Block 31

Question 1

State 6 key aspects of TB control.

Answer 1

1) Effective surveillance to monitor disease and outbreaks.
2) Prompt identification and treatment of disease.
3) Ensure patients complete treatment (poor compliance an issue).
4) Targeted prevention (BCG)
5) Screening for increased risk groups entering the UK (CXR).
6) Focus on key populations (migrants and deprived urban communities).

Question 2

State 4 opportunities for controlling the spread of TB.

Answer 2

1) Increase awareness amongst those working with high risk groups (housing support, migrants, prisons, substance misuse projects).
2) Identify and educate high risk groups.
3) Make public information readily available (online, leaflets in different languages).
4) Interpreters for non-english speaking patients.

Question 3

1) What is the goal of vaccination?
2) What are the strategic aims of vaccination?
3) What are the programmatic aims of vaccination?

Answer 3

1) To decrease morbidity and mortality from vaccine preventable infections.
2) Selective protection of the vulnerable, elimination (herd immunity) and eradication.
3) Prevent deaths, infection, transmission and clinical cases.

Question 4

Describe 3 groups of people who should receive a BCG vaccination.

Answer 4

1) Neonates (0-4 weeks) at high risk.
2) Those at high risk <16 years old who would have qualified for a neonatal BCG.
3) HCPs who have patient/ specimen contact.
4) Those who are in contact with someone who has active TB.

Question 5

State the 5 components of the WHOs strategy for TB control.

Answer 5

1) Government commitment (political will and centralised system for TB monitoring)
2) Case detection by sputum smear
3) Standardised treatment regimen (observed by HC worker for at least 2 months)
4) Stable and reliable drug supply
5) Standardised recording and reporting system

Question 6

What is a patient pathway?

Answer 6

The route that patients will take from 1st contact with health services to the finalisation of treatment.

**Patient pathways are useful to guide clinicians

Question 7

1) What would cause a neonate to be at high risk of TB?
2) Routine TB vaccination is not recommended for who?
3) How do you identify those <16 years old who are high risk?

Answer 7

1) One or more parent or grandparent born in a high-incidence country/ FHx of TB in the last 5 years.
2) 10-14 year olds.
3) Offer Mantoux testing and give a BCG is Mantoux test negative.

Question 8

State 5 ways that people can access health services.

Answer 8

1) GP
2) Self-referral (A&E/ online/ 111)
3) Social services/ local authority
4) Emergency (ambulance)
5) Educational institution (through welfare)
6) Dental practitioner
7) Charity/ community programmes
8) Lay-referral
9) Pharmacists

Question 9

State Zola’s 5 triggers to health-seeking behaviour.

Answer 9

1) Interference with work/ physical activity
2) Interference with social relations
3) Assigning time limits
4) Interpersonal crises (death/ divorce)
5) Sanctioning

Question 10

State 4 barriers to health seeking behaviours.

Answer 10

1) Inverse care law (poor areas = less provision)
2) Geographical distance (timely, transport costs)
3) Previous bad experiences (staff, waiting times, negligence?)
4) Childcare (availability/ costs)
5) Psychological factors (refusal to believe, worry, lack of education).
6) Perception/ evaluation of symptoms as harmless.

Question 11

Name 3 ways that barriers to health seeking behaviours can be mitigated.

Answer 11

1) Quality improvement
2) Community outreach programmes
3) Transport

Question 12

What will quality improvement to mitigate barriers to health seeking behaviours involve?

Answer 12

Identify barriers, implement change, audit with PDSA cycles (think about systems from a user’s perspective).

Question 13

Describe how community outreach programmes can help to mitigate barriers to health seeking behaviours.

Answer 13

Increase provision in the community rather than centralised provision which might be difficult to access.

Question 14

Describe how transportation can help to mitigate barriers to health seeking behaviours.

Answer 14

Volunteer drivers, discounted hospital buses, patient transport service.

Question 15

Why should NHS performance data be publicly available?

Answer 15

1) Public scandals increase pressure for outcomes to be published and used.
2) Other public sectors (schools/police) make this info. readily available.
3) Expectation is to collect outcome data and publish it

Question 16

Give 3 pros of publicly available performance indicators.

Answer 16

1) Increased information about healthcare providers.
2) Informs patients and increases and encourages choice.
3) Transparency = increase trust in healthcare providers.
4) May identify outliers which an learn from hospitals with decreased mortality.
5) Information is quantitive, so gives a clear numerical figure.

Question 17

What did the Keogh report publish?

Answer 17

Patient safety was published as hospital standardised mortality ratios (SMRs) which are the wrong approach to identifying efficacy of care.

**See cancer card set for limitations of SMRs.

Question 18

What types of strategies are beneficial in supporting behaviour change?

Answer 18

Advice from HCPs:

• Low salt/ cholesterol diet
• antismoking interventions (NRT, Buproprion, Varenicline)
• Exercise advice

Question 19

What types of strategies are ‘likely to help’ in supporting behaviour change?

Answer 19

Counselling to increase activity level
Self-help materials
Telephone advice service on smoking cessation

Question 20

What types of strategy are ineffective/ harmful in supporting behaviour change?

Answer 20

Acupuncture in smoking cessation

Anxiolytics in smoking cessation

Question 21

What is a population strategy of prevention?

Answer 21

Targeting all people within a population with a preventative measure no matter their risk for a disease in order to lower the risk of the whole population.

**The population strategy aims to shift the distribution of a risk factor in the entire population whereas the high-risk strategy targets individuals in the population who are at highest risk of disease and might benefit most from prevention.

Question 22

What are the positives to a population strategy of prevention?

Answer 22

There is a large potential to prevent more deaths from occurring.

Question 23

What are the negatives to a population strategy of prevention?

Answer 23

• There is small individual benefit.
• There is a low benefit:risk ratio so intervention must be very safe.
• Participants might have poor motivation (why do I need to make this change if I’m already at low risk?)

Question 24

What are the most widely accepted risk tables?

Answer 24

Joint British Societies (JBS) 10-year CVD risk prediction charts are most widely accepted.

Question 25

How were the Joint British Societies 10-year CVD risk prediction charts generated?

Answer 25

• Based on data from Framingham Study (cohort study) looking at heart disease risk factors and outcomes.
• 10,000 subjects were analysed for BP, diabetic status, smoking status and then outcomes were measured.
• Numerous factors were found to be associated with increased risk of CHD, CVA, HF and peripheral vascular disease.

Question 26

Name 3 roles of risk calculators.

Answer 26

1) Illustrate risk visually to patients.
2) Inform clinicians as to who to treat.
3) Emphasise what is important in terms of modifiable risk factors (i.e. more important to stop smoking than to eat extra fruit and veg).

Question 27

What are the 4 categories which are assessed in strategic planning?

Answer 27

1) Where are we now?
2) Where do we want to go?
3) How do we get there?
4) How will we know if we’re there?

Question 28

What questions are asked in the ‘where are we now?’ stage of strategic planning?

Answer 28

• What does baseline data show?
• How many people have the disease?
• How many are at risk?
• Who is affected?

Question 29

What questions are asked in the ‘Where do we want to go?’ stage of strategic planning?

Answer 29

• How much less disease do we want?
• Is that a realistic target?
• Will we have a balanced decrease across demographic/ socioeconomic classes?
• Where will be draw the line for treating ‘well people’ for a disease they don’t have?

Question 30

What questions are asked in the ‘How do we get there?’ stage of strategic planning?

Answer 30

What does the evidence base inform us that is effective:

• diet?
• exercise?
• medication?

Question 31

What questions are asked in the ‘How will we know if we’re there?’ stage of strategic planning?

Answer 31

• Measures of death?

- How many prescriptions have been cashed?

Question 32

What are national service frameworks?

Answer 32

Policies set by the NHS to define care standards for major diseases (cancer, CHD, COPD, DM) or for specific patient groups (elderly, palliative care).

Question 33

What are the two main roles of the national service frameworks?

Answer 33

1) Set formal quality requirements for care based on best evidence for/ against treatments and services.
2) Offer strategies or support to help organisations attain these requirements.

Question 34

What 3 processes are usually involved in developing a strategy to address CVD risk?

Answer 34

1) DoH create the strategy after identifying need for one.
2) Strategic health authority implement and manage it.
3) Consultation with patients, carers, public, charities, HCPs and industry about strategy.

Question 35

Suggest 3 factors which are considered when developing a strategy for CHD.

Answer 35

1) Look at risk factors and the patient pathway and identify areas for improvement.
2) Identify what the priorities for improvement should be.
3) Identify evidence in support of proposed interventions.
4) Strategy should include clear SMART goals (need to be quantified and time-related)
5) Outline what measures should be used to monitor the intervention.
6) Outline how this change can be implemented.

Question 36

Describe the epidemiology of ischaemic heart disease.

Answer 36

Incidence increases with age.
M>F.
Higher risk with FHx.
Higher risk in lower SES groups.
South Asia = increased mortality from IHD and stroke compare with Europeans.
African/ Caribbean = decreased risk of IHD mortality but increased risk stroke mortality compared with Europeans.

Question 37

State 3 reasons for why incidence of ischaemic heart disease differs between patients of different ethnicities.

Answer 37

1) Differences in access to healthcare and health-seeking behaviours (different ethnicities may hold firm health beliefs which arise from their native culture so they are less likely to seek help).
2) Services inaccessible due to a language barrier.
3) Genetic susceptibility
4) Discrimination (inverse care law = less provision?)
5) Increased prevalence of diabetes in South Asians.
6) Increased smoking prevalence, decreased F+V consumption, decreased exercise levels in Bangladeshi populations.

Question 38

Why might gender be a factor involved in causing differences in who develops ischaemic heart disease?

Answer 38

Oestrogen may have a protective effect (HRT can lead to decreased risk of IHD).

**There may be selection bias in this evidence, as HRT users are typically healthier in general compared with non-HRT users.

Question 39

How do ethnic and gender differences in risk of IHD affect population health?

Answer 39

• Larger populations of those at increased risk of IHD = higher average population risk.
• This information should be used to target interventions at where they are needed most (i.e. community education in areas with an increased population of those at risk).
• Shows a need to address barriers (e.g. provision of information in a range of languages)

Question 40

Describe how epidemiology of IHD has changed.

Answer 40

• UK incidence of IHD is falling in line with most of the developed world.
• Eastern Europe has the reverse pattern to the UK.
• A continual flux of race/ ethnicity in UK population carries with it changing risks for various diseases.

Question 41

State 4 modifiable risk factors for development of CVD.

Answer 41

HTN
Smoking (increases risk by 50%)
Diabetes
Total cholesterol and HDL:LDL ratio

Question 42

State 5 non-modifiable risk factors for the development of CVD.

Answer 42

Age
Sex
FHx
Ethnicity
Socio-economic status

Question 43

How has the risk factor of smoking for CVD changed across time?

Answer 43

Numbers of smokers have decreased overall, but there has been an increase in teenage female smokers.

Has one of the highest population attributable risks.

Question 44

How has the risk factor of poor diet/ obesity for CVD changed across time?

Answer 44

• Prevalence has increased rapidly worldwide.
• Has one of the highest population attributable risks.
• Thought to be responsible for 25-50% of CVS deaths per year.

Question 45

How has the risk factor of diabetes for CVD changed across time?

Answer 45

Prevalence has increased rapidly across the westernised world.

**There is a high population attributable risk for diabetes.

Question 46

Name 4 risk factors for CVD which have all decreased recently.

Answer 46

Smoking
Cholesterol
Population BP
Deprivation

Question 47

Why is social deprivation considered a risk factor for development of CVD?

Answer 47

Because a lower SES has a behavioural relationship with smoking and poor diets, etc.

Question 48

State 3 ways in which you could negotiate lifestyle modification with a patient.

Answer 48

1) Use of visual aids and a demonstration of how altering lifestyle can decrease risk.
2) JBS2 or QRISK2 online risk calculators.
3) A 2mmHg increase in BP can lead to a 7% increased risk for CVD and a 10% increased risk for cerebrovascular disease.
4) Inform them that diet and exercise are the most effective methods of decreased CVD risk.
5) If risk of CVD is decreased, there may be no need to take medications such as statins.