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Phase I: H&S > Block 12 > Flashcards

Block 12 Flashcards

1
Q

What type of study design would best help to answer a question about evaluation/acceptance of therapy? + Give an example question

A

“What do patient’s think of this therapy?”

Study design: qualitative research (systematic review / meta-synthesis also possible)

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2
Q

What type of study design would best help to answer a question about diagnosis? + Give an example question

A

“What is the best test to diagnose…?”

Study design: cross-sectional analytic study (systematic review also possible)

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3
Q

What type of study design would best help to answer a question about aetiology of disease? + Give an example question

A

“What causes this disease?”

Study design: cohort study or population based case-control study (systematic review also possible)

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4
Q

What type of study design would best help to answer a question about prognosis? + Give an example question

A

“What is going to happen if…?”

Study design: cohort study (systematic review also possible)

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5
Q

What type of study design would best help to answer a question about efficacy of treatment? + Give an example question

A

“What is the most effective way to treat…?”

Study design: RCT or systematic review of RCTs

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6
Q

What are the potential benefits of systematic reviews over individual primary studies?

A
  • include all the available evidence to answer a question
  • include unpublished research and non-english language publications
  • increase the total sample size (and so increase levels of certainty and precision)
  • indicate heterogeneity among studies
  • permit sub-group analyses
  • permit sensitivity analyses
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7
Q

What is bias?

A

The systematic introduction of error into a study that can distort results in a non-random way

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8
Q

What four aspects of a research study are assessed in an appraisal?

A
  • bias
  • applicability
  • limits
  • value
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9
Q

What is the point of appraising studies?

A

To identify whether the evidence the study provides is useful for answering your clinical question

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10
Q

What are the three discrete steps to appraising a study?

A

3 questions:

  • are the results valid?
  • what are the results?
  • can I apply the results to my specific patient’s care?
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11
Q

What is study validity?

A

The believability / credibility of the results

Do these results represent an unbiased estimate of the truth, or have they been influenced in some systematic fashion to lead to a false conclusion?

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12
Q

What questions do you need to ask when considering the generalisability of study results to your patient/population?

A
  • how similar are the patients in the study to my patient/s?
  • can the local health service provide the intervention / diagnostic test that has been studied?
  • what are the potential benefits and costs of the intervention? (including potential harms, financial implications of the intervention, and opportunity cost to others)
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13
Q

What should you consider when appraising whether a systematic review has tried to identify all relevant studies?

A
  • hand-searching
  • contacting authors / experts
  • non-english language searches
  • unpublished materials searches
  • which databases were used
  • if there was follow up from reference lists
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14
Q

What would make it more likely that a systematic review had only included high quality studies?

A
  • individual studies assessed for quality
  • quality assessment carried out by more than one reviewer
  • use of standardised review criteria to assess quality
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15
Q

What should you consider when assessing whether a systematic review has reasonably combined study results?

A
  • are the results of each study clearly displayed?
  • are the results similar from study to study? (look for tests of heterogeneity)
  • were reasons for variations in results discussed?
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16
Q

What should you consider about the results when appraising a systematic review?

A
  • how are the results expressed (e.g. OR, RR, etc)
  • how large is the size of the result
  • how meaningful is the result
  • how would you sum up the results in one sentence?
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17
Q

What should you consider when assessing the precision of a systematic review result?

A
  • were confidence intervals reported?
  • would you make the same decisions based on the upper confidence limit as you would on the lower confidence limit?
  • is a p-value reported if confidence intervals are unavailable?
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18
Q

What should you consider when assessing if the findings of a systematic review can be applied to your patient/s?

A
  • is the sample population different to your patient/s in a way that would produce different results?
  • does your setting differ much from that of the review?
  • can you provide the same intervention as the review in the setting that you are in?
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19
Q

When considering the important outcomes of a systematic review, the reviewers should consider the outcomes from the point of view of…

A
  • individual patients
  • policy makers and professionals
  • family/carers
  • the wider population
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20
Q

What is the maximum “Referral to Treatment” (RTT) time in England? How many patients should be treated within the target timeframe?

A
  • 18 weeks

- 90% (Dep. Health)

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21
Q

What does the NHS Constitution (2010) say about wait times?

A

The patient has the right to access services within maximum waiting times

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22
Q

What are unconditional max. wait time guarantees? Are they good?

A
  • wait time is same for everyone
  • easy to operationalise
  • contradict clinical prioritisation
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23
Q

What are conditional max. wait time guarantees? Are they good?

A
  • wait time is conditional on something e.g. clinical need, severity of prognosis, likely benefit or other factor
  • difficult to operationalise
  • permit prioritisaton
24
Q

How can you manage wait times in healthcare?

A
  • set targets
  • incentivise people to meet target (e.g. reward or sanction)
  • give value to patient choice and include the private healthcare sector
  • prioritise how long people wait depending on specific factors e.g. clinical need (2ww for sup. cancer vs. 18ww for susp. OA)
25
Q

What are the five statutory principles of the mental capacity act (2005) ?

A
  • presumption of capacity
  • right to be supported to make their own decisions
  • right to make eccentric or unwise decisions
  • best interests
  • least restrictive intervention
26
Q

What is mental capacity?

A
  • the ability to make a particular decision at the time the decision needs to be taken
  • must be able to understand, retain, and use or weigh the information given about the decision and then communicate their decision
27
Q

What are advance decisions to refuse treatment? ( = advance directives)

A
  • an advance refusal for a specific treatment in the event that the individual does not have capacity to decide at the time
  • cannot refuse basic care
  • must be valid and applicable to be legally binding
28
Q

What are the pros of advance decisions?

A
  • respects autonomy
  • encourages openness and forward planning
  • provides a legal right to refuse treatment
  • patient’s may be less anxious about receiving unwanted treatments in the future
29
Q

What are the cons of advance decisions?

A
  • difficulties verifying that the patient’s opinion has not changed since the AD was made
  • hard to ascertain that the current circumstances are what the patient foresaw when they made the AD
  • risk of patient being coerced into making an AD
  • question as to whether patients can imagine future situations sufficiently vividly to make an informed decision about the future
30
Q

What are critical interests?

A

things that really matter to a person, for example: relationships, personal identity, faith, valuing independence, valuing health etc

31
Q

What are experiential interests?

A

things that people may enjoy or not enjoy doing day to day, for example: like going to the cinema, dislike going to the dentist

32
Q

When critical interests oppose experiential interests, which takes precedent?

A
  • Critical interests will take precedent

- e.g. don’t like the experience of going to the dentist, but critically value your health so you will go

33
Q

What ethical dilemma does Dworkin pose re: advance directives?

A
  • If a person loses capacity should the critical interests they held when they were well, over-rule the experiential interests in the present?
  • e.g. If a life-long vegetarian gets diagnosed with dementia a year later requests a bacon sandwich for lunch, should it be given?
34
Q

Outline the personal identity argument against advance directives?

A
  • ADs should only be binding if the person making out the AD is numerically identical to the patient in the present (e.g. patient with advanced dementia)
  • The writer of the AD and the patient are not numerically identical because their psychologies are radically different
  • Therefore ADs should not be binding for people with dementia
35
Q

What are the big five complimentary therapies?

A
  • chiropractic
  • osteopathy
  • acupuncture
  • herbal medicine
  • homeopathy
36
Q

Which CAMs are statutory regulated?

A

chiropractic and osteopathy

37
Q

Which CAMs providers are registered professionals?

A

chiropractors and osteopaths

38
Q

How many consultations per year across the CAMs big five?

A

21 million

39
Q

Approximately how many chiropractic and osteopathy consultations per year?

A

7.5 and 7.3 million

40
Q

What percentage of the UK population access a CAM practitioner appointment each year?

A

12-16%

41
Q

What percentage of adults use some form of CAM in the UK?

A

20-28%

42
Q

How do people access CAM treatment and what is the potential problem with this?

A
  • 70% access CAM through self-referral

- potential to miss medical red flags if the therapist is not sufficiently trained

43
Q

How are the majority of CAM therapies financed?

A

67% self-financed

44
Q

For which conditions are CAM most frequently used?

A
  • MSK 68% (mainly back pain)
45
Q

Which types of CAM have evidence-based indications?

A
  • chiropractic and osteopathy for low back pain +/- sciatica
  • acupuncture for chronic tension-type headache and back-pain
  • herbal medicine: specific preparations for specific conditions e.g. St Johns Wort for mild/moderate depression
46
Q

What is confounding?

A

When a relationship between an exposure and an outcome is distorted by their shared relationship with something else

47
Q

How can confounding be addressed in study design and analysis?

A
  • restriction (exclusion)
  • matching
  • stratification
  • multiple variable regression
48
Q

How does restriction affect studies and the effect of confounding?

A
  • must be designed in
  • exclude participants with confounding factors
  • less data
  • difficult to operationalise when there are multiple confounders
49
Q

How does matching affect studies and the effect of confounding?

A
  • must be designed in
  • most common in case-control studies: cases and controls are matched on the possible confounder e.g. deprivation
  • useful for strong confounders (e.g. age, sex) but confounding must still be considered in the analysis
50
Q

How does stratification affect studies and the effect of confounding?

A
  • possible to add in at the analysis stage
  • involves analysis of exposure:outcome association in different subgroups of the confounder (e.g. deprivation) to determine a measure of the confounder’s effect
  • can adjust for confounding if number of variables involved is relatively small, but not for lots of variables at once
51
Q

What are the gaps in getting evidence into practice?

A
  • identifying need for knowledge
  • discovery of that new knowledge
  • synthesis of knowledge
  • application of knowledge
  • development of routine clinical actions or policy
52
Q

What is the first gap in translation?

A

Basic research to late clinical trials

53
Q

What is the second gap in translation?

A

Health technology assessment to healthcare delivery

54
Q

What are potential facilitators of uptake of evidence?

A
  • recommendation is easy follow, and compatible with existing norms and values
  • social influence of immediate team and influential peers
55
Q

What are potential barriers to uptake of evidence?

A
  • recommendation requires new skills, and/or is complex
  • lack of awareness of need for change
  • over-estimation of self-performance
  • negative attitudes towards the source of evidence, e.g. doubting credibility, overvaluing or reliance on other trusted/convenient sources
  • time constraints
  • limitation of necessary resources
  • organisational culture not compatible with intervention
  • social influence of immediate team and influential peers
56
Q

Outline the quality improvement cycle

A 
Plan
Do 
Check/Study
Act
Set new standard

Phase I: H&S (12 decks)

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