Block 12 - part 2 Flashcards
confounding factor
distortion of the relationship between an exposure and outcome due to shared relationship with something else, can either increase associated between exposure and outcome, or decrease association between exposure and outcome
4 ways of limiting confounding
restriction, matching, stratification, multiple variable regression
restriction
limit participants of your study who have possible confounders - means will have less data so difficult with multiple confounders
matching
create comparison group that is matched on the possible confounder, make case and control group as similar as possible on the confounder and then ask about exposure status
when is matching used
for strong confounders such as age and sex
stratification
analyse exposure:outcome association in different subgroups of the confounder, recombine data and use a weighted average of the strata
limitations with stratification
to take into account all confounders would require lots of strata and you may run out of data to fill all possible options in your strata
multiple variable regression
adjust for effects of multiple confounders, try and produce a linear model between outcome and different exposures - allows for adjustment of estimates for confounding
standardisation
way to limit confounding, often used to control for differences in age groups when comparing rates of disease in two populations with different age structures
standardised mortality ratio (SMR)
ratio between the observed number of deaths in a study population to the number of expected deaths
calculation for SMR
SMR = Observed (number of deaths)/expected (n.o.d)
direct standardisation
required we know the age-specific rates of mortality in all populations under study
indirect standardisation
only requires that we know the total number of deaths and age structure of the study population
when is indirect standardisation preferable
small numbers in particular age groups
why do we have waiting lists
limitless demand for health, limited resources
importance of waiting times to patients
patients condition may deteriorate while waiting, effectiveness of proposed treatment may be reduced, waiting itself can be distressing, adverse effect on family life, employment circumstances
ways to measure waiting times
average waiting time (mean.median), proportion who waited longer than x number of days, average wait of people currently on the list
theories of NHS waiting lists
backlog - implies need of occasional emergency injection of funds, demand management - waiting acts as a price to deter frivolous use, allows NHS resources to be fully employed, waiting lists are caused by underfunding and inefficiency
4 ways to reduce NHS waiting ties
manage deman, manage the queue, manage capacity, provide leadership
manage demand (reduce NHS waiting ties)
ensure each referral represents the most appropriate decision for the care of the individual patient
manage the queue (reduce NHS waiting ties)
ensure waiting lists are well managed and patients are called for treatment in appropriate order
manage capacity (reduce NHS waiting ties)
provide efficient and effective services that meet the level of demand from appropriate referrals
provide leadership (reduce NHS waiting ties)
ensuring all parts of the local NHS work together to acheive waiting time improvements in the best interests of patients
2000-2008 targets and terror
performance management of trusts and PCTs based on achievement of target waiting times, hospitals receive an overall performance score and managers could lose their jobs if targets missed
pros of targets and terror
no inpatients waiting over 3 months, outpatients reduced, significant increased expenditure alongside this, however funding has now remained constant so NHS is struggling despite increased demand
cons of targets and terror
sacrifice of professional autonomy - managers pressure drs to treat less urgent because of waiting times, unmeasured performance sufferers - things without target may suffer, adverse behavioural responses - emergency patients waiting in ambulances not classed as being in A&E until through door, data manipulation and fraud
possible criteria for priority on a waiting list (6)
clinical urgency, clinical severity, potential health gain, productivity and ecnomic loss, equity waiting, length of time witing
social impact of deafness
difficult to have conversations, isolation, intimacy issues, problems at work
psychological impact of deafness
anger, low confidence, frustration, depression, embarrassment
practical issues with deafness
doorbells, phones, theatre/cinema, TV, alarms
3 ways stroke can affect communication
aphasia, dysarthia, dyspracia
social consequences of speech and communication difficulties
not expressing self = isolating, depression, frustration, tiring, may not be able to participate in activities they used to enjoy
medico-legal implications for people with epilepsy
determination of fitness to drive/other dangerous activities, determination of intent for criminal activities
rules for driving with epilepsy
group 1 (cars, motorbikes) - seizure free for 12 months group 1 (HGVs) - seizure free and no antiepileptic medication for 10 years
new rules to whether people with epilepsy can drive depend on
only have seizures while they sleep, seizures don’t affect their consciousness, dr changed dose/meds but have now gone back to original
CAMs
complementary and alternative medicine
5 types of CAMs
acupuncture, chiropractic, herbal medicine, homeopathy, osteopathy
acupuncture
fine needles inserted at cetain 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 from plant parts
homeopathy
based on use of highly dilated substances, which practitioners claim can cause the body to heal itself
osteopathy
moving, stretching and massaging a person’s muscles and joints
underlying principles with CAMs
self-healing is triggered, longer term effects may be due to physiological and behavioural changes integral to treatment, each therapy has it’s own mechanisms whicha re mostly poorly understood
percentage of CAMs covered by the NHS
10%
barriers to CAMs on the NHS
regulatory issues, financial concerns in NHS, tribalism, inertia, mixed evidence of effectiveness
reasons for CAMs to be provided by the NHS
patient choice, preventative healthcare agenda, commissioning changes, personal budgets, growing evidence base
complementary therapy used most in MSK problems
osteopathy
what is osteopathy used mainly to treat
back pain, repetitive strain injury, changes to posture in pregnancy, postural problems caused by driving or work strain, pain of arthritis and sports injuries
What do chiropractors mainly treat
back, neck and shoulder problems, joint, posture and muscle problems, leg pain and sciatica, sports injuries
acupuncture used to treat
MSK patients, fertility/pregnancy, neurological pain, depression, eczema, chronic pain, irritable bowel
why do people use acupuncture
effectiveness gap - clinical area where available treatments are not fully effective or satisfactory for various reasons
reasons for effectiveness gap
lack of efficacy, adverse effects, acceptability to patients
evidence base for acupuncture
acupuncture correlated with physiological parameters, can be seen as having an overall effect vs usual care, more effective than no treatment or sham treatment for lower back pain, more and better research needed
criticisms of acupuncture
effect too small and not clinically relevant,
NSAIDs commonly given for back pain - NSAID vs placebo and acupuncture vs placebo have similar effect for pain reduction
NICE guidelines for CAMs management of lower back pain
consider manual therapy, do not offer acupuncture
NICE guidelines for CAMs management of osteoarthritis
manipulation and stretching should be considered as an adjunct to core treatments, do not offer acupuncture
NICE guidelines for CAMs management of headache/migraine
consider a course of up to 10 sessions of acupuncture over 5-8 weeks
