Block 34

Question 1

Describe the aims of clinical guidelines. (5).

Answer 1

1) Improve the quality of healthcare and increase the chance of better outcomes.
2) Provide recommendations for care based on the best evidence.
3) Used to develop standards against which healthcare professionals should be assessed.
4) Used in the education of professionals.
5) Help patients to make informed decisions.
6) Improve communication between patient and healthcare professional.

Question 2

What are the six domains used to assess if a guideline is decent?

Answer 2

Domain 1: Scope and purpose
Domain 2: Stakeholder involvement
Domain 3: Rigour of development
Domain 4: Clarity of presentation
Domain 5: Applicability
Domain 6: Editorial independence

Question 3

Describe what is meant by each of the following domains used to assess if guidelines are decent:

1) Domain 1: Scope and purpose
2) Domain 2: Stakeholder involvement
3) Domain 3: Rigour of development

Answer 3

1) Is there a described overall objective? Described specific health questions? Described population?
2) Have target users been defined? Have views/ preferences of the target population been sought?
3) Systematic search for evidence? Selection criteria? Appraisal of evidence? Methodology for formulation of recommendations? External review? Updating procedure?

Question 4

Describe what is meant by each of the following domains used to assess if guidelines are decent:

1) Domain 4: Clarity of presentation
2) Domain 5: Applicability
3) Domain 6: Editorial independence

Answer 4

1) Are guidelines specific and unambiguous? Are options clearly presented? Are key recommendations easily identified?
2) Are there advice and tools on how to put into practice? Are facilitators/ barriers described? Are there resource implications? Is there any monitoring/ auditing criteria?
3) Funding body did not influence content? Have any competing interests of committee involvement in development been recorded?

Question 5

What are the two categories which can provide barriers to the uptake of new evidence?

Answer 5

1) Characteristics of adopters

2) Organisation and environment

Question 6

Describe the characteristics of adopters which can provide barriers to the uptake of evidence. (3).

Answer 6

1) Knowledge: lack of awareness of new practice or how current practice is inappropriate.
2) Attitudes: doubts over credibility of sources and perceived patient resistance.
3) Skills and abilities: over-reliance on trusted/ convenient sources and lack of confidence in altering skill set.

Question 7

Describe how organisations and environments can provide barriers to the uptake of evidence. (3).

Answer 7

1) Limitations and constraints: time and resources.
2) Organisational culture: behaviour and pressure to act or follow certain rules.
3) Social influence: team norms and influential peers.

Question 8

Describe 3 ways that persons can be encouraged to adopt new evidence or new practices.

Answer 8

1) Quality improvement Project about how to apply the findings.
2) Engage participants across organisational levels.
3) Provide the knowledge and resources needed to implement.
4) Foster an environment where improvement and innovation is normal (this will improve performance, professional development and patient outcomes).
5) Removal or barriers to adoption of change.
6) Meetings with parties to be involved in the change.

Question 9

1) What is the best way to encourage people to adopt a new approach?
2) What does not work if aiming to encourage people to take up practice suggested in new evidence?

Answer 9

1) A multifaceted approach, actively disseminating information and removing barriers to adoption of evidence practice is the best way to bring about change.

**Patient initiatives (involving them from the start) give the highest rate of change.

2) Audits, pressuring poor performers, praising high performers, league tables.

Question 10

What are the 5 aims of an audit?

Answer 10

1) Clinical education
2) Encourage teamwork
3) Improve services and care
4) Gain financial incentives
5) Fulfil contractual obligations

Question 11

Name the 6 steps in an audit.

Answer 11

1) Set standards: NICE/ local guidelines
2) Measure current performance
3) Compare current performance vs. standards
4) Identify barriers and steps for improvement
5) Make changes
6) Re-audit

Question 12

Name 3 strengths of audits as an approach to quality improvement.

Answer 12

1) Encourage teamwork
2) Can lead to better patient outcomes
3) May get financial rewards
4) Emphasise best practice

Question 13

Name 3 limitations of audits as an approach to quality improvement.

Answer 13

1) Data is merely a ‘snapshot’ of performance
2) Lack of generalisability
3) Accuracy of data collection
4) May not be an adequate sample size
5) Short timescale for change - may not see long term benefits/ harms.
6) May lead to a rushed ‘quick fix’ which isn’t sustainable
7) Relies on staff to actually implement actions

Question 14

State 4 risk factors for the development of chronic liver disease.

Answer 14

Alcohol
Obesity
Viruses
Drugs

Question 15

Name 3 measures that could be taken to reduce the risk of alcohol in the development of chronic liver disease.

Answer 15

Public health campaigns
Minimum unit price
Taxation
Licensing restrictions
Sale restrictions (price, placement, promotions)

Question 16

Name 3 measures that could be taken to reduce the risk of obesity in the development of chronic liver disease.

Answer 16

Public health campaigns
Taxation (i.e. sugar tax)
Sale restrictions (price, placement, promotions)
Legislation forcing reformulation of foods
Community food/ exercise regimes
Education
Provide healthy snacks at school or work

Question 17

Name 3 measures that could be taken to reduce the risk of viruses in the development of chronic liver disease.

Answer 17

Vaccinate (Hep B/ yellow fever)
Screen blood products
Decrease needle sharing
Contraception
Disposable instruments/ sharps
Licensing and procedural laws for tattooing

Question 18

Name 3 measures that could be taken to reduce the risk of drugs in the development of chronic liver disease.

Answer 18

Needle banks
Decrease OTC availability of drugs
Paracetamol –> blister packets

Question 19

State 4 reasons why priorities for prevention of disease might differ internationally.

Answer 19

1) Disease prevalence differs
2) Different resources are available globally
3) There may or may not be political support for an intervention.
4) There are different population attributable risks for certain risk factors (In UK, PAR for obesity is much greater than in Africa where yellow fever is much more prevalent).

Question 20

What is population attributable risk?

Answer 20

The proportion of incidence of a disease in he population that is due to a certain exposure.

**It is the incidence of disease in a population which would be eliminated if the exposure were eliminated.

Question 21

What are the economic impacts of obesity in the UK?

Answer 21

• Estimated to cost NHS £5.1 billion (£3.3bn for smoking)

- about £10 billion in costs from decreased work productivity

Question 22

Name 10 professionals involved in the provision of diabetic services across the UK.

Answer 22

GP (BP, lipid and glycaemic control, annual review)
Diabetes specialist nurse
HCAs (BP, bloods, weight)
Podiatrist/ chiropodist
Ophthalmologist (diabetic eye review)
Renal physician
Gastroenterologist (if gastroparesis)
Endocrinologist (may advise in complex cases)
Vascular medics
Charities
District nurses (widens access to services)
Dieticians (advise on correct diet in group classes)

Question 23

Why do diabetic services tend to differ across different areas?

Answer 23

Differences in:

Funding
Prevalence
Staffing
Resources

Question 24

Describe the following two types of methods for deliverance of diabetes services:

1) Nurse-led/ community-led
2) GP-led

Answer 24

1) Patient centred and always allows for continuity of care, though may not be able to advise on complex cases.
2) Can advise complex cases and adjust medication but not as likely to receive continuity of care. Takes up time which might not be necessary for each review.

Question 25

Give 3 social impacts of pituitary, adrenal and thyroid disease.

Answer 25

• Constant burden of lifelong medication
• Stigma due to visual appearance (i.e. exophthalmos)
• Hormone deficiency can manifest as lethargy and malaise (decreased social mobility/ interactions, increased withdrawal
• Burden on family and relationships (others having to know and recognise signs and symptoms of acute complications, e.g. addisonian crisis)
• Infertility can impact on relationships

Question 26

Give 3 ways to prevent kidney injury and renal failure.

Answer 26

Tight BP control
Glycaemic control
Use of ACEi
Medication reviews (avoid nephrotoxins)
Avoid dehydration
Monitor function in acutely ill and elderly

Question 27

Describe the most cost effective treatment for chronic kidney disease and state why it is the most cost effective.

Answer 27

Transplantation is overall much more cost effective.

Transplant = £17000 and then £5000p/a for immunosuppression.
Haemodialysis = £35000p/a indefinitely
Peritoneal dialysis = £17,500 p/a indefinitely

**Transplantation offers a £25,800 saving p/a every year after transplant. If all patients on dialysis could have a kidney transplant, this would save the NHS £152 million a year.

Question 28

1) What is a market?

2) How is the blood donation/ organ donation system funded?

Answer 28

1) A network of buyers and sellers exchanging goods and services regulated by explicit and implicit rules.
2) Public funding (not a free/ costless system) and the storage facilities are privatised.

Question 29

What is altruism?

Answer 29

A regard for others as a principle for taking action, with the thought that you’d hope for reciprocity if in need of help yourself.

Question 30

1) What is the basis for donor schemes?

2) What is an alternate option for donor schemes as opposed to the basis already in use?

Answer 30

1) Altruism
2) Commercial principles (would it be better to use commercial mechanisms to encourage donation and to maintain an adequate supply of blood/ organs?

Question 31

Give 3 arguments against having a blood market system.

Answer 31

1) Represses altruism.
2) Erodes senses of community.
3) Sanctions ‘profits’ in healthcare provision
4) Increases blood supply from the poor or unemployed (rich less likely to give if for monetary gain?)
5) May increase infection.

Question 32

Give 3 arguments in favour of having a blood market system.

Answer 32

1) Blood is not different from any other tradable good.
2) Supply will increase by removing donor obstacles.
3) Financial rewards/ exemption from future payments beneficial to lower SES.

Question 33

Why would having a market for used body parts be beneficial?

Answer 33

1) Transplant is the most efficient treatment and gives a better quality of life.
2) Dialysis is expensive and gives a poor quality of life.
3) Altruistic supply of organs is dwarfed by demand (clinicians have to ration this resource)
4) Rationing means patients die on the waiting list as priority is decided.
5) In Iran, a market for used body parts has proven to increase supply.

Question 34

Give 4 ways that donations of blood and/ or organs would be improved.

Answer 34

• Continental Europeans assume consent to harvest without relatives.
• Opt out rather than opt in donor system (evidence unconvincing, still reliant on altruism - UK now opt out
• Use of transplant coordinators and clinical leads in hospitals.
• Financial incentives - may impinge on quality control?

Question 35

Briefly described the global donations policies for the following countries:

1) India
2) Spain
3) Austria
4) China
5) Iran

Answer 35

1) Mandatory to request donation in brain stem death.
2) Soft opt out policy (seek relatives views); highest donation rate.
3) Hard opt out system (do not seek relatives views)
4) Donations come from executed prisoners who have all ‘consented’.
5) Allows sale of kidneys for profit - no waiting list/ shortage for transplantation.

Question 36

What does the human tissue act of 2004 state regarding use and disposal of human tissues?

Answer 36

Consent is needed for scheduled purposes such as storage and use of tissues of the living/ deceased, including for research in connection with disorders or the functioning of the human body.

Question 37

Under the human tissue act 2004, all donors and recipients of organs are required to see who?

Answer 37

An independent assessor trained and accredited by the human tissue authority and who is not involved with the healthcare team.

Question 38

What is the purpose of donors/ recipients of organs seeing an independent assessor?

Answer 38

To ensure:

• donors are not forced against their will to donate
• no reward has been sought or offered in exchange for donation
• donor has the capacity to make an informed decision.

Question 39

1) How does the transplantation service ration the limited supply?
2) How are DBD (brain death) organs allocated?
3) How are DCD (circulatory death) organs allocated?

Answer 39

1) Everyone in need of a transplant is entered onto a national database and organs are allocated via an evidence-based computer algorithm based on 5 ranked tiers of recipients.
2) Via a national allocation scheme (NHSBT)
3) Allocated regionally (one kidney always offered preferentially to local transplant centre).

Question 40

List 3 ways in which points are given to patients on the national database for allocating organs.

Answer 40

1) Waiting time (1 point per day)
2) HLA match + age combined (more points for younger age and less mismatches)
3) Donor-recipient age difference (less points for bigger age difference).
4) Location
5) HLA-DR homozygosity
6) HLA-B homozygosity
7) Blood group match

Question 41

What are the criteria for tier A and tier B in the national database for organ allocation?

Answer 41

A = 000 mismatched paediatric patients (highly sensitised or HLA-DR homozygous).

B = 000 mismatched paediatric patients (all others).

Question 42

What are the criteria for tiers C, D and E in the national database for organ allocation and how are these patients prioritised?

Answer 42

C = 000 mismatched adult patients (highly sensitised or HLA-DR homozygous).

D = 000 mismatched adult patients (others) AND favourably mismatched paediatric patients (100, 010, 110).

E = all other eligible patients.

**Patients are prioritised according to a points based system (highest points = highest priority).

Question 43

What are the levels of resource allocation in decision making?

Answer 43

Macro level (strategic, societal or political level).

Micro level (clinical or individual patient level).

Question 44

Give 2 reasons as to why it would be feasible to to use age to allocate resources at the macro level.

Answer 44

1) Treatment and care of older people is very costly.
2) Fair innings argument; older people have had a full life already and younger people have not, therefore it would be much fairer for resources to be diverted from older patients to younger patients.

Question 45

What is the argument against allocating resources to younger people because treatment and care of older people is very costly?

Answer 45

1) The burden of cost is not related to age per se, but there is more relation between costs and illness and incapacity in final years (it is not the fact that people are elderly that is costly, it is the factors attached to old age that are costly).

Question 46

What is the argument against allocating resources to younger people based on the fair innings argument?

Answer 46

How can you determine what a ‘full’ life is? A patient may have had a long life, but the quality of life may have been poor.

Should length of life bear impact on allocation if outcomes would be better for the elderly?

Question 47

What is a micro level argument for allocating resources based on age?

Answer 47

Older people are less likely to respond positively to treatment.

Question 48

What is the argument against allocating resources to younger people because older people are less likely to respond positively to treatment?

Answer 48

Age alone is not a good predictor or responsiveness to treatment or of prognosis.

Age alone is also not a good predictor of who is likely to develop complications.

Question 49

The equality act of 2010 offers protection to 9 characteristics, what are they?

Answer 49

1. Age
2. Race
3. Sex
4. Gender reassignment status
5. Disability
6. Religion or belief
7. Sexual orientation
8. Marriage and civil partnership status
9. Pregnancy and maternity

Question 50

What is direct age discrimination?

Answer 50

This is when a direct difference of treatment based on age cannot be justified.

A direct difference of treatment is a situation in which a patient is, was or could be treated in a less favourable manner than another person in a comparable situation, based on his or her age.

Question 51

What is indirect age discrimination?

Answer 51

When a seemingly neutral provision, measure or practice has harmful repercussions on a person or group of persons. A service where the aim is to not discriminate against those older people, but nevertheless does discriminate against older people.

E.G. A service might be more difficult for older people to access.

E.G. Universally applied hospital discharge policy may be harmful to the elderly who haven’t had necessary time for recovery.