PH Flashcards
4 types economic evaluation
Cost-effectiveness analysis (CEA)
Cost-utility analysis
Cost-benefit analysis:
Cost-minimisation analysis
Cost-effectiveness analysis
Outcomes are measured in natural units (e.g. incremental cost per life year gained)
Cost-utility analysis
Outcomes are measured in quality adjusted life years (e.g. incremental cost per QALY gained)
Cost-benefit analysis:
Outcomes are measured in monetary units (e.g. net monetary benefit)
Cost-minimisation analysis:
Outcomes (measured in any units) are the same in both treatments. This is used when the aim is only to minimise costs.
incremental cost-effectiveness ratio (ICER)
cost-effectiveness can be summarised in terms of an incremental cost-effectiveness ratio (ICER)
he incremental costs of one treatment over another, divided by the incremental effects. So, if a new treatment produces 10 additional years of life more than current treatments and costs £10,000 more than current treatments, its ICER is 10,000 divided by 10, or £1,000 per life year gained.
The ICER, therefore, combines cost and outcome data in a simple summary measure. Treatments with lower ICERs produce units of health (e.g. life years) at lower cost than treatments with higher ICERs. As such, they are said to be more cost-effective
calculate QALYs
multiply the length of life expected to be gained by the new treatment or invention, by the quality of life a patient can expect to have.
how is quality of life measured?
on a 0 - 1 scale and this score represents the value of different levels of health. We’ll be exploring what these numbers mean and where they come from later on in this course.
We can think of a single QALY as being equivalent to one year in perfect health.
How do we find the ‘Q’ in QALYs
There are a number of elements required in order to do this:
We need to describe the health state that is going to be valued.- usually done using PROMs e.g. EQ 5D DL
We need a way to value the health state that we have described.
We need a group of people to provide the values.
A patient lives in a health state with a quality of life of 0.4 for 2 years, followed by a health state with a quality of life of 0.2 for 5 years, how many QALYs is this?
1.8
opportunity cost
The health benefits for patients that will be foregone if a new treatment is funded
obesogenic environemnt
physical: car culture
economic: expesive fruit and veg
sociocultural: family eating patterns
the runaway wt gain train
obesogenic environment=steep slope
knowledge, prejudice, phsyiology=ineffective brakes
vicious cycles mechanical dyfunct, psychological impact, ineffective deiting, low socioeconomic status=accelerators
mechanisms that maintain being overwt
physical: more wt=more difficult to exercie and dieting (metabolic response)
psychological: low self esteem, guilt, comfort eating
socioeconomic: rediced opportunities, employmeny, relationships, social mobility
epigenetics
The expression of a genome depends on the environment
allostasis
same as homeostasis
The stability through change of our physiological systems to adapt rapidly to change in environment
allostatic load
Long-term overtaxation of our physiological systems leading to impaired health (stress)
salutogenesis
Favourable physiological changes secondary to experiences which promote healing and health
role or primary care
Managing illness and clinical relationships over time
Finding the best available clinical solutions to clinical problems
Preventing illness
Promoting health
Managing clinical uncertainty
Getting the best outcomes with available resources
Working in the primary health care team
Shared decision making with patients
dangers of over prescribing abx
Unnecessary side effects
Medicalisation of self-limiting conditions
Antibiotic resistance
centor criteria
Tonsillar exudate
Absence of cough
Tender or large cervical lymphadenopathy
Fever
public health
the science and art of preventing disease, prolonging life and promoting health through organised efforts of society
3 domains of public health
Health improvement
Health protection
Improving services
key concerns of public health
Inequalities in health
Wider determinants of health
Prevention
health improvement
Societal interventions:
Inequalities
Education
Housing
Employment
Lifestyles
Family/community
Surveillance and monitoring of specific diseases and risk factors
health protection
Measures to control infectious disease risks and environmental hazards:
Infectious diseases
Chemicals and poisons
Radiation
Emergency repsonse
Environmental health hazards
improving services
organisation and delivery of safe, high quality services for prevention, treatment and care:
Clinical effectiveness
Efficiency
Service planning
Audit and evaluation
Clinical governance
Equity
applying health interventions
Delivered at an individual level (i.e. vaccinations to prevent an individual from getting ill)
Delivered at a community level (i.e. opening a new outdoor play area in a particular town)
Delivered at a population level (i.e. putting iodine in salt to prevent iodine deficiency)
What needs to be done/performed before a health intervention is made?
A health needs assessment
what is a health needs assessment
A systematic method for reviewing the health issues facing a population
Leading to agreed priorities and resource allocation that will improve health and reduce inequalities
diagram for health needs assessment
needs assessment ->planning ->implementaion ->evlauation ->repeat
3 approahes of health needs assessment
Epidemiological
Comparative
Corporate
define need
Ability to benefit from an intervention
define demand
what people ask for
health need and measurement
A need for health
Measured using - mortality, morbidity, socio-demographic measures
health care need
A need for healthcare – the ability to benefit from health care
Depends on the potential of prevention, treatment and care services to remedy health problems
felt need
individual perceptions of variation from normal health
expressed need
individual seeks help to overcome variation in normal health (demand)
normative need
professional defines intervention appropriate for the expressed need
comparative need
comparison between severity, range of interventions and cost
What does an epidemiological approach to a health needs assessment involve?
Define problem
Look at the size of the problem – incidence/prevelance
Services available – prevention/treatment/care
Evidence base – effectiveness and cost-effectiveness
Models of care – including quality and outcome measures
Existing services – unmet need; services not needed
Recommendations
What are some potential sources of data for an epidemiological HNA?
Disease registry
Hospital admissions
GP databases
Mortality data
Primary data collection (e.g. postal/patient survey
What are the advantages of an epidemiological HNA?
Uses existing data
Provides data on disease incidence/mortality/morbidity etc.
Can evaluate services by trends over time
What are the disadvantages of an epidemiological HNA?
Quality of data variable
Data collected may not be the data required
Does not consider the felt needs or opinions/experiences of the people affected
What does a comparative approach to a health needs assessment involve?
Compares the services received by a population (or subgroup) with others:
Spacial
Social (age, gender, class, ethnicity)
i.e. COMPARES THE SERVICES FOR A PARTICULAR HEALTH ISSUE IN TWO DIFFERENT AREAS
What factors might a comparative HNA examine?
Health status
Service provision
Service utilisation
Health outcomes (mortality, morbidity, quality of life, patient satisfaction)
What are the advantages of a comparative HNA?
Quick and cheap if data available
Indicates whether health or services provision is better/worse than comparable areas (gives a measure of relative performance)
What are the disadvantages of a comparative HNA?
May be difficult to find comparable population
Data may not be available/high quality
May not yeild what the most appropriate level (e.g. of provision or utilisation) should be
What does the corporate approach to a health needs assessment involve?
Ask the local population what their health needs are
Uses focus groups, interviews, public meetings etc.
Wide variety of stakeholders e.g. teachers, healthcare professionals, social workers, charity workers, local businesses, council workers, politicians
What are the advantages of a corporate HNA?
Based on the felt and expressed needs of the population in question
Recognises the detailed knowledge and experience of those working with the population
Takes into account wide range of views
What are the disadvantages of a corporate HNA?
Difficult to distinguish “need” from “demand”
Groups may have invested interests
May be influenced by political agendas
Define primary prevention and give an example
Preventing disease before it has happened
Examples – change4life, 5 a day
Define secondary prevention and give an example
Catching a disease in its early or pre-clinical phase
Example – breast screening programme (and all screening)
Define tertiary prevention and give an example
Preventing complications of a disease
Example – diabetic foot care, reviews for eyes in diabetic patients, attending physio/rehab after a stroke to prevent immobility and aspiration pneumonia
What are the 2 general approaches to prevention?
Population approach – preventative measures e.g. dietary salt reduction through legislation to reduce BP, adding iodine to salt to prevent iodine deficiency
High risk approach – identifying individuals above a chosen cut-off and treat e.g. screening for hypertension,
What is meant by the prevention paradox?
A preventative measure which brings much benefit to the population often offers little to each participating individual
i.e. it’s about screening a large number of people to help a small number of people
What is screening?
A process which picks out apparently well people who are at risk of a disease, in the hope of catching the disease at its early stage
NOT a diagnostic process – simply a means of assessing risk and catching diseases in their early stage
What are the Wilson and Junger criteria needed for a screening programme?
The disease must be an important problem
The disease must have a known and detectable latent phase
The disease must have a known natural course/progression
There must be a test which is acceptable to the population
There must be a treatment for the disease
There must be an agreed at-risk population of which to screen
There must be an agreed policy on who to treat
The costs of the screening should be economically balanced
What are the different types of screening?
Population-based screening programmes (e.g. cervical cancer, breast cancer)
Opportunistic screening (e.g. performing BP measurements in GP)
Screening for communicable disease
Pre-employment and occupational medicals
Commercially provided screening (where you can pay to get your blood sent off and tested for all sorts of genetic problems)
Genetic counselling (i.e. genetic testing for people with FHx of genetic disease)
What are some disadvantages of screening?
Exposure of well individuals to distressing or harmful diagnostic tests
Detection and treatment of sub-clinical disease that would never have caused any problems
Preventative interventions that may cause harm to the individual or population
sensitivity of a screening test and how do you calculate it?
The proportion of people with the disease who are correctly identified by the screening test
True positive / (true positive + false negative)
sensitivity of a screening test and how do you calculate it?
The proportion of people with the disease who are correctly identified by the screening test
True positive / (true positive + false negative)
specificity of screening and how is it calculated?
The proportion of people without the disease that are correctly excluded by the screening test
True negative / (true negative + false positive)
positive predicted value and how is it calculated?
the proportion of people with a positive test result who actually have the disease
True positive / (true positive + false positive)
negative predictive value and how is it calculated?
The proportion of people with a negative test result who do not have the disease
True negative / (true negative + false negative)
This is lower if the prevalence is higher
Define incidence?
The number of new cases of a disease in a population (e.g. per 100,000) in a given time frame (e.g. per year)
define prevalence
The total number of people with a condition per 100,000 per year
Number of existing cases/population/point in time
lead time bias?
When screening identifies an outcome earlier than it would otherwise have been identified
This results in an apparent increase in survival time, even if screening has no effect on outcome
length time bias?
A type of bias resulting from differences in the length of time taken for a condition to progress to severe effects that may affect the apparent efficacy of a screening method
descriptive study design
Case reports or case series – study individuals
Ecological studies – use routinely collected data to show trends in data and thus is useful for generating hypotheses. Shows prevalence and association, cannot show causation
cross sectional study
Divides populations into those without the disease and those with the disease and collects data on them once at a defined time to find associations at that point in time
They are used to generate hypotheses but are prone to bias and have no time reference
What are the advantages of cross sectional study?
Relatively cheap and quick
Provide data on prevalence at a single point in time
Large sample size
Good for surveillance and public health planning
What are the disadvantages of a cross sectional study?
Risk of reverse causality (don’t know whether outcome or exposure came first)
Cannot measure incidence (number of new cases)
Risk recall bias and non-response
case control study?
A type of analytical study
Retrospective
Takes people with a disease and matches them to people without the disease for age/sex/habitat/class etc
Study previous exposure to the agent in question
Quick and inexpensive
But retrospective nature shows only an association and data may not be reliable due to problems with patients’ memories
What are the advantages of a case-control study?
Good for rare outcomes (e.g. cancer)
Quicker than cohort of intervention studies (as the outcome has already happened – it’s retrospective)
Can investigate multiple exposures
What are the disadvantages of case-control studies?
Difficulties finding controls to match with cases
Prone to selection and information bias
What is a cohort study?
Prospective
Start with a population without the disease in question and study them over time to see if they are exposed to the agent in question and if they develop the disease in question or not
What are the advantages of a cohort study?
Possible to distinguish preceding causes from concurrent associated factors
Lower chance of selection and recall bias
Absolute, relative and attributable risks can be determined
Prospective - so can show causation where retrospective can’t
Good for common and multiple outcomes
What are the disadvantages of a cohort study?
Requires a control group to establish causation
Takes a long time
Loss to follow-up (people drop out)
Need a large sample size
What is a randomised control trial?
Patients are randomised into groups, one group is given an intervention and the other is given a placebo/control and the outcome is measured
Randomisation allows confounding factors to be equally distributed
Confounding and biases are minimalised
Lage, expensive, volunteer bias
Ethical issues – is it ethical to withhold a treatment that is strongly believed to be effective
Shows causation
What are the advantages of a RCT?
Low risk of bias and confounding
Can infer causality (gold standard)
What are the disadvantages of an RCT?
Time consuming
Expensive
Specific inclusion/exclusion criteria may mean the study population is different from typical patients (e.g. excluding very elderly people)
What are is the main issue with a controlled trial that is not randomised?
very subject to bias
Confounding factors are not equally spread across the groups
independent variable?
variable that can be altered in a study
dependant variable?
A variable that is dependant on the independant variables, or one that cannot be altered
What is meant by “odds” of an event and how is it calculated?
The odds of an event is the ratio of the probability of an occurrence compared to the probability of a non-occurrence
Odds = probability/ (1 – probability)
What is meant by odds ratio and how is it calculated?
The odds ratio is the ratio of offs for the exposed group to the odds for the non exposed groups
(P exposed/ (1- P exoposed)) / (P unexposed/ (1 – P unexposed))
Or can be interpreted as a relative risk when the event is rare
For case control studies it’s not possible to calcuate the relative risk, so the odds ratio is used
For X-sectional and cohort studies – both can be derived but odds ratio is used if it’s not clear which is the IV and which is the DV
epidemiology?
The study of frequency, distribution and determinants of disease and health related states in populations in order to prevent and control disease
Usual factors when measuring epidemiology of a disease – time, place, person (age, gender, class, ethnicity)
person time?
Measure of time at risk i.e. time from entry to a study to
i) disease onset
Ii) loss to follow-up
Iii) end of study
Used to calculate incidence rate which uses person time as the denominator
incidence rate
Number of persons who have become cases in a given time period / total person-time at risk during that period
absolute risk?
Gives a feel for the actual numbers involved i.e. has units (e.g. 50 deaths/ 1000 population)
attributable risk and how is it calculated?
The rate of disease in the exposed that may be attributed to the exposure
Attributable risk = incidence in exposed – incidence in unexposed
It’s about the size of the effect in absolute terms – gives a feel for the public health impact if causality is assumed
relative risk and how is it calculated?
Ratio of risk of disease in the exposed to the risk in the unexposed
Relative risk = incidence in exposed / incidence in unexposed
Tells us about the strength of association between a risk factor and a disease
relative risk reduction and how is it calculated?
The reduction in rate of the outcome in the intervention group relative to the control group
(incidence in non exposed – incidence in exposed) / incidence in non-exposed
absolute risk reduction and how is it calculated?
The absolute difference in the rates of events between the 2 groups
Gives an indication of the baseline risk and the intervention effect
Incidence in non-exposed – incidence in exposed
i.e. assuming exposed means they have had a particular intervention (such as giving statins to people with hypercholesterolaemia and then a control group who do not have statins and seeing how many in each group have a heart atttack to see if the intervention of statins is effective
number needed to treat and how is it calculated?
the number of patients we need to treat to prevent one bad outcome
NNT = 1/(risk in non-exposed – risk in exposed)
Aka 1/absolute risk reduction
5 factors that could be responsible if a study finds an association between an exposure and an outcome?
Bias
Chance
Confounding factors
Reverse causality (i.e. the one thing is actually causing the other)
A true causal association
bias
systematic deviation from the true estimation of the association between exposure and outcome
types of bias
Selection bias
Information (measurement) bias
Publication bias
selsection bias
A systematic error either in the selection of study participants or the allocation of participants to different study groups
E.g. non-response, loss to follow up, those in the intervention group different in some way from the controls other than the exposure in question
information/measurement bias?
systematic error in the measurement or classification of the exposure or outcome
potential sources of information/measurement bias?
Observer bias
Participant – recall bias, reporting bias
Instrument – a wrongly calibrated instrument
confounding?
A situation in which the estimate of association between an exposure and outcome is distorted because of the association of the exposure with another factor (confounder) that is also independently associated with the outcome
reverse causality?
This refers to a situation when an association between an exposure and an outcome could be due to the outcome causing the exposure rather than the exposure causing the outcome
Bradford-Hill criteria for causality?
Strength of association – the magnitude of the relative risk
Dose-response – the higher the exposure, the higher the risk of disease
Consistency – similar results from different researchers using various study designs
Temporality – does exposure precede the outcome
Reversibility (experiment) – removal of the exposure reduces the risk of disease
Biological plausibility – biological mechanisms explain the link
Coherence – logical consistency with other information
Analogy – similarity with other established cause-effect relationships
Specificity – relationship specific to outcome of interest
What can be offered in primary care to a newly presenting drug user?
Health check
Screening for blood borne viruses and referral if positive result
Contraception, smear
Sexual health advice
Check general immunisation status and hep A/B
Signpost to additional help – counselling, benefits, housing
Information on local drug services – including needle exchange
effects of cocaine
Confidence
Euphoria
Impulsivity
Increased energy
Alertness
Impaired judgement
Decreased need for sleep
Bad - Anxiety, HTN, arrhythmias, “crash”
effects of chronic cocaine use
Depression
Panic
Paranoia
Psychosis
Damaged nasal septum
CVA
Respiratory problems
health pyschology
Emphasises the role of psychological factors in the cause, progression and consequences of health and illness
health behaviour
behaviour aimed to prevent disease (e.g. eating healthy)
illness behavious
behaviour aimed at seeking remedy (e.g. going to the doctor)
sick role behaviour
any activity aimed at getting well (e.g. taking prescribed medications, resting)
health behaviours
health behaviour
illness behaviour
sick role behaviour
theory of planned behaviour?
Proposes that the best predictor of behaviour is INTENTION i.e. “I intend to give up smoking”
3 factors that determine intention in the theory of planned behaviour?
A persons attitude - e.g. I do not think smoking is a good thing
Subjective norms (the perceived social pressure to undertake the behaviour) – e.g. people who are important to me want me to give up smoking
Perceived behavioural control (a persons appraisal of their ability to perform the behaviour) – e.g. I CAN give up smoking
criticisms of the theory of planned behaviour?
Doesn’t take into account emotions
Relies on self-reported behaviour (i.e. people may lie)
Lack of temporal element (there is no timescale on it)
Assumes that attitudes, subjective norms and perceived behavioural control can be measured
6 stages of the stages of change model? Give an example for each
Pre-contemplation – haven’t thought about stopping smoking
Contemplation – thinking about stopping smoking
Preparation – goes to the doctor/pharmacy, gets a prescription for NRT/Champix to prepare them for stopping. Sets a stop date. Throws away cigarettes
Action – stops smoking on quit date, uses medications to help them
Maintenance – continues with abstaining from smoking by going for regular reviews, picking up more medication etc.
(relapse) – potential for relapse after a “trigger” type event
What is the other name for the stages of change model?
Transtheoretical model
advantages of the stages of change model?
Acknowledges individual stages of readiness
Accounts for relapse/allows patient to move backwards in the stages
Gives an idea of time-frame/progression (albeit arbitrary)
criticisms of the stages of change model?
Not all people move through every stage
Change might operate on a continuum rather than through discreet changes
Doesn’t take into account values, habits, culture, social and economic factors
role of motivational interviewing?
allow someone to change their behaviour by helping them make a decision about the behaviour – such as helping someone to see whether smoking was bad for them or no
nudge” theory?
changing the environment to make the best/healthiest option the easiest
For example placing fruit next to the checkouts at supermarkets instead of sweets, opt-out schemes such as pensions
typical transition points in life which may influence how someone changes their behaviour?
Leaving school
Starting work/new job
Becoming a parent
Becoming unemployed
Retirement
Bereavement
4 factors of the health beliefs model?
Perceived susceptibility
Perceived severity
Perceived benefits
Perceived barriers
4 factors of the health beliefs model?
Perceived susceptibility
Perceived severity
Perceived benefits
Perceived barriers
criticism for the health beliefs model?
Doesn’t consider the influence of emotions and behaviour
Does not differentiate between first time and repeat behaviour
Cues to action are often missing
other factors to consider when it comes to behaviour change?
Impact of personality traits on health behaviour – not everyone responds in the same way due to their own personality
Assessment of risk perception
Impact of past behaviour/habit
Automatic influences on health behaviour
Predictors of maintenance of health behaviours – does it stay changed 6 months down the line?
Social environment – environment massively influences behaviours
other factors to consider when it comes to behaviour change?
Impact of personality traits on health behaviour – not everyone responds in the same way due to their own personality
Assessment of risk perception
Impact of past behaviour/habit
Automatic influences on health behaviour
Predictors of maintenance of health behaviours – does it stay changed 6 months down the line?
Social environment – environment massively influences behaviours
meta analysis?
take lots of studies and combine the results (statistical procedure)
factors for poor compliance to medication?
Side effects (warn them)
Comorbidities (esp. mental health/dementia)
Polypharmacy
Complex drug regimes
Poor understanding of disease state
Social factors – i.e. they have dependants/act as carers for someone else so they don’t prioritise their own health
cohort study?
Prospective
Population free from disease initially
Follow up on exposed and non-exposed group and see what the outcome is
Limitation = very expensive
What approaches can be used to help people act on their intentions?
Perceived control – ask them to reflect on how they felt when something went well (i.e. when they said no to a cigarette)
Anticipated regret – ask them to reflect on how they felt when they didn’t do something (i.e. when they weren’t able to say no to a cigarette)
Preparatory actions – remind people to prepare for their change of behaviour (i.e. throwing away cigarettes)
Implementation intentions – help them help themselves incorporate the behaviour change into their routine (i.e. putting tablets next to the kettle so they know to take it when they make a cup of tea)
health promoting interventions at population level
cigarette ad alcohol tax
health promotion at commuity level
more cycle paths to make cycling safer, having to pay a fee for bringing a car into an area (London), building an outdoor gym in a particular town
health promotion at an individual level
patient centred approach to care. The care responds to their individual needs
Why do patients continue high risk behaviours despite knowing the risks?
Fun
Justifies behaviour with other things
Doesn’t have the willpower to stop
Unrealistic optimism
unrealistic optimism
The only theory for why patients engage in risky behaviours
Individuals continue to practice health damaging behaviours due to inaccurate perceptions of risk and susceptibility
i.e. they are aware of the risks but “don’t think it would happen to them”
factors of unrealistic optimism that influence people’s perception of risk?
Lack of personal experience with the problem
Belief that it’s preventable by personal action
Belief that if not happened by now, it’s not likely to
Belief that the problem is infrequent
What do NICE advise we do about behaviour change?
Planning interventions
Assessing the social context
Education and training
Individual level interventions
Community level interventions
Population level interventions
Evaluating cost-effectiveness
Assessing cost-effectiveness
What is the role of NCSCT?
NCSCT = national centre for smoking cessation and training
Role:
Delivers training and assessment programmes
Provides support services for local and national providers
Conducts research into behaviour support for smoking cessation
impact of smoking on health?
Leading cause of preventable death in the UK
100,000 people in the UK die each year due to smoking
Smoking-related deaths are mainly due to cancer, COPD and heart disease
About half of all smokers die from smoking related disease
What are the mechanisms by which communicable disease can be spread?
Cough/sneeze – airborne/droplet infection – 2 different respiratory route transmissions
Skin contact
Exchange of body fluids – sex, bite, needle stick injury
Animal to person (rabies, flu)
Mother to unborn child
Indirect contact (inanimate objects - e.g. remote control, desk surface)
Insect bites
Contaminated food/water
What makes a communicable disease of public health importance?
High mortality – e.g. rabies (100% mortality)
High morbidity – causes significant illness e.g. flu, meningococcal disease, E. Coli O157
Highly contagious – affects large no. of people (measles, flu)
Expensive to treat – prevention is cheaper than treatment (HIV)
Effective interventions available – e.g. Hep B (vaccine available)
What type of illnesses need notifying?
Individual cases of notifiable diseases
Outbreaks of a particular communicable disease
Other infections or contaminations (chemical or radiological) which are believed to present a significant risk to human health
Laboratories are also required to notify if they find an notifiable disease when they are looking at results
Who needs to be notified of notifiable diseases
The proper officer of the local authority
Usually the Consultant in Communicable Diseases of Public Health England
But not always – sometimes it’s the chief infective disease officer
How is notification of a notifiable disease carried out?
A registered medical practitioner should send a written notification so that it’s received within 3 days of the RMP forming the clinical suspicion
If the RMP thinks the case is urgent, they should notify orally by telephone within 24 hours (and still follow–up with written notification)
NB – written notifications need to be DOUBLE ENVELOPED to ensure confidentiality if sent to the wrong place
If telephoning – make sure you are speaking to the Communicable Disease Consultant for PHE
Give some examples of some diseases that must be notified urgently
Acute meningitis – if bacterial, meningococcal septicaemia
Acute poliomyelitis
Anthrax
Botulism
Cholera
Diphtheria
Typhoid
Food poisoning – if in outbreaks or clusters
Measles
Give some examples of communicable diseases that need to be notified, but not urgently
Acute encephalitis
Leprosy
Mumps
Rubella
Typhus
Whooping cough (if not diagnosed during acute phase – if diagnosed during acute phase it’s urgently notifiable)
What are some causes of infectious bloody diarrhoea?
Campylobacter
Shigella
E.Coli
What is the role of consultant in communicable disease control (CCDC)?
Surveillance – using notification, lab and other data to monitor communicable diseases
Prevention – trying to stop people getting infectious disease in the first place e.g. immunisation programmes, infection control advice
Control – what to do when outbreaks occur
Which is the strain of E.Coli that we need to know about?
E.coli O157
Tiny dose can cause large impact on many people
Bloody diarrhoea, cramps, usually self-limiting
Small proportion of children develop life threatening haemolytic uraemic syndrome
Wash hands, wash salads, boil water, cook thoroughly, avoid cross contamination
Exclude from school/work for 48 hours after symptoms stop
Exclude food handlers and healthcare workers until 2 negative stool samples
define cluster
n aggregation of cases – may or may not be linked
Define suspected outbreak
Occurrence of more cases of a disease than normally expected within a specific place or group of people over a given period of time
2 or more cases who are linked through common exposure, personal characteristics, time or location
A single case of a rare of disease disease such as diphtheria, rabies, viral haemorrhagic fever or polio
how should outbreaks be managed?
Make a diagnosis
Decide if it’s an outbreak
Get whatever help you need – microbiologist, ID consultant, infection control nurse
Outbreak meeting
Identify the cause
Initiate control measures
What action needs to be taken for food poisoning?
Identify affected cohort
Identify source
? Close restaurant
People sampling
Food sampling
Questionnaire
What are the levels of Maslow’s hierarchy of needs?
(at the bottom) – Physiological – breathing, food, water, sleep
Safety – security of employment, resource’s, family, health, property
Love/belonging - friendship, family, sexual intimacy
Esteem – self-esteem, confidence, achievement, respect of others
Self-actualisation - morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
What are some major health problems faced by homeless adults?
Infectious disease – TB, hepatitis
Poor condition of feet and teeth
Respiratory problems
Injuries – following violence, rape
Sexual health problems
Serious mental illness – schizophrenia, depression, personality disorders
Poor nutrition
Addiction/substance misuse
Define asylum seeker
A person who has made an application for refugee status
Define refugee
A person granted asylum and refugee status, usually means leave to remain for 5 years and then re-apply
What is humanitarian protection?
Failed to demonstrate claim for asylum but face serious threat to life if returned. Usually 3 years then re-apply
how do asylum seekers live?
No choice dispersal
Vouchers/70% of income support sum
NASS support package
Full access to NHS
Not allowed to work
What is meant by ’error’?
An unintended outcome
4 different ways in which errors can be classified?
intention
Action
Outcome
Context
4 different ways in which errors can be classified?
intention
Action
Outcome
Context
Describe how error can be classified based on intention
Failure of planned actions to achieve desired outcome
Skill based errors - action made is not what was intended
Rule-based mistakes – incorrect application of a rule/inadequacy of the plan
Knowledge based mistakes – a lack of knowledge in a certain situation
Automatically makes us prone to actions not as planned
Limited attentional resources
Memory containing mini theories rather than facts – liable to confirmation bias
Describe how an error can be classified based on outcome
Near miss
Successful detection and recovery
Death/injury/loss of function
Prolonged intubation/stay in ICU
Cost of litigation
Unplanned transfer
Describe how an error can be classified based on context
Anticipations and perseverations
Interruptions and distractions
Nature of procedure
Team factors
Organisation factors
Equipment and staffing issues
Accumulation of stressors
What are the 2 different perspectives on error?
The person approach – focus on the individual
The system approach – focus on the working conditions
Describe the person approach perspective on error
Essentially looks at and blames an individual or group of individuals
Errors are the product of unpredictable mental processes
Focuses on the unsafe acts of people on the front line
Shortcomings – anticipation of blame promotes ‘cover up’ and need for a detailed analysis to prevent recurrence
Describe the system approach perspective on error
Essentially blames some kind of flaw in the system
Errors are commonplace – adverse events are the products of many casual factors
Sharpenders are more likely to be the inheritors than the investigators
Remedial efforts directed at removing error traps and strengthening defences
Interaction between active failures and latent conditions – proactive risk management – remedy latent factors
What is the definition of a never event
Serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented
What are the 4 main leadership styles?
Inspirational
Transactional
Laissez-faire (letting things take their own course without interfering)
Transformational – inclusive leadership is distributed throughout all levels of an organisation
What are the 10 basic types of error?
Sloth
Fixation and loss of perspective
Communication breakdown
Poor team working
Playing the odds
Bravado
Ignorance
Mis-triage
Lack of skill
System error
negligence
Failure to take proper care over something
A breach of duty of care which results in damage
What are the factors that contribute to negligence?
System failure
Human factors
Judgement failure (defective decision making)
Neglect
Poor performance
Misconduct
What 4 questions need to be asked when negligence is suspected?
is there a duty of care?
Was there a breach in that duty?
Did the patient come to any harm?
Did the breach cause the harm?
What are 2 tests that can be used to decide whether there was a breach in a duty of care?
Bolam test = would a group of responsible doctors do the same?
Bolitho test = would it be reasonable of them to do so?
What are the factors that make up the tripartite model of types of learning?
Surface – fear of failure, desire to complete a course. Learning by rote and focus on particular tasks
Strategic – desire to be successful, leads to a patchy and variable understanding (well organised form of surface learning)
Deep approach – intrinsic, vocational interest, personal understanding. Making links across materials, search for deeper understanding of the material, look for general principles
What are the 4 types of learner?
Theorist – complex situation, can question ideas, offered challenges
Activist – new experiences, extrovert, likes deep end, leads
Pragmatist – wants feedback, purpose, may like to copy
Reflector – watches others, reviews work, analyses, collects data
What are the features of Kolb’s learning cycle?
Experience (activist)
Review, reflect on experience (reflection)
Conclusions from experience (theorist)
What can I do differently next time? (pragmatist)
7 types of question strategies?
Evidence – how do you know that? Where is the supportive evidence?
Clarification – can you give me an example? Can you explain that term?
Explanation – why is that the case? How would we know that?
Linking and extending – how does this idea support/challenge what we explored earlier in the session?
Hypothetical – what might happen if? What would be the potential benefits of x?
Cause and effect – how is this response related to management? Why is/isn’t that drug suitable for that condition?
Summary and synthesis – what remains unsolved/uncertain?
“iceberg” model of culture?
Things which are visible from the surface – you can have an idea of their age, nationality, ethnicity and gender
Things which you cannot possibly see from the surface – socioeconomic status, occupation, health, religion, education, sexual orientation, political orientation, cultural beliefs
culture
A socially transmitted pattern of share meanings by which people communicate, perpetuate and develop their knowledge and attitudes about life
Cultural identity may be based on heritage as well as indivial circumstances and personal choice
It is a dynamic entity
ethnocentrism
The tendency to evaluate other groups according to the values and standards of one’s own culture group, especially with the conviction that one’s own culture group is superior to that of others
stereotype
Involves generalisations about the ’typical’ characteristics of members of a group
prejudice
Attitude towards another person based solely on their membership of a group
discrimination
Actual positive or negative actions towards the objects of prejudice
Kleinman’s explanatory model of illness?
What do you call your illness? What name does it have?
What do you think has caused the illness?
Why and when did it start?
What do you think the illness does? How does it work?
How severe is it? Will it have a short or long course?
What kind of treatment do you think you should receive? What are the most important results you hope to achieve from treatment?
What are the chief problems the illness has caused?
What do you fear most about the illness?
3 allocation theories?
Egalitarian principles – provide all care that is necessary and appropriate to everyone. (challenge – tension between egalitarian aspirations and finite resources)
Maximising principles (utilitarian) – criteria that maximise public utility
Libertarian principles – each is responsible for their own health, well-being and fulfilment of life plan
What are the human rights articles that are frequently engaged in healthcare?
Article 2 – the right to life (limited)
Article 3 – the right to be free from inhumane and degrading treatment (absolute)
Article 8 – the right to respect for privacy and family life (qualified)
Article 12 – right to marry and found a family
What are the GMC duties of a doctor?
Make the care of your patient your first concern
Protect and promote the health of patients and the public
Provide a good standard of practice and care - keep professional skills up to date, recognise limits of competence, work with colleagues to serve patients best interests
Treat patients as individuals and respect their dignity and confidentiality
Work in partnership with patients
Be honest, open and act with integrity – act without delay if you believe a colleague is putting patients at risk
what are the 5 features of inflammation?
Rubor (redness)
Calor (heat)
Dolor (pain)
Tumour (swelling)
Loss of function
domestivc abuse
Controlling, coercive, threatening behaviour, violence of abuse between those aged 16 or over who are or have been intimate partners or family members
Includes – psychological, physical, sexual, financial and emotional abuse
3 main ways in which domestic abuse presents to healthcare?
Traumatic injuries following an assault – fractures, bruises, bleeds
Somatic problems or chronic illness consequent from living with abuse – headaches, GI disorders, chronic pain, premature delivery
Psychological or psychosocial problems secondary to the abuse – PTSD, attempted suicide, substance misuse, depression, anxiety, eating disorders
Which tool can be used to assess domestic abuse?
DASH tool (Domestic abuse and Sexual Harassment tool)
This tool encourages you to gather information about everything that is going on in the situation
There is no “score” that means they are at high risk, but they may say something that suddenly makes you think they are at high risk and you need to intervene
What do you do if you think someone is at medium/standard risk of domestic abuse?
in these cases it’s their CHOICE what they do
Give them contact details for domestic abuse services and let them decide what to do
What do you do if you believe someone is high risk for domestic abuse?
Refer to MARAC/IDVAS wherever possible with consent
In HIGH RISK – you can break confidentiality if you don’t get their consent, but always try and get consent first
hat are the 3 things that make up the framework for a health service evaluation?
Structure
Process
Outcome
What sort of things would be evaluated for structure?
Buildings – locations where a particular clinic is provided
Staff – number of vascular surgeons per 1000 population
Equipment – number of ICU beds in a hospital
What sort of things would be evaluated for process?
What is done… e.g.:
Number of patients seen in A&E
Number of operations performed (may be expressed as a rate)
What sort of things would be evaluated to assess outcomes?
Mortality
Morbidity
Quality of life/PROMS
Patient satisfaction
The 5 D’s can also be used – death, disease, disability, discomfort, dissatisfaction
What are some examples of PROMS questionnaires used in primary care?
Oxford Hip Score and Oxford knee score
EQ-5D
Aberdeen varicose vein questionnaire
When assessing the quality of health services, Maxwell’s classification lists 6 dimensions. List the 6 dimensions
3 A’s and 3 E’s:
Acceptability – how acceptable is the service for people needing it
Accessibility – geographical access, costs for patients, waiting times
Appropriateness – right treatment given to the right people?
Effectiveness – does the intervention produce the desired effect?
Efficiency – is the output maximised for a given input?
Equity – are patients being treated fairly?
How much alcohol is in a unit?
8g
What is the calculation for number of units of alcohol?
Litres x %
health problems due to alcohol
GI issues
Liver disease
CVD
Neurological – Wernicke’s, Korsakoff’s
MSK – gout
Birth defects – foetal alcohol syndrome
Gynae cancers
Kidney and bladder cancers
2 types of equity?
Horizontal equity – equal treatment for equal need (people with the same disease should be treated equally)
Vertical equity – unequal treatment for unequal need (e.g. areas with poorer health may need higher expenditure on health serviceS)
Explain the swiss cheese model of negligence
An organisations defences against failure are modeled as a series of barriers, represented as slices of cheese
The holes in the slices represent weakness in individual parts of the system
The holes are continually varying in size and position across the slices
The system produces failures when a hole in each slice momentarily aligns
Permitting a “trajectory accident opportunity” so that a hazard passes through holes in all of the slices – leading to failure
4 principles of ethics
● Autonomy
● Beneficence
● Mon maleficence
● Justice
deontology
duty; focused on action not the outcome [based on adherence to rules]
consequentialism
consequences; focus on outcome not the action
virtue ethics
moral character; focus on the character of the person
when to refer a death to the coronery
cause of death unknown
deceased not seen in last illness
unlawful killing/suicide/death related to occupation or caused by medical Tx or due to accident/abortion/neglect/anaethetic/medical intervention of any kind or death occurring in custody/under section [Mental Health Act]/due to medical negligence or within 24hrs of admission or if pt was receiving war or industrial pension [unless death is completely unrelated], or if any suspicious circumstances or death related to violence in any way.
cervical screening
women between the ages of 25-49 are invited every 3 years, and those aged 50-64 are invited every 5 years. Women w/ untreated cervical intraepithelial neoplasia develop squamous carcinoma [Successful screening programmes are based on detection & eradication of CIN] Women w/ HPV [Human Pappilomavirus] have increased risk of developing CIN, genital warts & cancer
breast screening
women between 50-69 are invited for a mammogram every 3 years [to be extended to women aged 47-73]
colorectal screening
men and women between 60-69 are invited every 2 years [to be extended to 75yo]. Reduces the risk of dying from bowel cancer by 16%. Offered via Faecal occult blood test which looks for the presence of blood in the stool [can miss cancer if there’s no blood when the FOB test was performed] bowel scope screening involves the insertion of a flexible instrument [colonoscopy] to look inside the lower part of the bowel and remove any growths -polyps
Immanuel Kent’s formulas:
- Formula of universal law: Before acting, consider: could I live in a world where everyone acted in this way?
- Formula of humanity: People are always to be treated as ends in themselves, never as means to an end
ethical prinicples that can be applied
seedhouses ethical grid
4 quadrants
4 quadrants approach
medical indications
patient preferneces
quality of life
contextual features
chain of infection
reservoirs of disease (where bulk of pathogen lives – humans 🡪 malaria, birds 🡪 influenza) 🡪 vector (vehicle of transmission - mosquito 🡪 malaria, ticks 🡪 TBE) 🡪 host
determinants of health
- Genetic
o Age
o Gender
o Ethnicity - Environmental
o Housing
o Socioeconomic status
o Access to education - Healthcare
o Economic factors
o Access
o Quality - Lifestyle
o Smoking status
o Wealth
o Employment
3 bucked model of error
self
context
task
