FoPC III Flashcards
what is epidemiology? state the 2 factors
looks at natural and type of illness in society using numerical science of epidemiology
looks at time and place and person affected
For example the rate of
occurrence of heart disease is very different between 18th Century English
women and 20th Century Finnish men.
what are the 3 main aims of epidemiology? Describe each
Description of the amount and distribution of disease in a population,
Explanation to elucidate the natural history and Aetiology of disease,
Disease control based on determining preventative measures, public health practice and therapeutic strategies
How might we compare Study Populations to determine epidemiologic clues?
- Aetiological Clues
- The Scope for prevention
- Identifying high risk or priority groups in society.
We compare how often an event appears in one group compared to another.
E.g. we determined that there is a link between smoking and lung cancer but this does not mean that all smoking always causes lung cancer
Define incidence.
The number of new cases of a disease in a given population at a specified period of time; indicates causation and Aetiology of disease
Define prevalence.
The total number of people with a specific illness in a population at a specified period of time; useful is assessing the workload for health services.
Define Relative Risk
The measure of the strength of an association between a suspected risk factor and the specified disease; it is calculated as incidence of exposed group over incidence of unexposed group
What are sources of epidemiological data?
- Mortality data
- Hospital activity statistics
- Reproductive health data
- Cancer statistics
- Accident statistics
- General practice morbidity
- Health and household surveys
- Social security statistics
- Drug misuse databases
- Expenditure data from the NHS
Name the different types of studies
- Descriptive Studies
- Analytical Studies
• Cross sectional
• Case Control Studies
• Cohort Studies
Define a descriptive study.
A study which attempts to describe the amount and distribution of a disease in a given population; it gives clues to possible risk factors and aetiologies of disease. They follow a time, place, person framework
When are descriptive studies useful?
- Identifying emerging public health problems through monitoring and surveillance of disease patterns
- Signaling the presence and effects worthy of further investigation
- Assessing the effectiveness of measures of prevention and control (such as screening programs)
- Assessing needs for health services and service planning
- Generating hypotheses about disease aetiology
What are the pros and cons of descriptive studies?
Pros: Cheap, quick, give valuable initial overview of a problem
Cons: no evidence of disease cause, do not test hypotheses.
What is a cross sectional study?
A study in which observations are made at a single point in time. Conclusions are drawn about the relationship between disease and variables of interest in a defined population
What are the pros and cons of a cross sectional study
Pros: provides quick results
Cons: usually impossible to infer causation
What is a case control study
An analytical study in which two groups of people are compared – those who have the disease of interest (cases) and those who do not have the disease (controls). The two groups are compared based on exposure to specific Aetiological risk factors to help give clue of disease cause. The results are published as ‘relative risks’
What is a cohort study?
Baseline data on exposure are collected from a group of people who do not have the disease under study. The group is then followed through time until a sufficient number have developed the disease to allow analysis. The original group is separated into subgroups based on exposure and incidence. They allow of calculation of cumulative incidence, allowing for differences in follow up time.
What are trials?
Experiments used to test ideas about Aetiology or to evaluate interventions. The randomized control trial is the definitive method of assessing any new treatment in medicine
What is a randomized control trial?
Two groups at risk of developing a disease are assembled; there is a study (intervention) group and a control group. The relative risk between the two groups is calculated to determine whether the intervention altered the incidence or course of the disease in any way
What factors must you consider when interpreting trial results?
- Standardization – removing or adjusting for variables when comparing populations
- Standardized mortality ratio – a standardized death rate converted into a ration for easy comparison (over a ratio of 100. E.g. A SMR of 120 indicates there were 20% more deaths than expected in a study populations)
- Quality of data – ensuring the data is trustworthy
- Case definition – to determine whether the individual has the condition of interest or not; necessary in determining true incidence
- Coding and Classification – ensuring all proper coding and classification has been accurately converted to ensure results are accurate
- Ascertainment – ensuring all data is accurate and that equal effort has been put into acquiring all aspects of information
What is bias?
Any trend in the collection, analysis, interpretation, publication or review of data that can lead to conclusions that are systematically different from the truth. There are 4 types of bias: selection bias, information bias, follow up bias, systematic error
What is selection bias?
When the study sample is not truly representative of the whole population, leading to inaccurate conclusions. E.g. deliberately allocating people to a specific group in a randomized control trial
What is Information Bias?
Systematic errors in measuring exposure or disease. E.g. a researcher knowing who is case vs. who is control prior to beginning an experiment may inadvertently lead to skewed results.
What is follow up bias?
When one group is followed up more carefully than the other leading to more accurate results in the one group. E.g. failing to accurately follow up members of a cohort group study
What is Systematic error?
A form of measurement bias where there is a tendency for measurements to always fall on one side of the true value due to inadequacies of the measuring instrument (through mechanical or human error)
What is a confounding factor?
A factor independently associated with both the disease and with the exposure under investigation, so it distorts the relationship between the exposure and the disease; age, sex and social class are common confounding factors.
How can one deal with confounding factors when designing a study?
- Randomization in trials
- Restriction of eligibility criteria to only certain study subjects
- Matching subjects for likely confounding factors
- Stratification of results according to confounding factors
- Adjusting results to take account of suspected confounding factors
What are the criteria for Causality?
- Strength of association (as measured by relative risk or odds ratio)
- Consistency (Repeated observation of an association in different population under different circumstances)
- Specificity (a single exposure leading to a single disease)
- Temporality (the exposure comes before the disease)
- Biological Gradient (Dose-response relationship; as exposure increases so does the risk of disease)
- Biological Plausibility (the association agrees with what is known about the disease)
- Coherence (the association does not conflict with what is known about the biology of disease)
- Analogy (exposure-disease relationship)
- Experiment (a suitably controlled experiment to prove the association is casual – uncommon in human populations)
NOTE: temporality is the only absolutely necessary criterion
What percentage of the population is expected to be over the age of 80 in 2050?
22%; the majority (80%) will live in low or middle income countries
Describe the population, fertility rate and life expectancy of people in Developed Countries.
The population has a steady INCREASE, Fertility rate is decreasing and total life expectancy is increasing
It is suggested that old people will be exceeding the young by 2050. Why might life expectancies be increasing?
- Migration
- Health education programs including AIDS and malaria prevention
- Improvements in public health related to housing, clean water and nutrition
- Increased involvement in aid agencies and charities
Describe the population, fertility rate and life expectancy of people in Developing Countries
The population is aging rapidly – even in lower socioeconomic classes, the fertility rate is decreasing and the life expectancy rate is increasing dramatically
Describe the population, fertility rate and life expectancy of people in Least Developed Countries
The population is aging and growing, fertility is decreasing and the life expectancy is growing
Describe how Scotland’s population has been changing.
There is an increasing life expectancy, an increase in the number of people ++65, and an increase in net migration, the young population (0-50) is going to decrease significantly
Explain the reasons for the ageing population in Scotland
- Baby Boomers after WW2 are ageing
- Mortality rates are improving
- There is an increasing emphasis on preserving health and fitness in the older population
How does an ageing population affect health care in Scotland?
- Increasing number of geriatricians and health professionals involved in care of the elderly will be required
- Increasing need for facilities for elderly health care
- Chronic disease care will be moving from secondary care to primary/community care
- Palliative care will be increasing
- Increasing specific health promotion campaigns for the elderly
How does an ageing population in Scotland affect Social health?
- Increasing dependence on families to take care of ageing relatives
- Increasing demand for home carers
- Increasing need for providing social activities for the elderly
- Changing role of elderly as grandparents, etc.
- Changing housing demands as more elderly people become capable of living on their own
How does an ageing population affect the Economic situation of Scotland?
- The retirement/pension age is increasing
- Finding employment for young people may be harder as elderly people stay in work for longer
- Proportionately fewer people will be paying taxes, making pension funds less adequate
- Decreasing adequacy of state pension funds
- Increasing cost of ‘free personal care for the elderly’ policy
How does an ageing population affect the Political situation of Scotland?
- Current decision making and planning must take into account the ageing population
- The elderly population will gain a bigger voice in influencing political decisions
Define ‘multimorbidity’
The co-existence of two or more long-term conditions in an individual; it is the norm, rather than the exception, in primary care patients
How does complexity affect patients?
Older patients may have more than one chronic health conditions making treatments more complex.
E.g. treating one condition may make another condition worse
What is the purpose of an Anticipatory Care Plan (ACP)
-Promotes discussion in which individuals, their care providers and those close to them, make decisions with respect to their future health or personal and practical aspects of care
When should an ACP be done?
-Any time in life that seems appropriate and continuously
Who should do an ACP?
Any doctor with an appropriate relationship
How should an ACP be done?
- Thinking ahead and make plans
- Be careful; write down everything
How can an ACP be shared?
Through a Key Information Summary (KIS)
What is included in an ACP?
1) Legal Matters
a. Welfare Power of Attorney
b. Continuing power of attorney
c. Guardianship
2) Personal
a. Advance statement (statement of values, preferences and priorities, advance decisions to refuse treatments, other people to contact)
b. Thinking ahead and making plans
1. Medical
a. SPAR
b. Home care packages
c. Potential Problems
d. GSFS
e. ePCS
f. DNA/CPR
g. Just in Case
h. Liverpool Care pathway
i. DN verification of death
Describe the steps of a reactive journey (undesirable)
- GPs, District Nurses ad hoc arrangements
- No discussion w/ patient or family on condition, outlook, anticipated problems, place of care
- Patient problems with pain, sickness, constipation and anxiety continue
- Patient makes a crisis call OOHs – there is no plan of care and no drugs in the home
- Patient is admitted to hospital after calling 999
- Patient dies in hospital after failed CPR
- Family is given minimal support grief
- There is no reflection by the profession team on care
Describe the steps of a Proactive Journey (desirable)
- Patient is on the GP register and is discussed at team meetings
- Social and financial support and information is given to the patient and carers
- There are usual GP and DN proactive support visits and phone calls to the patient
- Assessment of symptoms, partnerships with specialists and customized care are provided to the patient
- Care is continuously assessed, including respite and psychosocial needs
- The preferred place of care is noted and organized
- Care plan and medications are issued for patient use at home
- An end of life pathway is created with the patient
- Patient dies in the preferred place; family bereavement is met with support
- Staff reflect on patient’s death, audit gaps improve care and the whole MDT learns more about good patient practice
What is Occupational Health?
A sector of health care that focuses with the effects of health on work and work on health. It attempts to maximize people’s opportunity to benefit from healthy and rewarding work while not putting themselves or others at unreasonable risk
Define: Hazard
Something with the potential to cause harm
Define Risk
The likelihood of something causing harm
Define Risk Factor
Something that increases the risk of harm occurring
Define Protective Factor
Something that has the potential to decrease harm
Define Susceptibility
Something that influences the likelihood that something will cause harm
What questions are relevant to ask in an Occupational History?
- Demands of the job; Physical/intellectual
- Environment (office, shop, factory) and its Associated Risk Factors
- Temporal (shift work, early starts)
- Travel
- Organizational (lone working, customers, etc.)
- Layout (ergonomic, work equipment, etc.)
When assessing Occupational Health what are the components of a Functional Assessment
Stamina Mobility (walking/bending/sitting) Agility (dexterity/posture/co-ordination) Rationale (mental state/mood) Treatment (duration, side effects) Intellectual (cognitive abilities) Essential for Job Sensory Aspects
As a GP you may be asked to do an assessment of Fitness for Work. What does this entail?
The ability of a patient to do their job effectively (safety, performance, attendance, any pre-existing conditions)
-This may include assessment of fitness for specific jobs (especially Pilots, Offshore Workers, Fire-fighters, armed forces, seafarers, and HGC/PCV drivers
What occupations have the highest rate of fatal injuries?
Construction, agriculture, waste/recycling (Note: roughly 1 in 2000 employees report a non-fatal work injury)
What is the impact of Occupational Disease?
8000 Occupational Cancer Deaths in the UK, 4000 cases of COPD due to exposure, Occupational Asthma accounts for 15% of all adult asthma
The problem of Occupational Health is worse in developing nations
The majority of Occupational Health complaints are: stress, depression/anxiety and MSK disorders
It should be preventable
What does the Health and Safety at Work Act of 1974 state?
Act places a duty on employers “so far as is reasonably practicable to protect the health, safety and welfare.” of their employees, visitors and the public
What are the 5 steps of Risk Assessment in Prevention of occupational Disease
- Identify Hazards; requires knowledge of link between exposure and disease
- Determine who might be harmed and how
- Evaluate risks and decide on precautions
- Record findings and implement controls
- Review and update when necessary
What is the hierarchy of control measures for Occupational Health
SUBSTITUION – find a less hazardous procedure, a less hazardous agent or a less hazardous formulation
ENGINEERING CONTROLS – general ventilation, local exhaust ventilation, enclosures, silences, isolation/separation
ADMINISTRATIVE CONTROLS – permit to work systems, access controls, information/instruction/training, task rotation, equipment purchasing, maintenance
PERSONAL PROTECTIVE EQUIPMENT – hard hats, ear defenders, goggles, breathing apparatus, gloves, coveralls, body armour, safety boots
Why is PPE not the first line
It Is the LEAST effective control due to: maintenance, storage, replacement, training, usage, compatibility, ‘one size fits none’ and inappropriate selection
How do you manage occupational disease?
- Diagnosis – occupational history, clinical examination, clinical tests, workplace visit
- Investigation – workplace monitoring, biological monitoring
- Treatment
- Modifying Work Procedures – modified hours, duties, adjustments under the equality Act, redeployment
- Modify Workplace (unnecessary if employee does not become reaffected)
- Health Surveillance
- RIDDOR (Reporting of injuries, diseases and dangerous occurrences
- Regulations) reportable condition?
What are the 7 main current aspects of Global Health?
- Inequalities in health within and between countries
- Crisis in ‘Western’ Healthcare
- Managing expectations and facilitating behavioral changes
- Population, demographics and consumption
- Material inequalities
- Effective use of limited resources
- Politics/human rights/ gender issues
What is the biggest Global Health Threat of the 21st Century?
Climate Change leading to:
- Severe food shortages
- Extreme heat leading to more CVS and respiratory disease, infections and allergies
- Natural disasters leading to drought/famine, more waterborne disease, infections
- Human migration
How might we obtain sustainable healthcare?
Education Carbon Reduction Strategies Reduction of Waste New Technologies Increasing global interdependence in health care with sharing of resources including skilled workers
What are Human Factors in Health Care?
- Organisational/Management
- Safety Culture
- Managerial leadership
- Communication - Work Environment
- Work environment and hazards - Workgroup/ Team
- Teamwork structure/process
- Team leadership
- Individual Worker
- Cognitive skills (situation awareness, decision making)
- Personal Resources (stress, fatigue)
What does Human Factors Science acknowledge?
- the universal nature of human fallibility
- the inevitability of error
How can we use Human Factors to design the workplace?
- minimise the likelihood of error
- minimise the consequences of inevitable error
What are Non- Technical Skills?
- Situation Awareness
- Decision Making
- Communication
- Team Work
- Leadership
- Managing Stress
- Coping With Fatigue
(Some Dudes Can Tinkle Like My Corgi)
What is Situation Awareness?
Knowing and understanding what is going on around you by: Gathering Information, Interpreting Information, anticipating future states
How does one maintain situational awareness?
- Good briefing
- Minimising distractions and interruption
- Updating
- Monitoring
- Speaking up
- Time management
- Maintaining fitness for work
What is decision making?
The process of reaching a judgement or choosing a course of action to meet the needs of a given situation
What does one need for good Decision Making skills?
- Situation assessment
- Generation and consideration of multiple options
- Selection and implementation of the most appropriate option
- Review of outcome
What are the types of Decision Making?
- Rule based
- Comparison of options (choice)
- Recognition (primed based on experience)
- Creative
What is the Dual Process Theory of Decision Making?
Type 1. Intuitive = contextual, where most errors will occur
Type 2. Analytical
How can one improve Clinical Decision making?
Be aware of when decision making may be most at risk (e.g. stressful situations, fatigue, etc.)
Story Telling
Metacognition (higher cognitive function)
Relfection
Seek feedback on decision making
What are four important components of communication?
- What must be communicated?
- How might the information be communicated?
- Why is the communication taking place?
- Who are you communicating with?
What are internal barriers to effective communication?
Language, culture, motivation, expectations past experiences, prejudice, status, emotions/moods, deafness, voice level
What are external barriers to effective communication?
Noise, interference or distractions, separation in location/time, lack of visual cues (e.g. body language, etc.)
What are valuable communication skills?
- Active Listening
- Approach (passive vs. assertive vs. aggressive)
- Speaking Up (challenging the behavior of others, even if it breaks the hierarchy)
What is an assertive approach to communication?
a. Verbal communication (content, Use ‘I’ statements, offer solutions, obtain feedback, repetition)
b. Non-verbal communication (maintain eye contact, posture, inflections and tone of voice, timing)
What are the 5 key components of a team?
- More than one person
- Common goal
- Timing
- Co-ordination
- May involve people with different expertise (e.g. Multi disciplinary Team)
What are the features of an effective team?
- individuals have the ability to perform their given tasks effectively
- team workers support one another
- Teammates solve conflicts
- Exchanging of vital information
- Co-ordination of team activities
What are leadership requirements?
- use of authority where necessary
- maintenance of standards
- planning and prioritizing
- mgmt of workload and resources
What is stress?
The adverse reaction people have to excessive pressure or other types of demand placed on them
What are the elements of stress management?
- identify the cause of stress
- Recognize the symptoms and effects
- Implement coping strategies
What are sources of workplace stress?
- job demands
- Lack of control
- Relationships
- Change
- Home/Work interface
- Uncertainty
How can stress in the workplace be reduced?
- Increase resources and positive mediators
- provide necessary training and experience
- Avoid working too far outside of the comfort zone
- Maintain a good standard of fitness
- Identify personal workplace stressors
- Be aware of the symptoms of stress
- Look at coping mechanisms
- Take advantage of stress management offered in the workplace
- Prepare for new roles
- Look after yourself when not at work
What is fatigue?
the state of tiredness that is associated with long hours of work, prolonged periods without sleep, or requirements to work at times out of synch with the body’s biological or circadian rhythms
How does fatiqgue affect the worker?
COMMUNICATION = difficulty finding and delivering the correct information = speech less expressive SOCIAL = withdrawn =more acceptance of errors =less tolerant of others =neglect of small tasks =less likely to converse =increasing irritability =Increasingly distracted by discomfort THINKING = less able for innovative thinking and decision making =Decreased ability to cope with unforeseen circumstances =Decreased ability to adjust plans =Tendancy to rigid thinking MOTOR SKILLS = less co-ordination =Poor timing
What are the Wilson and Jungner criteria for setting up a screening programme for a disease? (10)
1, Will the test detect the condition at an early pre-clinical stage?
2. is the disease an important public health problem?
3. Is the natural history of the disease adequately understood?
4. Is a test available for the condition?
Is the test sensitive (low false negatives)
5. Is the test specific? (low false positives)
6. Is the test safe?
7. Is the test acceptable to the public and professionals involved
8. is the cost of the test reasonable?
9 Does the overall cost-benefit analysis make it worthwhile?
10. Is there effective treatment for the test being screened?
11. Is the treatment safe?
12. Is the treatment considered acceptable by the public, patients and medical professionals?
13. Are facilities available for diagnosis and treatment?
How would you explain a Cast-Control Group? (2)
- Two groups of people are compared: one group has the disease process being studied (case) and the other group does not have the disease (control)
- data is collected on both groups to determine what aetiological factors may be attributed to the disease in question.
How would you explain a Cohort Study? (2)
- Baseline data on exposure is collected in a group of people without the specific disease being studied
- The group is followed through time until a sufficient number of subjects have developed the disease, allowing analysis
What sources of data may be used to provide epidemiological information on a specific disease? (6)
- Mortality data
- Hospital activity statistics
- General practice morbidity/disease registers
- Health and household surveys/population census data
- Social security stats
- NHS expenditure data
A patient presents to you with contact dermatitis. What questions can you ask to assess if it is caused by occupational exposure? (5)
- Does he work with chemical irritants?
- How much exposure does he have to these irritants, incl. intensity and duration?
- Do his symptoms improve when he is away from work?
- Is PPE use encouraged in the workplace?
- Does he comply with PPE use?
- Does the company enforce PPE use?
- Do other colleagues have similar symptoms?
- Does he have any hobbies, pets, etc. that could be the cause?
- Does he use any creams or topical gels which he may be allergic to?
Name psychological and/or social stresses that may affect a foreign Oil and Gas worker who has recently moved to Aberdeen with his family? (5)
- anxiety re. travel
- depression and loneliness from being away from family
- Stress caused by shift patterns
- Pressure to maintain standard of living
- Difficulty adjusting to family life when onshore
- Abuse of drugs and alcohol
- Missing foreign culture and feels ethnic isolation
- anxiety about job security
What are the Stages of the Stage Model Cycle of Change? (6)
- Pre-contemplation e.g. I currently smoke and do not intend to stop
- Contemplation e.g. I currently smoke and am thinking about giving up
- Preparation e.g. I have booked an appointment with my GP about nicotine patches
- Action e.g. I stopped smoking one week ago
- Relapse e.g. I had stopped smoking but have had a couple because work has been so stressful
- Maintenance e.g. I no longer smoke and have not done so for 18 months
What difficulties might arise in a consultation between people of different countries/cultures? (10)
- Lack of knowledge about health issues
- Lack of knowledge about NHS
- Fear and distrust
- Racism
- Bias and athnocentrism
- Aterotyping
- Ritualistic behaviours
- Language barriers
- Presence of third party (translator) in the room
- Deifferences in perceptions and expectations
- Examination taboos
- Gender differences between doctor and patient
- Religious beliefs
- Difficulties using the language line
How will an ageing population affect health services? (3)
- Increased number of geriatricians and allied health professionals
- increased wards/health care facilities for elderly health care
- increased prevalence of long term chronic conditions
- necessity of health care promotions aimed at the elderly
How will an ageing population affect social care? (3)
- increased dependence on families/carers
- demand for home carers and nujrsing homes will increase
- increased emphasis of social activities for elderly within the community
- role of elderly as grandparents likely to change
- housing requirements will change as more elderly live on their own
