Foundations of Primary Care COPY Flashcards
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
understand medical evidence
reduce variations in practice
improve healthcare
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
Why is disability increasing?
Increased age of population Rise in injuries from car accidents, falls and violence, chronic diseases
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)
Define criteria for causality?
Criteria establishing epidemiologic evidence of a causal relationship between a presumed cause and an observed effect
What are the three main reasons for culturally competent healthcare?
1) eliminating misunderstandings in diagnosis or treatment planning 2) improve patient adherence with treatment 3) eliminate healthcare disparities
What are the components of the mental state exam? MSE - structured way of observing and describing a patients current state of mind
ASEPTIC - R Appearance - Age, sex, dress, unkempt? signs of self harm? and B- behaviour - alert? fidgeting? eye contact? inappropriate conduct? Speech Emotion (mood and affect - blunted, flat, labile) low, elated, anxious Perception - hallucinations Thought/ Thinking - Content (abnormal beliefs/delusions, obsessions) and Process - speed and fluency Insight and judgement - Do they think they have a problem? What do they think caused it? Do they want help? Cognition - orientation, attention and concentration
What is psychopathology? What is descriptive pathology? Define phenomenology? (phenomenon)
Psychopathology is concerned with abnormal experience, cognition and behaviour Descriptive pathology - describes and categorise the abnormal experience as described by the patient Phenomenology - in psychiatry refers to the observation and understanding of the psychological event or phenomenon so that the observer can as far as possible know what the patients experience feels like
What is the hypothetico- deductive process?
1) Make 4 or 5 diagnostic hypotheses 2) rare but not immediately concerning diagnosis excluded at this stage 3) strengthen case for diagnosis through brief history and examination 4) extend the search thereafter if no diagnosis identified 5) not about common diagnosis, rather about likely diagnosis
List two coping mechanisms used to cope with stress and describe
1) Problem focused e.g. enlist friends and family help 2) emotion focused e.g. seek counselling/stress management (positive) alcohol or drug misuse (negative)
What are the individual variables in risk perception?
Previous experience attitudes towards risk values beliefs socioeconomic factors personality demographic factors
What are the three principles that govern the perception of risk?
Feeling in control Size of the possible harm Familiarity with the risk
List four ethical principles and their meanings
Respect for autonomy; promote right to self determination, confidentiality, informed consent, promote capacity. Can we promote autonomy? Justice ; fairness/equity, individual vs population (non discrimination, equal treatment for equal need, rationing) Beneficence; To do good, what are the benefits of giving treatment? Non maleficence; avoidance of harm (to do no harm) what are the *harms* of giving treatment?
What are the 4 options of decision making? When are they used?
1) degree of certainty 2) speed of change Pattern recognition (both 1+2 high) if speed of clinical change is high and complexity or ambiguity is high (ie A and E/ ITU) Algorithms Speed of clinical change is high, complexity or ambiguity is low = childbirth Pathways Speed of clinical change is low and complexity is low. e.g. elective hernia surgery Scenario/option planning Speed of clinical change is low but complexity is high e.g. GP caring for patient at home with co-morbidity
Blaxter (1995) identified factors which influence lay beliefs around health (list 4)
Age - if older - see health as functioning, young people see health as fitness social class /difficult economic and social circumstances - more likely to think in terms of being able to work/care for others ie. functional Gender - women of higher social class or educational equlifications have a more multidimentional view of health. women include social aspects of health, find concept of health more interesting. Culture- e.g. Afro-Caribbean patients hypertension regarded as normal and less likely to take medication
List actions a government might take to promote health in the population as a whole (5 actions)
legislation/policies on smoking/alcohol (minimum age to buy products, licencing laws, taxation) improvements in housing provision of health education health and safety laws traffic/transport legislation/policies
List 5 reasons why people may feel they are in good health
1) no diagnosed long term conditions 2) not on medication 3) able to work/socialise 4) able to have children (fertile) 5) on a ‘healthy diet’ 6) ‘exercise regularly’
What is the difference between equality and equity?
Draw out the circle of change
