General Outcomes Flashcards
Define “Risk”
The probability of an event occurring in a given time period
Define “Risk Ratio”, also known as “Relative Risk”
The ratio of the probability an outcome in an exposed group to the probability of an outcome in an unexposed group
Define “Hazard Ratio”
Measure of an effect of an intervention on an outcome over time, in an exposed group vs. non-exposed group
Define “Odds Ratio”
Probability of an event occurring compared to the probability it does not
Define “Risk Difference” also known as “Attributable Risk” or “Absolute Risk Reduction”
Difference between risk of an outcome in an exposed group and the unexposed group
Define “Absolute Risk”
Measure of the risk of an event occurring
Define “Number Needed to Treat”
The average number of patients who need to be treated to prevent one additional bad outcome
What are the five stages of the Adjustment Process?
Denial Anger Bargaining Depression Acceptance
Give examples of Healthy Adjustment Behaviours which could be encouraged if you know someone who needs support. 6 points
- Encourage talking about processing emotions
- Understand and offer support
- Reassurance they are normal and worthy of inclusion
- Monitoring of progress in different environments
- Emphasise decision making especially regarding their health
- Promote participation in hobbies and activities
Give examples of Unhealthy Adjustment Behaviours exhibited in patients. 5 points
- Sadness, hopelessness, anhedonia, tearfulness, anxiety, worry, desperation
- Difficulty sleeping and concentration, poor driving, poor school work
- Avoidance of tasks such as bills
- Avoidance of friends and family
- Self-harm and suicidality
What are risk factors for poor adjustment in adolescence?
Family conflict, parental separation, school problems, changing schools, sexuality issues, death, illness, trauma in family
What are risk factors for poor adjustment in adulthood?
Marital conflict, financial conflict, health issues of onself or family member, loss of job, unstable employment conditions
What are the “positives” of Medically Unexplained Symptoms?
- Reduces stigma of mental illness
- Allows people to assume the sick role (can be maladaptive)
- It is a physical expression of distress, thus reduces internal emotional conflict
What are the “negatives” of Medically Unexplained Symptoms?
- Frustration, as patients experience MUS which are not reflected in diagnostic tests
- Feeling better comes with understanding the condition, and MUS is poorly understood so this process is hindered
- Patients may feel their symptoms are perceived as imaginary to others
Post-mortems are performed if they requested by which two people? What sorts of deaths do they request port-mortems for?
Coroner: If death is unexpected i.e. cot death, violent, unnatural, suspicious, accidental, after a hospital procedure, or if death is unknown
Hospital Doctor: To find out more about illness or cause of death, or for research purposes
What is a coroner? What qualifications must they have?
A judicial officer responsible for investigation of deaths. Are usually doctors or lawyers with >5 years experience
What is the ruling of consent on post-mortems requested by coroners and hospital doctors?
Coroner: No consent required by next-of-kin
Hospital Doctor: Consent required by next-of-kin
What is an “Inquest”?
A legal investigation into someone’s death
What is the role of a Strategic Clinical Network (SCN)?
SCNs work across the NHS system to support commissioners to make improvements to services, resulting in improved outcomes for patients
There are 12 Cancer SCNs for each region in England, with a Clinical Senate in each
What is the Cancer Registry?
A list of people diagnosed with cancer, collected directly from hospitals and healthcare professionals.
Most of the data is collected automatically from hospitals; for example their personal details, cancer diagnosis, cancer treatment and outcomes
State three Health Quality Measures
Structural Measures
Process Measures
Outcome Measures
What is the Structural Measure of Health Quality? Give some examples
Gives consumers a sense of healthcare provider’s capacity, systems and processes
Whether the system uses an electronic vs. paper record keeping, number of doctors in a trust, doctor:patient ratio
What is a Process Measure of Health Quality? Give some examples
Indicates what a provider does to maintain or improve health for both healthy people and those with conditions
Whether screening is offered to patients at risk of breast cancer, or if diabetics have their HbA1c checked regularly
What is the Outcome Measure of Health Quality? Give some examples
Reflects the impact of health care service / intervention of the health status of patients
I.e. mortality rates, complication rates
What is the National Cancer Research Network?
UK based government funding utility created by the Department of Health to provide infrastructure to the NHS to increase funding for clinical trials
What is the National Cancer Research Institute?
UK-wide partnership between cancer research funders, which promotes collaboration in cancer research
Give examples of Physical Consequences of cancer treatment?
Loss of functional organ, changes in appearance, prosthesis, scarring, hair loss, skin changes, weight change
Give examples of Psychological Consequences of cancer treatment?
Loss, anxiety, grief, depression, irritability, loss of confidence, self-conscious, feeling incomplete or a fraud, changes in sexual identity, changes in self-identity, reminder of cancer diagnosis, loss of trust in the body, changes in sleep and appetite, anhedonia, fatigue
Give examples of Social Consequences of cancer treatment?
Changes in roles (family, partner, friends), changes in sexual functioning, changes in existing intimate relationships, challenges in forming new relationships, paid employment, communal dressing rooms, social isolation
What is a “Clinical Audit”?
A process that has been defined as “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change
What were the findings of the Eurocare-II Report? 6 points
UK had one of the worst 5-year cancer survival rates in the whole of England. Why?
Differences in:
- Data collection, with some registry data being rejected
- Age of patient at presentation
- Staging of cancer at presentation
- Social classes of patient
- Treatment accessible by groups of patients
There was also a delay in getting patients into the cancer care pathway to get treatment
What were the recommendations of the Calmine-Hine Report 1995? 6 points
- Patients have equal access to cancer treatment
- Primary care at the centre of cancer patient’s journey
- Psychosocial issues of cancer patients must be met
- Development of Cancer care networks
- All cancers should be registered and monitored
- Public / professional education to recognise symptoms of cancer
What are Cancer Networks?
Cancer Networks were set up in 2000 at the recommendation of the Calmine-Hine Report 1995. There are 28 in total in England. Each network has several NHS organisations in it working together
What is the role of an MDT in cancer care? 6 points
- To discuss each new cancer case in the hospital
- To decide on management plan of each patient
- To inform primary care of the plan
- To designate a key worker for each patient
- To develop guidelines
- To audit
What are the seven steps to an Audit?
- Identify the topic
- Select the standards
- Data collection
- Data analysis
- Implement change
- Allow time for change to take place
- Re-audit
Discuss the complaints system of the NHS
- Every patient has right to complain, as outlined by NHS Constitution
- Complaints should be made within 12 months of event
1. Can complain to Service Provider directly or
- Can complain to Commissioner:
- If primary care complaint -> NHS England
- If secondary care / NHS 111 / MH -> CCG
- If Public health -> Local authority
- Cannot complain both to service provider and commissioner
Define “Adverse Event”
An adverse event is a negative consequence of care which has resulted in unintended illness / injury which may / may not have been prevented
Define “Near Miss”
An event with the potential to cause harm but did not result in injury
What are some ethical issues of Randomised Control Trials? 5 points
- Patients cannot enjoy personalised treatment
- Patients are at risk of an inferior treatment
- Patients may not feel empowered to decline participation, especially if they depend on their GP for ongoing care
- Use of placebos are sometimes deemed unethical, with patients believing they are receiving treatment but are not
- Patients are not given enough time. 24 hours is the norm but some need more
What are some practical issues of Randomised Control Trials? 2 points
- Low rates of recruitment
2. Having too broad / stringent inclusion / exclusion criteria, affecting generalisability of results
What are some negative attitudes experienced by older patients?
- Older patients less likely to be referred to secondary care for parkinsons’s, diabetes, CKD etc.
- GPs are less likely to follow cholesterol guidelines for older patients with
- Older patients are more likely to be placed in a mixed-sex environment as an inpatient in hospital than younger patients
- Older patients have to wait 2x as long for cataract surgery than younger patients
- Older patients have a poorly standard of end-of-life care compared to younger terminally ill patients
- Older patients often feel more “talked over” by medical staff
What are some negative attitudes experienced by Mental Health patients?
- Patients are often labelled by the mental health condition, irrespective of what problem they are coming in for
- Patients often feel “talked over” by medical staff
- Medical staff are less likely to trust mental health patients, with stereotypes of lying, absconding, being aggressive and dangerous assumed
What is a Mental Health Advocate? What is their role?
Someone who can help a Mental Health patient express their views and wishes
They will:
- Listen your views and concerns
- Help you explore your options with no pressure
- Provide information to help you make choices
- Help you contact relevant people / on your behalf
- Accompany you to meetings
They will not:
- Give their personal opinion
- Pass judgement
- Solve problems for you
If a patient wanted to stop smoking, what options are available to them?
- Nicotine Replacement Therapy or Varenicline or Bupripion
- 1-to-1 or group sessions on a 12-week programme
What are the benefits of Very Brief Advice?
- Quick (takes 30 seconds)
- Records smoking status
- Opportunistic (suitable for any consultation)
- Positive
- Non-confrontational
- Informative (offer ways to stop)
- Engaging (provides new information)
- Is evidence based
- Satisfies QOF
Give examples of Never (Critical) Events
- Wrong site surgery
- Wrong implant/prosthesis
- Retained foreign object post procedure
- Mis-selection of a strong potassium solution
- Administration of medication by the wrong route
- Overdose of insulin due to abbreviations or incorrect device
- Overdose of methotrexate for non-cancer treatment
- Mis-selection of high strength midazolam during conscious sedation
- Failure to install functional collapsible shower or curtain rails
- Falls from poorly restricted windows
- Chest or neck entrapment in bed rails
- Transfusion or transplantation of ABO-incompatible blood components or organs
- Misplaced naso- or oro-gastric tubes
- Scalding of patients
- Unintentional connection of a patient requiring oxygen to an air flowmeter
State the three types of Errors which can be made by healthcare professionals which may lead to an Advers event?
- Knowledge based (lack of knowledge)
- Rule based (Misapplication of guideline)
- Skills based (Attention / memory lapse)
State the four types of Violations which can be made by healthcare professionals?
- Routine: a violation that has become normal behaviour within a peer group
- Situational: context-dependent (e.g. time-pressure, lack of supervision, low staffing)
- Reasoned: deliberate deviation from protocol thought to be in patient’s best interest at the time
- Malicious: deliberate act intended to harm
What is a Latent error?
Errors which develop over time and lay dormant until they combine with other factors or active failures to cause an adverse event
What are four positives of a Clinical Audit?
- Encourages teamwork
- Emphasises best practice
- Improves patient outcomes
- Possible financial gain
What are negatives of a Clinical Audit? 5 points
- Data is only a “snapshot” of performance
- Lack of generalisability
- Short time scale, will there be long-term benefits?
- Too small sample size
- Data collection may not be accurate
How do you calculate NNtT and NNtH?
Number Needed to Treat: 1 / risk difference (rounded up)
Number Needed to Harm: 1 / risk difference (rounded down)
What is “Population Attributable Risk”?
The amount of disease in a population which would go away if an exposure was ended
Define “Bias”
Systematic introduction of error in a study
Define “Selection Bias”
Systematic introduction of error in a study, relating to the selection of participants in the cohort and/or who they are being compared to
Define “Information Bias”
Systematic introduction of error in a study, relating to the information studied of the participants
Define “Confounding”
The distortion of the apparent relationship between two variables due to the presence of a third variable
What are the four ways to address Confounding Factors?
- Restriction (Excluding it)
- Matching (Create comparison group matched on confounder)
- Stratification
- Multiple Variable Regression
If the p-value is small or large, what does this mean for Null hypothesis?
If small - reject null hypothesis
If large - accept null hypothesis
How do you calculate Positive Predictive Value?
Number of true positives / All those who tested positive
How do you calculate Negative Predictive Value?
Number of true negatives / All those who tested negative
Why is a D-Dimer a good rule OUT test?
It is sensitive and negative (SnNOUT)
Why is a CAGE is a good rule IN test?
It is specific and positive (SpPIN)
How many Cancer Registries are there?
4
What is a Never Event?
Largely preventable patient safety event that should not occur if the available preventative measures were put in place
If an NHS complaint is unresolved by the provider or commissioner, what is the next step?
Can take it up to Parliamentary and Health Services Ombudsman
How do you calculate SENSITIVITY?
No. of true positives / All those with disease
How do you calculate SPECIFICITY?
No. of true negatives / All those without disease
Give examples of measures which try to improve patient safety
National Patient Safety Agency (NPSA) National Reporting and Learning System (NRLS) Yellow Cards Medicines and Healthcare Products Agency Serious Hazards of Transfusion (SHOT)
