Block 12 Flashcards
All research studies shld be assessed for:
Bias
Applicability
Limits
Value
3 discrete steps of critical appraisal
- Are the results of the study valid?
- What are the results? - statistics e.g. RRR, NNT
- Can the results be applied to the specific patient of interests care?
Cons of critical appraisal
time-consuming
Pros of critical appraisal
- improves healthcare quality - closes gap btwn. research and practice
- systematic analysis of validity of results + hence usefulness of research study
Define disability
restriction or inability to do something as a result of an impairment
Define impairment
A physical loss/functional deficit
impact of disability on a patient’s life
- loss of independence + freedom
- frustration + anger at having to rely on other ppl
- anxiety/depression
- unemployment
- difficulty accessing buildings
- limited choice of activites
- loss of self-esteem + confidence
Occupational therapy role in reducing risk of falls
- assess home for hazards: loose rugs, pets, cluttered home etc.
- assess whether pt. has fear of falling + help them to break cycle of inactivity tht further increases falls risk
- assess side effects of any medications on cognitive functioning
Podiatry role in reducing risk of falls
- reccommend appropriate footwear + orthotic devices
- calf + ankle exercises for strengthening
Confounding
distortion of the association between the independent and dependent variables because a third variable is independently associated with both
Outline ways to reduce the effect of confounding variables
- randomisation
- restriction
- matching
- stratification
- linear/logistic regression
Primary prevention of stroke is
avoidance of disease before development of any signs or symptoms
Secondary stroke prevention is
avoidance of disease progression or later problems e.g. death
Outline some methods for primary prevention of stroke
- stopping smoking
- reducing alcohol consumption
- healthier diet
- increased physical activity
Outline some methods for secondary prevention of stroke
- Antiplatelet meds - Aspirin + Clopidogrel to reduce the risk of stroke recurrence
- Antihypertensives - manage BP
- Statins
- Anticoagulants
What are the effects of targeting high risk groups for prevention?
Larger potential benefit to individual
Smaller effect on population rate of stroke
Many of the conditions you treat are asymptomatic
May of the treatments have side effects
Non-modifiable and modifiable risk factors for stroke:
Non-modifable
- older age
- male gender
- race - Asian
- FHx
Modifable
- high BP* - most important by far for cerebral haemorrhage
- diabetes
- atrial fibrillation
- smoking
- hyperlipidemia
- obesity
- low physical activity
Outline some risk factors for falls
Muscle weakness
History of falls
Gait deficit
Balance deficit
Visual deficit
Arthritis
Impaired activities of daily living (ADL)
Cognitive impairment
Age - >80 years
Medical conditions - PD, stroke, hypotension, depression, epilepsy, dementia,
arthritis, peripheral neuropathy, dizziness and vertigo
In which care settings are the risk of falls increased?
Residential/Care homes
Risk factors for hip fracture
- low BMD
- long-term corticosteroid use
- ethnicity
- being female
- low body weight
- psychotropic drugs
- smoking
- Fhx of hip fracture
What did the PROGRESS trial show? (Stroke)
reducing BP reduces chance of stroke recurrence (secondary prevention)
Implementation gap
Gap between scientific understanding and patient care
What does quality improvement involve?
Foster environment where improvement and innovation are viewed as normal
Empowering staff to strive for change
Provide knowledge and methods to implement change
Remove barriers to change
- engages participants across organisational levels
- interactive + iterative i.e builds on knowledge you already have
Give some examples QI initiatives targeting organisations
- Revision of professional roles
- Introduction of multi-disciplinary teams
- Changes in skill mix, or in the setting of service delivery
Financial incentives- CQUIN, QOF
Guidelines
Outline the QI improvement cycle (PDSA cycle)
P - plan
D - do
S - study, analyse data
A - act, evaluate data and decide on nxt step
Give some examples QI initiatives targeting networks
- facilitate auditing + benchmarking cycles to regularly assess current practice + identify variations
- Network recognition for high-quality practice - talking to colleagues from other departments
- Promote inter-institutional communication and collaboration, can implement competition to motivate improvement
QI initiatives targeting HCPs
- Educational meetings
- Local consensus processes to identify or prioritise interventions
- Educational outreach visits
- Local opinion leaders
- Reminders (written, verbal)
- “Tailored” approaches, such as focus groups or surveys, to identifying specific barrier
What makes a QI initiative effective?
Mutlifaceted interventions that act at different levels of barriers to change:
- shld be tailored to key barriers
- patient mediated - encouraged pts. to challenge doctors
What is QOF?
Quality outcomes framework
- annual financial incentive for GP excellence
Compares delivery and quality of care against previous years
What are the aims of QOF?
Aims to improve standards of care by assessing and benchmarking the quality of care patients receive
Outline the evidence for financial incentives
- they offer small improvements but at the expense of another factor tht might not have been measured
- when incentives are removed performances lvls generally remain stable
Barriers to evidence implementation
Characteristics of reccomendations
- may be complex
- may require new skills
Characteristics of adopters:
- may not trust credibility of source
- may already have a trusted/convenient information source
- may feel as though their are a tsunami of guidelines i.e too many too read
Characteristics of organsations
- may be limited by time, resources, equipment
- social influence - if the most influential ppl in the org don’t like the reccomendation may be harder to follow
- organisational culture - current values, attitudes + behaviour of the organisation
What is QI?
Quality improvement
- facilitates the uptake + continuing use of evidence based medicine by focussing on reccurent problems within care systems
aims to improve:
performance - in terms of the systems outcomes for patients
professional development - support clinicians
service-user outcomes
Why are waiting times important?
Because their a major source of patient dissatisfaction + uncertainty
Supply in healthcare will depend on:
- availability of healthcare professionals
- availability of beds
- availability of infrastructure
- capacity of operating theatres
Need in healthcare will depend on
- general health status of the population
- the technology available
- the more there are new treatments available
Outpatient waiting time
time between being referred by your GP to a specialist
Inpatient waiting time
time between specialist assessments and starting specialist’s recommended treatment
In the UK outpatient + inpatient waiting time is combined to give
referral to treatment waiting time
Why is waiting time more important compared to waiting list?
because you can have a very long waiting list but if the waiting time is short then patient satisfaction is improved
Most common waiting time policy
introduction of a maximum waiting time:
- Sanctions if these aren’t met (Eng, Fin)
- option to switch to a different healthcare providers if this target isn’t met (Denmark, Netherlands, Portugal)
Unintended effects of sanctions for waiting times:
- may mean pts. with less severe problems treated quickly over others just to meet target
- higher probability of being treated as pt. approached max wait target
- lower probability of being treated the more the pt. passed the max wait
In 2010 NHS constitution introduced target: ‘max wait from GP referral to treatment’ how long was this?
18 weeks
- expectation tht 92%-95% of pts. shld be treated within this target
- breach of these targets - reduction of up to 5% of revenues for relevant speciality in month breach occurs
- initial reduction in waiting times but have been rising since pre COVID
Which agency in Finland was used to help regulate waiting times
Valvira - National Supervisory Agency
had authority to penalise municipalities tht failed to comply
BUT this had a “rubber band” effect - any time supervisory regime was lessened, waiting times increased
Outline the basis of Denmark’s policies to reduce waiting times
Choice-based policy
if hospital cannot fufil max wait → pt. can choose to receive treatment in another public or private hospital
expected max wait declined significantly aft 2002 and these have been sustained
What info can you gather from visiting a pt in their home?
- their socioeconomic status
- whether they are caring for themselves
- whether they are a carer for anyone else
- how they are taking their medication and where they store it
- mobility and how it affects their ADLs i.e are they able to get up the stairs
- any cold or damp that may be causing respiratory symptoms
Immediate manifestations of grief
- Denial
- Fluctuating mood/depression
- Preoccupation
- Agitation
- Blame
- Bargaining
- Guilt
- Numbness
5 main complementary therapies:
Acupuncture - Fine needles are inserted at certain sites in the body for therapeutic or preventative purposes
Chiropractic - Spinal manipulation aims to treat ‘vertebral subluxations’ which are claimed to put pressure on nerves
Herbal medicine - Medicines with active ingredients made from plant parts
Homeopathy - Based on the use of highly diluted substances, which practitioners claim can cause the body to heal itself
Osteopathy - Moving, stretching and massaging a person’s muscles and joints
MAIN barriers to CAMs on NHS:
- mixed effectiveness => not all are evidence-based
- regulation issues
- resistance to change
Which complementary therapy is most used for MSK problems?
Osteopathy
What is osteopathy mainly used to treat?
Back pain
Repetitive strain injury
Changes to posture in pregnancy
Postural problems caused by driving or work strain
The pain of arthritis and sports injuries
What does the NICE guidelines state about acupuncture in lower back pain, osteoarthritis, and headaches?
SUMMARY: for low back pain + osteoarthritis do not offer acupuncture but for headaches + migraines can consider course
Low back pain - Consider manual therapy, do not offer acupuncture
Osteoarthritis - Manipulation and stretching should be considered as an adjunct to core treatments, do not offer acupuncture
Headache/migraine - Consider a course of up to 10 sessions of acupuncture over 5-8
weeks
What are the criticisms of the evidence for acupuncture?
- effect is too small and not clinically relevant
- similar effects in pain reduction are seen when comparing NSAIDs vs placebo vs acupuncture for chronic back pain
What is the evidence for acupuncture?
- acupuncture correlated with physiological measurements i.e with decreases in brain flow
- acupuncture showed effectiveness compared to sham or no treatment for low back pain indicating it has more than placebo effect
- acupuncture showed no difference in effectiveness when compared to conventional therapies
- acupuncture shows an overall effect compared to usual care
Effectiveness gap
clinical area where available treatments are are not fully effective or satisfactory for various reasons including lack of efficacy, adverse effects and acceptability to patients
Things that might impair decision making abilitiies (think capacity, there are 5 main categories)
- cognitive impairment e.g. dementia
- lack of insight => Person suffers from some disability but seems unaware of the existence of their disability
- presence of psychosis
- severe depressive symptoms
- learning disability
Why is it important to support patients in DM?
- respects patient autonomy
- professional requirement of GMC
- legal requirement of Mental Capacity Act 2005
- patient are generally happier if they can make their own decisions
- improves doctor-pt relationship
How might doctors assist patients in decision making?
Using a different form of communication
Providing information in a more accessible form
Treating a medical condition affecting the person’s capacity
Having a structured programme to improve a person’s capacity
According to the Mental Capacity Act 2005 when can does a person lack capacity?
A person LACKS CAPACITY IF unable to:
Understand information that may be relevant to the decision, including the consequence
Retain information, even for a short time
Use or weigh information to make decisions
Communicate decision
What determines the response of a carer to a dementia diagnosis?
- nature of the carer-patient relationship
- how the patient reacts
- their understanding of the illness
What are the pros of advanced directives?
- respects patient autonomy
- encourages forward planning
- pts will be less anxious about unwanted treatments
- may lessen healthcare costs as patient will opt for less aggressive treatment
What are the cons of advances directives?
Difficult to verify if the patient’s opinion has changed since making AD
Difficult to ascertain whether the current circumstances are what the patient
foresaw when making AD
Possibility of coercion on behalf of the patient
Possible wrong diagnosis
Can patients imagine future situations sufficiently vividly to make their current decisions adequately informed?
Numremberg code 1947
early code for research ethics principles:
- need for voluntary consent
- avoidance of all unnecessary physical/mental suffering+injury
- conducted only by scientifically qualified ppl
List some basic research ethics principles that should be considered
- fairness - who will it favour
- risks - shld be minimal
- confidentiality - respects pt’s information
- consent - valid, informed, voluntary + competent
- usefulness
- has sought + gained approval from ethics committee
3 things needed for consent to be valid
- voluntary
- informed
- patient competent
What might a doctor do to facilitate gaining valid consent from a patient?
- presentation of information in a way tht’s easy to understand
- summary of keys points
- opportunity to ask questions
- time to decide
How might we increase confidentiality levels?
- encrypt identifiable info
- securely store info
- limit access to identifiable info
- properly dispose/destroy i
What is an ethics committee
body of ppl responsible for ensuring medical experiments + human research is carried out in an ethical manner in accordance with international + national law
Why does research need ethics approval?
- to protect participants
- to protect researches
- many publishes won’t accept research if it is no ethically approved
- researches won’t be covered if claim against them made
- won’t be eligible for financial support
Examples of research ethics committees
- NHS research committee
- MOD => Ministry of Defence research committee
- HEI => higher education institution research comittee
- Social care research committee
According to the Human Tissues Act 2004, when would you not need consent for use of human tissue from living patients?
- when the human tissue will be anonymous to the researches
- when the research has ethics approval
