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Block 12 Flashcards

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1
Q

name the 5 big CAMs

A 
Chiropractic
Osetopathy
Acupuncture
Herbal medicine
Homeopathy
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2
Q

Most used CAM

A

Chiropractic

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3
Q

least used CAM

A

Homeopathy

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4
Q

Which 2 CAMs have statutorys regulation of professionals

A

Chiropractic

Osteopathy

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5
Q

Number of people using chiropracters a year

A

7.5 million

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6
Q

Number of people using acuptuncture a year

A

3.1 million

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7
Q

Number of people using homeopathy a year

A

1.3 million

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8
Q

3 ways people can access CAMS?

A

Self-referral
GP referral
NHS professional referral

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9
Q

Most common way of accessing CAMS

A

Self-referral (70%)

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10
Q

What % of CAMs use if GP referal

A

17%

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11
Q

Ways of financing CAMs

A

Self
NHS
Other

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12
Q

What % of CAMs is financed on NHS

A

14%

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13
Q

CAMS is mostly accessed through what and funded through what?

A

Self-referral

Self funding

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14
Q

68% of CAMS is used for what kinds of problem:

A

MSK

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15
Q

Effectiveness gap =

A

An area where there is a lack of efficacy for treatment

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16
Q

What % of people believe there is an effectiveness gap for msk problems?

A

95%

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17
Q

The key principles that underline CAM use for msk problems can be shown by what model?

A

Biopsychosocial model

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18
Q

biological side of CAMs:

A 
Manipulation 
Moblisation
Massage
Guided movement
Acupuncture
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19
Q

Psychological aspects of CAMs

A

Communication
Compassion
Changing beliefs/perceptions
Promote self-efficacy

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20
Q

Social aspects of CAMs

A

Advice on adjustments

Promote back to work

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21
Q

NICE guidelines for lower back pain:

A
  • Don’t offer acupuncture

- Consider manual therapy (massage, manipulation)

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22
Q

Why don’t NICE offer acuptuncture for LBP?

A

> 0.5 placebo effect with sham needling

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23
Q

NICE guidelines for headache:

A
  • Consider course of 10 sessions of acupuncture for chronic tension-type headache
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24
Q

NICE guidelines for osteoarthritis =

A
  • Do not offer acupuncture

- Manipulation and stretching core treatments

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25
Q

Why do we need research ethics?

A

Historical examples
Social and political trends towards increased autonomy
Legislation
Research ethics codes

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26
Q

Historical examples of why we need research ethics =

A

Nazi medical experiments
Tuskegee syphilis study
Alderhey
Wakefield

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27
Q

Name some legislations which are related to research ethics involving humans/human tissues

A

Human Rights Act

Human tissues act

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28
Q

Name 2 research ethics codes of conduct

A

Numremberg Code

Helsinki declaration

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29
Q

Nuremberg code comprises a set of principles concerning research with

A

Humans

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30
Q

Nuremberg code states that research with humans should be:

A
  • Voluntary consent
  • Avoid all unneccessary physical and mental suffering
  • Be done by scientific qualified persons
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31
Q

Helsinki declaration requires what

A

Any form of human research to be subject to independent ethical review

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32
Q

Why is human research more tricky than some others?

A

Need for consent
Respect autonomy
Reduce harm

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33
Q

Which research subjects are important in research ethics?

A

Vulnerable - children, mentally ill, reduced capacity

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34
Q

6 key principles of research ethics =

A
  1. Usefulness
  2. Necessity
  3. Risk
  4. Consent
  5. Confidentiality
  6. Approval
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35
Q

Usefulness =

A

Is the study likely to find something new?

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36
Q

Necessity =

A

Does the study need to be done on humans/this particular group?

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37
Q

Risk in research should be

A

Minimised, outweighed by potential benefits

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38
Q

Consent =

A

Getting permission from a person before involving them in research project

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39
Q

Why is consent important?

A
  • Respects patients autonomy

- Less likely to cause harm

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40
Q

Consent must be

A

Informed

Voluntary

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41
Q

How can we aid informed consent?

A

Giving patient information sheets

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42
Q

How to facilitate consent =

A 
Patient info sheet
Clear, avoid jargon
Summary of key points
Time for patient to ask questions
TIme to think about/decide
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43
Q

Human tissues act =

A

Consent for stoarge and use of tissue for ‘schedules purposes’ required for tissue from living or deceased persons

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44
Q

Why is confidentiality important?

A

Autonomy
Aids good care
Reduces harm - stops info getting in hands of wrong people
- Trust

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45
Q

Guidlines for confidentiality in research =

A
  • All info confidential
  • Anonmyised/coded
  • Stored securely
  • Accessed on need to know
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46
Q

When is research ethics approval needed?

A

Humans
Human tissue
Personalised data

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47
Q

When is research ethics not normally needed?

A

Clinical audit

Service evaluations

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48
Q

Why do we need ethics approval?

A 
Ensure research adheres to ethical principles
Protects patients
Protects researchers
Minimises negligence claims
Keeps integrity of profession
Legal
Publication.funding
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49
Q

Who is approval needed from?

A

NHS - if used patient data or facilities

Uni faculty/research ethics committee

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50
Q

What do RECs consider when looking at an application?

A
  • Purpose and scientific/ethical important
  • Potential risks
  • Consent procedure
  • Vulnerable groups involved
  • Method of recruitment
  • Use of patient info sheet
  • Storage procedure/confidentiality
  • Likelihood of achieving aims
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51
Q

Process of EBDM =

A
  • Answerable question
  • Search
  • Critical appraisal
  • Make a decision: evidence, resources, patient preference, clinical experience
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52
Q

PICO =

A

Patient, problem, population
Intervention
Control, comparator, comparison
Outcome

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53
Q

When you have a factor you cannot control, what type of question do you use?

A

PEO

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54
Q

PEO =

A

Patient
Exposure
Outcome

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55
Q

Study for diagnosis question =

A

Cross-sectional study

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56
Q

Study of aetiology question:

A

Cohort

Case-control

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57
Q

Study for prognosis question:

A

Cohort study

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58
Q

Study for treatment question:

A

RCT

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59
Q

Study for evaluation question:

A

Qualitative research

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60
Q

Systematic reviews =

A

Type of literature review that uses systematic methods to collect secondary data, critically appraise and synthesise studies.

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61
Q

Benefits of SR over individual primary studies =

A

Include all avaliable evidence
Research that is unpublished/not in English language journals
- Increases total sample size
- Meta analysis
- Indicate variation among studies
- Permit subgroup and sensitivity analysis

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62
Q

Subgroup analysis =

A

Evaluation of treatment effects for a specific end point in subgroups of patients defined by baseline characteristics

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63
Q

Sensitivity analysis =

A

Asks whether results are sensitive to quality of the research (e.g. what happens if we only look at 10 strongest trials)

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64
Q

Error =

A

Difference between average values in study population and average values in true population

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65
Q

Bias =

A

Systematic introduction of error into a study that can distort the results in a non-random way

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66
Q

We should assess a research study for:

A

Bias
Limitations
Values
Applicability

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67
Q

3 discrete questions when assessing study results:

A

Are the results valid
What are they
Can I apply them to my patient?

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68
Q

Validity =

A

Do the results represent an unbiased estimate of the treatment effect or have they been distorted in a systematic fashion to lead to a false conclusion

69
Q

How might results be presented in an RCT?

A

Report relative risk reductions, absolute risk reduction, odds ratio, NNT (numbers needed to treat), confidence intervals

70
Q

Relative risk reductions =

A

relative decrease in the risk of an adverse event in the exposed group compared to an unexposed group.

71
Q

NNT =

A

number of patients you need to treat to prevent one additional bad outcome

72
Q

How might results be presented in a study looking at diagnosis?

A

Sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, confidence intervals

73
Q

How might results be presented in a study looking at prognosis?

A

Report how likely the outcomes are over time and how precise the prognostic estimates are (relative risks or odds ratios), confidence intervals

74
Q

How might results be presented in a study looking at aetiology?

A

• Harm/aetiology

Report relative risk, odds ratio, NNH (numbers needed to harm), confidence interval

75
Q

NNH =

A

indicated how many persons on average need to be exposed to a risk factor over a specific period to cause harm in an average of one person who would not otherwise have been harmed.

76
Q

What makes a study generalisable/particularisable

A

Population similar to patient
Resources/service
Cost, risks

77
Q

What provides the frame work to empower and protect people who may lack capacity to make decisions for themselves?

A

Mental capacity act (2005)

78
Q

5 Statutory principles of the mental capacity act:

A
  1. Presumption of capacity
  2. Right to be supported to make own decision
  3. Right to make eccentric or unwise decisions
  4. Anything done on behalf of patient must be in best interest
  5. Least restrictive interventions
79
Q

How might you determine a patient’s best interest?

A

Advance statement of wishes
Look at previous decisions
Talk to family
Least restrictive option possible

80
Q

Criteria for mental capacity =

A

Understand
Retain
Use/weigh up
Communicate decision

81
Q

Capacity is specific to what?

A

The time

The task

82
Q

What does ‘ability to understand’ mean

A

Patient must not be able to understand, not sufficient that they don’t understand (this may just be communication)

83
Q

Considerations for patients ability to use/weigh up

A

Importance is that they can, should not be based on how the information is weighed up

84
Q

How is a doctor to make a decision when a patient is deemed to lack capacity?

A

Advanced decision/directive
Best interest
Least restrictive possible

85
Q

2 types of advanced care planning

A

Advanced statement of wishes

Advanced decision/declaration

86
Q

Which type of advanced care planning is legally binding?

A

Advanced directive/decisions

87
Q

Advanced directives are specific to (wishes of treatment/refusal of treatment)

A

Refusal of treatment

88
Q

An AD is legally binding if:

A

Applicable to that circumstance
>18
Informed, specific

89
Q

Refusal to life saving treatment must be

A

Written, signed, witnessed

90
Q

Pros of ADs

A

Encourage openness and forward planning
Patient autonomy
Reduces anxiety about unwanted treatment
Legal right to refuse treatment

91
Q

What can patient’s not refuse?

A

Basic care

92
Q

Cons of ADs

A

Difficulties varifying whether opinion has changed
Ascertaining circumstances are what patient forsaw
Can patients ever truely be informed?
Coercion

93
Q

If a person lacking capacity is very happy why should an AD apply?

A

Dworkin - experiential vs critical interests.

ADs preserve critical

94
Q

Experiential interests =

A

First hand experiences

95
Q

Critical interests =

A

Across time, values, the kind of life we want to live

96
Q

Why might some say an AD shouldn’t be resepected for someone who undergoes severe personality changes?

A

Personal identity argument - numerically different due to changes psychologies.

97
Q

Why should practice be research informed?

A
  • Personal experience is bias
  • Medical knowledge is incomplete
  • Research involves application of the scientific method
  • Recommendations assessed for cost/clinical effectiveness
  • Standardise care
98
Q

Describe the research cycle:

A

Clinical problem - basic research - applied research - clinical care

99
Q

Clinical problems can be:

A

Observational
Association
Prognosis

100
Q

What can we use to decide whether a clinical problem is important for research?

A

Priority setting partnerships - identify problems by doctors/public

101
Q

Ex of a priority setting partnership

A

James Lind Alliance

102
Q

2 practice gaps identified:

A
  1. From bench to bedside - going from basic research into cinical trials
  2. Implementation gap - from trial to clinical practice/policy
103
Q

What can help with the gap between basic and clinical research

A

MRC - medical research council

104
Q

What may help in gap between research and practice?

A

NICE

105
Q

Characteristics of what may make barrier to uptake of evidence?

A

Recommendation
Adopters
Organisational/structural

106
Q

Recommendation characteristics which may be barrier to uptake =

A

Complex
Requires new skill
Doesn’t fit with existing norms

107
Q

Recommendation characteristics which may facilitate uptake:

A

Simple/easy to understand

Fit with existing norms/values

108
Q

Adopter characteristics which may be barrier to uptake:

A

Knowledge - lack of knowledge, too many guidelines
Attitudes - percieved patient resistance, doubt credibility, reliance on trusted sources
Skills and abilities

109
Q

Organisational characteristics which may be barrier to uptake:

A

Limitations: time, resources
Culture: behaviourm norms
Social norms: team norms

110
Q

What may help change social norms in an organisation?

A

Opinion makers/influential team leaders

111
Q

What can help get evidence into practive:

A

Quality improvement

112
Q

QI aims to:

A

facilitate the uptake and continued use of evidence-based policy.

113
Q

QI should be:

A 
Interactive
Involve all
Empower staff
Foster a culture of change
Provide knowledge
Remove barriers
114
Q

QI initiatives targeting organisations:

A 
Revision of professional roles
MDT
Skill mix
Setting of delivery
Financial incentives
115
Q

QI initiatives targeting health care professionals:

A 
Education
Outreach visits
Local opinion leaders
Reminders
Multi-factoral
116
Q

Name 2 financial incentives for QI

A

CQUIN

QOF

117
Q

CQUIN =

A

Commissioning for quality and innovation

118
Q

What does CQUIN do?

A

Links a proportion of providers incomes to QI initiatives/achievement of goals

119
Q

Example of CQUIN initiatives:

A

Reduce impact of serious infection
Improve staff wellbeing
Reduce disease from risky behaviours

120
Q

QOF =

A

Quality and outcomes framework

121
Q

QOFs target

A

GP

122
Q

Do QOFs work: yes

A

When removed, improvements stable

123
Q

Drawback of QOFs

A

Small detrimental effects on aspects not incentivised

124
Q

Most common policy to manage waiting lists =

A

Some form of maximum wait

125
Q

Current maximum wait in England

A

18 weeks

126
Q

Current maximum wait in Denmark

A

4 weeks

127
Q

Implementation of maximum wait can differ:

A
  1. Target and sanctions
  2. Choice, competition, private sector
  3. Prioritisation
128
Q

Countries which implement target and sanctions

A

England

Finland

129
Q

Countries which implement choice and competition

A

Denmark
Netherlands
Portugal

130
Q

Countries which implement prioritisation

A

Australia
New Zealand
Canada

131
Q

England 2000-2005

A

Maximum wait time guarantee

Penalty: higher chance of hospital managers losing job

132
Q

What might penalties cause:

A

Fraud
Misprioritisation of patients
Counter intuitive

133
Q

Mis-prioritisation of patients =

A

Once the target has passed, no incentive to treat patient proptly and probablity of being seen decreases

134
Q

NHS constitiution (2010) patient entiltlements:

A

Right to access care within max waiting time (18 weeks)

135
Q

DoH expects what % of patients to be treated in target

A

90%

136
Q

Breach of targets in England can result in what

A

Up to 5% reduction in that specialties funding for month of breach

137
Q

Management of waiting lists in Denmark =

A

4 week wait regardless of disease
If hospital cannot fulfil max. wait, can go to another private or public at the expense of region
DRG tariff - profitable to keep patients in country

138
Q

New Zealand system:

A

Booking:

  1. Booked, treated within 6 months
  2. Certainty of treatment within 6 months
  3. Active care, review - sent back to GP
139
Q

In NZ, patients waiting time depends on

A

Need

Ability to benefit from specialist

140
Q

What helps Canada and NZ assess need?

A

Priortisation tools

141
Q

Prioritisation tools can be

A

Expensive to develop

142
Q

Prioritistation tools help

A

Rules be applied in a consistent way

143
Q

Australia prioritisation of patients:

A

3 urgency groups;

(1) Less than 30 days  deteriorate quickly, may become an emergency
(2) Less than 90 days  some pain, not likely to become emergency
(3) Less than 365 days  minimal or no pain, does not have the potential to become an emergency

144
Q

Norway prioritisation f patients:

A

(!) Emergency

(2) Elective with individual maximum waiting time
(3) Elective without maximum waiting time

145
Q

Unconditional wait guarantees are

A

Easy to operate

Contradict proritisation

146
Q

Conditional wait guarantees are

A

Difficult to operationalise

Do not contradict prioritisation

147
Q

Confounding =

A

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

148
Q

A confounder may:

A

Increase apparent relationship

Decrease apparent relationship

149
Q

A variable is not a confounder if -

A

No association with exposure
No association with outcome
On the causal pathway between outcome and exposure

150
Q

Which type of studies are most subject to confounding?

A

Observational studies: cohort, case-control

151
Q

RR >1

A

Risk higher in exposed group

152
Q

RR <1

A

Risk lower in exposured group

153
Q

RR = 1

A

Risk the same in both groups

154
Q

Risk differnece +ve

A

Risk higher in exposed

155
Q

Risk difference -ve

A

Risk lower in exposed

156
Q

4 ways to reduce confounding

A

Restriction
Matching
Stratification
Multiple variable regression

157
Q

Restriction and matching are a feature of

A

Design

158
Q

Stratification and multiple variable regression are a feature of

A

Analysis

159
Q

Restriction =

A

Limiting sample group to eliminate confounding

160
Q

Problems with restriction =

A

Less data collected/greater study needed for same amount
Wasteful
Difficult when you have many confounders

161
Q

Matching is most commonly used in what type of study

A

Case-control

162
Q

Matching is good for

A

Strong confounders (age, sex)

163
Q

Problems with matching =

A

Still need to consider confounding in analysis

Not on its own an answer to confounding

164
Q

Stratification =

A

Analyse exposure-outcome relationship in sub-groups associated with confounder. Adjust for confounder

165
Q

Adjustment gives a

A

Weighted average of the effect seen in each stratum

166
Q

Limits of stratification -

A

Eventually run out of data to fill strata

167
Q

in y=a+bx b is the

A

gradient/regression coefficient

168
Q

in y=a+bx a is the

A

Y-intercept

169
Q

Multiple regression coefficent, like stratification allows for

A

Adjustment

Health and society (6 decks)

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