Definitions/Waffly shit Flashcards
What is Epigenetics?
expression of genome depending on the environment
What is Allostasis?
stability through change, our physiological systems have adapted to react rapidly to environmental stressors
What is Allostatic load?
long term overtaxation of our physiological systems leads to impaired health (stress)
What is Salutogenesis?
favourable physiological changes secondary to experiences which promote healing and health.
What is Emotional Intelligence?
the ability to identify and manage one’s own emotions, as well as those of others
What is primary care for?
managing illness
preventing illness
promoting health
shared decision making with patients
managing clinical uncertainty
What are the 3 domains of public health?
Health improvement
Health protection
Improving services
What is health improvement?
Social interventions aimed at :
a) preventing disease
b) promoting health
c) reducing inequalities
What are some aspects of health improvement?
Education
Housing
Employment
Lifestyles
Community
Surveillance and monitoring of specific diseases and risk factors
What is health protection?
Measures to control infectious disease risks and environmental hazards
What are some aspects of health protection?
infectious diseases
chemicals and poisons
radiation
emergency response
environment health hazards
What is improving services?
The organization and delivery of safe, high quality services for prevention, treatment and care
What are some aspects of improving services?
clinical effectiveness
efficiency
service planning
audit and evaluation
clinical governance
equity
What is a health needs assessment?
Systemic method for reviewing the health issues facing a population, leading to :
i) agreed priorities ii) resource allocation
that will
i) improve health ii) reduce inequalities
What are the different approaches to a health care assessment?
Epidemiological
Comparative
Corporate
What are the adv and disadv to a epidemiological approach to health care assessment?
Adv - uses existing data, can evaluate services by trends over time
disadv - quality of data variable, data collected mat not be data required, doesn’t take into account opinions of people involved
What are the adv and disadv to a comparative health care assessment?
quick and cheap
gives a measure of relative performance
may be difficult to find comparable population
data may not be available/quality
What are the adv and disadv to a corporate health care assessment?
based on opinions of population in question
takes into account knowledge and experience of those in popln
takes into account wide range of views
difficult to distinguid need from demand
may be influenced by poilitcal agendas
What is Primary, Seconday and Tertiary prevention?
Primary prevention - preventing disease before it has happened
Secondary prevention – catching disease in the pre-clinical or early phase
Tertiary prevention – preventing complications of disease
What are the 2 approaches to prevention?
Population approach - preventative measure eg. dietary salt reduction through legislation to reduce bp
High risk approach – identify individuals above a chosen cut off and treat – eg. screening for high bp
What are the different kinds of screening?
- Population-based screening programmes
- Opportunistic screening
- Screening for communicable diseases
- Pre-employment and occupational medicals
- Commercially provided screening
What are the disadvantages to screening?
- Exposure of well individuals to distressing or harmful diagnostic tests
- Detection and treatment of sub-clinical disease that would never have caused any problems
- Preventive interventions that may cause harm to the individual or population
What is the Wilson and Junger criteria?
The condition being screened for should be an important health problem
The natural history of the condition should be well understood
There should be a detectable early stage
Treatment at an early stage should be of more benefit than at a later stage
A suitable test should be devised for the early stage
The test should be acceptable
Intervals for repeating the test should be determined
Adequate health service provision should be made for the extra clinical workload resulting from screening
The risks, both physical and psychological, should be less than the benefits
The costs should be balanced against the benefits
What is lead time bias?
When screening identifies an outcome earlier than it would otherwise have been identified this results in an apparent increase in survival time, even if screening has no effect on outcome.
What is length time bias?
Type of bias resulting from differences in the length of time taken for a condition to progress to severe effects, that may affect the apparent efficacy of a screening method
What are the advantages and disadvantages of a cross sectional study/survey?
Relatively quick and cheap
Provide data on prevalence at a single point in time
Large sample size
Good for surveillance and public health planning
Risk of reverse causality (don’t know whether outcome or exposure came first)
Cannot measure incidence
Risk recall bias and non-response
What are the advantages and disadvantages of a case-control study?
Good for rare outcomes (e.g. cancer)
Quicker than cohort or intervention studies (as the outcome has already happened)
Can investigate multiple exposures
Difficulties finding controls to match with cases
Prone to selection and information bias
What are the advantages and disadvantages of a cohort study?
Can follow-up a group with a rare exposure (e.g. a natural disaster)
Good for common and multiple outcomes
Less risk of selection and recall bias
Takes a long time
Loss to follow up (people drop out)
Need a large sample size
What are the advantages and disadvantages of a randomised control trial?
Low risk of bias and confounding
Can infer causality (gold standard)
Time consuming
Expensive
Specific inclusion/exclusion criteria may mean the study population is different from typical patients (e.g. excluding very elderly people
What is the odds of an event?
the ratio of the probability of an occurrence compared to the probability of a non-occurrence.
Odds = probability/(1-probability)
What is the odds ratio?
The odds ratio is the ratio of odds for exposed group to the odds for the not exposed groups.
OR = {Pexposed/ (1 – Pexposed)}
{Punexposed/ (1 – Punexposed)}
What is incidence?
new cases, denominator, time
What is prevalence?
existing cases, denominator, point in time
What is incidence rate?
= (No.of persons who have become cases in a given time period)/(Total person-time at risk during that period)
What is a never event?
serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented
surgery - wrong site/implant
medication - wrong preparation/route
mental health - suicide
misidentification
What is sensitivity?
the proportion of people with the disease who are correctly identified by the screening test
What is specificity?
the proportion of people without the disease who are correctly excluded by the screening test
What is positive predictive value?
the proportion of people with a positive test result who actually have the disease
What is negative predictive value?
the proportion of people with a negative test result who do not have the disease
What are predictive values dependent on?
underlying prevalence
What is person time?
measure of time at risk, i.e. time from entry to a study to (i) disease onset, (ii) loss to follow-up or (iii) end of study. Used to calculate incidence rate which uses person time as the denominator.
Association between exposure and outcome can be attributed to?
Bias
Chance
Confounding
Reverse causality
a true causal association
What types of bias are there?
selection bias - a systematic error in selection of participants, allocation of participants to different study groups
information/measurement bias : systematic error in the measurement of classification of exposure/outcome e.g. observer bias, recall bias, reporting bias, instrument
publication bias -
What is bias?
a systemic deviation from the true estimation of the association between exposure and outcome
What is confounding?
situation in which the estimate between an exposure and an outcome is distorted because of the association of the exposure with another factor (confounder) that is also independently associated with the outcome
What is reverse causality?
this refers to the situation when an association between an exposure and an outcome could be due to the outcome causing the exposure rather than the exposure causing the outcome
What is the criteria for causality?
Bradford-hill criteria
What is the Bradford-hill criteria?
Sally Did Come To Russia but Cassie Annoyed Sally
strength of association
dose-response
consistency
temporality
reversibility
biological plausibility
coherence
analogy
specificity
What are some acute effects of dependent drug use?
complications of injecting (DVT, abscesses)
overdose (resp depression)
poor pregnancy outcomes
side effect of opiates (constipation, low salivary flow)
What are some chronic effects of dependent drug use?
blood-borne virus transmission
effects of poverty
Effects of dependant drug use can divided into 4 subsections, what are they?
Physical - acute, chronic
Social
Psychological
What is harm reduction for a heroin user?
action to prevent deaths (safe injections, not mixing, reducing amount after tolerance lost)
action to prevent blood borne virus transmission (sharing needles, condoms, hep vaccination)
referral where appropriate
What are steps in management for heroin user?
harm reduction
detox - buprenorphine
maintenance - methadone, buprenorphine
relapse prevention - naltrexone
psych interventions
What are the 3 health behaviours?
health behaviour - prevent disease (eating healthily)
illness behaviour - to seek remedy (going to doctor)
sick role behaviour - aimed at getting well (taking medicine, resting)
What is the theory of planned behaviour?
best predictor of behaviour is ‘intention’ - I intend to give up smking
What is intention determined by?
Attitude - persons attitude towards behaviour
Subjective norms - perceived social pressure to undertake the behaviour
Perceived behavioural control - persons appraisal of their ability to perform the behaviour
What are criticisms of theory of planned behaviour?
lack of temporal element
lack of direction of causality
Rational belief - patient may not be thinking rationally
Attitudes and social norms cant be measured
What are the stage models of health behaviour?
precontemplation
contemplation
preparation
action
maintenance
What is motivational interviewing?
counselling approach for initiating behaviour change by resolving ambivalence
What is Nudge theory?
‘nudge’ the environment to make the best option the easiest
- opt-out schemes such as pensions
- placing fruit next to checkouts
What are some typical transition points?
leaving school
entering the workforce
becoming a parent
becoming unemployed
retirement
bereavement
What is the NCSCT?
A social enterprise to support the delivery of effective evidence-based tobacco control programmes and smoking cessation interventions provided by local stop smoking services. The NCSCT:
– delivers training and assessment programmes
– provides support services for local and national providers
– conducts research into behavioural support for smoking cessation
What are the measure of quality assurance used by the NCSCT for their programmes?
knowledge and skills of stop smoking practitioners
interventions are evidence based
clinical effectiveness
professional development
Why should you notify the health protection agency about a notifiable disease?
so HPA can take urgent control measures
may be the only one who can tell HPA
duty of registered medical practitioners
What things should the HPA be made aware of?
Notifiable diseases
Infection which could present sig harm to human health
contamination which could present sig harm to human health
How would you manage an outbreak?
clarify problem (diagnosis)
outbreak? (2 or more related cases of communicable disease)
if so, help (microbiologists, consultant in infectious disease, health visitors)
call an outbreak meeting
identify cause
initiate control measures
What are maslows hierarchy of needs? examples?
Physiological - breathing, food, water, sex
Safety - security of body, employment, family, health
Love/Belonging - friendship , family, sexual intimacy
Esteem - self-esteem, confidence, achievement
self-actualization - morality, creativity, problem solving, lack of prejudice
What are some causes of homelessness?
mental illness/breakdown
domestic abuse
disputes with parents
bereavement - ‘no family ties’
What are health problems faced by the homelss?
TB
hepatitis
poor feet and teeth
violence and rape
sexual health
mental illness
addicitons
Barries to healthcare for the homeless?
access - opening times, location
integration - housing, social service
other things on their mind - do not prioritiese health
may not know where to find help
Asylum seeker vs refugee?
asylum seeker - person who has made an application for refugee status
refugee - a person granted asylum and refugee status - usually 5 years and then reapply
How do asylum seekers live?
no choice dispersal
vouchers/income support
NASS support package
full access to NHS
not allowed to work
Health condition of asylum seeker?
illness from home
injuries war and travel
no previous health surveillance/screening/immunisaitons
malnutrition
abuse
infestations
communicable disease
PTSD
Why is safety compromised so often?
healthcare is complex and high risk
resource intensive
system, patient and practitioners interaction
responsibilities are often shared
practitioners often take risks unknowingly
What are some common issues in medicine?
wrong diagnosis
wrong plan
medication reconciliation
high conc. medication solutions
patient identification
patient care handovers
How are errors classified?
Intention (skill-based, rule-based, knowledge based)
Action (generic, task specific factors)
Outcome (near miss, successful detection and recovery, death/injury/loss of function)
Context (anticipations and perseverations, interruptions an distractions)
What are different perspectives on error?
Person approach - error are the product of wayward mental processes, unsafe acts
System approach - errors are commonplace, remedial efforts directed at removing error traps and strengthening defences
Strategies to reduce errors and harm?
simplification and standardisation of clinical processes
checklists and aide memoires
information technology
team training
risk managemnent programmes
mechanisms to improve uptake of evidence based treatment patterns
What are some tools of risk identification?
incident reporting
complaints and claims
audit
benchmarking
external accreditation
active measurement/compliance
What are some leadership styles?
Inspirational
Transactional - reward employees for what they do
Laissez-faire - who embrace it afford nearly all authority to their employees.
Transformational - inclusive leadership throughout all levels of organisation
Mechanisms underlying inhumane behaviour?
bystander effect
pressing situational factors can override explicitly announced value systems
unwillingness to speak out against prevailing view
Basic types of errors?
Sloth
Fixation and loss of perspective
Communication breakdown
Poor team working
Playing the odds
Bravado (timidity)
Ignorance
Mis-triage
Lack of skill
System error
Why do things go wrong?
system failure
human factors
judgement failure
neglect
poor performance
misconduct
What is the Swiss Cheese model?
organization’s defence against failure are modelled as a series of barriers, represented as slices of cheese
Holes represent weaknesses in individual parts of system and are continually varying in size and position across the slices
failure = when a hole in each slice momentarily aligns > trajectory of accident opportunity > failure
What is the negligence assessment?
is there a duty of care?
was there a breach in that duty? - support from others? Bolam test, Bolitho test
did patient come to any harm?
did the breach cause the harm?
How is the patient compensated?
must demonstrate that it was your action/inaction that caused the harm
if successful - how much depends on : loss of income, cost of extra care, pain and suffering
What are Bolam and Bolitho test?
Bolam - would a group of responsible doctors do the same?
Bolitho - would it be reasonable of them to do so?
What is the tripartite model of learning?
Surface - fear of failure, desire to complete course
Strategic - desire to be successful > patchy and variable understanding
Deep - personal understanding, making links across material , look for general principles
What are the types of learner?
Theorist - can question ideas, offered challeneges
Activist - new experience, extrovert
Pragmatist - wants feedback, purpose, may like to copy
Reflector - watches others, reviews work and analyses
What is kolb’s learning cycle?
Activist > Reflector > Theorist > Pragmatist
Why teach about diversity?
Better health outcomes for patient (drs identify patient problems more accurately, patients more likely to adhere, fewer diagnostic tests and referrals
More satisfying doctor-patient encounters (doctor more time efficient, fewel complaints)
What is culture?
socially transmitted pattern of shared meanings by which people communicate, perpetuate and develop their knowledge and attitudes about life. An individual’s cultural identity may be based on heritage as well as individual circumstances and personal choice and is a dynamic entity
What is ethnocentrism?
The tendency to evaluate other groups according to the values and standards of one’s own cultural group, especially with the conviction that one’s own cultural group is superior to the other groups
What is a stereotype?
Involve generalisations about the ‘typical’ characteristics of members of a group.
What is prejudice?
Attitude towards another person based solely on their membership of a group
What is discrimination?
- Actual positive or negative actions towards the objects of prejudice
What is rationing? Why have rationing needs increased?
Resource is refused because of lack of affordability rather than clinical ineffectiveness
- Shift from acute illness to chronic long term
- Normal physiological events medicalised
- Increase in choice and increase in expensive drugs
What are some allocation theories?
Egalitarian principles
Maximising principles
Libertarian principles
What are the egalitarian principles? What is its weakness?
provide all care that is necessary and appropriate to everyone.
o Challenge: tension between egalitarian aspirations and finite resources.
What are the libertarian principles?
each is responsible for their own health, well being and fulfillment of life plan
What rights are frequently engaged in healthcare?
- Art 2 – the right to life (limited)
- Art 3– the right to be free from inhuman and degrading treatment (absolute)
- Art 8– the right to respect for privacy and family life. (qualified)
- Article 12 – right to marry and found a family
What are some benefits of social media?
wider and diverse social and professional networks
engage public and colleague in debates
public access to accurate health info
patient access to services
What are some disadvantages to social media?
loss of personal privacy
potential breaches of confidentiality
unprofessional
offensive
risk of posts being reported to media or employers
GMC duties of a doctor?
Make the care of your patient your first concern
Protect and promote the health of patients and the public
Provide a good standard of practice and care
Treat patients as individuals and respect their dignity
Work in partnership with patients
Be honest and open and act with integrity
What are the components of a planning cycle?
needs assessment > planning > implementation > evaluation
As a qualified doctor, how can you improve the health of patients in two main ways?
treating individual patients
influencing the services available to patients
Define evaluation?
assessment of whether a service achieves its objectives
What is the Donabedian framework for health service evaluation?
Structure
Process (+output)
Outcome
What is structure? Examples?
buildings, staff and equipment
e.g. number of ICU beds/1000, number of vasc surgeons/1000 population
What is process? examples?
what is done?
process through which patients go in A&E (where and when is patient first seen)
can also include output e.g. number of operations performed
What is outcome?
classification of health outcomes
5Ds
death (mortality)
disease (morbidity)
disability (quality of life)
discomfort (quality of life)
dissatisfaction
What are the issues with health outcomes?
cause and effect between health service provided and health outcome may be difficult to establish (many other factors involved)
time lag between service provided and outcome may be long (intervention in childhood diet and type 2 incidence)
large sample size needed
data may not be available
issues with data quality ( CART = completeness, accuracy, relevance , timeliness)
How would evaluate the quality of healthcare?
Maxwell’s dimensions of quality (3es and 3as)
Effectiveness
Efficiency
Equity
Acceptability
Accessibility
Appropriateness (right people at right time?)
What are two evaluation methods?
Qualitative
Quantitative
What are some qualitative methods of evaluation?
consult relevant stakeholders (staff, patients, policy makers)
observations (participant and non participant observation)
Interviews
Focus groups
Review of documents
What are some quantitative methods of evaluation?
routine collected data (hosp admissions; mortality)
review of records
surveys
special studies (epidemiological methods)
What is the general framework of evaluating a health service?
define what service is and what it includes
what re the aims/objectives
framework (structure, process, outcome)
methodology to be used (qualitative, quantitative, mixed methods)
results, conclusions and recommendations
Exam Questions
Donabedian’s “structure, process, outcome” is a useful
framework to use when carrying out evaluation of health
services. Explain what is meant by “structure”.
When assessing the quality of health services, Maxwell’s
classification lists six dimensions. List the six dimensions.
Although using measures of health outcomes is desirable in
evaluation of health services, there are potential limitations.
Explain why it may be difficult to attribute a health outcome to
the service provided.
