clinical operations and processes

Question 1

What does a LM exam involve

Answer 1

Vital signs, Risk factor assessment, Physical exam, Lab work, Diagnosis and management, Collaborative care and referrals

Question 2

What is the only LM validated assessment tool

Answer 2

Physical Activity Vital Sign (PAVS) - days per week x minutes per day (of moderate to vigorous exercise)

Question 3

Name 3 disease specific screening tools

Answer 3

Question 4

Name some nutrition assessment tests

Answer 4

mini nutrition assessment validated for 65+
Interactive dietary reference intake calculator DRI
Harris Benedict calculator CDC

Question 5

What is the PAVS PA ask

Answer 5

Days of moderate to strenuous exercise / minutes per day = minutes per week. Resistance training - how many days do they perform muscle strength training

Question 6

Single item sleep questionnaire

Answer 6

Question 7

Name two other sleep questionnaires

Answer 7

Global sleep Assessment questionnaire (GSAQ) 11 Q based on past 4 weeks - screen tool for insomnia, OSA, restless legs - no total scores - any answer besides never should be investigated

Stop BANG - screen for sleep apnea

Pittsburg sleep quality index (PsQ) - 7 areas - quality, latency, duration, efficiency, disturbances, medication use and daytime dysfunction over last month

Question 8

% visits to primary care provider related to stress - less like to engage in healthy habits

Answer 8

70%

Question 9

Brief stress assessment tools

Answer 9

PHQ-2 - validated - last two weeks - 2Q
Preceived stress scale - 4 Q
Generalised Anxiety Disorder GAD-2 - validated

Question 10

In depth stress test tools

Answer 10

PHQ-9
Perceived stress scale - 10-items
General Anxiety disorder 7 item (GAD-7 validated)
Non-abbreviated form of SWLS -validated

Question 11

What does the Audit C question ask to screen alcohol intake

Answer 11

How often do you have a drink containing alcohol
how many drinks containing alcohol do you have on a typical day when you are drinking
how often do you have 6 or more drinks on one occasion

Question 12

What is TAPS1 and TAPS2

Answer 12

Tobacco, alcohol and prescription medicine and other substances

Question 13

how does BMI 35 rate and what is a healthy body fat for women and a healthy waist measure / waist hip ratio in a physical exam

Answer 13

Question 14

what BP level is pre-hypertension and high risk HPT

Answer 14

Question 15

outline lifestyle heart trial (5 year RCT) Ornish

Answer 15

Intervention: Low-fat (10% of calories) veg diet, aerobic exercise, stress management, and group psychological support – no lipid medication used
Key Conclusions: a significant reduction in both LDL and angina episodes after one year and showed even more regression of coronary atherosclerosis
Patients following usual care showed more progression after 5 years than after 1 year, with twice as many cardiac events,

Question 16

Other trials that show lifestyle able to manage disease

Answer 16

Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease (12-month RCT) -> Exercise training was associated with a 16% increase in 02 uptake. Exercise is less expensive than PC over 12 months. Both groups’ clinical symptoms improved during the study.

Primary care-led weight management for remission of T2D (DIRECT) 12-month RCT
Objective: assess if intensive weight management would achieve remission, through either a weight management program or best practice guidelines.
Key Conclusions: 12 months almost 46% achieved remission. Weight loss was associated with remission for the entire study population

DPP Trial (2.8 years RCT)
Objective: modifying weight/activity with a program or giving metformin would prevent or delay diabetes.
Key Conclusions: Lifestyle and metformin both reduced the incidence of diabetes Lifestyle was more effective than metformin at 2.8 years.

Question 17

What did the Portfolio diet show

Answer 17

Effect dietary portfolio of cholesterol-lowering foods versus lovastatin on serum lipids and C - reactive protein (3 months RCT)
Objective: a diet low in saturated fat and an emphasis on plant sterols, viscous fibre, soy protein, and nuts reduce cholesterol as compared to statin.
Key Conclusions: Both average decreases of 8%, with no significant difference between diet and statin group.

Question 18

diabetes diagnosis

Answer 18

Diabetes
Normal - HbA1c <5.7%, Fasting <100 (5.5), 2-hour oral GTT <140 (7.6)

Pre DM - HbA1c 5.7-6.4%, Fasting 100-124 (5.5-6.9), 2 hour GTT 140-199 (7.7-11)

DM HbA1c > 6.5%, Fasting > 125mg/dL (7), 2 hr GTT > 200mg/dL (11.1)

Partial remission hba1c <6.5, Fasting GTT < 100-125 (5.5-6.9) maintained for > 1 year

Weight loss goal 5-10% intensive 8kg within 6 months

Question 19

how do you manage a plateau

Answer 19

10% weight loss - non resting energy expenditure decreases by 30%, need to reduce eating by 10-15% fewer calories

Question 20

USA cholesterol cut off

Question 21

BP cut off

Question 22

High rates of diabetes reversal in newly diagnosed Asian Indian young adults with T2D with intensive lifestyle therapy

Answer 22

Objective: variable reports in young people so studies it.
Key conclusions: remission rates at 3 months, 1 year and 2 years 75%, 75% 69%. 22% achieved partial at 3 months. So should receive intensive lifestyle intervention

Question 23

Collaborative and chronic care models

Answer 23

*Innovative care for chronic conditions report by WHO update practices to care for chronic disease
o Micro level – patient and family
o Meso level – health care organisations and community
o Macro level – policy
* The collaborative Care Manager Model by the Agency for Healthcare Research and Quality is a model showing how patients, clinical experts, residents, nurse practitioners, and interdisciplinary teams can collaborate in an academic setting to provide care.
* Valued-based care – financial incentives for accountable care organisations
* Chronic care model, explains the involvement of the community and health care system
Guidelines for implementing Chronic Care model
Local medical practice
* Seek community co-ordination
* Create links between community and practice
* Partner with community
Health system delivery e.g. open disclosure
Self-management support
Delivery system design
* Reminders etc
Decision support
* Access to best practice information, integrate guidelines
Clinical information systems
HER

Examples of chronic care Models
* Ornish-based chronic care model
* Medical Fitness Association

Benefits and features of the chronic care model
* Interdisciplinary team care – high levels of compliance
* Healthy eating activities – weight reduction, BP maintained behaviour over 5 months
* Lifestyle modification in primary care.

Question 24

QI using plan, study, do act cycle

Answer 24

• PDSA – focuses on small-scale improvements over short periods of time that typically require several cycles to create desired change
  o Plan
  o Do – carry out the plan
  o Study –complete the data analysis, summarises lessons learned
  o Act – what needs to be changed
• Root cause analysis – use this when something goes wrong or a near-miss, ask 5 whys to get to the root cause, ask SO WHAT - what are the consequences to determine cause and effect
  FISH BONE ANALYSIS - head of fish problem/ effect, scales each component of the process

Question 25

Assess effectiveness of interventions such as patient activation measure and therapeutic alliance measures

Answer 25

PAM - patient activation measures
* Important in the push for patient-centred care and is often used to measure patient engagement
PAM 100-point scale
* Sorted into key patient abilities that lead to improved health outcomes
o Self-manage illness and problems
o Engage in activities that maintain functioning and reduce health decline
o Involve treatment and diagnostic choice
o Collaborative with providers
o Select providers and organisation based on performance quality
o Navigate the healthcare system

Question 26

Therapeutic alliance measures

Answer 26

Ability of the therapist and client to develop a healthy emotional connection leading them to work together toward therapeutic goals. Characterised by 3 features
o Mutually agreed upon treatment goals
o Alignment of treatment tasks
o Emotional bond between the therapist and client

Recent review of 300 studies including 30,000 clients participating in psychotherapy found strong positive correlation between the therapeutic relationship and patient mental health outcomes regardless of treatment modality.
Measured by using
* Working alliance inventory (WAI)
* California Psychotherapy Alliance Scale (CALPAS)
* Helping Alliance Questionnaire (HAQ)
* Vanderbilt Psychotherapy Process scale (VPPS)