Foundations of Primary Care Flashcards
List 5 principles of person centred care
CRAPI 1) Choice and Empowerment 2) Respect 3) Access and Support 4) Patient involvement in health policy 5) Information
What are the leading causes of death in men and women? overall?
men = cardiovascular disease women = dementia both = cardiovascular disease, lung cancer, stroke, dementia
Define disability
one with physical, mental or sensory impairment which has a substantial adverse and long term (> 12 months) effect on ‘normal’ day to day activities.
What are the three ways to define illness:
AEI 3)Actions - What actions they take in response to them. 1)Experience -what people experience when they are unwell 2)Interpret - How they interpret or define those symptoms
What are the individual factors that can affect the impact of disability?
(the) SEA SPARES (you) Sex Education level Age Support network Personality Attitudes of family/community/society Resources available Early experience and attitudes Socioeconomic background
Define ‘burden of treatment’
the impact of the “work of being a patient”on functioning and well-being. This work includes 1) medication management 2)self-monitoring 3) visits to the doctor 4) laboratory tests 5) lifestyle changes Coping with all these healthcare tasks requires a significant amount of time, effort, and cognitive work from patients and caregivers.
Define biographical disruption
A long term condition leads to a loss of confidence in the body. There is then a loss of confidence in social interaction or self‐identity
Define incidence
the number of new cases of a disease in a population in a specified period of time (water dripping IN the bath)
Define Prevalence
the number of people in a population with a specific disease at a single point in time or in a defined period of time (existing cases/water already in bath)
Define relative risk
the likelihood of an event (or developing a disease) relative to exposure (e.g. smokers have a higher risk of lung cancer vs non smokers)
to explain the World Health Organisation (WHO) framework of body structure and function impairment, activity limitation and participation restrictions
BAP • Body structure and function impairment - is defined as abnormalities of structure, organ or system function (organ level) • Activity limitation - is defined as changed functional performance and activity by the individual (personal level) • Participation restrictions - is defined as the disadvantage experienced by the individual as a result of the impairments and disabilities (interaction at social and environmental level)
Effects on other members of family/community of diability
Parents • Mother and/or father may not be able to combine work with the demands of caring for disabled child - financial implications for family • Guilt at having passed on the causative gene if genetic disorder • Psychological strain • Caring for disabled child may be detrimental to parent’s physical health • Some parents may have difficulty bonding with disabled child • Some parents may form a particularly strong bond with disabled child • Marital problems • Increased risk of child abuse • Over-protection of disabled child • May become a strong advocate for their child Siblings • Resentment at time parents spend caring for disabled child • Resentment at restrictions to normal family life • May have to develop carer role • Grow up with greater understanding of disability Peers • May “look out” for disabled child • Friend may be stigmatised along with disabled child • May grow up with greater understanding of disability • May need to adapt activities to include disabled friend • Teasing by other peers Teachers • May have lack of understanding of disability/lack of training • May have tendency to over-protect disabled child • May be lack of willingness to integrate in mainstream activities • May be additional challenges in personalising education for disabled child • Stress of managing both mainstream and additional support needs pupils in the same class
Expert Patient definition
Patient/carer has an in-depth knowledge of their condition (or in this case the condition of the person they care for), sometimes exceeding that of health professionals
Where do patients get information from?
• peers / family / friends • Internet - general information e.g. google, social media • TV • Health pages of newspaper or women’s magazine • “What should I do?” / “When should I worry?” booklet • SHOW (Scotland’s health on the web) website, NHS inform website • GP practice leaflet • GP practice website • Adverts in public places e.g. bus stops, railway stations • Health awareness events e.g. health fairs • Pharmacies e.g. posters, leaflets
list several medical and non-medical factors which may influence an individual’s desire to seek medical attention and/or “trigger” the uptake of medical care
Factors affecting uptake of care- Medical Factors • new symptoms • visible symptoms • increasing severity • duration Non medical factors affecting uptake of care • crisis • peer pressure “wife sent me” • patient beliefs • Expectations • social class • Economic • Psychological • Environmental • Cultural • Ethnic • Age • Gender • Media
Define health literacy
SCUnK Health literacy is about people having the knowledge, skills, understanding and confidence to use health information, to be active partners in their care, and to navigate health and social care systems.
What are the three aims of SIGN
• Help health and social care professionals and patients understand medical evidence and use it to make decisions about healthcare • Reduce unwarranted variations in practice and make sure patients get the best care available, no matter where they live • Improve healthcare across Scotland by focusing on patient-important outcomes
Give examples of sources/types of epidemiological data.
michael gove HIDES CHARM Health and household surveys ISD Scotland statistics Drug misuse databases Expenditure data from NHS Social security statistics Cancer statistics Hospital activity statistics Accident statistics Reproductive health statistics Mortality data
Define a confounding factor
A confounding factor is one which is associated independently with both the disease and with the exposure under investigation and so distorts the relationship between the exposure and disease.
List three common confounding factors
• Age • Sex • Social class
List Reasons not to do with healthcare why numbers of elderly population increasing
• Decrease in birth/fertility rates • Improvements in housing • Improvements in water supplies • Improvements in sanitation/sewerage systems • Improvements in nutrition • Improved safety and reduction of injury • Migration (some areas only) • War/genocide (some areas only)
social implications associated with Scotland’s increasing elderly population
• Increasing dependence on families and/or carers who are also ageing and perhaps still working themselves • Demand for home carers likely to increase • Demand for Care home/nursing home places likely to increase • Increasing emphasis on social activities for the elderly within communities • Role of elderly as grandparents and carers of grandchildren likely to change e.g. may have fewer/no grandchildren, may still be in employment themselves • Housing demands are likely to change as more elderly people live alone e.g. increased demand for one-bedroom flats, sheltered housing • Elderly people remaining in employment for longer may lead to an increase in unemployment rates in the young (this point could equally well be made as an economic implication)
What are the different options for care when an elderly person becomes more ill?
• Living in own home with support from family • Living in own home with support from social services • Sheltered Housing • Residential Home • Nursing Home Care
What is an anticipatory care plan
Advance and anticipatory care planning promotes discussion in which individuals, their care providers and often those close to them, make decisions with respect to their future health or personal and practical aspects of care.
examples of legal issues which may be included in an Anticipatory Care Plan for any patient
• Welfare power of attorney • Financial power of attorney • Guardianship (POA = arranged with patient when has capacity, guardian is arranged through court when no POA made and person no longer has capacity).
examples of medical issues which may be included in an Anticipatory Care Plan for any patient
• Potential problems • Home care package • Wishes re DNA CPR • Scottish Palliative Care Guidelines • Communication which has occurred with other professionals • Details of “just-in-case” medicines • Electronic care summary • Assessment of capacity/competence • Current aids and appliances (helps assess current functional level)
examples of personal issues which may be included in an Anticipatory Care Plan for any patient
• Statement of wishes regarding treatment/advance directive • Next of kin • Consent to pass on information to relevant others • Preferences and priorities regarding treatment • Who else to consult/inform • Preferred place of death • Religious and cultural beliefs re death • Current level of support e.g. family/carers
List all members of the MDT in community
• GP - day to day medical support, monitoring of Parkinson’s disease and other conditions, co-ordination of care • District nurse - dressings and management of pressure sore • Nurse practitioner or paramedic practitioner or physician’s associate-acute home visits with GP phone support or follow up visit • Home carer - practical tasks e.g. bathing, dressing • Pharmacist - advice on medication, dosette box • Social worker/care manager - advice on benefits e.g. attendance allowance, contact with agencies • Occupational therapist - adaptation of living environment to maximise independence • CPN - assessment and management of low mood • Physiotherapist - continue to improve mobility and stability • Dietician - advice on improving appetite, assessment nutrition • Receptionist - first point of contact for any issues/concerns/house calls • GMED/NHS 24 - out-of-hours care for unexpected deterioration/new condition • Parkinson’s Nurse specialist - specialist advice to Sandra and her family relating to Parkinson’s disease, assist contact with local Parkinson’s support group • Community geriatric nurses - discharge assessment, support with development of a care plan • Community geriatrician - specialist overview of care/advice on care
Define the sick role
– the privileges and obligations which accompany illness.
What does the sick role do to patients?
• The sick role exempts ill people from their daily responsibilities • The patient is not responsible for being ill, regarded as unable to get better without the help of a professional. • The patient must seek help from a healthcare professional. • The patient is under a social obligation to get better as soon as possible to be able to take up social responsibilities again.
Why is disability increasing?
Increased age of population Rise in injuries from car accidents, falls and violence, chronic diseases
The sick role – Health professional role
Must be objective and not judge the patients morally Must not act out of self interest or greed but put the patients interests first He/she must obey a professional code of practice Professional must have the necessary knowledge and skills to treat patients Professional has right to examine patient intimately, prescribe treatment and has wide autonomy in medical practice.
What are descriptive studies and what are they used for?
Descriptive studies attempt to describe the amount and distribution of a disease in a given population This kind of study does not provide definitive conclusions about disease causation, but may give clues to possible risk factors and candidate aetiologies. Such studies are usually cheap, quick and give a valuable initial overview of a problem
What are cross sectional studies?
(disease frequency, survey, prevalence study) In cross-sectional studies, observations are made at a single point in time
What are case control studies?
two groups of people are compared: a group of individuals who have the disease of interest are identified (cases), a group of individuals who do not have the disease (controls).
What are cohort studies?
In cohort studies, 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.
What is meant by a trial? A randomised controlled trial?
Trials are experiments used to test ideas about aetiology or to evaluate interventions. The “randomised controlled trial” is the definitive method of assessing any new treatment in medicine.
What is standardisation?
A set of techniques used to remove (or adjust for) the effects of differences in age or other confounding variables, when comparing two or more populations. An age-sex standardised rate represents what the unstandardised (crude) rate would have been in the study population if that population had the same proportion of males and females, and of people in different age groups, as the standard population. Rates can be standardised for any other relevant confounding factor (eg, social class). Comparisons of incidence or mortality rates in a population over time, or between two different populations, or between population subgroups, should always be based on standardised rates, never on crude rates.
What is the Standardised Mortality Ratio (SMR)?
This is a special kind of standardisation which you may encounter in your reading. It is a standardised death rate converted into a ratio for easy comparison. The figure for a standard reference population (eg, Scotland) is taken to be 100 and the standardised death rates for the comparison (study) populations (eg, Grampian) are expressed as a proportion of 100. A figure below one hundred means fewer than expected deaths, and above 100 means more. For example, an SMR of 120 means that 20% more deaths occurred than expected in the study population, allowing for differences in the age and sex structure of the standard and study populations and an SMR of 83 means 17% fewer deaths occurred.
What is meant by case definition?
The purpose of case definition is to decide whether an individual has the condition of interest or not. It is important in because not all doctors or investigators mean the same thing when they use medical terms. Differences in incidence of disease over time or in different populations may be artefact, due to differences in case definition, rather than differences in true incidence.
What is meant by Coding and classification?
This is related to the issue of case definition. When data are being collected routinely (eg, death certificates), it is normal to convert disease information to a set of codes, to assist in data storage and analysis. Rules are drawn up to dictate how clinical information is converted to a code. If these rules change, it sometimes appears that a disease has become more common, or less common, when in fact it has just been coded under a new heading
Define bias?
Bias is 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 very many types of bias which can creep into epidemiological studies. Four important types are described below.
Define Selection bias?
Occurs when the study sample is not truly representative of the whole study population about which conclusions are to be drawn. For example, in a randomised controlled trial of a new drug, subjects should be allocated to the intervention (study) group and control group using a random method. If certain types of people (eg, older, more ill) were deliberately allocated to one of these groups then the results of the trial would reflect these differences, not just the effect of the drug.
Define Information bias?
arises from systematic errors in measuring exposure or disease. For example, in a case control study, a researcher who was aware of whether the patient being interviewed was a ‘case’ or a ‘control’ might encourage cases more than controls to think hard about past exposures to the factors of interest. Any differences in exposure would then reflect the enthusiasm of the researcher as well as any true difference in exposure between the two groups.
Define follow up bias?
arises when one group of subjects is followed up more assiduously than another to measure disease incidence or other relevant outcome. For example, in cohort studies, subjects sometimes move address or fail to reply to questionnaires sent out by the researchers. If greater attempts are made to trace these missing subjects from the group with greater initial exposure to a factor of interest than from the group with less exposure, the resulting relative risk would be based on a (relative) underestimate of the incidence in the less exposed group compared with the more exposed group.
Define Systematic error?
A form of measurement bias where there is a tendency for measurements to always fall on one side of the true value. It may be because the instrument (eg, a blood pressure machine) is calibrated wrongly, or because of the way a person uses an instrument. This problem may occur with interviews, questionnaires etc, as well as with medical instruments.
Define Cofounding factor?
A confounding factor is one which is associated independently with both the disease and with the exposure under investigation and so distorts the relationship between the exposure and disease. In some cases the confounding factor may be the true causal factor, and not the exposure that is under consideration.
List two common cofounding factors
Age Sex
List how cofounding factors are dealt with in trials
depending on the particular study design: • In trials, the process of randomisation (in effect the play of chance leads to similar proportions of subjects with particular confounding in the intervention and control groups). • Restriction of eligibility criteria to only certain kinds of study subjects . • Subjects in different groups can be matched for likely confounding factors. • Results can be stratified according to confounding factors. • Results can be adjusted (using multivariate analysis techniques) to take account of suspected confounding factors.
Define multimorbidity
the co-existence of two or more long-term conditions in an individual (multi-morbidity often results in polypharmacy)
What are the pros of screening?
- Early detection of cancer: As discovering the cancer when it is small increases the chances of successful treatment. 2. Mortality reduction: breast cancer screening saves about 1400 lives per year in UK. 3. Possibility of breast conserving surgery: Screening will help to find the cancer when it is small and this will help in having lumpectomy instead of mastectomy.
What are the cons of screening?
• Personal costs include problems with false positive results, which can lead to distress and possible unnecessary treatment. • Individuals who choose not to participate in screening may be disadvantaged - for example, being labelled as from a ‘positive family’ with regard to genetic susceptibility, when other family members have chosen to be screened and have been found to be positive. • False negative tests. No test is 100% sensitive, which can then lead to false reassurance by both patients and doctors. This may even dissuade patients from returning for future screening tests. • False positive tests. One study found that 15% to 25% of cases of breast cancer detected by screening are overdiagnosed, translating to 6 to 10 women over-diagnosed for every 2,500 women invited. • Misinterpretation of results can lead to a false sense of security - eg, patients with normal cholesterol or normal blood pressure may continue to smoke. • Costs to society: actual costs of equipment, services, treatment, etc; also, the time taken off work for people to attend the screening test and for the treatment.
give examples of measures to prevent activity limitation in children and adults
Disease prevention: e.g. folic acid given to pregnant mothers to prevent spina bifida Disease prevention interventions e.g. vaccination programmes Screening heath education and promotion e.g. stop smoking Disease modifying drugs e.g. analgesia in rheumatoid arthritis Physiotherapists and OTs input (safe working conditions so no further injury, maximise persons optimal functioning after injury)
What is the process of clinical audit?
1) Selecting a topic. 2) Agree/review standards 3) Collect data on current practice 4) Compare data with standards 5) Implement change if needed 6) (cycle starts again) review standards
how epidemiological data may be used in daily practice in community and hospital settings
Epidemiology: the study of changing patterns of disease with the aim to improve the health of populations Assist in making a diagnosis (e.g. in COPD, the patient having all the risk factors making it more likely) Assess which services are required for prevention, diagnosis, primary care, secondary care, rehabilitation Ensure a high quality of these services (clinical audit, implementation of guidelines) Care out health need assessments to provide a rational framework for decisions on prioritisation of COPD healthcare resources.
Define criteria for causality?
Criteria establishing epidemiologic evidence of a causal relationship between a presumed cause and an observed effect
List some criteria for causality? What are the famous causality criteria?
Bradford Hill criteria 1. Strength (effect size): A small association does not mean that there is not a causal effect, though the larger the association, the more likely that it is causal. 2. Consistency (reproducibility): Consistent findings observed by different persons in different places with different samples strengthens the likelihood of an effect. 3. Specificity: Causation is likely if there is a very specific population at a specific site and disease with no other likely explanation. The more specific an association between a factor and an effect is, the bigger the probability of a causal relationship.[1] 4. Temporality: The effect has to occur after the cause (and if there is an expected delay between the cause and expected effect, then the effect must occur after that delay). 5. Biological gradient: Greater exposure should generally lead to greater incidence of the effect. However, in some cases, the mere presence of the factor can trigger the effect. In other cases, an inverse proportion is observed: greater exposure leads to lower incidence. 6. Plausibility: A plausible mechanism between cause and effect is helpful (but Hill noted that knowledge of the mechanism is limited by current knowledge). 7. Coherence: Coherence between epidemiological and laboratory findings increases the likelihood of an effect. However, Hill noted that “… lack of such [laboratory] evidence cannot nullify the epidemiological effect on associations”. 8. Experiment: “Occasionally it is possible to appeal to experimental evidence”. 9. Analogy: The effect of similar factors may be considered.
List causes of disability around the world
Congenital Injury Communicable Disease Non-Communicable Disease Alcohol Drugs-iatrogenic effect and/or illicit use Mental Illness Malnutrition Obesity
Describe the variety of individuals’ responses to long term conditions and the reasons for these – personal reactions to disability
PARENTS Personality/ mood of person All those around them (reactions) Resources /role of person (e.g. job) Education Nature of the disability Time since disability Support network
• Medical and Social Models for Disability; to be able to explain theoretical models of activity limitation; medical model and social model
Medical ▪ Individual/personal cause e.g. accident whilst drunk ▪ Underlying pathology e.g. morbid obesity ▪ Individual level intervention e.g. health professionals advise individually ▪ Individual change/adjustment e.g. change in behaviour Social ▪ Societal cause e.g. low wages ▪ Conditions relating to housing ▪ Social/Political action needed e.g. facilities for disabled ▪ Societal attitude change e.g. use of politically correct language.
What are the tasks of consultation from a doctors point of view according to neighbour?
1) Connect with the patient 2) summarise and verbally check the reasons for attendance are clear 3) handover and bring the consultation to a close 4) ensure a safety net exists and no serious possibilities exist 5) deal with housekeeping of recovery and reflection Connect, Summarise, Handover, Safety net, Housekeeping.
What 5 factors increase the chance of someone changing their behaviour?
1) Think advantages of change outweigh disadvantages 2) Anticipate a positive response from others to your behaviour change 3) There is social pressure for you to change 4) You perceive the new behaviour to be consistent with your self image 5) You believe you are able to carry out the new behaviour in a range of circumstances 1) adv vs dis, positive response, social pressure, self image consistent, able
What is the difference between equality and equity?
Draw out the circle of change
