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FinalMB Part III - Short Answer Questions (SAQs) > Improving Health (IH) > Flashcards

Improving Health (IH) Flashcards

1
Q

What is meant by the term ‘incidence’?

A

The number of new health-related events that occur in a defined population within a specified period of time

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2
Q

How may incidence be represented numerically? (3)

A
  • Frequency count; the number of new cases
  • Proportion; a percentage/decimal of the population
  • Rate; a number of cases per number of person-years
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3
Q

What is meant by the term ‘prevalence’?

A

The number of individuals who have a disease as a proportion of the at risk population

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4
Q

Outline the two main ways of expressing prevalence? (2)

A
  • Point prevalence; the proportion of individuals with a disease at a specific timepoint
  • Period prevalence; the proportion of individuals with a disease over a certain period of time
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5
Q

Outline the two main ways by which prevalence may be high? (2)

A
  • High incidence
  • Long duration of the disease
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6
Q

The larger the relative risk (RR) the […]

A

The larger the relative risk (RR) the more likely the exposed group is to develop the outcome compared to the non-exposed group

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7
Q

The absolute risk reduction (ARR) implies that for every 100 members of the exposed group, […], compared to the number of cases of the disease in the non-exposed group

A

The absolute risk reduction (ARR) implies that for every 100 members of the exposed group, there will be a number of people equal to the value of the ARR more cases of the disease, compared to the number of cases of the disease in the non-exposed group

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8
Q

Outline the hierarchy of evidence? (8)

A
  • Systematic review or meta-analysis of ≥ 2 randomised controlled trials (RCTs)
  • Randomised controlled trial (RCT)
  • Non-randomised experimental designs
  • Cohort-studies
  • Case-control studies
  • Cross-sectional studies
  • Case series/case studies
  • Personal communication
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9
Q

Outline the features of the Bradford-Hill criterion for causal relationships? (6)

A
  • Strength of association; the stronger the association, the greater the likelihood that that association is the result of a causal relationship
  • Dose-response; the greater the exposure to the risk the greater the incidence of the outcome
  • Temporality; disease risk factor (exposure) must predate the disease (outcome)
  • Consistency; same association demonstrated in multiple independent repeats
  • Biological plausibility; biomedical reason or explanation to account for a causal relationship
  • Reversibility; reduction or withdrawal of the risk factor should reduce/withdraw the outcome
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10
Q

What is meant by the term ‘bias’?

A

A systematic error in the design, conduct or analysis of a study that results in a conclusion that is different from the truth

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11
Q

Outline the main types of bias? (4)

A
  • Selection bias; regarding the choice/inclusion of participants
  • Information/measurement bias; regarding the appropriateness of exposure/outcome measures
  • Observer bias; regarding the observers prior knowledge about the subject’s exposure to a risk factor and how this may influence results
  • Recall bias; regarding the phenomenon where the subject with the outcome is more likely to remember an exposure than a subject without the outcome
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12
Q

What is meant by the term ‘confounder’?

A

The presence of another factor that provides an explanation for the results other than the conclusion determined by the study

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13
Q

What is meant by the term ‘chance’?

A

The likelihood that the observed effect/outcome could have been observed solely as a result of coincidence

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14
Q

In relation to study design, what is the main factor that influences the likelihood of any conclusion reached being purely the result of chance?

A

Sample size; the larger the sample size, the less likely that the results are to have been determined purely by chance

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15
Q

Which two variables are used to express chance? (2)

A
  • Probability values (p-values)
  • Confidence intervals (CIs)
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16
Q

What can be inferred by a p-value of 0.001?

A

A p-value of 0.001 means that there is a 1 in (1 / 0.001 1000) 1000 (0.1%) chance that the observed difference is due to chance

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17
Q

What is meant by the term ‘confidence interval (CI)’?

A

The confidence interval denotes the range of values that the true size of the effect lies within, for a given degree of assurance/confidence (%)

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18
Q

What is meant by the term ‘standardisation’?

A

The technique for removing the effect of confounding variables (i.e. age) on individuals when comparing between different populations

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19
Q

Outline the two main ways of standardising data in an epidemiological investigation? (2)

A
  • Direct standardisation; observed rates in the population of interest are stratified according to the confounding variable and applied to a reference population
  • Indirect standardisation; rates within a reference population are stratified according to to the confounding variable and applied to the population of interest
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20
Q

In terms of the information that they require, what is the difference between direct and indirect standardisation? (2)

A
  • Direct standardisation; used when the number of events within each of the confounding variable (i.e. age) groups of the population of interest is known
  • Indirect standardisation; used when the number of events within each of the confounding variable (i.e. age) groups of the population of interest is not known
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21
Q

Which parameter is calculated as a result of indirect standardisation when looking at mortality rates?

A

Standardised mortality ratio (SMR)

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22
Q

What can the value of the standardised mortality rate (SMR) tell you about the mortality rate between two difference populations? (3)

A
  • SMR < 1; the population of interest has a lower mortality rate than the reference population
  • SMR 1; the population of interest has the same mortality rate as the reference population
  • SMR > 1; the population of interest has a greater mortality rate than the reference population
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23
Q

Outline the components of an audit cycle? (5)

A
  • Set and agree the gold-standard for assessment/management of the problem
  • Monitor performance against those standards over a certain timeframe (retrospective or prospective)
  • Identify deviations from agreed standards and reasons why they occurred
  • Implement changes to correct those unwanted deviations from the standard
  • Repeat the cycle to assess the effectiveness of the implemented changes
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24
Q

Outline the key features that make for good goal setting in the audit process? (5)

A

SMART;
- Specific
- Measurable
- Achievable
- Realistic
- Timely

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25
Q

Outline the treatment-specific considerations that need to be taken into account by healthcare funding bodies when deciding whether or not to fund a new treatment? (4)

A
  • Safety; whether the treatment can cause adverse effects
  • Efficacy; whether the treatment achieves its intended outcome
  • Effectiveness; to what extent does the treatment achieve its intended outcome
  • Efficiency (cost-effectiveness); the additional cost/saving associated with the new treatment compared with the additional health benefits versus that of the previous/next best treatment
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26
Q

Where to find evidence when assessing whether to fund a new treatment;

  • Safety; Medicines and Healthcare products Regulatory Agency (MHRA), European Medicines Agency (EMA)
  • Efficacy; National Institute for Health and Care Excellence (NICE), Medline, Cochrane Database
  • Effectiveness; […]
  • Efficiency (cost-effectiveness); National Institute for Health and Care Excellence (NICE), Scottish Medicines Consortium (SMC)
A

Where to find evidence when assessing whether to fund a new treatment;

  • Safety; Medicines and Healthcare products Regulatory Agency (MHRA), European Medicines Agency (EMA)
  • Efficacy; National Institute for Health and Care Excellence (NICE), Medline, Cochrane Database
  • Effectiveness; Clinical Evidence, National Institute for Health and Care Excellence (NICE), Published Randomised Controlled Trials (RCTs)
  • Efficiency (cost-effectiveness); National Institute for Health and Care Excellence (NICE), Scottish Medicines Consortium (SMC)
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27
Q

Where to find evidence when assessing whether to fund a new treatment;

  • Safety; Medicines and Healthcare products Regulatory Agency (MHRA), European Medicines Agency (EMA)
  • Efficacy; National Institute for Health and Care Excellence (NICE), Medline, Cochrane Database
  • Effectiveness; Clinical Evidence, National Institute for Health and Care Excellence (NICE), Published Randomised Controlled Trials (RCTs)
  • Efficiency (cost-effectiveness); […]
A

Where to find evidence when assessing whether to fund a new treatment;

  • Safety; Medicines and Healthcare products Regulatory Agency (MHRA), European Medicines Agency (EMA)
  • Efficacy; National Institute for Health and Care Excellence (NICE), Medline, Cochrane Database
  • Effectiveness; Clinical Evidence, National Institute for Health and Care Excellence (NICE), Published Randomised Controlled Trials (RCTs)
  • Efficiency (cost-effectiveness); National Institute for Health and Care Excellence (NICE), Scottish Medicines Consortium (SMC)
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28
Q

Where to find evidence when assessing whether to fund a new treatment;

  • Safety; […]
  • Efficacy; National Institute for Health and Care Excellence (NICE), Medline, Cochrane Database
  • Effectiveness; Clinical Evidence, National Institute for Health and Care Excellence (NICE), Published Randomised Controlled Trials (RCTs)
  • Efficiency (cost-effectiveness); National Institute for Health and Care Excellence (NICE), Scottish Medicines Consortium (SMC)
A

Where to find evidence when assessing whether to fund a new treatment;

  • Safety; Medicines and Healthcare products Regulatory Agency (MHRA), European Medicines Agency (EMA)
  • Efficacy; National Institute for Health and Care Excellence (NICE), Medline, Cochrane Database
  • Effectiveness; Clinical Evidence, National Institute for Health and Care Excellence (NICE), Published Randomised Controlled Trials (RCTs)
  • Efficiency (cost-effectiveness); National Institute for Health and Care Excellence (NICE), Scottish Medicines Consortium (SMC)
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29
Q

Where to find evidence when assessing whether to fund a new treatment;

  • Safety; Medicines and Healthcare products Regulatory Agency (MHRA), European Medicines Agency (EMA)
  • Efficacy; […]
  • Effectiveness; Clinical Evidence, National Institute for Health and Care Excellence (NICE), Published Randomised Controlled Trials (RCTs)
  • Efficiency (cost-effectiveness); National Institute for Health and Care Excellence (NICE), Scottish Medicines Consortium (SMC)
A

Where to find evidence when assessing whether to fund a new treatment;

  • Safety; Medicines and Healthcare products Regulatory Agency (MHRA), European Medicines Agency (EMA)
  • Efficacy; National Institute for Health and Care Excellence (NICE), Medline, Cochrane Database
  • Effectiveness; Clinical Evidence, National Institute for Health and Care Excellence (NICE), Published Randomised Controlled Trials (RCTs)
  • Efficiency (cost-effectiveness); National Institute for Health and Care Excellence (NICE), Scottish Medicines Consortium (SMC)
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30
Q

Outline the population-specific factors that need to be taken into account by healthcare funding bodies when deciding whether or not to fund a new treatment? (6)

A
  • What is the likely demand for the healthcare resource
  • Do resources exist locally to provide such healthcare resource
  • What are the opportunity costs associated with offering such healthcare resource
  • Do other CCGs offer the healthcare resource and if so, how effective is it
  • Would a decision to fund/not fund be equitable (does the healthcare problem effect all individuals within a population equally
  • How does the decision to fund accord with the views of the local population
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31
Q

Which piece of statutory legislation outlines the types of discrimination that are prohibited by law?

A

Section 149 of the Equality Act (2010)

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32
Q

Outline the specific types of discrimination that are prohibited by law under Section 149 of the Equality Act (2010)? (8)

A
  • Age
  • Disability
  • Gender
  • Pregnancy/maternity
  • Race
  • Religion/belief
  • Sex
  • Sexual orientation.
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33
Q

Outline the responsibilities of the NHS and other public bodies as indicated by Section 149 of the Equality Act (2010)?

A

Public bodies have a due regard to eliminate discrimination and advance equality of opportunity between persons who share a relevant protected characteristics and persons who do not

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34
Q

Is there any legal framework prohibiting discrimination based on financial state?

A

No; there is no statutory legislation stating that this is illegal

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35
Q

Outline the main components to a focussed clinical question? (4)

A

PICO;
- Population; which population of patients should be studied
- Intervention; which intervention, treatment or approach should be used
- Comparison; what are the alternatives to the intervention being considered
- Outcome; which outcomes should be measured and how

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36
Q

Outline the structure and function of an ecological study? (4)

A
  • Observational descriptive study
  • Conducted at the population level
  • Assesses geographic correlation
  • Generate hypotheses as to the explanatory variable that governs the observed difference
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37
Q

What is meant by the term ‘ecological fallacy’?

A

Specific problem associated with ecological studies where an apparent association between exposure and outcome is true at the population level but not necessarily true at the individual level

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38
Q

Which type of bias are ecological studies particularly subject to?

A

Aggregation bias; a type of information bias whereby aggregated data can show an effect at the population level that is the opposite to the effect seen at the individual level

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39
Q

Outline the structure and function of a cross-sectional trial? (3)

A
  • Observational analytical or observational descriptive
  • Single examination of a population at one point in time (snapshot)
  • Looks at attitudes, behaviours, health conditions or risk factors
  • Can be repeated at subsequent timepoints to measure the change in the population over time
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40
Q

With regards to a cross-sectional trial, what is meant by a ‘sampling frame’?

A

A list of all those within the target population from which inviduals can be selected to act as subjects forming a sample of that population

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41
Q

Outline the main subtypes of a cross-sectional study? (2)

A
  • Descriptive; measuring only one parameter in the target population at a single timepoint
  • Analytical; measuring a single exposure and a single outcome in the target population at a single timepoint
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42
Q

What is the main disadvantage of an analytical cross-sectional study?

A

Temporality; it is impossible to determine if the outcome developed before or after the exposure occurred

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43
Q

Outline the structure and function of a case-control study? (3)

A
  • Analytical observational trial
  • Retrospective; outcome has already occurred within a target population
  • Data is collected on the exposure of individuals within that population with the outcome (cases) and those without the outcome (controls)
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44
Q

What is assessed when comparing between cases and controls in a case control study? (2)

A
  • The prevalence (p) of the risk factor (exposure) of interest amongst cases and controls
  • The influence of the risk factor (exposure) of interest on the outcome
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45
Q

How is information about the exposure gathered from the population in a case-controlled study?

A

By means of questionnaire

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46
Q

Outline the main issues associated with case-control studies? (4)

A
  • Selection of cases; a clear definition of individuals that qualify for selection as ‘cases’ is needed
  • Selection of controls; controls need to be selected from a population as similar as possible to the population from which the cases were selected
  • Reverse causality; additional studies are required to prove temporality and determine if the exposure preceded the outcome or not
  • Bias; in order to ascertain the exposure and outcome, bias must be minimised
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47
Q

Which two types of bias are particularly important in case-control studies? (2)

A
  • Recall bias; individuals with an outcome are more likely to remember an exposure compared to those without the outcome
  • Observer bias; where the observer is more likely to look for an exposure in an individual if they already know the outcome in that individual
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48
Q

What process needs to be carried out in case-control studies to control for any potential confounding factors?

A

Matching of cases and controls based on age, sex, and other relevant and potentially confounding factors

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49
Q

Outline the main advantages of case-control studies? (4)

A
  • Useful for rare outcomes
  • Can examine multiple exposures
  • Useful for outcomes with long latency
  • Quick and inexpensive
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50
Q

Outline the main disadvantages of case-control studies? (4)

A
  • Rely on recall/records to determine exposure
  • Difficult to identify controls
  • Heavily influenced by confounders
  • Information (recall and observer) bias
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51
Q

Outline the main advantages of cohort studies? (4)

A
  • Ethically safe
  • Subjects can be matched
  • Can identify temporal relationships
  • Can directly measure outcome (incidence)
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52
Q

Outline the main disadvantages of cohort studies? (4)

A
  • Inefficient for rare outcomes
  • Influence of hidden confounders
  • Controls may be difficult to identify
  • Validity affected by follow-up
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53
Q

Outline the main advantages of interventional studies such as randomised controlled trials (RCTs)? (3)

A
  • Randomisation minimises effect of confounders
  • Blinding eliminates information bias
  • Can demonstrate causality
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54
Q

Outline the main disadvantages of interventional studies such as randomised controlled trials (RCTs)? (3)

A
  • Expensive and time-consuming
  • Can be unethical
  • Volunteer bias
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55
Q

Outline the main advantages of cross-sectional studies? (2)

A
  • Cheap and simple
  • Ethically safe
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56
Q

Outline the main disadvantages of cross-sectional studies? (2)

A
  • Cannot establish causality
  • Recall bias
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57
Q

Outline the main difference between a case-control study and a cohort study? (2)

A
  • Case-control study; the outcome of interest has already occurred, cases and controls defined by whether they have the outcome of interest or not
  • Cohort study; the outcome of interest has not already occurred, cases and controls defined by whether they were exposed to the risk factor or not
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58
Q

Outline the main similarity and main difference between prospective and retrospective cohort studies? (2)

A
  • Similarity; in both, the outcome of interest has not yet occurred
  • Difference; in retrospective cohort studies, the exposure has already occurred whereas in prospective cohort studies, it has not
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59
Q

Outline the main issues associated with cohort studies? (4)

A
  • Selection; case and control groups need to be as similar as possible apart from the exposure being investigated
  • Non-participation; only a proportion of those eligible actually participate, these participants may differ from non-participants in terms of health behaviours
  • Follow-up; loss to follow-up can influence conclusions, this can be related to exposure, outcome or both
  • Data collection; exposure and/or outcome data must be collected as objectively as possible in order to minimise measurement bias
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60
Q

Outline the main advantages of ecological
studies? (2)

A
  • Can assess geographical correlation
  • Good for generating hypotheses
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61
Q

Outline the main disadvantages of ecological studies? (2)

A
  • Ecological fallacy
  • Aggregation bias
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62
Q

What is the main type of primary intervention study?

A

Randomised controlled trial (RCT)

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63
Q

Outline the key principles in the design of primary intervention trials? (4)

A
  • Randomisation; the allocation of subjects to different treatment groups based on chance
  • Blinding; the extent to which the investigators, participants and analysts are aware of which subjects are allocated to which treatment groups
  • Follow-up; inclusion of clear final outcomes at the end-point of the trial for both treatment groups
  • Equal treatment; identical treatment of both groups with the only exception being the experimental treatment
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64
Q

Outline the types of randomised controlled trial blinding? (3)

A
  • Single blinding; participants do not know which treatment they receive
  • Double blinding; participants and investigators do not know which treatment is being received
  • Triple blinding; participants, investigators and analysers do not know which treatment is being received
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65
Q

What is the benefit of single blinding?

A

Eliminates the placebo effect and recall bias

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66
Q

What is the benefit of double blinding?

A

Eliminates the placebo effect, recall bias and observer bias

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67
Q

What is the benefit of triple blinding?

A

Eliminates the placebo effect, recall bias, observer bias and assessment bias

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68
Q

What is meant by ‘intention to treat analysis’?

A

Method of analysis used in randomised controlled trials (RCTs) where all individuals within the treatment group at the start of the trial are analysed together regardless of whether or not they changed treatment groups or dropped out of the trial

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69
Q

Outline the benefit of carrying out an intention to treat analysis?

A

Preserves the baseline comparability between treatment groups which guards against bias that would be introduced where changes to protocol/subject dropout would influence the outcome

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70
Q

Outline the definition of the number needed to treat (NNT)?

A

The number of individuals, on average, that need to be treated in order for the treatment to produce one additional successful outcome

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71
Q

Outline the definition of the number needed to harm (NNH)?

A

The number of individuals, on average, that need to be treated in order for the treatment to produce one additional adverse outcome

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72
Q

Outline the three components to consider when critically analysing research? (3)

A
  • Results; what the conclusion of the research is
  • Validity; how trustworthy the research is
  • Relevance; how useful the research is
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73
Q

What is meant by the term ‘systematic review’?

A

A review of all the literature on a particular topic, which has been systematically identified, appraised and summarised giving a summary answer

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74
Q

Outline the features of a good systematic review? (5)

A
  • Asking a clear and focussed question
  • Clearly defined inclusion and exclusion criteria
  • Reproducibility
  • Appraisal of included studies
  • Assessment of publication bias
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Perfectly
75
Q

What kind of analysis can be used to assess whether a systematic review is affected by publication bias?

A

Funnel Plot; if publication bias is present, then smaller studies with negative results (control better than treatment) are likely to be missing, making the funnel plot appear asymmetrical

76
Q

What is meant by the term ‘meta-analysis’?

A

A statistical technique for quantitatively pooling the results of individual studies

77
Q

How are the results of a meta-analysis typically displayed?

A

As a Forrest Plot (blobbogram)

78
Q

Outline some of the typical causes of heterogeneity that prevents the inclusion of different studies as part of a meta-analysis? (5)

A
  • Chance
  • Clinical differences in treatment regimens between trials
  • Different measured outcomes
  • Different populations
  • Methodological differences between trials
79
Q

What scoring system can be used to rate the quality of evidence for a particular outcome across studies within a systematic review?

A

Grading of Recommendations Assessment, Development and Evaluation (GRADE)

80
Q

What features are assessed as part of the GRADE system of evidence classification? (5)

A
  • Study limitations; risk of bias
  • Inconsistency; heterogeneity of treatment effects across different studies
  • Indirectness; degree of differences between studies
  • Imprecision; random error
  • Publication bias; selection of publications for review
81
Q

Outline the tiers of the GRADE system of evidence rating? (4)

A
  • High quality; further research unlikely to change confidence in the estimate of effect
  • Moderate quality; further research likely to have an impact on confidence in the estimate of effect
  • Low quality; further research likely to have an impact on confidence and/or change the estimate of effect
  • Very low quality; further research is needed as current estimate of effect is very uncertain
82
Q

What is meant by the term ‘demographic transition’?

A

Demographic transition describes the changing age structure that exists within a population as that population progresses through stages of development

83
Q

What is a population pyramid?

A

A population pyramid is a histogram of age distribution across both sexes within a population that can indicate the stage of development that the observed population is in

84
Q

What is meant by the term ‘epidemiological transition’?

A

Epidemiological transition describes the shift in the predominant contribution to morbidity and mortality from infectious disease and malnutrition early in population development to that of non-communicable diseases and cancer in developed populations

85
Q

Which parameter is considered the most sensitive indicator of population development?

A

Infant mortality rate (IMR); the number of deaths occurring < 1 year of age per 1000 live births

86
Q

Outline the main types of screening? (3)

A
  • Primary; screening that aims to prevent a disease from occurring (e.g. vaccinations)
  • Secondary; screening that aims to detect a disease at an early enough stage to allow intervention (e.g. bowel cancer FIT testing)
  • Tertiary; screening for complications of a disease that has already developed (e.g. diabetic eye screening)
87
Q

Describe the inclusion criteria for the screening of genetic diseases after birth?

A

Newborns typically day 5-7 of life

88
Q

Describe the inclusion criteria for the screening of abdominal aortic aneurysms (AAAs)? (2)

A
  • All men > 65 years
  • Women > 70 with risk factors
89
Q

Describe the inclusion criteria for the screening of bowel cancer using the faecal immunochemical test (FIT)?

A

All patients aged 60-74 years every 2 years and followed-up with a colonoscopy if positive

90
Q

Describe the inclusion criteria for the screening of breast cancer? (2)

A
  • Most women; mammogram (X-ray) or breast ultrasound every 3 years from age 50-70
  • Women with family history of breast or ovarian cancer; mammogram (X-ray) or breast ultrasound every 3 years from age 40
91
Q

Describe the inclusion criteria for the screening of cervical cancer? (3)

A
  • Women aged 25-49; every 3 years
  • Women aged 50-64; every 5 years
  • Women 65+; only if 1 of the last 3 tests were abnormal
92
Q

Describe the inclusion criteria for the screening of fetal anomalies during pregnancy?

A

Pregnant women at 20 weeks gestation

93
Q

Outline the two main sets of criteria that set out the principles of screening tests? (2)

A
  • Wilson and Junger criteria
  • UK National Screening Committee (NSC) criteria
94
Q

Outline the key components that make up the UK National Screening Committee (NSC) Criteria for suitable screening programmes? (4)

A
  • Condition; important health problem, identifiable in early stages
  • Test; simple, safe and validated screening test
  • Treatment; evidence of early intervention producing better outcomes
  • Programme; evidence that the proposed programme is effective
95
Q

Outline the main sources of bias affecting screening programmes? (3)

A
  • Lead-time bias; screening increases the perceived survival time without actually affecting the course of the disease
  • Length-time bias; diseases with a long-latent time are more likely to be detected by screening than those with a short-latent time
  • Volunteer bias; those who accept invitations to be screened are more likely to be those at lower risk and healthier generally
96
Q

Outline the main advantages associated with screening programmes? (2)

A
  • Cost-effective by preventing disease
  • Better outcomes as intervention possible at an earlier stage
97
Q

Outline the main disadvantages associated with screening programmes? (5)

A
  • Health-related anxiety
  • Overdiagnosis and overtreatment
  • Detected disease may never have caused a problem in the first-place (incidentalomas)
  • False reassurance if screening negative
  • Requires large investment and infrastructure
98
Q

What can be inferred if a diagnostic test has a high sensitivity? (3)

A
  • Low false negative
  • Highly likely that the test will be positive given the presence of the disease
  • A negative test result effectively rules out the disease
99
Q

What can be inferred if a diagnostic test has a high specificity? (3)

A
  • Low false positive
  • Highly likely that the test will be negative given the absence of the disease
  • A positive test result effectively rules in the disease
100
Q

In the context of diagnostic testing, what is meant by the term ‘sensitivity’ (Se)?

A

Sensitivity (Se) describes the probability of a diagnostic test being positive given the presence of disease

101
Q

In the context of diagnostic testing, what is meant by the term ‘specificity’ (Sp)?

A

Specificity (Sp) describes the probability of a diagnostic test being negative given the absence of disease

102
Q

In the context of diagnostic testing, what is meant by the term ‘positive predictive value’ (PPV)?

A

Positive predictive value (PPV) describes the probability of the disease being present if the test is positive

103
Q

In the context of diagnostic testing, what is meant by the term ‘negative predictive value’ (NPV)?

A

Negative predictive value (NPV) describes the probability of the disease being absent if the test is negative

104
Q

Give examples of systems used to measure population health? (5)

A
  • Life expectancy at birth
  • Healthy life expectancy
  • Disability-adjusted Life years (DALYs)
  • Fertility rates
  • Infant mortality rates
105
Q

Outline the key factors for consideration in the context of setting priorities of a healthcare resource? (5)

A
  • Equity; are there avoidable or remedial differences amongst different groups in terms of access to this healthcare resource
  • Efficacy; whether the healthcare resource achieves its intended beneficial outcome
  • Effectiveness; what extent does the healthcare resource achieve its intended outcome
  • Efficiency; the benefit of a healthcare resource in relation to the effort expended to provide such a resource
  • Opportunity cost; the cost incurred as a result of not using that healthcare resource for its next most valued use
106
Q

How can you determine the cost effectiveness of a healthcare resource?

A

Carry out a cost-effectiveness analysis

107
Q

In the context of healthcare resource provision, what is an ‘economic evaluation’?

A

An economic evaluation is a comparative analysis of alternative courses of action in response to a healthcare problem in terms of their costs and consequences

108
Q

Outline the main challenges faced by the national health service (NHS) in regard to resource allocation? (4)

A
  • Finite resources
  • Balancing equality of access and equality of outcome
  • Cost-effectiveness
  • Political turbulence and associated priorities of public spending
109
Q

Outline the main approaches that are used to ration resources in the NHS? (4)

A
  • Exclusion; not funding certain healthcare resources
  • Dilution; increasing number of appointments by shortening their length
  • Termination; discharging earlier than what would be desirable
  • Delay; use of waiting lists
110
Q

Which bodies are responsible for deciding how healthcare resources are allocated in the UK at the national, local and individual level? (3)

A
  • National level; the treasury, department of health (DoH), National Institute for Health and Care Excellence (NICE)
  • Local level; clinical commissioning groups (CCGs), local authorities (LAs)
  • Individual level; hospitals, clinicians
111
Q

Outline the main types of healthcare evaluation? (3)

A
  • Outcome/effectiveness evaluation; assesses whether a healthcare intervention is effective/achieves its intended goals
  • Economic evaluation; considers whether a healthcare intervention is cost-effective
  • Process evaluation; assesses whether the components of a healthcare intervention function as expected
112
Q

What aspect of a healthcare evaluation process can increase its effectiveness?

A

If the evaluation is done prospectively and built into the healthcare service from the outset

113
Q

Outline the key domains used to help evaluate a healthcare resource? (7)

A
  • Effectiveness; whether and to what extent a healthcare resource achieves its intended goals
  • Safety; whether a healthcare resource causes adverse effects or harms
  • Efficiency (cost-effectiveness); the additional cost/saving associated with the healthcare resource compared with the additional health benefits versus that of the previous/next best alternative
  • Equity; whether a healthcare resource is judged as fair
  • Accessibility; whether those in need of the healthcare resource can access the service
  • Quality; whether a healthcare resource achieves intended non-clinical goals and establishes an adequate process of care
  • Satisfaction; the service users’ overall judgement of the healthcare resource
114
Q

Outline the key domains that make up Donabedian’s framework for healthcare service evaluation? (4)

A
  • Structure; evaluation of appropriate delivery facilities, staffing and equipment
  • Process; evaluation of everything done to the patient as part of the provision of the healthcare resource
  • Outputs; the number of cases identified and individuals successfully accessing the healthcare resource
  • Outcomes; additional health-related gains as a result of the healthcare resource
115
Q

What is meant by the term ‘clinical governance’?

A

Clinical governance describes the framework through which healthcare providers and their staff are held accountable for the quality of patient care

116
Q

Outline the components that make up clinical governance framework? (6)

A
  • Audits of practice
  • Appraisals
  • Revalidation
  • Regular departmental meetings to highlight concerns
  • Clear routes of accountability for staff
  • Risk management structure (e.g. Datix)
  • Complaints and Patient Advice and Liaison Service (PALS)
117
Q

Which four domains of a doctor’s performance can be assessed? (4)

A
  • Knowledge; up-to-date understanding of the information required for them to do their job
  • Skills; continued demonstration of clinical capabilities
  • Attitudes; professionalism, respect for patients, probity and self-scrutiny
  • Systems; continued professional development (CPD), record-keeping, revalidation
118
Q

Outline the idea surrounding the ‘prevention paradox’ suggested by Rose (2008)?

A

Prevention paradox; a preventative measure that brings about large benefits for the population offers little benefit to each participating individual

119
Q

Outline the key levels at which healthcare and good health can be promoted? (5)

A
  • Interventions aimed at the individual
  • Local community actions; media campaigns, warning signs, information leaflets
  • Providing supportive environments; infrastructure, legislation
  • Healthy public policy; minimal alcohol pricing, indoor smoking bans
  • Reorientation of healthcare services; healthcare services tackling key problems in high-risk groups
120
Q

Outline what is meant by the term ‘primary prevention’ of disease?

A

Primary prevention; aims to prevent disease developing in the first instance

121
Q

Outline what is meant by the term ‘secondary prevention’ of disease?

A

Secondary prevention; aims to reduce the severity and/or prevent recurrence of disease once it has developed

122
Q

Outline what is meant by the term ‘tertiary prevention’ of disease?

A

Tertiary prevention; aims to reduce the consequences of an established disease

123
Q

Give an example of a primary disease prevention measure?

A

Immunisation against communicable diseases

124
Q

Give an example of a secondary disease prevention measure?

A

Screening programmes

125
Q

Give an example of a tertiary disease prevention measure?

A

Rehabilitation programmes

126
Q

Outline the difference between a targeted approach and a population approach to disease prevention? (2)

A
  • Targeted approach; aims to target disease prevention in high-risk groups to reduce individual risk but no substantial effect on the risk in the general population
  • Population approach; universal prevention measures reduces the proportion of people above the treatment threshold and therefore the risk of disease amongst the general population, although also reducing the amount of people which benefit from the prevention
127
Q

Outline some of the main ways by which healthcare services are improved? (5)

A
  • Revalidation; regulation of professionals providing that service
  • Inspection; regulation of healthcare-providing premises
  • Education; increasing knowledge of up-to-date evidence
  • Setting standards/targets; realistic goals encourage development
  • Clinical guideline information; evidence-based practise
128
Q

Outline the domains that make up the healthcare commissioning cycle? (4)

A
  • Plan
  • Do
  • Review
  • Analyse
129
Q

Outline the three main domains that make up the determinants of health? (3)

A
  • Lifestyle determinants; smoking, alcohol, diet, exercise
  • Social determinants; education, economic background, employment
  • Environmental determinants; air quality, water quality, sanitation, food availability
130
Q

Give examples of some of the commonly used socioeconomic deprivation indicators? (3)

A
  • Townsend deprivation score (TDS)
  • Index of multiple deprivation (IMD)
  • National Statistics Socio-Economic classification (NS-SEC)
131
Q

Outline the purpose and function of a health needs assessment (HNA)?

A

Assessments that are conductive to inform the development of services so as to determine if a health problems can be addressed by an effective intervention or service provision

132
Q

When does a healthcare problem become a healthcare need?

A

If it has the potential to benefit from an intervention

133
Q

Outline the three main components that make up a health needs assessment (HNA) according to the Stevens, Rafferty and Mant model? (3)

A
  • Assessment of the size of the population and the incidence and prevalence of that healthcare problem
  • Assessment of the current service provisions for prevention and treatment of that healthcare problem
  • Review of the current evidence for the effectiveness and cost-effectiveness of the proposed intervention
134
Q

Outline the epidemiological triad of factors that affect disease transmission? (3)

A
  • Host; the innate susceptibility of the affected individual
  • Agent; the innate infectiousness of the causative agent
  • Environment; the factors that increase the chances of transmission
135
Q

What is meant by the term ‘basic reproductive number’ (R0)?

A

The basic reproductive number (R0) is the number of new cases that occur in a totally susceptible population

136
Q

What is meant by the term ‘effective/net reproductive number’ (Rn)’?

A

The effective/net reproductive number (Rn) is the number of new cases that occur in a population where they may be both susceptible and immune people presence

137
Q

What needs to happen to the value of the effective/net reproductive number (Rn) in order for disease transmission to stop?

A

It must drop below 1 meaning that each new case infects less than 1 other individual

138
Q

Outline the two main definitions of a disease outbreak? (2)

A
  • Where ≥ 2 people who experience a similar illness or confirmed infection are linked by a common factor
  • Where an observed number of cases of an illness or confirmed infection exceed what would be expected for a given place and time
139
Q

Outline the key attributes of effective disease surveillance? (6)

A

PAC3T;
- Practical
- Accurate
- Continuous
- Consistent
- Complete
- Timely

140
Q

What is the definition of communicable disease surveillance?

A

The conintued scrutiny of all aspects of a disease occurance and spread that are amenable to effective control

141
Q

What is the main requirement when a notifiable disease is suspected?

A

Public Health England (PHE) must be informed within 3 days where there is a clinical suspicion or verbally within 24 hours if the case is confirmed and urgent

142
Q

What type of trial design is considered the gold-standard for interventional trials?

A

Randomised controlled trials (RCTs)

143
Q

What is meant by ‘type 1 error’ (α)?

A

Type 1 error (α) refers to the incorrect rejection of a true null hypothesis, otherwise referred to as a false positive

144
Q

What is meant by type 2 error (β)?

A

Type 2 error (β) refers to the failure to reject a false null hypothesis, otherwise referred to as a false negative

145
Q

What is the main factor that influences the type 2 error (β) and thus power of a study?

A

Sample size; smaller sample sizes will have a greater type 2 error (β) and therefore diminished power

146
Q

Outline the current Public Health England (PHE) list of notifiable diseases? (34)

A
  • Acute encephalitis
  • Acute infectious hepatitis
  • Acute meningitis
  • Acute poliomyelitis
  • Anthrax
  • Botulism
  • Brucellosis
  • Cholera
  • COVID-19
  • Diphtheria
  • Enteric fever (typhoid or paratyphoid fever)
  • Food poisoning
  • Haemolytic uraemic syndrome (HUS)
  • Infectious bloody diarrhoea
  • Invasive group A β-haemolytic streptococcal disease
  • Legionnaires’ disease
  • Leprosy
  • Malaria
  • Measles
  • Meningococcal septicaemia
  • Monkeypox
  • Mumps
  • Plague
  • Rabies
  • Rubella
  • Severe Acute Respiratory Syndrome (SARS)
  • Scarlet fever
  • Smallpox
  • Tetanus
  • Tuberculosis
  • Typhus
  • Viral haemorrhagic fever (VHF)
  • Whooping cough
  • Yellow fever
147
Q

Outline the obligation of healthcare professionals to disclose a new diagnosis of a notifiable disease to Public Health England (PHE)?

A

There is a statutory legal obligation for healthcare professionals to disclose cases of notifiable diseases under Section 3 of the Infectious Diseases Act (1889)

148
Q

What is meant by the term ‘odd’s ratio’ (OR)?

A

The odds ratio (OR) is a ratio of the odds of exposure in cases to the odds of exposure in controls.

149
Q

Outline the benefits of matching cases and controls in case-control studies? (2)

A
  • Balances the key confounders between the two groups
  • This will mean that these confounding variables can be excluded when considering any associations observed
150
Q

Which type of study design is the only one in which causality can be inferred?

A

Interventional studies such as randomised controlled trials (RCTs)

151
Q

What is the key difference between a systematic review and a meta analysis? (2)

A
  • Systematic review may or may not include a statistical combination of the results from the various studies reviewed
  • Meta analysis always involves a statistical combination and the production of a combined estimate of results.
152
Q

What is the root cause of publication bias in meta-analyses and systematic reviews?

A

Difficulty in including data from studies that have not been published

153
Q

What is the mathematical definition of ‘relative risk’ (RR)?

A

Relative risk (RR); the ratio of the incidence of the outcome of interest in the exposed group compared to the incidence of the outcome of interest in the unexposed group

154
Q

What can be inferred if a diagnostic test has a low sensitivity? (3)

A
  • High false negative
  • Not unlikely that the test will be negative despite presence of the disease
  • A negative test result does not effectively rule out the disease
155
Q

What can be inferred if a diagnostic test has a low specificity? (3)

A
  • High false positive
  • Not unlikely that the test will be positive despite the absence of the disease
  • A positive test result does not effectively rule in the disease
156
Q

Outline the two main types of study design? (2)

A
  • Observational studies; where the investigator(s) observe a natural occurrence
  • Interventional studies; where the investigator(s) intervene actively
157
Q

Give examples of observational studies? (5)

A
  • Cohort studies
  • Case-control studies
  • Cross-sectional studies
  • Case reports/series
  • Ecological studies
158
Q

Give examples of interventional studies? (2)

A
  • Randomised controlled trials (RCTs)
  • Non-randomised trials
159
Q

Which three factors need to be considered before determining a causal relationship? (3)

A
  • Chance
  • Bias
  • Confounding
160
Q

Which parameter is calculated as a result of direct standardisation when looking at mortality rates?

A

Directly age-standardised rate (DASR)

161
Q

What parameter is calculated in a case-control study in order to quantify the magnitude of the influence of the risk factor (exposure) on the outcome?

A

Calculating the odds and odds ratio (OR) between the case and control populations

162
Q

Denoting risk;

  • Case-control studies; […] as the outcome has already occurred
  • Cohort studies; use both the odds ratio (OR) and the relative risk (RR) as the outcome has not occurred
A

Denoting risk;

  • Case-control studies; use only the odds ratio (OR) as the outcome has already occurred
  • Cohort studies; use both the odds ratio (OR) and the relative risk (RR) as the outcome has not occurred
163
Q

Denoting risk;

  • Case-control studies; use only the odds ratio (OR) as the outcome has already occurred
  • Cohort studies; […] as the outcome has not occurred
A

Denoting risk;

  • Case-control studies; use only the odds ratio (OR) as the outcome has already occurred
  • Cohort studies; use both the odds ratio (OR) and the relative risk (RR) as the outcome has not occurred
164
Q

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • OR = 1; the exposure does not affect the odds of the outcome
  • […]; the exposure increases the odds of the outcome
A

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • OR = 1; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
165
Q

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • […]; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
A

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • OR = 1; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
166
Q

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • OR = 1; the exposure does not affect the odds of the outcome
  • OR > 1; […]
A

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • OR = 1; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
167
Q

Odds Ratio (OR) Interpretation

  • OR < 1; […]
  • OR = 1; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
A

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • OR = 1; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
168
Q

Odds Ratio (OR) Interpretation

  • […]; the exposure decreases the odds of the outcome
  • OR = 1; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
A

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • OR = 1; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
169
Q

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • […]; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
A

Odds Ratio (OR) Interpretation

  • OR < 1; the exposure decreases the odds of the outcome
  • OR = 1; the exposure does not affect the odds of the outcome
  • OR > 1; the exposure increases the odds of the outcome
170
Q

Broadly speaking, what is indicated by the value of the relative risk (RR)?

A

How many times more likely the exposed group are to develop the outcome than the non-exposed group

171
Q

Broadly speaking, what is indicated by the value of the absolute risk reduction (ARR)?

A

For every 100 exposed individuals, a number equal to the value of the ARR more inviduals will go on to develop the outcome compared to the number of inviduals who will develop the outcome from a group of 100 non-exposed individuals

172
Q

Broadly speaking, what is indicated by the value of the odds ratio (OR)? (2)

A
  • The greater the value of the odd’s ratio (OR) is above 1, the more likely that those with the disease will have been exposed than those without the disease
  • The greater the value of the odd’s ratio (OR) is below 1, the more likely that those without the disease will have been exposed than those with the disease
173
Q

What is meant by the term ‘power’?

A

The probability of rejecting the null hypothesis if it is false

174
Q

What is meant by the term ‘randomisation’?

A

The process used in interventional trials where study subjects are randomly allocated by chance to separate groups that recieve different interventions

175
Q

Which equation is used to calculate the number needed to treat (NNT)?

A
176
Q

Which equation can be used to calculate prevelance?

A
177
Q

Using the table below, how would you calculate the specificity (Sp) of a diagnostic test?

A
178
Q

Using the table below, how would you calculate the sensitivity (Se) of a diagnostic test?

A
179
Q

Using the table below, how would you calculate the prevalence (P) of a diagnostic test?

A
180
Q

Using the table below, how would you calculate the positive predictive value (PPV) of a diagnostic test?

A
181
Q

Using the table below, how would you calculate the negative predictive value (NPV) of a diagnostic test?

A
182
Q

Using the table below, how would you calculate the relative risk/risk ratio (RR) of the exposed group developing the outcome?

A
183
Q

Using the table below, how would you calculate the odds ratio (OR) describing the magnitude of the relationship between the exposure and the outcome?

A
184
Q

Using the table below, how would you calculate the absolute risk reduction (ARR)?

A
185
Q

Outline the equation used to calculate the power of a study?

A
186
Q

How can you calculate the effective/net reproductive number (Rn)?

A
187
Q

What is meant by the term ‘screening’?

A

Screening is a public health service in which members of a defined population, who do not necessarily perceive they are at risk of, or are already affected by a disease or its complications, are asked a question or offered a test, to identify those individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of a disease or its complications

FinalMB Part III - Short Answer Questions (SAQs) (2 decks)

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