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 Contents vii

11.14 Sources of Epidemiologic Data. . . . . . . . . . . . . 238 14.4 Example of an Ecological Study. . . . . . . . . . . . 292
11.15 Healthcare Marketing. . . . . . . . . . . . . . . . . . . . . . 239 14.5 Cohort Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Exercise 11.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 14.6 Example of a Prospective Cohort Study . . . . 300
Exercise 11.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 14.7 Example of a Retrospective Cohort Study. . . . 302
Case Study 11.1: Example of Regional 14.8 Case-Control Studies. . . . . . . . . . . . . . . . . . . . . . . 303
Market Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 14.9 Example of a Case-Control Study. . . . . . . . . . . 307
Case Study 11.2: Planning for Mental 14.10 Risk Factor and Exposure in Cohort
Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 and Case-Control Studies����������������������������������� 309
11.16 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 14.11 Comparison of Cohort and Case-Control
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Study Design ����������������������������������������������������������� 310
14.12 Association and Causality����������������������������������� 310
Chapter 12 Prevention, Detection, 14.13 Bias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
and Monitoring of Disease. . . . . . 249 14.14 Confounding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
12.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Case Study 14.1: An Ecological Study. . . . . . . . . . . . . . 315
12.2 The Nature, Scope, and Levels Case Study 14.2: Prospective Cohort Study. . . . . . . . 316
of Prevention������������������������������������������������������������� 250 Case Study 14.3: Retrospective Cohort Study. . . . . . 317
12.3 Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Case Study 14.4: Case-Control Study. . . . . . . . . . . . . . 318
12.4 Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266 14. 15 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Exercise 12.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Exercise 12.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Chapter 15 Experimental Studies. . . . . . . . . . 323
Case Study 12.1: Nosocomial Infection
Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 15.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Case Study 12.2: Screening for Colorectal Cancer. . . . 272 15.2 Experimental or Interventional
12. 5 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Study Design����������������������������������������������������������� 325
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 15.3 Categorization of Experimental Studies . . . . 327
15.4 Randomized Controlled Trials
or Clinical Trials ������������������������������������������������������� 328
Chapter 13 Basic Statistical Concepts 15.5 Example of a Randomized Clinical Trial. . . . . 330
and Tests . . . . . . . . . . . . . . . . . . . . 277 15.6 Community Trials. . . . . . . . . . . . . . . . . . . . . . . . . . 331
13.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 15.7 Example of a Community Trial. . . . . . . . . . . . . . 331
13.2 Examples. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 15.8 Natural Experiments. . . . . . . . . . . . . . . . . . . . . . . 332
13.3 Basic Statistical Concepts . . . . . . . . . . . . . . . . . . 281 15.9 Factorial Trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
13.4 Statistical Tests for Comparison of Groups. . . . 286 Case Study 15.1: Randomized Control
Exercise 13.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Trial – Chlorhexidine Bathing in ICUs
Exercise 13.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 to Prevent HAIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
13.5 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288 15.10 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Chapter 14 Observational Studies . . . . . . . . . 289
14.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
14.2 Observational Studies. . . . . . . . . . . . . . . . . . . . . . 290 Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
14.3 Ecological Studies. . . . . . . . . . . . . . . . . . . . . . . . . . 291 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
© Monsitj/Getty Images

About the Author

A
mir A. Khaliq is a Professor of Health Adminis- 2000. He was trained as a physician in Pakistan and
tration and Policy at the University of ­Oklahoma received MSc in Community Health and MS in Health
Health Sciences Center, College of Public Services degrees from the Universities of London and
Health, where he has taught courses in ­Managerial Epi- California. He earned a PhD in Health Administration
demiology, Operations Research, D ­ ecision Analysis, from the University of Toronto.
and Comparative International Health Systems since

viii
© Monsitj/Getty Images

Preface
M
any academic programs offering a degree in the reader for these discussions by introducing the
health administration include a course on underlying concepts of epidemiology, management,
managerial epidemiology in their curric- and evidence-based management.
ulum. The content of these courses, understandably, Chapters 2–5 focus on the determinants, assess-
differs from one program to another. The diversity in ment, and measurement of health in individuals and
the content of managerial epidemiology courses across populations and the characterization of health and
programs reflects the diversity of opinions about disease in terms of person, place, and time. Chapter
the scope and nature of the field called ­managerial 2 explains the holistic concept of health and the pop-
epidemiology. Increasingly, program directors and ulation model of health as opposed to the traditional
instructors favor content that combines elements of medical model. The chapter also provides a detailed
traditional introductory epidemiology courses with discussion of genetic, socioeconomic, and racial or
traditional population health courses. The desire to ethnic determinants of health. Chapter 3 deals with
combine concepts, methods, and skills from epide- the complex concepts of disease, death, and disabil-
miology and population health is not accidental but ity and various approaches to assess the health and
reflects two important realities. First, the whole idea of well-being of individuals and populations. Chapter 4
managerial epidemiology is to extend the boundaries discusses various measures of morbidity and mortal-
of epidemiology from an investigation of the deter- ity and different types of summary statistics reported
minants and distribution of disease and injury to the in literature as indicators of population health status.
examination of the determinants and distribution of The chapter includes clear and concise definitions
health outcomes in populations. Second, because of for a number of epidemiologic concepts necessary to
the changes taking place in our thinking about health measure the health status and distribution of diseases
and healthcare delivery, there is a growing need for in populations. Chapter 5 discusses the demographic,
healthcare managers to acquire epidemiologic skills geographic, and temporal characterization and report-
on one hand and develop an understanding of the ing of health problems in terms of person, place, and
concepts and methods related to population health time. The chapter also includes a discussion of differ-
on the other. As such, managerial epidemiology must ent types of descriptive epidemiologic investigations
include the application of information regarding the in the way of case reports and cross-sectional studies.
determinants and distribution of disease and injury to Chapters 6–9 focus on the determinants of health
health promotion, disease prevention, and planning in relation to lifestyle and personal behavior, the dis-
of health services. This text presents a combination of tribution of infections and injuries in populations, and
materials from epidemiology and population health assessment of quality of care delivered by the health-
with the view that future healthcare managers need care system. The materials presented in these chapters
to have a good grasp of various aspects of population represent different dimensions of population health.
health as well as a foundational understanding of the Chapter 6 deals with health problems related to life-
epidemiologic principles and methods. The need for a styles and personal behavior, including sedentary
new text in managerial epidemiology is evident from lifestyle, substance abuse, and the impact of lifestyles
the dearth of existing textbooks on this subject. on the prevalence of cardiovascular disease and dia-
Chapter 1 in the text is foundational in nature betes in different populations. Chapter 7 engages in
and sets the stage for in-depth discussions in succeed- a detailed discussion of infectious disease epidemiol-
ing chapters on the determinants and distribution of ogy in the United States and worldwide, including the
health in individuals and populations, assessment of problem of emerging infectious diseases and antimi-
population health status, and methods for commu- crobial drug resistance in microorganisms. ­Chapter 8
nity health needs assessment. The chapter prepares discusses the epidemiology of various kinds of injuries

ix
x Preface

and provides national and international data on vio- technical aspect of designing and conducting various
lence, drownings, and burns. Chapter 9 explains the kinds of epidemiologic investigations. Chapter 13
relationship of the structure and processes of care serves as a convenient resource for brushing up on basic
with health outcomes and various methods of moni- quantitative and statistical concepts. Chapters 14 and
toring and reporting ambulatory and inpatient quality 15 provide comprehensive information on the design,
of care. The chapter also includes a discussion of the comparative suitability, and technical challenges of
impact of severity of disease and case mix on health observational and experimental epidemiologic inves-
outcomes and indicators of healthcare quality. tigations. Chapter 14 discusses the importance, intri-
Chapters 10 and 11 are designed to equip future cacies, and comparative advantages of prospective and
healthcare managers with the tools and skills nec- retrospective cohort and case-control studies. Chapter
essary for community health needs assessment and 15 provides a discussion of the frequency and rele-
planning for adequate delivery of services. The chap- vance of experimental epidemiologic investigations in
ters include various methods for estimating primary the form of randomized controlled trials and the prac-
and secondary service areas, determination of the size tical aspects of conducting experimental studies.
of a geographic market, level of competition in a geo- The content and case studies in various chapters
graphic market, and estimation of market share held are organized in a manner suitable to meet the needs
by various providers. Chapter 11 describes different of a diverse body of students and are drawn from a
approaches toward healthcare planning, setting prior- vast body of literature. The author hopes this text will
ities, determining levels of access, and designation of make a meaningful contribution to the field of man-
health professional shortage areas by the U.S. Health agerial epidemiology and serve as a valuable resource
Resources and Services Administration. worthy of the time and attention of students and
Chapters 12–15 deal with the concepts of preven- instructors in health administration programs.
tion, monitoring, surveillance, and reporting of dis-
eases that pose serious public health threats and the Amir A. Khaliq
© Monsitj/Getty Images

CHAPTER 1
Epidemiology for Evidence-
Based Management
LEARNING OBJECTIVES
Having mastered the materials in this chapter, the student will be able to:
1. Explain what the terms epidemiology and managerial epidemiology mean.
2. Explain what the terms management and evidence-based management mean.
3. Explain how epidemiologic data can be used in evidence-based management.

CHAPTER OUTLINE
1.1 Introduction 1.8 Scenario for Application of Managerial
1.2 Epidemiology Epidemiology
1.3 Management 1.9 Sources of Epidemiologic Data
1.4 Decision-Making Process Case Study 1.1 – Impact of Administrative Decisions
1.5 Evidence-Based Management on Patient Outcomes
1.6 Epidemiology and Evidence-Based Case Study 1.2 – Epidemiologic Patterns that Can
Management Guide Policy Decisions
1.7 Managerial Epidemiology 1.10 Summary

KEY TERMS
Epidemiology Evidence-based practice Managerial epidemiology
Evidence-based management (EBP) Nonprogrammed decisions
(EBM) Management Programmed decisions

1
2 Chapter 1 Epidemiology for Evidence-Based Management

▸▸ 1.1 Introduction and from pharmaceuticals to plant diseases. Concur-

rent with these developments, more refined analytic

G
ood management involves decisions that are and statistical techniques have been developed to
guided by both quantitative and qualitative evi- address issues resulting from the complexities of study
dence. By its very nature, effective healthcare design. Easy availability of vast amounts of clinical,
management requires the collection of appropriate data public health, demographic, and socioeconomic data
and application of decision-support tools from different from a variety of sources that can be integrated and ana-
disciplines. The purpose of managerial epidemiology is lyzed within minutes with the help of relatively inex-
to familiarize both aspiring and practicing healthcare pensive powerful computers has enormously increased
managers with the tools available from the fields of epi- the number of epidemiologic investigations being con-
demiology and management and give them the abil- ducted. Every year, thousands of research articles based
ity to make a concerted use of these tools for efficient on epidemiologic investigations are being published
and informed decision making. The combined use of in dozens if not hundreds of conventional and open-­
techniques from epidemiology and management is the access journals from every corner of the world.
foundation of the emerging field of evidence-based There is a mutually supportive and symbiotic rela-
management (EBM). Before discussing the application tionship between the practice of medicine and epi-
of epidemiologic methods in healthcare management, demiology. Epidemiology is population medicine in
it is important to remind ourselves of the nature of the that it deals with the identification, investigation, and
two ­disciplines called epidemiology and management. control of diseases in populations. The same is done at
In the following sections, we introduce the terminology the individual level by those who practice medicine—
and basic principles of epidemiology and management namely physicians.2 Clinical medicine benefits from
and then explain how EBM can use the quantitative the knowledge of the frequency of a disease in a given
evidence generated by epidemiologic investigations. population obtained through epidemiologic investi-
Two case studies at the end of the chapter demonstrate gations. Conversely, epidemiologic investigations rely
how epidemiologic evidence can be used for effective on accurate identification of diseases in individuals by
healthcare management and policy formulation. physicians. Although epidemiologic ­information is
essential for better practice of medicine and formula-
tion of control strategies, assessment of the incidence
▸▸ 1.2 Epidemiology and prevalence of disease in a population is entirely
dependent on accurate diagnosis and reporting of
Porta1 defines epidemiology as “The study of the disease by clinicians.2 For example, community-level
occurrence and distribution of health-related events, strategies for the prevention and control of AIDS or
states, and processes in specified populations, includ- delivery of medical and social services to Alzheimer’s
ing the study of the determinants influencing such pro- disease patients require data regarding the frequency
cesses, and the application of this knowledge to ­control and distribution of these diseases in the population.
relevant health problems.” A less-­comprehensive older Such data can only become available through accurate
definition states that epidemiology is “the study of the diagnosis and reporting by physicians.
distribution and determinants of diseases and inju-
ries in human populations.” 2 The implication of both
definitions is that diseases and their causes are distrib-
uted neither randomly nor evenly across populations.
▸▸ 1.3 Management
Understanding the distribution of diseases across Management can be defined as “The act, manner,
populations, time, and space can give us valuable or practice of managing, supervising, or controlling.” 3
information about their causes, and this information Another way to describe management is that it
can be used to develop prevention and control strat- involves “getting results through the work of others for
egies. Recognizing that diseases differentially afflict the benefit of the client.” 4 In either case, management
dwellers of different regions or people of different col- involves the use of organizational resources and han-
ors, creeds, and sexes has been an important element dling of processes, situations, and relations. A number
in our quest to live a healthier and longer life. of theoretical models have been developed to explain
The field of epidemiology has experienced tre- what managers do and how they do it.4-6 Management
mendous growth and methodologic sophistication of healthcare organizations such as hospitals, clinics,
in the last few decades. The scope of epidemiologic and nursing homes poses challenges that are different
investigations now spans from genetics to social sci- from those of other organizations. Healthcare man-
ences, from forensic medicine to veterinary medicine, agement requires knowledge of healthcare policy,
 1.4 Decision-Making Process 3

r­ egulatory environment, and insurance. Additionally, functions of managers. The interpersonal role involves
it requires an understanding of issues related to access, leadership through motivation and mentoring. The
utilization, and biomedical ethics, as well as analytic informational role involves collection and dissemina-
skills to use epidemiologic data for decision making. tion of information and serving as a spokesperson for
Researchers explore how healthcare managers carry a department or the organization. As entrepreneurs,
out their responsibilities and make decisions, and what mangers set goals and objectives for their departments
factors explain different styles of management. For or organizations, and as “disturbance handlers,” they
practitioners, management means attaining efficiency, resolve conflicts and solve problems.
improving quality, motivating staff, and achieving In the “art” and “science” of management, the sci-
organizational goals. As practitioners, healthcare man- entific component relies on systematic analysis of data
agers have to learn the principles of leadership, motiva- and use of evidence, whereas the art of management
tion, financial management, and quality improvement. requires creative thinking and innovation to solve a
They have to employ “soft power” and diplomatic given problem.5 The unique blend of art and science
skills, as well as “hard” ­analytic skills.7 employed by a person creates his or her management
The purpose of management is to specify, com- style. Clearly, the management style of a person is also
municate, and achieve the goals and objectives of the a function of individual characteristics, values, experi-
organization in a consistent manner while provid- ence, analytic skills, and the level of authority enjoyed
ing a harmonious work environment for employees. in the organization. Strong quantitative skills are essen-
Researchers have identified three main goals of health- tial for problem solving and finding the best solutions.
care management:8 first, manage the financial affairs of Analytical tools are especially useful for solving prob-
the organization to ensure financial stability; second, lems that are discrete in nature and lend themselves to
provide highest quality services through efficient use of quantitative analysis. Although managers frequently
resources; and third, maintain high moral and ethical encounter problems that are ambiguous or multi-
standards while serving competing or divergent inter- dimensional, off-the-cuff decision making without
ests of stakeholders. The success of an organization in quantitative analysis and empirical evidence can be
achieving these goals is a direct measure of the suc- very detrimental to the goals of an organization. The
cess of its managers. Given the challenging economic, element of art in decision making is meant only to sup-
political, and social environment in which healthcare plement the scientific approach toward decision mak-
organizations operate, some of these goals can be in ing rather than replace it. Based on quantitative data, a
conflict with one another. For example, the necessity good understanding of the demographic characteris-
of attaining monetary success can compel managers to tics of the community, demand for services, and evolv-
forego desirable social objectives, such as delivery of ing patterns of morbidity and mortality are critically
discounted care to socially marginalized populations. important for excellence in healthcare ­management.
While specific duties of managers inevitably vary
from one organization to another or from one depart-
ment to another, these duties are conventionally
categorized into planning, coordination, directing,
▸▸ 1.4 Decision-Making Process
and control functions. Such a categorization is help- According to management theory, managerial deci-
ful in developing a framework in which appropriate sions vary in complexity and can be divided into two
empirical data or evidence can be used to understand main categories: programmed and nonprogrammed
managerial functions and to make a case for rational decisions.10 Programmed decisions address prob-
decision making. In practice, these roles merge and lems that are encountered frequently and are repet-
mix during the daily process of decision making and itive in nature. In dealing with these problems,
problem solving. Managers transition back and forth ­managers do not need to find new solutions. Because
into these roles without compartmentalizing their of the familiarity of managers with such problems,
work into these conceptual domains. In carrying out rules and procedures usually exist to resolve them.
all these managerial functions, the use of data and The level of risk associated with such decisions is
empirical evidence can make the difference between minimal because of successful past application of
an effective and ineffective manger. similar decisions. Nonprogrammed decisions,
Mintzberg9 challenges the “planning, organiz- on the other hand, are unprecedented and demand
ing, coordinating, and controlling” model of man- innovative solutions. In both programmed and non-
agerial functions developed in the earlier part of the programmed situations, managers are expected to
20th century and offers “interpersonal, informational, adopt a rational and systematic approach to problem
entrepreneurial, and decisional” activities as the main solving and decision making.
4 Chapter 1 Epidemiology for Evidence-Based Management

Researchers have also identified four different of medicine and, (2) focus on the whole person rather
approaches toward decision making.10 The underly- than episodic treatment of “cases” of diseases. The
ing premise in all these approaches is that import- demand for evidence-based decisions in the practice
ant decisions are complex, and individuals are of medicine stems from studies showing that, in the
­constrained in their ability to make sound decisions past, only about 15% of physicians’ decisions were
because of their inability to simultaneously process based on evidence.13 Following these developments
multiple dimensions of a complex problem.11 The in the practice of medicine, two similar developments
first of these approaches focuses on the application occurred in health services management: (1) a grow-
of operations research or management science meth- ing emphasis on EBM and (2) a focus on population
ods such as linear programming, Bayesian probabili- health. EBM simply means using data or statistical
ties, and simulation modeling. The second approach evidence to guide managerial decisions. Statistical
emphasizes that decisions are not made individually evidence allows managers to make better decisions
by top managers such as the chief executive officer, by rank-ordering priorities based on empirical evi-
but through an alliance and coalition-building pro- dence and following a systematic process in which
cess involving multiple participants. A collective or steps are taken sequentially to arrive at the final deci-
participatory process is primarily needed for clar- sion. EBP is often used as an umbrella term instead of
ifying the nature and importance of the problem ­discipline-specific terms such as evidence-based medi-
and for negotiations among internal stakeholders cine, evidence-based nursing, and evidence-based man-
to determine organizational priorities. The third agement. EBP is defined as “making decisions through
model posits that decisions are made in multiple conscientious, explicit and judicious use of the best
steps through an incremental process in which a available evidence from multiple sources.”14
series of smaller decisions finally lead to the culmi- A variety of approaches, ranging from role mod-
nating decision. According to this model, the process eling to teachable moments of the lived experiences
of arriving at a decision evolves over time and goes of mentors, are recommended for teaching EBM.
through the stages of identification, development, and McAlearney and Kovner15 have suggested the follow-
selection. The fourth model, known as the “garbage ing six steps for EBM: first, framing a question for
can” model, characterizes the decision-making pro- which an answer can be found; second, finding the
cess to be highly chaotic, nonlinear, and fluid.12 This data or evidence to answer the question; third, assess-
model applies to organizational environments char- ing the validity of the evidence; fourth, aligning the
acterized by a high level of uncertainty in which par- evidence to the specific circumstances of the orga-
ticipants come and go, and the emergence of ideas, nization; fifth, determining whether the evidence is
problems, and solutions is independent or even a adequate to guide the decision; and sixth, determin-
random event. As a result, in the garbage can model, ing whether the organization can take action on the
solutions may be offered or implemented when a basis of the available evidence.
problem does not even exist, choices may be made In contrast to clinical decisions, which are usually
that do not solve a problem, or people may stop try- made by individuals in a relatively short timeframe,
ing to solve the problem, either because they become important managerial decisions are made by teams or
used to it or no suitable solutions exist. groups of individuals through a consultative process
The use of any of these decision making models over weeks and months.16 The results of these deci-
depends on the characteristics of the organization sions can take years to become clear. As such, there
as well as the specific situation or problem that calls is enough time to collect data from various sources
for a decision. Therefore, approaches toward decision to guide important managerial decisions. Electronic
­making vary across different organizations as well as resources and decision-support technologies can
within the same organization at different occasions. be used to identify, assess, and evaluate quantitative
and/or qualitative evidence in the pursuit of EBM.
­Barends et al.14 argue that the nature of “evidence” in
▸▸ 1.5 Evidence-Based EBP does not strictly translate into quantitative data,
Management but rather should be interpreted as information that
may be quantitative, qualitative, or descriptive in
In conjunction with the development of electronic nature and that may come from a variety of sources.
health records, two other developments that have altered They argue that six misconceptions exist regarding the
the practice of medicine in the last couple of decades nature of evidence in EBM: (1) it “ignores the prac-
are (1) emphasis on evidence-based ­practice (EBP) titioner’s professional experience”; (2) it “is all about
 1.7 Managerial Epidemiology 5

numbers and statistics”; (3) “managers need to make on the frequency and duration of disease in various age
decisions quickly and don’t have the time for EBM”; groups. In EBM, priority problems are identified and
(4) “each organization is unique, so the usefulness of rank-ordered by combining data on disease frequency,
scientific evidence is limited”; (5) “if you do not have severity, lethality, and responsiveness to treatment in
high-quality evidence, you cannot do anything”; and mathematical algorithms and developing an index or
(6) “good-quality evidence gives you the answers to a composite score for each disease. Recent efforts in
the problem.” In their opinion, these myths are com- using epidemiologic data for healthcare planning and
pletely unfounded and should not be allowed to get in setting priorities have relied on the estimation of years
the way of EBM. of potential life lost (YPLL) due to a disease. Calcu-
According to McVey et al.,17 “Evidence Based Man- lation of YPLL in a population takes into account life
agement (EBM) is about removing emotion, opinion, expectancy at various ages and premature deaths due to
bias, and personal experience from ­decision-making.” one disease or another in a population. The disease or
Similarly, Pfeffer and Sutton13 argue that “gut feeling” condition responsible for the most number of YPLL is
and obsolete “best practices” have no place in decision usually ranked as the number one priority.
making. They contend that instead of using empiri- Epidemiologic data are also valuable in evaluating
cal evidence generated by research studies, typically the comparative impact of various services, strategies,
managers use the following six substitutes for best and technologies. Such an assessment involves com-
evidence: (1) obsolete knowledge, (2) personal expe- parison of population health statistics, such as infant
rience, (3) specialist skills, (4) hype, (5) dogma, and mortality or teen pregnancy rates, before and after the
(6) mindless mimicry of top performers.13 Rather implementation of new strategies and services. The
than using obsolete knowledge, hype, or dogma, Pfef- outcome of interest or the measure of impact in such
fer and Sutton have developed the following guiding studies can be the reduction in disease-specific disabil-
principles for the practice of EBM (http://evidence ity, mortality, or YPLL that can be directly attributed
-basedmanagement.com/): to the new strategy or intervention.
1. Face the facts and build a culture in which
people are encouraged to tell the truth, even
if it is unpleasant. ▸▸ 1.7 Managerial Epidemiology
2. Be committed to “fact-based” decision mak-
ing, which means being committed to get- Managerial epidemiology is defined in various
ting the best evidence and using it to guide ways. Fos and Fine18 defined it as “the study of the
actions. distribution and determinant of health and diseases,
3. Treat your organization as an unfinished including injuries and accidents, in specified pop-
prototype—encourage experimentation and ulations and the application of the study to the pro-
“learning by doing.” motion of health, prevention, and control of disease,
4. Look for the risks and drawbacks in what the design of healthcare services to meet population
people recommend—even the best medi- needs, and the elaboration of health policy.” Fleming
cine has side effects. et al.19,20 defined it as “the application of the tools and
5. Avoid basing decisions on untested but principles of epidemiology to the decision-making
strongly held beliefs, what you have done process within healthcare settings.” Accordingly, man-
in the past, or uncritical “benchmarking” of agerial ­epidemiology entails the use of epidemiologic
what winners do. tools in designing health services and formulating
health policy to meet the needs of target populations.
Because epidemiologic investigations provide criti-
cal ­information to managers and planners regarding
▸▸ 1.6 Epidemiology and the burden of disease in populations and potential
Evidence-Based Management demand for health services, it is “virtually impossi-
ble to develop a comprehensive strategic plan with-
The origins of various approaches to incorporating out ­incorporating estimates of the prevalence of dis-
epidemiologic data into the healthcare management ease.”20 Rohrer21 posited that managerial epidemiology
and decision-making process can be traced back to involves planning for populations rather than individ-
the techniques developed at the Central University of uals, planning for prevention rather than treatment,
­Venezuela in the early 1960s. These techniques were later and planning for health rather than disease. He argued
refined by the U.S. Institute of Medicine by using data that managers are primarily concerned with issues
6 Chapter 1 Epidemiology for Evidence-Based Management

r­ elated to cost, quality, and access; therefore, mana- of investigations would be necessary to
gerial epidemiology needs to draw from clinical epi- c­ ollect data regarding the demographic and
demiology, the study of the determinants and impact socioeconomic characteristics of the target
of clinical decisions. Managerial epidemiology can ­population?
do so by assessing the value of therapeutic and pre- 3. What evidence exists regarding the success
ventive interventions in relation to their costs, qual- of treatment procedures such as artificial
ity, and impact on access to health services. Inclusion insemination and in-vitro fertilization,
of clinical variables in studies related to the cost and where did that evidence come from, and
quality of care can be useful in addressing managerial how good is that evidence?
concerns. The most direct application of clinical epi- 4. What are the size, boundaries, and socio-
demiology to address a managerial concern is in the economic characteristics of the geographic
improvement of healthcare quality through reduction market that would be served by the pro-
of healthcare-­associated complications, morbidity, posed center?
and mortality.20 5. What is the projected volume of assisted
reproductive services that Blue Sky can
expect to provide every year?
▸▸ 1.8 Scenario for Application 6. Who are the competitors for infertility
of Managerial Epidemiology treatment services in this geographic mar-
ket, and what is the current distribution of
The management of Blue Sky Health, a hypothetical market shares among those providers?
healthcare system that operates several urban and 7. What is the projected number of deliver-
rural inpatient facilities and community-based out- ies resulting from infertility treatment ser-
patient clinics in St. Louis, Missouri, is interested in vices and the volume of obstetric services
adding a full-service infertility treatment center to its that Blue Sky can expect to provide at its
portfolio. Blue Sky wishes to have this center go into ­facilities?
operation by early 2020 in the Doctor’s Plaza building 8. What volume of patients and fee structure
adjacent to its main hospital in South St. Louis. for various procedures would be necessary
For planning and marketing the proposed infer- to make the proposed center financially
tility treatment center, Blue Sky would like to con- ­viable?
duct a feasibility study in the fall of 2018. Mark Plato, Through a cursory examination of available liter-
the vice president for planning and marketing, has ature, Mark Plato has collected the following epidemi-
developed a list of epidemiologic questions he would ologic information.
like the feasibility study to address. These questions Currently 7.5 million American women aged
must be addressed before developing amortized pro- 15–44 years—that is, 12.3% of women in this age
jections of fixed and variable costs and determina- group—have impaired ability to get pregnant or carry
tion of a fee structure to achieve a reasonable return a baby to term. Nearly 6.9 million of them—that is,
on investment and a steady revenue stream. He 11.3% of women aged 15–44—have used some form of
believes the study proposal must also identify meth- infertility services.22 Since 2003, there has been a 65%
ods for primary data collection and a list of second- increase in in-vitro fertilization (IVF) in the United
ary data sources. Plato, who had taken a course in States. Every year, approximately 50,000 ­babies—
managerial epidemiology at Lyceum University, real- about 1.6% of all babies born in the ­country—are
izes that many of the questions in the feasibility study born through IVF. In 2013, about 175,000 cycles of
can be answered with the help of concepts, methods, IVF were completed in the United States.23 In a survey,
and techniques described in the chapters of a good 55% of those who had experienced infertility reported
managerial epidemiology textbook. The following is it to be more stressful than unemployment, and 61%
a partial list of questions Mark ­Plato thinks he needs reported it to be more stressful than divorce. Approx-
to have answered by the feasibility study. imately 58% of respondents indicated that because of
1. How common is infertility, and what are the cost and lack of coverage by insurance companies as
geographic, demographic, and socioeconomic an essential health benefit, they would forgo infertility
characteristics of the affected population (i.e., treatment.24 Without assisted reproductive technol-
what is the epidemiology of infertility)? ogy, fertile 30-year-old American women each month
2. If epidemiologic data were not available only have a 20% chance of conceiving.25,26 About 61%
to answer the above question, what kinds of ­single-embryo transfers and 65% of two-embryo
 Case Study 1.1: Impact of Administrative Decisions on Patient Outcomes 7

transfers result in a live birth. Nearly 30% of all IVF source to another or from one agency to the next.
pregnancies and 46% of two-embryo transfers result However, cross-sectional and longitudinal data from
in a twin delivery. Births through assisted reproductive these and other sources can be successfully integrated
technology (ART) pose greater risk for both mother and analyzed to guide managerial decisions. In the
and child than a normal pregnancy. For ­example, United States, some of the most common and use-
women who deliver through ART are much more likely ful sources of epidemiologic and demographic data
to have multiple births than women who conceive nat- ­include the following:
urally. In 2013, more than 160,000 ART procedures 1. U.S. Census Bureau – Census Data (http://
were performed at 467 infertility clinics in the United www.census.gov/2010census/data/)
States, with a use rate of approximately 2,520 proce- 2. National Center for Health Statistics –
dures per million women aged 15–44 years. These pro- ­National Vital Statistics System (https://
cedures involved more than 135,000 embryo transfers www.cdc.gov/nchs/nvss/index.htm)
and resulted in more than 65,000 pregnancies, with 3. National Health Interview Survey (NHIS)
about 66,700 live-born infants.27 The total cost for one (http://www.cdc.gov/nchs/nhis/index.htm)
embryo transfer was estimated to be approximately 4. National Survey of Children’s Health
$48,500, and $90,500 for two-­embryo transfers.24 (NSCH) (http://www.nschdata.org/)
With the help of tools and methods described 5. Health Resources and Services­
in the following chapters and infertility-related epi- Administration – Maternal and Child
demiologic information provided in the preceding Health Bureau (http://mchb.hrsa.gov/)
paragraphs, the student can find answers to Mark 6. Centers for Disease Control and Prevention –
Plato’s questions. Naturally, some assumptions about Behavioral Risk Factor Surveillance System
the size of the geographic market and the number of (BRFSS) (http://www.cdc.gov/brfss/)
competitors in the service area of Blue Sky will have 7. U.S. Census Bureau – American Com-
to be made. At the completion of the course for which munity Survey (https://www.census.gov
this text is being used, the student is encouraged to /­programs-surveys/acs/)
undertake this task and create multiple estimates by 8. Harvard University’s Maternal and Child
changing assumptions regarding population density, Health (MCH) Data Connect – A cat-
socioeconomic characteristics of the population, cost alog of more than 150 sources of data
and coverage of fertility services by insurance compa- (https://­d ataverse.harvard.edu/dataverse
nies, and the size of the service area. /­dataconnect)
9. Cornell University’s National Data Archive
on Child Abuse and Neglect (http://www
▸▸ 1.9 Sources of Epidemiologic .ndacan.cornell.edu/)
Data 10. U.S. Bureau of Labor Statistics – Injuries,
Illnesses, and Fatalities (http://www.bls
A wide variety of demographic, epidemiologic, and .gov/iif/)
socioeconomic data are available on the Internet. As 11. Centers for Disease Control and Prevention –
is often the case with the sources of secondary data, National Center for Injury Prevention and
the type and quality of available data varies from one Control (https://www.cdc.gov/injury/)

CASE STUDY 1.1: Impact of Administrative Decisions on

Patient Outcomes
Modified from: Yarnell CJ, Shadowitz S, Redelmeier, DA. Hospital readmissions following physician call system change: a comparison of concentrated and distributed schedules. Am J Med.
2016;129(7):706–714. Copyright © 2016 with permission from Elsevier.

The physician call schedule is an important determinant of the quality of care at a hospital. However, it also presents a
paradox between two conflicting variables: (1) physician sustainability (i.e., a physician cannot be available at all times)
and (2) continuity of care (i.e., patients prefer to interact with the same physician throughout their hospital stay). In a

(continues)
8 Chapter 1 Epidemiology for Evidence-Based Management

recent study, Yarnell et al. examined the impact of changes in the physician call schedule at an academic tertiary care
hospital by comparing patient readmission rates before and after a change in the call system.
On January 1, 2009, Sunnybrook Health Sciences Center in Toronto, Canada, transitioned from the old
“concentrated” (or “bolus”) call schedule system for all general medicine inpatient physician teams to a new “distributed”
(or “drip”) system. The main feature of the old system was that one team was on call every fourth day and managed all
admissions in that 24-hour period. The main feature of the new system was that admissions were distributed over all
teams every day. The new system entailed a host of additional changes. For example, a different member from each
team was on call each day, and one member from each team was absent postcall each day. The schedule of rotating
attending faculty remained unchanged. The change from the concentrated to the distributed call system was intended
to improve quality and continuity of care by having at least one team member from a given team be present each day.
The general internal medicine service at Sunnybrook comprised four teams—each with an attending physician, a senior
resident, two or three first-year residents, and two or three medical students. Each team was responsible for 15–25
patients.
The researchers identified all consecutive adult patients who were originally admitted through the Emergency
Department at Sunnybrook hospital and were later discharged from internal medicine teams during the 10-year period
(January 2004 through December 2013) and examined whether each patient was readmitted for any reason within 28
days following discharge. Patients discharged for a surgical, obstetric, or psychiatric diagnosis were excluded from the
study.
The study reported that during the 10-year period, 89,697 patients were discharged from the general internal
medicine service, of whom 10,001 (11%) were readmitted within 28 days following discharge, and 4,280 died. The
risk of readmission increased by 26% after the change in the physician call system (from 9.7% readmission rate before
the change in call system to 12.2% after the change; P < .001). Using a computer algorithm (LACE score), the risk of
readmission was adjusted for patient characteristics such as predischarge length of stay in the hospital, total number of
Emergency Department visits in the preceding 6 months, and the Charlson comorbidity index—a composite measure
of the overall effect of all other coexisting medical conditions or diseases a patient might have. To assess whether
increased readmission rates at Sunnybrook were related to the change in the physician call system, Sunnybrook’s
readmission rates were compared with readmission rates at a similar nearby hospital (North York General Hospital)
during the same interval. North York General Hospital is similar to Sunnybrook in all other respects, except it did not
experience a change in the physician call system.
Before the call system change, a total of 37,982 patients were discharged, of whom 1,643 died and 3,675 were
readmitted within 28 days after discharge. After the call system change, a total of 51,715 patients were discharged
of whom 2,386, died and 6,326 were readmitted within 28 days after discharge. The results showed that, even after
adjusting for extraneous factors, increased risk of readmission after the change in the physician call system persisted
across all patient age groups and medical diagnoses. The overall negative impact of change in the physician call system
was estimated to be about 7,240 additional patient days in the hospital. However, no increased risk of patient deaths
was found to be associated with increased hospital readmissions and change in physician call schedule. TABLE 1.1
provides data and assessment of the relative risk of readmission or death within 28 days of discharge before and after
the call system change.

Questions
Question 1. What was the purpose of this study?
Question 2. How does the study relate to managerial decisions?
Question 3. What were the overall findings of the study?
Question 4. What impact, if any, did the management’s decision to change the physician call system have on the
quality of care?
Question 5. How did the investigators ensure that their findings regarding the impact of the physician call system were
not tainted by extraneous factors, such as the characteristics of the hospital?
Question 6. Based on the data presented in Table 1.1, after the change in the call system, how much higher or lower
was the overall risk of readmission or death within 28 days following discharge? Explain your answer with the help of
data shown in Table 1.1.
Question 7. Based on the data presented in Table 1.1, after the change in the call system, how much higher or lower
was the risk of readmission or death within 28 days following discharge for men and for those with congestive heart
failure? Explain your answer with the help of data shown in Table 1.1.
 Case Study 1.1: Impact of Administrative Decisions on Patient Outcomes 9

TABLE 1.1 Readmissions or Deaths Within 28 Days Following Discharge

Before Call System After Call System

Characteristic Change Change Relative Risk (95% CI)

Total 5,318 (14%) 8,712 (17%) 1.20 (1.17–1.24)

Age in Years

18–49 802 (9%) 1,215 (11%) 1.31 (1.21–1.43)

50–64 910 (12%) 1,729 (16%) 1.29 (1.20–1.39)

65–79 1,651 (16%) 2,605 (18%) 1.17 (1.10–1.23)

80 or older 1,955 (18%) 3,163 (20%) 1.10 (1.05–1.16)

Sex

Female 2,624 (14%) 4,206 (17%) 1.16 (1.11–1.22)

Male 2,694 (14%) 4,506 (17%) 1.24 (1.19–1.30)

Medical Diagnosis*

Congestive heart failure 919 (23%) 1,286 (25%) 1.10 (1.02–1.19)

Ischemic heart disease 1,067 (16%) 1,306 (17%) 1.08 (0.99–1.18)

Influenza or pneumonia 537 (18%) 786 (20%) 1.11 (1.01–1.23)

Renal failure 671 (22%) 997 (24%) 1.08 (0.99–1.18)

Fall or fracture 307 (6%) 394 (7%) 1.24 (1.08–1.44)

Stroke or delirium 396 (11%) 746 (16%) 1.36 (1.21–1.52)

Duration of Admission in Days

0–2 973 (11%) 1,942 (13%) 1.21 (1.13–1.31)

3–5 1,310 (13%) 2,167 (15%) 1.21 (1.14–1.29)

6–10 1,190 (14%) 2,035 (19%) 1.32 (1.24–1.41)

11 or more 1,845 (18%) 2,568 (22%) 1.20 (1.14–1.27)

* Selected list, not comprehensive. 1 patient may have had more than 1 diagnosis.
Reprinted from: Yarnell CJ, Shadowitz S, Redelmeier DA. Hospital readmissions following physician call system change: a comparison of concentrated and distributed schedules.
Am J Med. 2016;129(7):706–714. Copyright © 2016 with permission from Elsevier.
10 Chapter 1 Epidemiology for Evidence-Based Management

CASE STUDY 1.2: Epidemiologic Patterns That Can Guide

Policy Decisions
Modified from: Anglemyer A, Miller ML, Buttrey S, Whitaker L. Rates and predictors of violent suicide within military. Ann Intern Med. 2016; 165(3):167–174.

Suicide rates have increased globally in the last half-century, and suicide now ranks as one of the leading causes of
death among those between the ages of 15 and 44 years. In the U.S. military, the suicide rate nearly doubled between
2001 and 2011.
In a recent study, Anglemyer et al. calculated suicide rates per 100,000 active duty enlisted (nonofficer) U.S. military
personnel from 2005 to 2011. The purpose of the study was to examine suicide rates in different years across different
branches of the military and identify personnel at the highest risk. For mortality statistics and demographics, the
researchers used data from the Suicide Data Repository, which combines data from the U.S. Centers for Disease Control
and Prevention and the Military Mortality Database. To obtain the count of enlisted personnel in each branch of the
military in each of the study years, researchers used data from the military. The study did not include suicides committed
outside the United States. Altogether, 1,455 active duty enlisted personnel in the U.S. Army, Air Force, Marine Corps,
and Navy committed suicide during the study period. With 29.44 and 29.15 suicides per 100,000 individuals in 2009
and 2010, respectively, the rates were highest among Army personnel (see FIGURE 1.1). The rates were lowest in the Air
Force and Navy in 2005 (9.95 and 9.79, respectively). More than 95% of suicides were committed by men. Only 1 female
Marine and 9 female Navy personnel committed suicide. Of the 1,455 total suicides, 1,416 were among nontrainees
(TABLE 1.2). As shown in Table 1.2, about 60% of nontrainee suicides occurred in the lower ranks of enlisted personnel
(E1 to E4). In the Navy and Air Force, less than 50% of suicides were in lower ranks, but in the Army, about 66.9% were in
lower enlisted ranks. More than 75% of suicides in all branches were among white enlisted personnel.

Questions
Question 1. What percentage of suicides in the Marine Corps was among lower rank (E1 to E4) enlisted personnel?
Question 2. What percentage of suicides occurred in white Marines?
Question 3. Across various branches, was there much difference in the percentage of suicide by marital status?
Question 4. Across various branches, was there much difference in the percentage of suicides among those who
were never married?
Question 5. What percentage of all suicides occurred in service members who only had a high school diploma?
Question 6. What was the overall number and percentage of female suicides across all branches of the military?
Question 7. Across all branches, what was the overall number and percentage of suicides among those who had
education higher than a high school diploma?
Question 8. Based on the data presented in Table 1.2, what, if any, effect do education and rank have on the overall risk
of suicide in the military and across various branches?
Drawdown in Iraq

50 Troop surge Troop surge

Army in Iraq in Afghanistan
Navy
40 Marines
Air force
Rate per 100,000

30

20

10

2005 2006 2007 2008 2009 2010 2011

Year

FIGURE 1.1 Suicide rates per 100,000 persons (2005 to 2011), by branch of service.
Reproduced from: Anglemyer A, Miller ML, Buttrey S, Whitaker L. Suicide rates and methods in active duty military personnel, 2005 to 2011: a cohort study. Ann Intern Med. 2015;165(3):167–174. Copyright © 2016 American College of Physicians.
All Rights Reserved. Reprinted with permission of American College of Physicians, Inc.
 Case Study 1.2: Epidemiologic Patterns That Can Guide Policy Decisions 11

TABLE 1.2 Characteristics of Suicides Among Active Duty Military Personnel, 2005–2011*

Characteristic Navy (n = 226) Army (n = 744) Air Force (n = 236) Marines (n = 210)

Median age (IQR), yrs. 26 (23–32) 25 (22–30) 26 (22–32) 22 (20–25)

Sex

Female 9 (4.0) 37 (5.0) 13 (5.5) 1 (<1.0)

Male 217 (96.0) 707 (95.0) 223 (94.5) 209 (99.5)

Rank

E1 5 (2.2) 53 (7.1) 4 (1.7) 11 (5.2)

E2 3 (1.3) 73 (9.8) 7 (3.0) 32 (15.2)

E3 26 (11.5) 140 (18.8) 43 (18.2) 77 (36.7)

E4 67 (29.6) 232 (31.2) 63 (26.7) 30 (14.3)

E5 64 (28.3) 120 (16.1) 59 (25.0) 39 (18.6)

E6 45 (19.9) 63 (8.5) 35 (14.8) 14 (6.7)

E7 12 (5.3) 48 (6.5) 22 (9.3) 6 (2.9)

E8 2 (<1.0) 12 (1.6) 3 (1.3) 0 (0)

E9 2 (<1.0) 3 (<1.0) 0 (0) 1 (<1.0)

Race

White 160 (70.8) 560 (75.3) 172 (72.9) 179 (85.2)

African American 33 (14.6) 104 (14.0) 34 (14.4) 14 (6.7)

Asian/Pacific Islander 11 (4.9) 33 (4.4) 6 (2.5) 4 (1.9)

American Indian/Alaska Native 8 (3.5) 13 (1.7) 6 (2.5) 1 (<1.0)

Missing 14 (6.2) 34 (4.6) 18 (7.6) 12 (5.7)

Marital Status

Never married 108 (47.8) 347 (46.6) 82 (34.7) 106 (50.5)

Married 118 (52.2) 353 (47.4) 127 (53.8) 96 (45.7)

Divorced/separated/widowed 0 (0) 43 (5.8) 27 (11.4) 8 (3.8)

Missing 0 (0) 1 (<1.0) 0 (0) 0 (0)

(continues)
12 Chapter 1 Epidemiology for Evidence-Based Management

TABLE 1.2 Characteristics of Suicides Among Active Duty Military Personnel, 2005–2011* (continued)

Highest Level of Education

No high school diploma 22 (9.7) 153 (20.6) 0 (0) 21 (10.0)

High school diploma 181 (80.1) 482 (64.8) 197 (83.5) 179 (85.2)

Some college 9 (4.0) 31 (4.2) 0 (0) 3 (1.4)

Associate degree 4 (1.8) 32 (4.3) 31 (13.1) 5 (2.4)

Bachelor’s or graduate degree 7 (3.1) 22 (3.0) 8 (3.4) 1 (<1.0)

Missing 3 (1.3) 24 (3.2) 0 (0) 1 (<1.0)

Religion

Catholic 32 (14.2) 125 (16.8) 41 (17.4) 44 (21.0)

Protestant 77 (34.1) 296 (39.8) 124 (52.5) 84 (40.0)

Other religion 7 (3.1) 38 (5.1) 9 (3.8) 10 (4.8)

No religion 103 (45.6) 196 (26.3) 54 (22.9) 48 (22.9)

Missing 7 (3.1) 89 (12.0) 8 (3.4) 24 (11.4)

* Values are numbers (percentages) unless otherwise indicated. Percentages may not sum to 100 due to rounding.
Modified from: Anglemyer A, Miller ML, Buttrey S, Whitaker L. Rates and predictors of violent suicide within military. Ann Intern Med. 2016;165(3):167–174. Copyright © 2016 American
College of Physicians. All Rights Reserved. Reprinted with permission of American College of Physicians, Inc.

▸▸ 1.10 Summary allocating resources, and convincing stakeholders

based on empirical evidence. Such ­evidence may be
The materials presented in this chapter introduce the derived from economic, market, and demographic
student to the fields of management and epidemiology data in the service area or may be generated through
and bridge the two disciplines by discussing how quali- targeted epidemiologic investigations.
tative and quantitative data can be used to set priorities In Case Study 1.1, Yarnell et al.28 show the impact
and make evidence-based decisions. There is growing of change in physician scheduling on hospital read-
emphasis on the need for managers to make decisions missions. This study demonstrates how epidemiologic
that are informed by evidence rather than by personal studies can reveal the positive or negative impact of
preferences or anecdotal information. We also explain administrative decisions and can provide evidence
in this chapter what is meant by EBM and how epide- to support a change in policy. In Case Study 1.2,
miologic data that are readily available from a variety ­Anglemyer et al.29 provide comparative information
of sources can be used by healthcare managers. It is on suicide rates in different branches of the U.S. mili-
important that managers find a balance between the tary for different years. These kinds of studies generate
art and science of management—the art of manage- data that reveal the characteristics of high-risk indi-
ment relates to negotiation, compromise, and appreci- viduals. Such data can be used by public and private
ation of the interests of various stakeholders, whereas sector agencies for developing training programs and
the science of management relates to setting ­priorities, marketing resource centers for suicide prevention.
 References 13

References 16. Walsh K, Gundall TG. Evidence-based management: from

theory to practice in health care. Milbank Q. 2001;79(3):
1. Porta M, editor. A dictionary of epidemiology. 6th ed. New 429–456.
York: Oxford University Press; 2014 [cited 2017 Jul 20]. 17. McVey L, Fazzino K, Palmucci J. Evidence-based man­­
Available from: http://irea.ir/files/site1/pages/dictionary age­­ment in healthcare. 2012. White paper [cited 2016
.pdf Mar 18]. Available from: http://healthleadersmedia.com
2. Mausner JS, Kramer S. Mausner & Bahn epidemiology: an /content/276574.pdf
introductory text. Philadelphia: WB Saunders; 1985. 18. Fos PJ, Fine DJ. Managerial epidemiology for health care
3. Webster’s new world college dictionary [Internet]. 5th ed. organizations. San Francisco: Jossey-Bass; 2005.
Boston: Houghton Mifflin Harcourt; 2016. Management 19. Fleming ST, Scutchfield FD, Tucker TC. Managerial
[cited 2017 Jul 20]. Available from: http://websters epidemiology. Chicago: Health Administration Press; 2000.
.yourdictionary.com/ 20. Fleming ST. Managerial epidemiology: it’s about time. J Prim
4. Shenhar AJ, Renier J. How to define management: a modular Care Community Health. 2013;4(2):148–149.
approach. Manage Dev Rev. 1996;9(1):25–31. 21. Rohrer JE. Managerial epidemiology (editorial). J Prim Care
5. Mintzberg H. The manager’s job: folklore and fact. Harv Bus Community Health. 2013;4(2):82.
Rev. 1990;68(2):47–63. 22. Centers for Disease Control and Prevention. Infertility. 2016
6. Leavitt HJ. Corporate pathfinders. Homewood, IL: Dow [cited 2017 Jun 29]. Available from: https://www.cdc.gov
Jones-Irwin; 1986. /nchs/fastats/infertility.htm
7. Liebler JG, McConnell CR. Management principles for 23. Society for Assisted Reproductive Technology. Clinic
health professionals. 4th ed. Sudbury, MA: Jones and Bartlett summary report. 2015 [cited 2017 Jun 29]. Available from:
Publishers; 2004. https://www.sartcorsonline.com/rptCSR_PublicMultYear
8. Haddock CC, Chapman RC, McLean RA. Careers in .aspx?ClinicPKID=0
healthcare management: how to find your path and follow it. 24. Reproductive Medicine Associates of New Jersey. Infertility
Chicago: Health Administration Press; 2002. in America: 2015 survey and report [cited 2017 Jun 29].
9. Mintzberg H. Managers not MBAs. San Francisco: Berrett- Available from: http://www.rmanj.com/wp-content/uploads
Koehler Publishers; 2004. /2015/04/RMANJ_Infertility-In-America-SurveyReport
10. Daft RL. Organization theory and design. 3rd ed. St. Paul, -_04152015.pdf
MN: West Publishing Company; 1989. 25. American Society for Reproductive Medicine. Age and
11. Simon HA. Theories of bounded rationality. In: McGuire CB, fertility: a guide for patients–2012 [cited 2017 Jul 20].
Radner R, editors. Decision and organization. Amsterdam: Available from: http://www.care4ba.com/uploads/Age_and
North-Holland Publishing Company, 1972; p. 161–176 _Fertility_ASRM.pdf
[cited 2017 Jul 20]. Available from: http://innovbfa.viabloga 26. Centers for Disease Control and Prevention, American
.com/files/Herbert_Simon___theories_of_bounded Society for Reproductive Medicine, Society for Assisted
_rationality___1972.pdf And also from: http://pages.stern Reproductive Technology. 2012 assisted reproductive
.nyu.edu/~rradner/publishedpapers/100BoundedCostlyRat technology fertility clinic success rates report. Atlanta: U.S.
.pdf Department of Health and Human Services; 2014.
12. Cohen MD, March JG, Olsen JP. A garbage can model of 27. Sunderam S, Kissin DM, Crawford SB, et al. Assisted
organizational choice. Admin Sci Q. 1972;17(1):1–25. reproductive technology surveillance: United States, 2013.
13. Pfeffer J, Sutton RI. Evidence-based management. Harv Bus MMWR Morb Mortal Wkly Rep. 2015;64(SS11):1–25.
Rev. 2006 [cited 2017 Jul 20]. Available from: https://hbr 28. Yarnell CJ, Shadowitz S, Redelmeier DA. Hospital
.org/2006/01/evidence-based-management readmissions following physician call system change: a
14. Barends E, Rousseau DM, Briner RB. Evidence-based comparison of concentrated and distributed schedules. Am
management: the basic principles. Amsterdam: Center for J Med. 2016;129(7):706–714.
Evidence-Based Management; 2014. 29. Anglemyer A, Miller ML, Buttrey S, Whitaker L. Suicide
15. McAlearney AS, Kovner AR. Health services management: rates and methods in active duty military personnel, 2005
Cases, readings, and commentary. 10th ed. Chicago: Health to 2011: a cohort study. Ann Intern Med. 2016;165(3):
Administration Press; 2013. 167–174.
Other documents randomly have
different content
Correspondence, 1751, P- 3* Country Correspondence, 175 1, p. 4 ;
Extraordinary Occurrences, January 17, 1751. * Extraordinary
Occurrences, March 18 and May 6, 1751. He had about 600
Europeans.
 56 DUPLEIX AND CLIVE came in contact, near a fort called
Valikondapuram,* in July. Each side endeavoured to win the Killedar
over. He, however, very much preferred to admit neither side into his
fort. After a fortnight's negotiations, Gingens lost patience, and,
posting himself between Chanda Sahib and the town, opened fire on
the latter, and carried it by assault, but could not effect an entrance
into the citadel. Next day the French advanced. The English officers
could not decide whether to attack or retreat ; their poor spirit
infected the men ; and after having won an initial advantage,
Gingens retired towards Trichinopoly, with the loss of much
baggage." He fell back on a strong defensive position, but
abandoned this also, after a couple of skirmishes, and withdrew first
to the north bank of the Coleroon, then across the river into the
island of Srirangam, and finally across the Cauvery under the walls
of Trichinopoly. This singularly inglorious campaign marks with the
greatest plainness the signal incapacity of the English commander,
who was also hindered by quarrels and cabals among his
subordinate officers.' The only excuse that can be found is that
offered by Captain Dalton : "To say the truth, we were all young
soldiers, at that time little experienced in the country method of
making war." * If the Enghsh had shown no greater vigour and
intelligence than they had hitherto displayed against the French, in
spite of all the advantages of the command of the sea, they could
never have won India. But the moment had come for them to show
their better qualities. For some time Muhammad Ali had been
proposing a diversion in the direction of Arcot." At first Saunders and
the Council thought this might be effected by Gingens leaving a
sufficient garrison in Trichinopoly and himself marching with the
remainder into the Arcot country. But Gingens was too sluggish, and
denied the possibility of such a course. At that moment Captain Clive
returned from conducting a convoy to Trichinopoly.' Probably
Muhammad Ali had urged the Arcot ' The " Volcondah " of Orme. *
Extraordinary Occurrences, June 17 and 26, 175 1 ; Country
Correspondence, 175 1, p. 41 : " We lost an ensign and five or six
men in the action, and may say all our courage." Orme MSS., India,
v. f. 1062. ' They were also conducting an ajiimated dispute with the
Council aboat the rate of their batta, or allowances in the field. > «
Orme MSS., India, iii. f. 521. ' Country Correspondence, 1751, pp. 42
and 48. • CHvc came out a Writer to Madras in 1744 ; after the
capture of the place he escaped to St. David's and accepted a
commission as ensign. He served
 THE FAILURE OF DUPLEIX 67 plan on him, and he was one
of those men " who see things and their consequences in an
instant." On his return he persuaded Saunders to send him into the
Arcot country with any troops that could be spared. A party of 130
was made up at St. David's and sent by sea to Madras under his
command. There he was joined by 80 more. With these and a few
sepoys he marched on Arcot and, beyond expectation, occupied it, a
body of 3000 native troops retiring before him.^ His object was, if
possible, to raise contributions for Muhammad AU, and at all events
to interfere with the collection of revenue for Chanda Sahib. In his
first object he failed altogether. He marched against two or three
Killedars near Arcot, but could nowhere halt long enough to produce
any effect. Meanwhile he had to look to his own security ; and
although Chanda Sahib's people whom he had driven from Arcot did
not dare to attack him, their flying parties of horse hindered getting
in provisions. 2 In spite of this, however, adequate supplies seem to
have been collected, and CUve resolved to hold the fort in spite of
its large circuit and ruinous defences. The news of this violation of
his capital caused great annoyance to Chanda Sahib. He wrote an
indignant letter of protest to the English, which they ignored ; * and
dispatched troops to expel the intruders. He had, indeed, no
alternative. To leave Clive undisturbed at Arcot would have involved
a loss of revenue which he could ill afford. As was usually the case in
Indian warfare, strategy was at the mercy of finance. But to avoid
weakening the forces at Trichinopoly more than need be, the main
part of the attacking troops were drawn from Pondich^ry. until news
of peace arrived in 1749, and then reverted to Civil employment. He
was named " Steward." The occupant of this post supplied what
provisions were needed either for the Governor's table or for the
garrison. When the troops took the field, the duty of provisioning
them was naturally assigned to Clive. As their numbers swelled, the
employment became unexpectedly advantageous, and Clive thus
founded his fortune. 'Sep. Des. to England, September 30, 175 1 ;
Extraordinary Occurrences and Fort St. David Cons., August 19, 1751
; Country Correspondence, 1755, p. 26. * Extraordinary
Occurrences, September :2, 175 1. It is to be feared that the story
of Clive's sepoys contenting themselves with rice-water must be
given up as a myth, in spite of Sir George Forrest's acceptance of the
story. Clive reports three months' provisions in his magazines in
October (Extraordinary Occurrences, October 7, 175 1 ). The only
contemporary reference which lends the least colour to the story is a
reference to the besiegers " upbraiding " the besieged with their
want of provisions " (French Correspondence, T752, p. lit). *
Extraordinary Occurrences, October 7, 175 1.
 58 DUPLEIX AND CLIVE According to his usual practice,
Dupleix, in default of soldiers, sent out 200 sailors — " tarpaulin
rascalls," as Saunders calls them » — with some sepoys ; and these
were strengthened by a body of Chanda Sahib's horse. The French
detachment was commanded by the Chevaher Mouhy ; ^ and the
troops were accompanied by Raza Sahib, Chanda's son. These
troops appeared before Arcot on October 4, and invested the fort.
Saunders at once endeavoured to reheve the place by ordering
Gingens to leave behind enough troops to defend Trichinopoly and
to march north with the rest. But this was agreeable neither to the
Nawab nor to Gingens ; and Saunders' orders were left
unexecuted.* Another attempt at rehef was made from Madras,
whence a party without guns marched for Arcot. But this was
encountered by a body of the enemy, who forced the relievers with
some loss to take refuge in the fort of Poonamallee ; this party was
subsequently strengthened, but only reached Arcot when the siege
had been raised by other means.* Meanwhile Clive had been more
vigorously beleaguered than had been expected — " We
apprehended nothing further from them than a blockade," wrote a
sergeant who was present in Arcot.* But the enemy kept up a
regular fire which was extremely harassing, and the houses of the
town were so close to the fort walls that Clive had several people
hurt by stones thrown in.* Moreover, the extent of the fort rendered
the duty of the guards so exhausting that he feared his men would
drop with fatigue.' However, as his tottering walls crumbled before
the enemy's fire, he counterworked the breaches when repair was
no longer possible. Raza Sahib, surprised at the obstinacy of the
defence, offered good terms and a considerable present to Clive.
The offer was rejected. Then news arrived of the approach of some
Marathas and of the renewed advance of the English relieving party.
On November 25 • Saunders to Clive, August 25, 175 1 (Orme MSS.,
Various, 287, f. 129). ' Castonnet dcsVosfics, Dupleix, ses derniires
luties, p. 8. But cf. Orme MSS., Various, XV. f. 163, where Goupil is
said to have been in command on November 19/30. ^ Orme MSS.,
India, ii. f. 493 and v. f. 1066; Extraordinary Occurrences, October
30, 175 1. * The first party consisted of 130 Europeans under
Lieutenant Innes, the second was commanded by James Killpatrick
{Extraordinary Occurrences, October 21 and 31, 1751; Saunders to
Qive, October 18, 1751 (Onne MSS., Various, 287, f. 169). ' Orme
MSS., Various, 15, ff. 153, etc. • Loc. cit. ' Extraordinary
Occurrences, October 21, 175 1.
 THE FAILURE OF DUPLEIX 59 the enemy attempted to
storm the breaches. The attempt was made by their sepoys only, for
the French troops took no part in the assault. By this time, Chve had
only 240 men effective,* nevertheless he made good the defence.
After an hour the enemy desisted. That night they withdrew from
Arcot. It was the first conspicuous success the English had obtained
since they had entered the lists against the French. The main body
of the Marathas under Morari Rao moved on to join Muhammad AH
at Trichinopoly ; but they left a body of 1000 horse to co-operate
with Give against Raza Sahib. The small forts near Arcot, which on
Clive's first appearance had defied him, now submitted without delay
; but the Marathas proved intractable aUies, and scattered to
plunder the country, until some of them were attacked and killed by
Raza Sahib's people. Then they joined Clive, who on December 6
marched from Arcot.- On the 14th he came up with the French near
Ami. Here again the French troops failed to distinguish themselves.^
After an action lasting from noon to five o'clock, they retreated ; and
Clive, moving at once on Conjeeveram, occupied it on the flight of
the garrison. The province of Arcot was for the moment clear of the
enemy.* However, they returned as soon as the English troops had
gone into garrison. They marched along the Coast, plundered
Poonamallee and the Mount,* and reoccupied Conjeeveram. Clive
was resting from his labours at St. David's ; but was hastily sent up
to Madras, where luckily a reinforcement of 100 men had arrived
from Bengal. With these, the sepoys he had recently raised, and
drafts from the garrisons of Arcot and Madras, he took the field, with
forces somewhat inferior in infantry to those of the enemy, and with
nothing to oppose to the 2500 horse who marched with the latter.
They had entrenched themselves at Vendalore, 25 miles from
Madras, but on Clive's approach hiu-riedly marched away towards
Arcot in the hope of surprising it. Clive hastened after them, first
towards Conjeeveram, whither he supposed them to have gone, and
then towards Arcot. He came upon them suddenly at Coverypauk as
dusk was falling, and his first warning of their presence was their
artillery opening ' Orme MSS., Various, 15, f. 159, etc. 'Extraordinary
Occurrences, November 22 and 25 and December 2, 1751. * Clive
said their sepoys behaved better (Ormo MSS., India, ii. f. 297). *
Extraordinary Occurrences, Decemt>er 6, l8, and 23, 1751. ' Where
the English had country villas.
 60 DUPLEIX AND CLIVE fire at 250 yards on his advanced
guard. Clive ordered his troops into a deep watercourse on the left
of the road, whence by the hght of the moon the action was
continued. Finding by the report of a sergeant whom he sent to
reconnoitre, that the enemy's rear was unguarded, he detached half
his force to attack them, and himself accompanied the detachment
part of the way. On returning to the men he had left behind, he
found them quitting the watercourse, and could scarcely drive them
back to the position they had deserted. After a tedious interval of an
hour, the sound of musketry in the rear was heard. The detachment
had reached unobserved a position only 50 yards in rear of the
French, whence they had poured in a general volley, which did great
execution and struck the enemy with panic. They fled, abandoning
everything. ^ This uninterrupted course of success won Clive great
reputation. His victories were indeed the only successes which the
English had obtained ; and while his brother-officers felt some
jealousy of his sudden promotion and the contrast between his
achievements and theirs, the soldiers, Europeans and Indians alike,
looked to him as an infallible leader. " I am informed," wrote
Saunders to him shortly after the siege of Arcot, " the Mullahs are
writing a history of the wars of Arcot wherein you will be dehvered
down to future ages." ^ Indeed, he had acquired that reputation for
good fortune which in later years was to give him so remarkable an
ascendancy over the Indian mind. About this time, Muhammad Ah
wrote to him : " By God Almighty's grace you are very lucky in all
engagements ; as you have met with an incomparable success in all
your expeditions, I am well assured that fortune is bent in your
favour. . . ." ^ All this time affairs at Trichinopoly had been dragging
on with great lack of enterprise on both sides. Gingens, although
superior to the French in Europeans,^ had, as we have seen,
crossed the Cauvery and taken refuge under the walls of Trichino»
Clive's narrative, ap. Orme MSS., India, ii. ff. 298, etc. Cf. also the
letter from the French surgeon at Karikal, September 10, 1752
{French Correspondence, 1752). The latter says Very
 THE FAILURE OF DUPLEIX 61 poly. On this Chanda Sahib
and the French crossed the Coleroon and occupied the island of
Srirangam, which hes opposite to the city, but d'Auteuil, who
commanded the French, contented himself with firing on the town
with his larger guns. D'Auteuil was then recalled, and a younger
officer, Law, was sent in his place, with orders to bring the affair to a
rapid conclusion. He crossed the Cauvery without opposition,^ but
then found he had not men enough to invest the city, and contented
himself with establishing posts at a respectful distance from the
place. ■^ Gingens, without a thought of molesting the enemy, wore
his men out by making them sleep on their arms, and thought
wistfully of the protection he might obtain by retiring behind the city
walls.' Towards the close of the year the Marathas arrived, and a
little later a considerable body of Mysore troops, whom Muhammad
Ali had obtained by making great promises. This gave the English a
superiority of native troops ; and they were still about equal to the
French in Europeans, in spite of the reinforcements sent by Dupleix.
But Gingens refused to attack. The Council at last grew weary of this
method of war, which exhausted their funds by keeping men in the
field * without obtaining any of the advantages that had been hoped
for. Immediately after Clive had destroyed the French force in the
province of Arcot, they summoned him to St. David's with all his
forces ; a detachment of 200 men had arrived from Bengal ; and it
was resolved to send all these to Trichinopoly and overwhelm the
French before they could receive reinforcements from Europe. Clive
was about to march with these troops when there arrived the
Durrington, with Stringer Lawrence aboard. He had interviewed the
Directors, induced them to restore the pay they had deprived him of,
and so returned once more to the command of their troops. Within
forty-eight hours of his arrival,^ he had marched to the southward
on his way to Trichinopoly. ' An active oliicer would surely have
endeavoured to defend the line of the river, especially as it was full
and deep. ' I-aw complained that 50CX) men were sent away to
Arcot, and that left him with only 6800. This of course includes all
the native troops of Chanda Sahib. 'Extraordinary Occurrences,
October 7, 1751. * Tlie expense of an army in the field was about
twice as much in mere pay as when it was in garrison. • The
Durrington arrived March 14/25, and the troops set out from St.
David's F March 16/27. ^B March 16/3
 62 DUPLEIX AND CLIVE His arrival was extremely fortunate.
Had Clive commanded the expedition, there would certainly have
been bitter disputes about his rank at Trichinopoly, where none of
the older captains would have served under him/ and where even
the lieutenants would have grumbled about having to obey a man
who had been thrust over their heads by the Council's partiality.
Clive could have ill tolerated the languor and indecision of his
brothercaptains ; while his lack of military experience might have
been urged as a strong reason for not entrusting him with the
command. But Lawrence's arrival solved all these difficulties, and his
authority suppressed any outward manifestations of the jealousy
which certain of the captains undoubtedly felt for Clive. 2 On April 7,
Lawrence arrived lo miles from Trichinopoly. He had with him about
400 Europeans and a body of sepoys whom Clive had raised and
trained in his campaigns round Arcot. On the news of this advance,
Law fell into a state of great indecision. He seems to have leaned to
an immediate retreat into the island of Srirangam ; Dupleix, who
may have under-estimated Lawrence's force, urged an advance to
crush the approaching convoy ; ^ and it is evident that by awaiting
action near Trichinopoly, Law was facilitating the English task of
bringing both parts of their force against him at the same moment.
It is probable that in no case would he have crushed Lawrence, who,
if need were, could have declined battle. But he would have had a
much better chance of doing so had he marched towards him with
his whole force while the convoy was yet at a distance, for he might
have been sure that Gingens would not have followed close at his
heels. Instead, he remained on Trichinopoly plain, sending out a
small detachment which could neither check nor divert Lawrence's
march. On the 9th, Lawrence was joined by a strong detachment
sent out by Gingens ; the French after a considerable cannonade
were unable to prevent his march into Trichinopoly, and could claim
only the empty honour of remaining on the battle-field. » Even
Dalton, an intimate friend of Clive's, and moreover under heavy
pecuniary obligations to him, would only serve under him as a
volunteer. Almost the whole of Clive's military service at this period
was passed on detachment, where the question of his rank could not
be raised by the other captains. The situation closely resembled that
raised by Dupleix trying to give supreme command to Paradis in
1746. ' Notably Gingens and Scrimsour. *See the correspondence
printed by Hamont (Dupleix, pp. 186-188).
 THE FAILURE OF DUPLEIX 63 They were not to wait long
for the results of this junction. Two days after Lawrence's arrival, a
party was sent out by night to beat up Chanda Sahib's camp. The
attempt failed, owing to a mistake of the guide. But it increased
Law's nervousness. Like many other bad officers, he lacked, not
physical, but moral courage. He was confronted by a superior force
and was unspeakably afraid of being beaten. He insisted then on
retreating into the island of Srirangam, so as to put the Cauvery
between him and the enemy. This movement was approved by a
council of war ; so was Peyton's flight from the Coromandel Coast in
1746 ; so was to be Clive's hasty proposal not to advance on Plassey
in 1757. Law's timidity encouraged the Enghsh to a plan which
against an active foe might have led to their undoing. They resolved
to separate their forces, keep part south of the Cauvery under
Lawrence, and send the rest under Clive to take post north of the
Coleroon, so as to besiege Law in his island. The proposal came
from the bold spirit of Clive, and there were not wanting officers
who exaggerated Law's capacity and predicted nothing but failure
from the scheme.^ The decision was taken on April 15, and that
night ^ CUve set out with 400 Europeans, 1200 sepoys, and 3000
horse, ^ and established himself at Samiaveram. The French had
two posts on the north bank of the Coleroon, in the country forts of
Lalgudi and Pitchanda. In the former was a large store of grain,
which was guarded only by a party of sepoys. This Clive carried
against a mere show of resistance; and as Law had found but little
grain in Srirangam, the loss of the magazine at Lalgudi was a serious
blow.* But more serious business was at hand. A convoy was
approaching from Pondichery, under d'Auteuil, whom Dupleix sent
once more to take command. He had with him only 40 Europeans,
but was joined by a party whom Law had sent out to escort him
safely into Srirangam.* Chve had therefore to keep a sharp watch in
both directions — on Law in his island and on d'Auteuil to the north'
On May 4/15 Daltoii wrote to Clive, " I give you joy, my dear friend,
on the success of your scheme, which I think must be utter ruin to
the enemy's army. As everybody almost disapproved of it, you have
all the honour " (Orme MSS., India, iii. f. 664). ' Orme MSS., India, ii.
f. 301, and v. f. 1072. * Ibid., ii. f. 476. * Ibid., Various, 287, f. 29. •
Orme {History, vol. i. p. 222) seems in error when he says d'Auteuil
brought 120 Europeans from Pondichfery. Cf. Dupleix' letter to Law
of April 24 ap. Hamont, op. cit., pp. 194-195.
 64 DUPLEIX AND CLIVE ward ; he seems to have asked
Lawrence to send an additional force across the river ; but Lawrence
refused/ and Clive had therefore to be particularly active and
vigilant. On receiving news that the convoy had with it seven lakhs
of rupees and was at Utatur, Clive made a sudden march that way
by night ; but as the French had heard of his coming, they withdrew
and he returned hot-foot to Samiaveram lest the enemy should
occupy it in his absence. Law did indeed make the attempt, but with
too sinall a party. He sent about 80 Europeans, half of whom were
English deserters. They reached Samiaveram after Clive 's return,
but deceived the sentinels by pretending to be a reinforcement sent
from Lawrence. A confused conflict followed, in which Clive escaped
death by a hairsbreadth ; but the French were overpowered, and
their whole party killed or taken. ^ This affair led to a renewed
apphcation from Clive to Lawrence for assistance, this time urging
him to move his troops into Srirangam, so as to be able to come at
once to his assistance should Law cross the Coleroon ; but Lawrence
pointed out that, should he do so, he would have to leave
unguarded the way southward to Karikal and thus expose the whole
scheme to failure.* However^ he soon after detached a party under
Dalton to attack d'Auteuil, who had returned to Utatur.* This new
detachment encountered the French near that place, and drove
them into it with such vigour that in the following night d'Auteuil
withdrew to a more respectful distance.* Lawrence then recalled
Dalton, but the Coleroon was too high to be crossed, and Dalton put
his troops under Clive 's command * for the siege of Pitchanda, the
only post Law then had on the north bank of the » Lawrence to
Clive, April 13, 1752. Onne MSS., India, ii. f. 458. * This occurred on
the night of April 26-27. The French oificer in command was named
Zilvaiguer : he had with him one Kelsey, an English deserter, to
whom Dupleix had given a commission. He was hung by Lawrence's
orders out of hand. See Dupleix to Saunders, May 18, 1752 {French
Correspondence, 1752) ; Lawrence to Clive, April 16, 1752 (Orme
MSS., India, ii. f. 461).] ^ Clive to Lawrence, Orme MSS., India, iii. f.
662, and Lawrence's answer of April 20 {ibid., ii. f. 463). Mr. S. C. Hill
points out that Orme misdates Clive's letter May, and that it must be
earlier. » The date of this is uncertain. Orme {History , i. p.
226);givcs May 9/20 ; but although this date is supported by
Dalton's Narrative, the Orme MSS. (India, ii. f. 478 and iii. f. 663)
contains letters from Dalton of May 3, 4, and 5. Orme's date is
probably New, not Old Style. » Loc. cit. ' Dalton himself served as a
volunteer. This was the only way in which Uc could participate while
leaving the command with his junior, Clive.
 THE FAILURE OF DUPLEIX 65 Coleroon. This was taken
after a brief cannonade on May 20.^ Lawrence meanwhile had taken
the French post at Coiladi. Law was thus completely shut in. It is
curious that he made no attempt to escape. He had 800 Europeans,
while Lawrence at this moment had but 400, and the Coleroon was
too high for Clive and Dalton to come to his help in case of action. *
He had therefore a reasonable prospect of being able to cut his way
out to the southward. He probably distrusted Chanda Sahib's troops/
but he seems also to have lost all energy and will, and to have made
up his mind that the only possible escape lay in coming to terms
with Muhammad Ah.* He therefore lay without movement in the
pagodas he had occupied. It was the worst possible course he could
have adopted. The capture of Pitchanda enabled Clive to open fire
with his guns on Chanda Sahib's camp. This harassment, combined
with lack of pay and food, determined most of the latter's forces to
leave him, and, when the English promised them a safe-conduct, .
they did so gladly. Many joined Clive. To complete Law's
encirclement the capture or destruction of d'Auteuil's force was still
necessary. Clive therefore marched against him. He hoped to catch
the French in the open, moving towards Srirangam, but d'Auteuil
after beginning to move forward fell back towards Valikondapuram.
The Governor had been won over to the English side ; and when
d'Auteuil was driven within the walls, he was refused admission into
the citadel, and obliged to surrender.* This news produced an offer
from Law to leave half his heavy guns behind and march away to
Pondich^ry. But the English had not beleaguered him so long in
Srirangam only to give up all the fruits of their success. Muhammad
Ali replied that he must surrender at discretion. Meanwhile the
leader of the Tanjore ' See declaration of the French officers
appended to Dupleix' letter of May 31 {French Correspondence,
1752). Orme dates the capture May 16, which is wrong, whether
new or old style. For this service Muhammad Ali bestowed on Clive
the title of Sabat Jang Bahadur (Chatham MSS., i. 99). • Dalton's
Narrative, Orme MSS., India, iii. f. 545. • Dupleix to Law, May 13,
1752 (Plainte du Sieur Law, p. 38). • Op. cit., p. 32. Cf. also Dupleix
to d'Auteuil, May 21, 1752 (ap. Ilamont, op. cit., p. 195), in which he
discusses a possible treaty between Chanda Sahib and Muhammad
Ali. ' This was June 9. The treasure was mostly plundered ; and a
captain's share of the prize-money only amounted to 3000 rupees
(Orme MSS., India, iii. f. 548). At the time of his surrender d'Auteuil
only had 70 Europeans, 400 sepoys, and 300 horse (Orme MSS.,
India, u. f. 477). 5
 66 DUPLEIX AND CLIVE troops with the Nawab offered to
assist Chanda Sahib to escape to Karikal. Chanda Sahib sought Law's
advice, and on June ii a messenger came with pressing letters to
both of them. That evening Law met the Tanjorean within the
enemy's hnes, and demanded a hostage for Chanda Sahib's security.
The other answered " that if he had a mind to break his word, the
hostage would signify nothing," and objected that a hostage would
expose the plan to discovery. However, he took the most solemn
oaths not to betray Chanda. Law at last gave way, and Chanda Sahib
was conducted into the enemy's camp.^ Why Chanda should have
hoped to find mercy from a Tanjorean is hard to discover. He had
been the bitterest enemy of the little kingdom. Time and time again
he had laid it waste, and at least twice besieged its capital. He had
been tne prime enemy of the Hindu principaUties of the south. To
suppose that a man who had so much reason to hate him would let
him go, was to beheve him either inconceivably poor-spirited or
magnanimous beyond what was usual in the East. But the Tanjorean
had never intended to let him go. A thousand horse patrolled the
outskirts of the French encampment to catch him in case he
preferred flight to the Tanjorean offers.* On arriving in his enemy's
camp, he was detained. Next day a conference was held, at which
each of the allies demanded the custody of the prisoner.^ Two days
later Chanda SaJiib was beheaded, in the very choultry, it was said,
where he had taken that false oath by which, sixteen years earUer,
he had secured possession of the town.* On the same day that the
seizure of the French protege was known, Law was again summoned
to surrender at discretion. On June 13 he obtained an interview with
Lawrence, in which the • These details are given in a declaration
made by Law and forwarded by Dupleix to the English with his letter
of July 7 {French Correspondence, 1752). I can see no reason for
suspecting this version of events, which agrees well enough with
what we know from other sources. • Dalton's Narrative, Orme MSS.,
India, iii. S. 549-550. ' In a statement appended to Saunders' letter
to Dupleix of August 22 (French Correspondence, 1752) Lawrence
seems to deny that any conference was held. But I do not think
much weight attaches to this. He expressly says the opposite in his
narrative (Cambridge, p. 28). • Wilks, op. cil., vol. i. pp. 176, etc.
The assertion that Monaji sacrificed a large reward by not facilitating
Chanda's escape is absurd. Chanda's resources were exhausted, and
he probably carried all the wealth he possessed on his person ; while
the French were for the moment discredited. He was beheaded June
14 (Cambridge, loc. cil.).
 THE FAILURE OF DUPLEIX 67 latter reminded him that the
pagodas were not tenable against heavy artillery, and offered as his
only concession to release the officers with their arms and baggage
on parole. With these terms Law was forced to comply. Early next
day an EngUsh detachment marched into the pagoda which the
French had occupied, and as they drew up with bayonets fixed and
colours flying, the French " threw down their arms in a confused
heap before us and were secured under a guard." ^ This surrender
was of great importance. It left Pondich^ry practically undefended
except by a few recruits. But for the peace between the French and
EngUsh Crowns, Dupleix could not have held his chief settlement for
a week. The effect of the news, when it reached France, was to
bring about the recall of Dupleix. The French Governor himself was
fully alive to the disastrous nature of the blow that had been dealt to
his schemes. On June 13, before he had heard of Chanda Sahib's
death or Law's surrender," he wrote to Saunders stating that he had
been authorised by the Subahdar of the Deccan to settle the affairs
of the Camatic by granting possession of Trichinopoly to Muhammad
Ali.^ The EngUsh waited to see how matters went at Trichinopoly
before replying. On June 23, Saunders answered that he was very
ready to promote peace — " Indeed, as Chanda Sahib is dead, I can
see no reason why it may not be easily accompUshed." * But
Dupleix demanded the release of all prisoners as a preUminary to
discussing terms.* In other words, he invited the EngUsh to deprive
themselves of their principal advantage over him, and to restore him
to his former military strength, before he had bound himself to any
terms. Saunders decUned to negotiate on such conditions. The war
therefore continued. No doubt the diplomacy of Dupleix was
stiffened by the knowledge that he was on the eve of receiving
considerable reinforcements. On July 28 two ships reached
Pondich^ry with 500 soldiers aboard.* The EngUsh had meanwhile
been greatly embarrassed by a breach between Muhammad Ali and
the King of Mysore. It suddenly appeared that the Nawab had only
secured Mysorean help by promising to cede Trichinopoly. He now
evaded performance of his promise under various pretexts. The
EngUsh • Law's declaration ut supra, and Dalton's Narrative (Orme
MSS., India, iii. £. 552). ' He might have heard of d'Auteuil's capture
on June 9. • French Correspondence, 1752. * Letter of June 12, ibid.
' Letter of July 7, ibid. • Hamont, op. cit., p. 216.
 68 DUPLEIX AND CLIVE had not been consulted in the
negotiations, and were not concerned from a moral standpoint to
secure the performance of the agreement. But the quarrel was
inconvenient poUtically. It involved leaving a good garrison in
Trichinopoly. With less reason it was thought that the absence of the
Mysorean troops involved a diminution of military strength. But,
neither against the French before Trichinopoly, nor afterwards
against the English, when Mysore had definitely changed sides, does
it appear that these troops were capable of any other service than
terrifying unprotected convoys or plundering unguarded countries.
After delaying for about a fortnight in the hope that the dispute
might be composed, Lawrence left Trichinopoly under the command
of Captain Dalton, and himself marched with the rest of his army to
Tiruviti, whence a watch could be kept on the French movements at
Pondich6ry. About this time there had arrived at Madras, Major
Kinneer, an oificer who had served in the Royal army, and who was
to comrnand next under Lawrence. He was naturally burning to
emulate the feats of Clive and his chief ; and unluckily for him
Saunders had resolved to adopt a proposal of Muhammad Ali and
besiege Gingee.^ In spite of Lawrence's urgent protests, Kinneer
was sent with a couple of hundred Europeans and some sepoys —
with a much smaller force, that is, than had been engaged when the
French escaladed the place two years before. Kinneer found an
attack out of the question, and in his withdrawal he encountered a
body of French whom he engaged without duly reconnoitring their
position. He suffered severe loss in his attack, himself being
wounded, and retreated in haste. Soon after he died of fever
heightened by disappointment. ^ Lawrence quickly redeemed this
misfortune. He proceeded from Madras, whither he had gone to
protest against the futile attempt on Gingee, and took command of
the troops at Tiruviti. He then moved towards the French on August
28, but they fell back towards Pondichdry, and contented themselves
with preventing any attempt on their forts of Valudavur and Gingee,
although the English ravaged the country forming the new French
acquisitions. Finding he could not bring the French ' This seems to
be the only case in whicli Sauntlers' good sense deserted him. ^
Shortly before this the English troops had been exceedingly
discontented, almost to the point of mutiny (Matlras Ltrs. Reed.,
1752. No. 135) ; but it does not appear that this affected Kinneer's
expedition — at least I can find no allusion to its having been
supposed to have done so.
 THE FAILURE OF DUPLEIX 69 commander, Kerjean, to
action, Lawrence then fell back on Bahur. Kerjean moved after him,
presumably in order to cover the French territories from further
ravage ; but moved too far and too close to the English, who, in the
early morning of September 6, fell upon their camp, slew many, took
the commander and 15 officers with 100 men prisoners, and
captured all their guns and baggage. This victory at Bahur reduced
the French to miUtary inactivity for the next six months, * while the
Enghsh hold on the Carnatic was strengthened by Clive's capture of
French posts at Covelong and Chingleput. But though incapable for
the moment of military effort, Dupleix displayed great diplomatic
activity. He busily widened the breach between the Mysoreans and
Muhammad Ali, and set to work to detach the Marathas under Morari
Rao from his enemies. Both attempts succeeded to his desire. The
latter was merely a question of money or credit. In December the
Maratha chief, who had hesitated for a time after the French defeat
at Bahur, joined the French on condition of receiving a lakh and a
quarter of rupees a month. In the following February an agreement
was made with the Mysoreans which was a real diplomatic victory.
On condition of Dupleix furnishing troops and munitions for the siege
of Trichinopoly, Nandi Rajah, the principal minister and real director
of the State, agreed to pay down four lakhs of rupees, to pay eleven
lakhs more on the capture of the place, to meet the expenses of the
troops engaged there, and to find three lakhs annually for the
French Company.^ These astounding terms were obtained by the
pressure Dupleix was able to exercise through the presence of
French troops in the Deccan, and the control exercised by Bussy
over the policy of the Subahdar, Salabat Jang. Unless Mysore agreed
to the French terms, Salabat Jang was to have enforced his claim to
tribute by an invasion. A third diplomatic operation which Dupleix
carried out at ' Historians have diUcreil about the responsibility for
this action, some saying Dupleix orilercd Kerjean to come to action,
others that Kerjean was burning to distinguish himself before his
expected supersession by the arrival of his senior, Ija. Touche. I
beUeve neither version to be correct. Dupleix distrusted the
steadiness of his recruits too much to be willing to risk an action
(see his letter of August 7, ap. Hamont, op. cit., pp. 218-219), and
Kerjean was so far from eager to achieve military renown at this
moment that he was demanding his recall from Dupleix with much
urgency (sec Dupleix' letter to him of August 30, French
Correspondence, 1752). I conclude that the action resulted from his
inadvertently putting himself within Lawrence's reach. • Cultru, op.
cit., pp. 316, etc.
 70 DUPLEIX AND CLIVE this time was less successful. On
the death of Chanda Sahib, Dupleix seems for a moment to have
contemplated standing forth himself as Nawab of the Carnatic.^ But
his need of money, if nothing else, rendered this inadvisable. Chanda
Sahib's son, Raza Saliib, also lacked resources to help the French in
their struggle with the English. Dupleix therefore turned to an old
candidate for the Nawabship of Arcot — Murtaza Ali Khan the
Killedar of Vellore, he who had murdered Nawab Safdar Ali Khan and
was beUeved to have murdered Safdar All's son. He was reputed
rich, and Dupleix reckoned that his ambition would induce him to
pay lavishly for French support, while his fortress of Vellore would
form a base of operations from which to attack and weaken the
EngUsh hold on the province of Arcot. Murtaza Ali fell in with these
plans so far as to accept the title, to visit Pondich6ry early in 1753,
and to contribute five lakhs to the French exchequer. But his
suspicious and tortuous mind was too acute not to see the danger
he ran of becoming a puppet in the hands of the French Governor.
He departed, convinced, as Orme says,^ that he had met a more
cunning man than himself. He declined to receive a French garrison
into his fortress,' and did no more than plunder territory round Arcot.
A year later he made his peace with the EngUsh. Meanwhile, military
affairs had been very much at a standstill. Dupleix still had a body of
some 500 Europeans at his disposal, but their quality was not such
as to warrant an engagement on anything like equal terms with the
English, in spite ^of their being supported by Morari Rao's
horsemen, who were far more than a match for the wretched cavalry
with which Muhammad Ali suppUed the EngUsh . In Januciry the
French marched from Valudavur and took up a position near Tiruviti,
where they protected their camp with a ditch and rampart, a glacis,
and raveUns to cover the re-entering angles.* Lawrence lay near
them. Various skirmishes followed with the Maratha horse, who
harrassed every convoy that brought money from Fort St. David. But
the French withdrew on the only occasion when the two armies
came in sight of each other ; * and the French ' He had received a
grant as such from Salabat Jang in 175 1. It is printed in Lettres et
Conventions, p. 256. Sec also the extract of a letter from Bussy
dated July 13, 1752, ap. Mimoire pour le Sieur Godeheu, p. 58. *
History, vol. i. pp. 275-276. » " A renunciation of the Koran would
sooner have been agreed to by him " (Orme to Holdemcsse, March i,
1756) (Orme MSS., Various, 17, f. 296). ♦ Mil. Cons., 1753. p. 56. »
Ibid., p. 53.
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