Cardiorespiratory Flashcards
what is relative risk?
indicates strength of association between risk factor and event
what is population attributable risk?
takes into account RR associated with a brisk factor, as well as prevalence of this risk factor in the population.
oi.e. RF a and RF b have same RR for MI, compared to not having this RF
oMORE PEOPLE in the population have RF a than RF b -> RF a has a ↑er population attributable risk
describe the prinicples of number needed to harm/treat/benefit?
oInterventions have both NNtharm/treat
oNeed to think about: comparison, time period, baseline risk
oWhen calculating NNT Harm -> ROUND ↓DOWN↓
oWhen calculating NNT Treat/benefit ->ROUND ↑UP↑
oIn 2° prevention absolute risk difference is larger ->NNT ↓er than in 1° prevention -> fewer people need to take meds for one to benefit
oLonger time period -> ↑ risk therefore ↓NNT, when compared to shorter time period
what are the key aspects of TB control
•Effective surveillance to monitor disease + outbreaks
•Prompt ID + treatment
•Ensure people COMPLETE treatment (compliance an issue)
•Targeted prevention – BCG
•Screening for ↑ risk groups (CXR) entering the UK.
•Focus on key populations
oMigrants
oDeprived urban communities
what are the potential opportunities for controlling the spread of TB?
•↑ awareness amongst those working with high risk groups:
oHousing support
oMigrants (especially Russia + eastern Europe)
oPrisons + substance misuse projects
•ID + Educate high-risk groups: Symptoms, how it’s spread, TB is treatable + curable, common HIV co-infection
•Public info made available: online, leaflets in various languages etc.
•Interpreters for non-English speaking patients
what is the goal of vaccination?
↓mortality + morbidity from vaccine-preventable infections.
what are the strategic aims of vaccination?
selective protection of the vulnerable, elimination (herd immunity), eradication
what are the programmatic aims of the BCG vaccination?
prevent deaths, infxn, transmission (2° cases), clinical cases
o In neonates (0-4 weeks) who will be at high-risk (high incidence area, ≥1 parent/grandparent born in high-incidence country, FH in last 5 years)
oRoutine vaccination not recommended for 10-14 yrs
oID unvaccinated who are ↑risk before 16 years, who would have qualified for neonatal BCG. Offer Mantoux tesing + BCG if –ve
o Healthcare professionals who have patient/specimen contact.Those who hav FH
o Those who are in contact with someone who has active TB -> TEST + VACCINATE
what is DOT?
directly observed treatments
TB control
what are the 5 components of directly observed treatment?
oGovernment commitment (political will + centralised system of TB monitoring_
oCase detection by sputum smear
oStandardised treatment regimen, observed by healthcare worker for at least 2 months
oStable + reliable drug supply
oStandardised recording + reporting system
what is a patient pathway?
- A patient-pathway describes the ‘best’ route from 1st contact with services ->stages of investigation/treatment ->definitive treatments ->discharge from NHS + social services.
- Useful to guide clinicians and to inform patients what is to happen next.
what are the ways for people to access services?
- GP
- Self-referral (A&E, online)
- Social services/local authority
- Emergency – ambulance
- Educational institution – welfare
- Dental practitioner
- Charity?/Community programmes
- Lay-referral
- Pharmacists
what are zola’s triggers to health seeking?
- Interference with work/physical activity
- Interference with social relations
- Assigning arbitrary time limit
- Interpersonal crisis (deaths, divorces etc.)
- Sanctioning
what are the barriers to health seeking?
-Inverse care law (poor areas=less provision)
-Geographical distance – transport costs, time
-Previous bad experience (staff, waiting times)
-Childcare(availability + costs)
Psychological factors (refusal to believe, worried, lack of education)
-Context of event (Xmas, birthdays, weddings)
-Perception/Evaluation of symptoms as harmless
what are the ways to overcome barriers to health seeking?
•Quality improvement – ID barriers, think about changes, implement change, audit. (PDSA cycles)
oThinks about the system from a user’s perspective
•Community outreach programmes - ↑ provision in the community, rather than centralised provision which may be ↑difficult to access.
•Transport - Volunteer drivers, Discounted hospital buses,
what was the keogh report?
pt safetyPublished hospital standardised mortality rates (SMRs) -> WRONG APPROACH
describe the need for publicly available performance indicators?
- Public scandals ↑ pressure for outcomes to be published and used.
- Other public sectors (schools, police) make this info. available -> right to access it?
- Expectation to collect outcome data + publish it ->arrival of coded computerised clinical databases means that data is there to be used.
what are the advantages of publicly available performance indicators?
- ↑ information about healthcare providers
- Informs patient, ↑ + encourage choice – Caveat emptor
- Transparency, honest + open ->↑ trust in health providers
- May ID outliers – can learn from hospital with ↓↓↓mortality, to improve those with ↑↑↑mortality.
- Quantitative – clear numerical figure
what are the disadvantages of publicly available performance indicators?
Hospital SMRs are NOT FIT FOR PURPOSE
•Only work when considered alongside avoidable deaths (PRISM study -> 5.2% avoidable deaths + no correlation, r=0.03, between SMR + avoidable deaths)
•Dependent on non-hosp care (i.e. prehosp/variation in planned place of death (i.e. hospice)
•Data vagaries (unexplicable change in definition/coding)
•Choice of case mix adjustment model ->leads to varying results dependent on which you use
•Relationship with quality of care (validity) not demonstrated
•Even if all treatment/care was uniform, there would ALWAYS be random variation in mortality rates across hospitals, as each patient is unique!
•Must be adjusted for confounders (i.e. age) as older people ↑ likely to die, therefore hospital serving an older population -> ↑ SMR…
•No evidence that publishing these influences patients, lots of evidence showing that it influences clinicians + managers.
•Incentivising targets may be a pervert practice – i.e. people avoid complex cases, to ↓SMR
describe primary CHD prevention?
before onset of disease, stopping it developing in first instance
i.e. smoking cessation, healthy eating, exercise
describe secondary CHD prevention?
With disease, preventing progression or any adverse events once disease is developed
antiplatelet therapy post-MI, statins, hypertension treatment
describe tertiary CHD prevention?
limiting the impact that adverse events have on health
i.e with cardiac rehab, CABG/PCI
what is the prevention paradox?
A preventive measure that brings large benefits to the community offers little to each participating individual
describe the prevention paradox in heart disease?
- Most heart disease is occurring amongst people who are not at high risk
- But way more people are at moderate/low risk than are at high risk
- If we target ALL (including this group) with a population strategy then more people are at lower risk -> greatest population benefit.
describe the population strategy of prevention?
lower the exposure of WHOLE population.
•PROS: Large potential to prevent more deaths.
•CONS: Small individual benefit, poor motivation (why should I make this change if I’m already @ risk?), low benefit:risk (must be safe to do!)
what risk factors for heart disease have the greatest population attributable risk?
ApoB/ApoA-1 - 49% smoking. - 36% diabetes - 10% hypertension - 18% abdominal obesity - 20% psychosocial - 33% fruit and veg daily - 14% exercise - 12% alcohol - 7%
describe the 10 year CVD risk prediction chart?
- These are based on DATA from the Framingham Study, a cohort study looking at RFs + outcomes.
- 10,000 subjects analysed for BP, diabetic status, smoking status + outcomes measured.
- Found numerous factors were associated with ↑ risk of CHD, CVA, HF and peripheral vascular disease.
describe the role of risk calculators in CHD?
- Illustrates visually to patient – RED = BAD
- Informs the clinician as to who to treat
- Emphasises what’s important in terms of modifiable risk factors (i.e. more important to stop smoking than to eat extra fruit + veg)
what is strategic planning?
- Where are we now? Baseline data, how many people have the disease? How many at risk? WHO is affected?
- Where do we want to go? We want less. How much? Is that realistic? Will we have balance ↓ across demographic/socioeconomic classes? Where we draw the line, between treating ‘well people’ for a disease they don’t have?
- How to get there? -> Evidence base should inform us what’s effective – diet? Exercise? Medication?
- How will we know if we’re there? Measures of…death? Cashed prescriptions? + NSFs
what are national service frameworks?
• Policies set by NHS to define care standards for major diseases (Cancer, CHD, COPD, DM etc.) or for specific patient groups (elderly, palliative care)
• TWO main roles:
1) Set formal quality requirements, based on best evidence for/against treatments/services
2) Offer strategies/support to help organisations attain these
who would be involved in developing a national service framework strategy?
- Department of Health create the strategy, after IDing need for one
- Strategic Health Authority implement + manage it
- Consultation with patients, carers, public, charities, healthcare professionals and industry
what factors go into developing a strategy for CHD?
- Look at risk factors and patient pathway (rapid referral, diagnostic testing) and ID areas for improvement.
- ID what priorities should be • Evidence in support of proposed interventions
- Should include clear (SMART) goals, which should be quantified and time-related
- Outline what measures would be used to monitor this
- Outline HOW this change can be implemented
What are the ethnic and gender differences in ischaemic heart disease?
- Incidence ↑ with age
- M>F
- FH
- Social disadvantage
- South Asia - ↑ mortality of IHD + stroke, c.f Europeans
- African/Caribbean - ↓ risk of IHD mortality but ↑ stroke, c.f. Europeans
what are the reasons for ethnic and gender differences in ischaemic heart disease?
- Difference in access to healthcare, health-seeking behaviour – different ethnicities may hold firm health beliefs, which arise from their native culture, ↓ likely to seek doctor help.
- Inaccessible due to language barrier
- Genetic susceptibility
- Discrimination – Inverse care law
- ↑diabetes prevalence in S asians
- Smoking prevalence↑, ↓ F+V consumption, ↓ exercise levels in Bangladeshi population
describe why there is gender difference in ischaemic heart disease?
• Oestrogen may have protective effect – HRT ↓ IHD
o May be selection bias as HRT users typically healthier in general, than non-HRT users.
how do ethnic and gender differences in ischaemic heart disease affect population health?
- Larger populations of of those at ↑risk -> ↑Average population risk
- Should be used to target intervention where it is needed most i.e. community education in areas with ↑population of those at risk.
- Need to address other barriers – to focus on prevention i.e. provision of information, interpreter access
describe the changing prevelance and incidence of ischaemic heart disease?
- UK incidence of IHD is falling, in line with most of developed world.
- Eastern Europe has the reverse pattern!!
- Continual flux of race/ethnicity in our population, carries with it changing risks for various diseases.
what are the modifiable risk factors for CVD?
- HYPERTENSION
- SMOKING (↑50%)
- DIABETES
- TOTAL CHOLESTEROL + HDL:LDL RATIO
what are the non-modifiable risk factors for CVD?
- AGE
- SEX
- FAMILY HISTORY
- ETHNICITY
- SOCIO-ECONOMIC POSTION (?)
how has smoking as a risk for CVD changed over time?
↓numbers but ↑teenage F smokers
Factor with one of highest population attributable risk
how has poor diet/obesity as a risk for CVD changed over time?
– thought to be responsible for 25-50% of CVS deaths per year
o Prevalence↑ rapidly worldwide
o Factor with one of highest population attributable risk
how has diabetes as a risk factor for CVD changed over time?
↑prevalence rapidly across the westernised world
o Also has high population attributable risk
how has smoking, cholesterol, population BP fall, deprivation as risk factors for CVD changed over time?
All have ↓ recently – accounts for reduction from 70s
how can lifestyle modification be negotiated with patients?
- Visual aids + demonstration of how altering lifestyle can ↓ risk
- JBS2 or QRISK online aids
- 2 mmHg ↑ 7% ↑ in CVD and a 10%↑ in Cerebrovascular disease
- Inform that diet and exercise are the MOST EFFECTIVE methods of ↓ CVD risk
- If ↓ risk, less or no need to take medication (i.e. statins)
what works in supporting behavioural change?
- BENEFICIAL – Advice from healthcare professionals re: ↓Na+/Cholesterol diet, antismoking interventions (NRT, Buproprion, Varenicline), exercise advice,
- LIKELY TO HELP - counselling to ↑activity levels, self-help materials, telephone advice service on smoking cessation
- INEFFECTIVE/HARMFUL – acupuncture in smoking cessation, anxiolytics in smoking cessation
Studies of these influences are bound to be susceptible to confounding factors and also are very heterogeneous, making meaningful meta-analyses DIFFICULT to assess. However trials have showed benefit.
