First test on humanFirst test on humanLimitted clinical trialLimitted clinical trialLarge scale clinical trialLarge scale clinical trialLarge scale field trialLarge scale field trialSurveillanceSurveillance
SAMPLE
ExperimentalGroup
R
ControlGroup
POST
TEST
Intervention(New Drug)
Standard Rx(Placebo)
- Pretest Posttest Control Group Design Classical or Full Experimental Design
Assignment
PROSPECTIVEPROSPECTIVE
PRE
TEST
SAMPLE
Experimenta1 Group
R
POST
TEST
Posttest - Only Control Group Design
Intervention (New Drug)
Control Group
Standard Rx or Placebo
Assignment
PROSPECTIVE
- BEFORE AFTER STUDY
INTERVEN
TION
SAMPLE
BEFOREBEFOREASSESSMENTASSESSMENT
AFTERAFTERASSESSMENTASSESSMENT
BEFOREBEFORE AFTERAFTER
20%
80%
100
80
60
40
20
0
% K
TIME SERIES DESIGN
SAMPLEO1 O2 O3 O4 O5 O6
INTERVENTIONINTERVENTION
- PRE TEST - POST TEST
TIME
001 1 002 2 003 3 004 4 005 5 0066
INTERVENTIONINTERVENTION
- -Pre test Post test
- - - -Pre test Post test Pre test Post test
OO 1 1 OO 2 2 OO 3 3 OO 4 4 OO 5 5 OO66 INTERVENTIONINTERVENTION
OO 1 1 OO 2 2 OO 3 3 OO 4 4 OO 5 5 OO 6 6
INTERVENTIONINTERVENTION
OO 1 1 OO 2 2 OO 3 3 OO 4 4 OO 5 5 OO66 INTERVENTIONINTERVENTION
CROSS-OVER DESIGN
SAMPLE
S1S1
Carry-overCarry-overEffectEffect
(PLACEBO)(PLACEBO)
Intervention BIntervention B(Drug B)(Drug B)
Intervention AIntervention A(Drug A)(Drug A)
Run inRun inperiodperiod
INTERVENTIONPOPULATION OUTCOME
Experimental Group
Control Group
POPULATION
SampledPopulation
Sampling
SAMPLE R
Allocation
Follow-up
OUTCOMEPrimary
1.)……….2.)……….3.)……….4.)……….5.)……….
secondary
RiskComorbidity
Age ; sex ; etc.
stratabalance
ContaminationCointerventionCompliance
DropoutDuration
RelevantCapableCredibleAccuracyAvailable
Blinding
HEART FAILURE
EXERCISEEXERCISENO EXERCISENO EXERCISE
205070
YES NO8050
130
100100200
Extraneous to the question R.F. of the “outcome” Associated with “exposure” (Not equally distributed)
CONFOUNDING FACTORCONFOUNDING FACTOR
Angina PectorisAngina Pectoris
Restriction inclusion criteria Restriction inclusion criteriaMatchingMatching
Stratified Sampling (Prognostic Stratification) Stratified Sampling (Prognostic Stratification)RandomizationRandomization
-Stratified Analysis (Post stratification) -Stratified Analysis (Post stratification)AAjjustment/Standardizationustment/StandardizationModelingModeling
HOW TO AVOID CONFOUNDING
TARGET POPULATION
POPULATIONto be
SAMPLED
SAMPLING TECHNIQUES
SAMPLE
N = ?
Agent Host Unequilibrium Diseases
Seeking CareSeeking Care
30
20
10
Care Death
HealthHealth
CareCare
SystemSystem
DisabilityDisability
Env.
CureCureDisabilityDisabilityDeathDeath
Restriction inclusion criteria Restriction inclusion criteriaMatchingMatching
Stratified Sampling (Prognostic Stratification) Stratified Sampling (Prognostic Stratification)RandomizationRandomization
-Stratified Analysis (Post stratification) -Stratified Analysis (Post stratification)AAjjustment/Standardizationustment/StandardizationModelingModeling
HOW TO AVOID CONFOUNDING
PROBLEMS OF CLINICAL TRIAL
PATIENT (SUBJECT) VARIATION RACE
GENETIC AGE, SEX, HIEGHT, BODY WEIGHT
PHYSIOLOGY PROCESS BIOCHEMISTRY LEVEL
DISEASE VARIATIONTYPESTAGEDURATION EARLY
LATESEVERITY
CONCOMITANT DISEASE
BIOLOGICAL VARIATION
INCLUSION EXCLUSIONSAMPLE
AgeAge Confounders ConfoundersSexSex Unethical Unethical
Dx. Criteria Dx. Criteria Not feasible Not feasibleDis.SeverityDis.SeverityDis.DurationDis.Duration
Referal Filter Referal Filter
PRIMARY OUTCOME EVENT RATE (CONTROL GROUP)
CLINICAL SIGNIFICANCE TYPE I & TYPE II ERROR
VARIATION OR STAND. DEVIATION
JUSTIFICCATION OF THE SAMPLE SIZE
2 POSSIBLE ERRORS OF INTERPRETATION
CONCLUSION[drawn from
analysiswhen the trialis completed]
TREATMENTBENEFIT
NOTREATMENT
BENEFIT
CORRECT
TYPE II ERROR
TYPE I ERROR
CORRECT
TREATMENTBENEFIT
NO TREATMENTBENEFIT
THE TRUTH
EXPERIMENT GR.INTERVENTION
CONTROL GR STD. Rx.
PLACEBO
OUTCOMES
SUBJECT
ALLOCATION
A
B
STRATA BALANCE?BLIND?
100
100
Each subject has the same chanceEach subject has the same chanceof being assigned to eitherof being assigned to either‘‘Experimental’ or ‘Control Group’Experimental’ or ‘Control Group’
COMPARABILITYCOMPARABILITY
Prognostic factors (Baseline characteristics)Prognostic factors (Baseline characteristics)
Statistical test will have valid significance levelsStatistical test will have valid significance levels
RR
SAMPLE ALLOCATION(Randomization)
Control Group
Experimental Group
Standard TreatmentPlacebo
InterventionNew Treatment
BLIND
Simple Randomization
Chronologicalpatient No.
112233445566778899101011111212
1048022368241304216737570
7792199562963018957985475
2891863553094291036507119
5108502368010115216207056
0153625595225270624381837
1100856420054636366153342
8823148235526368572971048
5182152404333624636933787
1501146573483609309339975
0690772905919771434236857
6957840961939696112997336
1276521382540925391697628
0201185393972656168016656
4275169994079721028153988
3326703427927378568908178
5125960268949045858609998
9164689198648091637691782
5349831016209221810359533
7993669445334885226713916
1630819885041461451306691
8164730995763950785606121
2775698872188761745353060
7099749626889474823777233
7745289368312732321642698
RANDOM NUMBER
Simple Randomization
Chronologicalpatient No.
Randomnumber
112233445566778899101011111212
112222443377999988882266
Simple RandomizationIf Random number is even assign treatment AIf Random number is odd assign treatment B
Chronologicalpatient No.
Randomnumber Assignment
112233445566778899101011111212
112222443377999988882266
Simple RandomizationIf Random number is even assign treatment AIf Random number is odd assign treatment B
Chronologicalpatient No.
Randomnumber Assignment
112233445566778899101011111212
112222443377999988882266
BBAAAAAABBBBBBBBAAAAAAAAA7A7B5B5?
BLOCK RANDOMIZATIONBLOCK RANDOMIZATION
AVOID AVOID IMBALANCEIMBALANCE IN NO. SUBJECTS ASSIGNED IN NO. SUBJECTS ASSIGNED TO EACH GROUPTO EACH GROUP
NO. SUBJECTSNO. SUBJECTS IN EACH gr. WILL IN EACH gr. WILL BE EQUALBE EQUAL
METHODMETHOD
CHOOSE CHOOSE BLOCK BLOCK OF OF EVEN SIZEEVEN SIZE (e.g.4) (e.g.4)(ENSURE THAT AFTER EVERY 4 R SUBJECT(ENSURE THAT AFTER EVERY 4 R SUBJECTNO. SUBJECTSNO. SUBJECTS IN EACH gr. IS IN EACH gr. IS EQUALEQUAL))
WRITE DOWN ALL WRITE DOWN ALL POSSIBLE WAYSPOSSIBLE WAYS OF OF gr. ASSIGNMENTgr. ASSIGNMENT
R THE R THE ORDER ORDER IN WHICH THESE COMBINATIONA ARE IN WHICH THESE COMBINATIONA ARE SELECTEDSELECTED
All possible ways of ‘Group assignment’All possible ways of ‘Group assignment’
I II III IV V VI
All possible ways of ‘Group assignment’All possible ways of ‘Group assignment’
I II III IV V VIA B A B A BA B B A B AB A A B B AB A B A A B
R the ‘order’ in whichR the ‘order’ in whichthese combinationthese combinationare selectedare selected
BLOCKBLOCKII, VI, IV, III, I, VII, VI, IV, III, I, V
ChronologicalPatient No.
Block Assignment
1234
II BBAA
5678
VI BAAB
9..
IV BA
PROGNOSTIC STRATIFICATIONPROGNOSTIC STRATIFICATION
H.T.H.T.
MildMild
ModerateModerate
SevereSevere
SEVERITYSEVERITY
Prognostic factorPrognostic factor
RR
EE
CC
RR
EE
CC
RR
EE
CC
Prognostic Stratification
SEX
40 - 49
50 - 59
60 - 69
MildModerateSevere
EC
40 - 49
50 - 59
60 - 69
MildModerateSevere
+
AGE SEVERITY
R
EC
R
R
R
R
R
INTERVENTION (MANOEUVRE)
PRECISIONPRECISION POTENCYPOTENCY COMPARISONCOMPARISON MULTIPLICITYMULTIPLICITY CONCURRENCYCONCURRENCYSENSIBILITYSENSIBILITYAVAILABILITYAVAILABILITYACCEPTABILITYACCEPTABILITYAVOID BIASESAVOID BIASES CONTAMINATIONCONTAMINATION COINTERVENTIONCOINTERVENTION COMPLIANCECOMPLIANCE
HISTORICAL CONTROL TRIAL
333328285513139944INH + PASINH + PAS2020191911INH + RFINH + RF
NONOYESYESDEATHDEATH
5.05.0%%30.8%30.8%
4141303011111919141455INH + PASINH + PAS2222161666INH + RFINH + RF
NONOYESYESDEATHDEATH
27.3%27.3%26.3%26.3%
CONTAMINATION
SAMPLE R
CONTROLGROUP
INTERVENTION
EXPERIMENTALGROUP
INTERVENTION 10
SECONDARY
1.1.2.2.3.3.
F.U.
F.U.
OUTCOMEMEASUREMENT
SAMPLE R
CONTROLGROUP
STANDARD RxPLACBBO
EXPERIMENTALGROUP
INTERVENTION 10
SECONDARY
1.2.3.
F.U.F.U.
F.U.F.U.
OUTCOMEMEASUREMENT
CO-INTERVENTION
THE USEFULNESS OFTHE USEFULNESS OF
BLINDNESSBLINDNESS
Avoid CO-INTERVENTIONAvoid CO-INTERVENTION
Avoid Biased of OUTCOME MEASUREMENTAvoid Biased of OUTCOME MEASUREMENT
FIVE YEAR MORTALITY IN THE CORONARY DRUG PROJECTFIVE YEAR MORTALITY IN THE CORONARY DRUG PROJECT
POORPOORCOMPLIANCECOMPLIANCE
<80%<80%
GOODGOODCOMPLIANCECOMPLIANCE
>>80%80%
# ofPts.
357
882
%mortality
24.6
28.2
# ofPts.
708
1813
%mortality
15.0
15.1
Clofibrate
Placebo
COMPINANCE IMPROVING STRATEGIES(SHORT-TERM Rx)
1.1. Clear verbal and written instructionClear verbal and written instruction2.2. Patient CounsellingPatient Counselling3.3. Intramuscular injectionIntramuscular injection4.4. Pill calendarsPill calendars5.5. Unit dose packagesUnit dose packages6.6. Signal-alarm pill containersSignal-alarm pill containers
COMPINANCE IMPROVING STRATEGIES(LONG-TERM Rx)
1.1. Increased supervision Increased supervision (especially by paraprofessionals)(especially by paraprofessionals)2.2. Rewards and positive reinforcement for complyingRewards and positive reinforcement for complying3.3. Cueing (tailoring of the regimen to the patient’s Cueing (tailoring of the regimen to the patient’s
habits)habits)4.4. Self-monitoringSelf-monitoring5.5. Contingency contractingContingency contracting6.6. Counselling, instruction, and group discussionsCounselling, instruction, and group discussions7.7. Parenteral treatment under supervisionParenteral treatment under supervision8.8. Increased convenience of care-regimenIncreased convenience of care-regimen
- Follow up - Self report
Pill count Home Surprise Visit
Laboratory Test
Compliance MonitoringRx
OUTCOME
HARDOBJECTIVE
SOFTSUBJECTIVE
V.S.V.S.INDICATOR CRITERIA
P.E.P.E.LAB.LAB.
PAINPAINANXIETYANXIETYNAUSIANAUSIA
RELEVANT TO THE STUDY QUESTIONRELEVANT TO THE STUDY QUESTION
CAPABLE OF OPERATIONAL DEFINTIONCAPABLE OF OPERATIONAL DEFINTION
CREDIBLECREDIBLE
COMPREHENSIBILITYCOMPREHENSIBILITY
ACCEPTANCEACCEPTANCE
ACCURACYACCURACY
RELIABILITYRELIABILITY
RESPONSIVENESS TO CHANGERESPONSIVENESS TO CHANGE
AVAILABILITY & COSTAVAILABILITY & COST
CRITERIA FOR SELECTING HEALTH MEASURES
Consequence ofConsequence of‘‘Cholesterol - lowering drug therapy’Cholesterol - lowering drug therapy’
TCTC
LDL - CLDL - C
HDL - CHDL - C Mortality
CHDOther Causes
Prevent‘atherosclerosis’
CHD
QOL
OutOutputput Outcome Impact Outcome Impact
LEVEL OF OUTCOME MEASUREMENT
Intermediatelevel
Tertiarylevel
Secondarylevel
HEALTHCARE
PROGRAM
เท่ียง ตรง(RELIABILITY) (VALIDITY)
CONTENTCONTENT
FACEFACE
CRITERIONCRITERION
DISCRIMINANTDISCRIMINANT
CONSTRUCTCONSTRUCT
VARIATIONVARIATION
Observer Instrument Subject
Intra-Observer
Inter-ObserverQuestionnaire
Record Form
Enumeration/Measurement
SOURCES OFOBSERVERS VARIATIONS
MULTIPLE OBSERVERS
DIFFERENT INSTITUTIONS
DIFFERENT TECHNICAL CONSTRAINS
DIFFERENT Dx. PRACTICES
DIFFERENT IN COMPLETENESS OF
MEDICAL RECORDS
APPROACH TO VARIATIONS
COMMON PROTOCOL
STANDARDIZATION OF METHODS
TRAINING OF PERSONNELS
OUTCOMEOUTCOMEMEASUREMEASURECRITERIA FOR SELETING OUTCOME MEASURECRITERIA FOR SELETING OUTCOME MEASURE
RELEVANCEOPERATIONALDEFINITIONCREDIBLEACCURACYAVAILABLE
Low Cost?
OUTCOMEMEASURE
DataSourc
e
HOWto
Measure ?
WHOwill
measure ?
REMARKS(U of Analysis)
WHENwill
measure ?OBJECTIVES
1………………….
2………………….
3………………...
1.1)….....……1.2)…………..1.3)…………..
2.1)…………..2.2)…………..
3.1)………….
……………..……………..……………..
……………..……………..
……………..
……………………….……………………….……………………….
……………………….……………………….
……………………….
……………………….……………………….……………………….
……………………….……………………….
……………………….
……………………….……………………….……………………….
……………………….……………………….
……………………….
………………………………………………………………
…………………………………………
……………………
APPROACH TO VARIATIONS
COMMON PROTOCOL
STANDARDIZATION OF METHODS
TRAINING OF PERSONNELS
OUTCOMEOUTCOMEMEASUREMEASURECRITERIA FOR SELETING OUTCOME MEASURECRITERIA FOR SELETING OUTCOME MEASURE
RELEVANCEOPERATIONALDEFINITIONCREDIBLEACCURACYAVAILABLE
Low Cost?
OUTCOMEMEASURE
DataSourc
e
HOWto
Measure ?
WHOwill
measure ?
REMARKS(U of Analysis)
WHENwill
measure ?OBJECTIVES
1………………….
2………………….
3………………...
1.1)….....……1.2)…………..1.3)…………..
2.1)…………..2.2)…………..
3.1)………….
……………..……………..……………..
……………..……………..
……………..
……………………….……………………….……………………….
……………………….……………………….
……………………….
……………………….……………………….……………………….
……………………….……………………….
……………………….
……………………….……………………….……………………….
……………………….……………………….
……………………….
………………………………………………………………
…………………………………………
……………………
Long Term Clinical TrialsLong Term Clinical TrialsFor Possible Early TerminationFor Possible Early Termination
Unexpected HarmUnexpected HarmClear Therapeutic BenefitClear Therapeutic Benefit
would we want to stop ?would we want to stop ?
Optimal care of study patientsOptimal care of study patientsOptimal care of nonstudy &Optimal care of nonstudy &future patients through quickerfuture patients through quickerpublication of the resultspublication of the resultsEfficient use of time & resourcesEfficient use of time & resources(invertigators)(invertigators)
would we want to stop ?would we want to stop ?
MONITORINGMONITORING
WHENWHEN
WHYWHY
QUALITY OF RESEARCH WORK
DESIGN METHODOLOGY
STATISTICS
Adm.KNOWLEDGEOF
THE SUBJECT
STATE-OF-THE-ART
TEAM WORKrust (เชื่อใจซึง่กันและกัน)
nthusiasm (กระตือรอืรน้)greement (ประคับประคอง)
utual Benefit (ผลประโยชน์รว่มกัน)illingness (ต้ังใจ & เต็มใจ)pportunity (ให้โอกาสฯ)
ecognition (ยอมรบันับถือ)nowledge Transfer (แลกเปลี่ยนความรู)้
TEAMWORK
ETHICS : NORMETHICS : NORM
Scientifit DesignScientifit DesignCompetent InvestigatorCompetent InvestigatorRisk / Benefit BalanceRisk / Benefit BalanceInform ConsentInform ConsentConfidentialityConfidentialitySelection of SubjectsSelection of SubjectsCompensation of InjuryCompensation of Injury
THANKTHANK