Public Health PTS

Question 1

Why is health economics relevant?

Answer 1

Finite resources
Hard choices – some patients will not get something that will benefit them
As a doctor we have to explain this to patients
As a commissioner – will have to decide

Question 2

What is opportunity cost?

Answer 2

To spend resources on one activity (e.g. heart transplant) means a sacrifice in terms of a lost opportunity cost elsewhere (e.g. fewer hip replacements)

The opportunity cost of an activity is the sacrifice in terms of the benefits forgone from not allocating resources to the next best activity
i.e. if one patient gets a very expensive treatment, others miss out on another treatment

Question 3

What is economic efficiency?

Answer 3

Achieved when resources are allocated between activities in such a way as to maximise benefit

i.e. if you have £3000 to spend and one treatment costs 1500 compared to another which costs 300, it would be more efficient to go with the cheaper treatment to save more lives/help more people

Question 4

What is economic equity?

Answer 4

About what is fair and just
Fair and just distribution of costs and benefits
Economists are clear in principle about the definition of efficiency, but there are opposing views about what is ‘fair’
Such considerations are difficult to quantify and the decision making process is much more complex and subjective

Question 5

What is meant by an equity-efficiency trade-off?

Answer 5

Improving equity often leads to a loss in efficiency

For example – funding the treatment of rare disease with very expensive drugs that may only have a limited benefit
This funding is then not available to treat other people with common diseases where the benefits will be much greater for the same cost
On balance there is a loss of health
This is inefficient, but it’s more equitable

Question 6

Define economic evaluation

Answer 6

The assessment of efficiency - a comparative study of the costs and benefits of healthcare interventions (i.e. cost benefit analysis)

Costs and effects are analysed in terms of their ‘increments’ or differences
Are the incremental benefits of a new treatment worth the incremental costs?

Question 7

How can health benefits be measured?

Answer 7

Natural units – e.g. blood pressure/pain score/number of cases detected

Quality adjusted life years

Monetary value

Question 8

What is a quality adjusted life year (QALY)?

Answer 8

Combines length of life with quality of life
Length (years) x quality (“utility”) weighting (0 to 1 scale)

One QALY = 1 year perfect health
One QALY = 2 years in half perfect health
Allows comparison across diseases

Question 9

What are the 4 types of economic evaluation?

Answer 9

Cost-effectiveness analysis

Cost-utility analysis

Cost-benefit analysis

Cost-minimisation analysis

Question 10

What is cost-effectiveness analysis?

Answer 10

Outcomes measured in natural units

E.g. incremental cost per life year gained

Question 11

What is cost-utility analysis?

Answer 11

Outcomes measured in QALYs

E.g. incremental cost per QALY gained

Remember because the name for quality of life in the QALY eqution is utility

Question 12

What is cost-benefit analysis?

Answer 12

Outcomes measured in monetary units

e.g. net monetary benefit

Question 13

What is cost-minimisation analysis?

Answer 13

Outcomes (measured in any units) are the same in both treatments

Therefore, just minimise cost

Question 14

What is incremental analysis?

Answer 14

Everything is relative

There must always be a comparison – for example:
New drug vs old drug
New treatment vs watch and wait
New surgical option vs medical treatment

Question 15

What is cost effectiveness analysis?

Answer 15

Simplest form of economic evaluation is cost-effectiveness analysis (CEA)
Uses ‘natural’ units to measure health e.g. life years gained
Comparison across disease areas difficult

Which do you fund:
ICER (heart transplants) = £10,000 per life year gained
ICER (hip replacement) = £3,000 per pain-free year gained

Question 16

Cost utility analysis?

Answer 16

More complex – using QALYs
Combined length of life and quality of life

In principle, all treatments can be evaluated using CUA – making funding decisions easier
ICER (heart transplants) = £18,000 per QALY
ICER (hip replacements) = £8,000 per QALY

Question 17

Cost benefit analysis?

Answer 17

Rarely used in healthcare
As it requires putting a monetary value on all outcomes which is difficult

Question 18

What is a funding threshold?

Answer 18

When a new more experience treatment is funded, another treatment somewhere else in the NHS needs to have its funding stopped to pay for it
NICE thinks that any services that are closed down to fund new services probably generate benefits at around £20,000 per QALY
Taking £20,000 from somewhere else therefore loses 1 QALY
So it only makes sense to fund new things if we get at least 1 QALY per £20,000 (cost must be less than £20,000 per QALY)

Question 19

What are some other considerations that need to be taken into account in health economics?

Answer 19

Age (equity)
Severity of illness (equity)
End-of-life (equity)
Rarity of condition (equity)
Causation (equity)
Innovation (wider economic benefit)
Patient convinience (and choice)

Question 20

What are the 3 main models of financing healthcare?

Answer 20

Publicly-funded health systems

Social insurance funded health systems

Privately funded health systems

Question 21

Define epigenetics

Answer 21

The expression of a genome depends on the environment

Question 22

Define allostasis

Answer 22

The same as homeostasis

The stability through change of our physiological systems to adapt rapidly to change in environment

Question 23

Define allostatic load

Answer 23

Long-term overtaxation of our physiological systems leading to impaired health (stress)

Question 24

Define salutogenesis

Answer 24

Favourable physiological changes secondary to experiences which promote healing and health

Question 25

Define emotional intelligence

Answer 25

The ability to identify and manage one’s own emotions, as well as those of others

Question 26

What is the role of primary care?

Answer 26

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

Question 27

What are the main dangers of over-prescribing antibiotics?

Answer 27

Unnecessary side effects

Medicalisation of self-limiting conditions

Antibiotic resistance

Question 28

What criteria should be used for prescribing antibiotics to someone with a sore throat?

Answer 28

CENTOR criteria

Question 29

What are the centor criteria?

Answer 29

Tonsillar exudate

Absence of cough

Tender or large cervical lymphadenopathy

Fever

Question 30

What are some other criteria for when to prescribe antibiotics?

Answer 30

Bilateral otitis media < 2 years old
Otitis media with otorrhoea
Acute sore throat with ≥ 3 centor criteria
Systemically very unwell
High risk – e.g. comorbidities, immune suppression, ex-prem baby
Aged > 65 and 2 of the following, or >80 and one of the following – hospital admission within the last 12 months, DM, CCF, glucocorticoid use
Pneumonia, mastoiditis, peritonsillar abscess, cellulitis

Question 31

Which antibiotics should be used for otitis media?

Answer 31

Amoxicillin

500mg TDS for 5 days

Question 32

Which antibiotics are used for sinusitis?

Answer 32

Amoxicillin

Or doxycycline

Question 33

Which antibiotics should be used for tonsillitis?

Answer 33

Penicillin V for 10 days

Question 34

Which antibiotics should be used for LRTI?

Answer 34

Amoxicillin

Question 35

Which Abx should be used for a UTI?

Answer 35

Trimethoprim – 200mg BD for 3 days

OR nitrofurantoin – 50mg QDS for 3 days

Question 36

Define public health

Answer 36

The science and art of preventing disease, prolonging life and promoting health through organised efforts of society

Question 37

What are the 3 domains of public health?

Answer 37

Health improvement

Health protection

Improving services

Question 38

What are the key concerns of public health?

Answer 38

Inequalities in health

Wider determinants of health

Prevention

Question 39

What is the domain of health improvement concerned with?

Answer 39

Societal interventions:
Inequalities
Education
Housing
Employment
Lifestyles
Family/community
Surveillance and monitoring of specific diseases and risk factors

Question 40

What is the public health domain of health protection concerned with?

Answer 40

Measures to control infectious disease risks and environmental hazards:
Infectious diseases
Chemicals and poisons
Radiation
Emergency repsonse
Environmental health hazards

Question 41

What is the public health domain of improving services concerned with?

Answer 41

Organisation and delivery of safe, high quality services for prevention, treatment and care:
Clinical effectiveness
Efficiency
Service planning
Audit and evaluation
Clinical governance
Equity

Question 42

How can health interventions be applied?

Answer 42

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)

Question 43

What needs to be done/performed before a health intervention is made?

Answer 43

A health needs assessment

Question 44

What is a health needs assessment?

Answer 44

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

Question 45

What are the 3 different approaches of health needs assessments?

Answer 45

Epidemiological

Comparative

Corporate

Question 46

Define need

Answer 46

Ability to benefit from an intervention

Question 47

Define demand

Answer 47

What people ask for

Question 48

Define supply

Answer 48

What is provided

Question 49

What is a health need and how is it measured?

Answer 49

A need for health
Measured using - mortality, morbidity, socio-demographic measures

Question 50

What is a health care need?

Answer 50

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

Question 51

What are the 4 sociological perspectives of need?

Answer 51

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

Question 52

What does an epidemiological approach to a health needs assessment involve?

Answer 52

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

Question 53

What are some potential sources of data for an epidemiological HNA?

Answer 53

Disease registry
Hospital admissions
GP databases
Mortality data
Primary data collection (e.g. postal/patient survey)

Question 54

What are the advantages of an epidemiological HNA?

Answer 54

Uses existing data
Provides data on disease incidence/mortality/morbidity etc.
Can evaluate services by trends over time

Question 55

What are the disadvantages of an epidemiological HNA?

Answer 55

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

Question 56

What does a comparative approach to a health needs assessment involve?

Answer 56

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

Question 57

What factors might a comparative HNA examine?

Answer 57

Health status
Service provision
Service utilisation
Health outcomes (mortality, morbidity, quality of life, patient satisfaction)

Question 58

What are the advantages of a comparative HNA?

Answer 58

Quick and cheap if data available
Indicates whether health or services provision is better/worse than comparable areas (gives a measure of relative performance)

Question 59

What are the disadvantages of a comparative HNA?

Answer 59

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

Question 60

What does the corporate approach to a health needs assessment involve?

Answer 60

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

Question 61

What are the advantages of a corporate HNA?

Answer 61

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

Question 62

What are the disadvantages of a corporate HNA?

Answer 62

Difficult to distinguish “need” from “demand”

Groups may have invested interests

May be influenced by political agendas

Question 63

Define primary prevention and give an example

Answer 63

Preventing disease before it has happened

Examples – change4life, 5 a day

Question 64

Define secondary prevention and give an example

Answer 64

Catching a disease in its early or pre-clinical phase

Example – breast screening programme (and all screening)

Question 65

Define tertiary prevention and give an example

Answer 65

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

Question 66

What are the 2 general approaches to prevention?

Answer 66

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,

Question 67

What is meant by the prevention paradox?

Answer 67

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

Question 68

What is screening?

Answer 68

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

Question 69

What are the Wilson and Junger criteria needed for a screening programme?

Answer 69

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

Question 70

What are the different types of screening?

Answer 70

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)

Question 71

What are some disadvantages of screening?

Answer 71

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

Question 72

What is the sensitivity of a screening test and how do you calculate it?

Answer 72

The proportion of people with the disease who are correctly identified by the screening test

True positive / (true positive + false negative)

Question 73

What is the specificity of screening and how is it calculated?

Answer 73

The proportion of people without the disease that are correctly excluded by the screening test

True negative / (true negative + false positive)

Question 74

What is the positive predicted value and how is it calculated?

Answer 74

The proportion of people with a positive test result who actually have the disease

True positive / (true positive + false positive)

Question 75

What is the negative predictive value and how is it calculated?

Answer 75

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

Question 76

Define incidence?

Answer 76

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)

Question 77

Define prevalence

Answer 77

The total number of people with a condition per 100,000 per year
Number of existing cases/population/point in time

Question 78

What is meant by lead time bias?

Answer 78

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

Question 79

What is meant by length time bias?

Answer 79

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

Question 80

What does a descriptive study design involve?

Answer 80

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

Question 81

What does a descriptive and analytical study design involve?

Answer 81

Cross section study/survey

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

Question 82

What are the advantages of cross sectional study?

Answer 82

Relatively cheap and quick
Provide data on prevalence at a single point in time
Large sample size
Good for surveillance and public health planning

Question 83

What are the disadvantages of a cross sectional study?

Answer 83

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

Question 84

What is a case control study?

Answer 84

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

Question 85

What are the advantages of a case-control study?

Answer 85

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

Question 86

What are the disadvantages of case-control studies?

Answer 86

Difficulties finding controls to match with cases

Prone to selection and information bias

Question 87

What is a cohort study?

Answer 87

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

Question 88

What are the advantages of a cohort study?

Answer 88

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

Question 89

What are the disadvantages of a cohort study?

Answer 89

Requires a control group to establish causation
Takes a long time
Loss to follow-up (people drop out)
Need a large sample size

Question 90

What is a randomised control trial?

Answer 90

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

Question 91

What are the advantages of a RCT?

Answer 91

Low risk of bias and confounding

Can infer causality (gold standard)

Question 92

What are the disadvantages of an RCT?

Answer 92

Time consuming
Expensive
Specific inclusion/exclusion criteria may mean the study population is different from typical patients (e.g. excluding very elderly people)

Question 93

What are is the main issue with a controlled trial that is not randomised?

Answer 93

Very subject to bias

Confounding factors are not equally spread across the groups

Question 94

What is an independent variable?

Answer 94

A variable that can be altered in a study

Question 95

What is a dependant variable?

Answer 95

A variable that is dependant on the independant variables, or one that cannot be altered

Question 96

What is meant by “odds” of an event and how is it calculated?

Answer 96

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)

Question 97

What is meant by odds ratio and how is it calculated?

Answer 97

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

Question 98

What is meant by epidemiology?

Answer 98

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)

Question 99

What is meant by person time?

Answer 99

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

Question 100

Define incidence rate

Answer 100

Incidence rate = Number of persons who have become cases in a given time period / total person-time at risk during that period

Question 101

What is meant by absolute risk?

Answer 101

Gives a feel for the actual numbers involved i.e. has units (e.g. 50 deaths/ 1000 population)

Question 102

What is meant by attributable risk and how is it calculated?

Answer 102

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

Question 103

What is meant by relative risk and how is it calculated?

Answer 103

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

Question 104

What is relative risk reduction and how is it calculated?

Answer 104

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

Question 105

What is absolute risk reduction and how is it calculated?

Answer 105

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

Question 106

What is meant by number needed to treat and how is it calculated?

Answer 106

NNT = 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

Question 107

What are the 5 factors that could be responsible if a study finds an association between an exposure and an outcome?

Answer 107

Bias

Chance

Confounding factors

Reverse causality (i.e. the one thing is actually causing the other)

A true causal association

Question 108

Define bias

Answer 108

A systematic deviation from the true estimation of the association between exposure and outcome

Question 109

What are the 3 main types of bias?

Answer 109

Selection bias

Information (measurement) bias

Publication bias

Question 110

What is a selection bias?

Answer 110

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

Question 111

What is an information/measurement bias?

Answer 111

A systematic error in the measurement or classification of the exposure or outcome

Question 112

What are some potential sources of information/measurement bias?

Answer 112

Observer bias

Participant – recall bias, reporting bias

Instrument – a wrongly calibrated instrument

Question 113

What is meant by confounding?

Answer 113

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

Question 114

What is meant by reverse causality?

Answer 114

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

Question 115

What are the Bradford-Hill criteria for causality?

Answer 115

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

Question 116

Define addiction

Answer 116

Craving, tolerance, compulsive drug/substance seeking behaviour, physiological withdrawal state

Question 117

What are the 3 main effects of dependant drug use?

Answer 117

Physical

Social

Psychological

Question 118

Describe some physical effects of dependant drug use

Answer 118

ACUTE:
Complications of injecting (DVT, abscesses, SBE – subacute bacterial endocarditis)
Overdose (respiratory depression)
Poor pregnancy outcome
Side effects of opiates – constipation, dry mouth
CHRONIC:
Blood-borne virus transmission
Effects of poverty (e.g. spending money on drugs so not being able to afford food)
Side effects of cocaine (vasoconstriction, local anaesthesia)

Question 119

Describe some social effects of drug use

Answer 119

Effects on families
Drive to criminality
Imprisonment
Social exclusion

Question 120

Describe some psychological effects of drug use

Answer 120

Fear of withdrawal
Craving
Guilt
Depression
Pre-occupation with finding the next load of the drug can lead to anxiety and low mood

Question 121

How often must heroin be used in people with heroin dependency to avoid withdrawal?

Answer 121

8 hourly

Question 122

What are the effects of heroin?

Answer 122

Eurphoria
Intense relaxation
Miosis
Drowsiness

Question 123

What are the adverse effects of heroin?

Answer 123

Dependence
Withdrawal symptoms
Nausea
Itching
Sweating
Constipation
Overdose 🡪 respiratory depression and death

Question 124

What can be offered in primary care to a newly presenting drug user?

Answer 124

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

Question 125

What is some harm reduction advice you can give to a drug user?

Answer 125

Not injecting or safe injecting (don’t share needles, use a new one each time)
Not mixing respiratory depressants
Not using drugs alone
Reducing amount taken after intervals where tolerance is lost
Call an ambulance if necessary
Safe sex
Information about blood borne viruses

Question 126

Where can you refer someone with a drug problem?

Answer 126

Specialist drug services

Voluntary sector services

Infectious disease services

Question 127

In which groups of patients is detoxification more likely to work?

Answer 127

Younger users
Less time addicted
Lower level of drug use

Question 128

What medication can be used for heroin detoxification?

Answer 128

Buphrenorphine (subutex) first line treatment

Question 129

Which medication is used for heroin overdose?

Answer 129

Naloxone

Question 130

Which medications can be used for maintenance of staying off heroin?

Answer 130

Methadone (full opioid agonist)

Buprenorphine (partial agonist/antagonist)

Question 131

What non-medical treatments should be used to help treat heroin users?

Answer 131

Psychological interventions and counselling

Alternative therapies – exercise, art therapy etc.

Referral for associated problems (Hep C, STIs)

Question 132

What are the aims of treatment for heroin users?

Answer 132

To reduce harm to the user, family and society

To improve health

To stabilise lifestyle and reduce amount of elicit drug use

To reduce crime

Question 133

What is the evidence for using methadone and buprenorphine in recovering heroin users?

Answer 133

Significantly reduces mortality
Reduces drug-related morbidity
Reduces crime
Reduces risk-taking behaviour and spread of blood borne viruses
Evidence that this can be done safely without increased iatrogenic mortality

Question 134

How can cocaine/crack be taken?

Answer 134

Oral
Snorting
Smoking
IV

Question 135

What is the mode of action of crack/cocaine?

Answer 135

Blocks reuptake or serotonin and dopamine at synapse 🡪 intense pleasurable sensation

Depletion of serotonin and dopamine at secretory neurone 🡪 anxiety, panic, adrenaline secretion, ’wired’

Question 136

What are the effects of cocaine?

Answer 136

Confidence
Euphoria
Impulsivity
Increased energy
Alertness
Impaired judgement
Decreased need for sleep
Bad - Anxiety, HTN, arrhythmias, “crash”

Question 137

What are the chronic effects of cocaine use?

Answer 137

Depression
Panic
Paranoia
Psychosis
Damaged nasal septum
CVA
Respiratory problems

Question 138

How is cocaine/crack use treated?

Answer 138

Harm reduction – advice on risky behaviour, safe sex advice, blood borne virus advice

Brief intervention – explanation of effects and risks, advice on controlled use, setting limits, cognitive based approaches

Team working – referral for sexual health/infectious diseases, voluntary agencies, specialist advice

Question 139

What is health psychology?

Answer 139

Emphasises the role of psychological factors in the cause, progression and consequences of health and illness

Question 140

What are the 3 main types of health behaviours?

Answer 140

Health behaviour – behaviour aimed to prevent disease (e.g. eating healthy)

Illness behaviour – 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 can also be health impairing or health promoting

Question 141

What is the theory of planned behaviour?

Answer 141

Proposes that the best predictor of behaviour is INTENTION i.e. “I intend to give up smoking”

Question 142

What are the 3 factors that determine intention in the theory of planned behaviour?

Answer 142

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

Question 143

What are some criticisms of the theory of planned behaviour?

Answer 143

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

Question 144

What are the 6 stages of the stages of change model? Give an example for each

Answer 144

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

Question 145

What is the other name for the stages of change model?

Answer 145

Transtheoretical model

NB they are interchangeable in the exam

Question 146

What are some advantages of the stages of change model?

Answer 146

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)

Question 147

What are some criticisms of the stages of change model?

Answer 147

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

Question 148

What is the role of motivational interviewing?

Answer 148

A counselling approach for initiating behaviour change by resolving ambivalence

Ambivalence = the state of having mixed feelings or contradictory ideas about something

i.e. the role of motivational interviewing is to 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 not

Question 149

What is meant by “nudge” theory?

Answer 149

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

Question 150

What are the typical transition points in life which may influence how someone changes their behaviour?

Answer 150

Leaving school
Starting work/new job
Becoming a parent
Becoming unemployed
Retirement
Bereavement

NB these factors could either make someone more likely or less likely to change their behaviour, depending on the person and their attitude

Question 151

What are the 4 factors of the health beliefs model?

Answer 151

Perceived susceptibility

Perceived severity

Perceived benefits

Perceived barriers

Question 152

Give an example for each stage of the health belief model

Answer 152

Individuals will change their behaviour if they:

Believe they are susceptible to the condition
Believe that the condition has serious consequences
Believe that taking action reduces susceptibility (benefits of changing)
Believe that the benefits of taking action out weight the costs

Question 153

Which factor of the health beliefs model has been shown to be the most important?

Answer 153

Perceived barriers

This is all about the patient having poor self-efficacy (i.e. not being able to stick to a behaviour change they have made)

Question 154

What are some criticism for the health beliefs model?

Answer 154

Doesn’t consider the influence of emotions and behaviour

Does not differentiate between first time and repeat behaviour

Cues to action are often missing

Question 155

What are some examples of cues to action which may influence behaviour change?

Answer 155

Cues can be internal or external

Internal = increase in pain, decrease in ADLs

External = reminders in the post, reminders for GP apts, pressure from families etc.

Question 156

What are some other factors to consider when it comes to behaviour change?

Answer 156

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

Question 157

What impact does social norms have on health behaviours?

Answer 157

Social norms = behaviours and attitudes that are most common in a group
One of the most important factors influencing behaviour
Sometimes belief or norms is different to actual norms – allows people who want to do high risk behaviours to think they’re just doing what everyone else is doing (but is often not the case)
Providing the truth about social norms could decrease high risk behaviours – e.g. only 20% of people smoke
However – DOESN’T work when the risky behaviour is the social norm (drinking alcohol, obesity)

Question 158

What is a meta analysis?

Answer 158

Take lots of studies and combine the results (statistical procedure)

Not the same as a systematic review – this doesn’t involve a stats procedure

Question 159

What are some factors for poor compliance to medication?

Answer 159

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

Question 160

What is a cohort study?

Answer 160

Prospective
Population free from disease initially
Follow up on exposed and non-exposed group and see what the outcome is

Limitation = very expensive

Question 161

What approaches can be used to help people act on their intentions?

Answer 161

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)

Question 162

Give examples of how health promoting interventions can be applied at a population, community and individual level

Answer 162

Population level – cigarette and alcohol tax

Community level – introducing 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

Individual level – patient centred approach to care. The care responds to their individual needs

Question 163

Why do patients continue high risk behaviours despite knowing the risks?

Answer 163

Fun
Justifies behaviour with other things
Doesn’t have the willpower to stop
Unrealistic optimism

Question 164

What is meant by unrealistic optimism?

Answer 164

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”

Question 165

What are the factors of unrealistic optimism that influence people’s perception of risk?

Answer 165

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

You need to figure out what your patients think about their risk level and see how you can address it. If someone doesn’t think they are at risk, then they are less likely to comply to their medications/come to their follow up appts

Question 166

What do NICE advise we do about behaviour change?

Answer 166

Planning interventions
Assessing the social context
Education and training
Individual level interventions
Community level interventions
Population level interventions
Evaluating cost-effectiveness
Assessing cost-effectiveness

Question 167

What can doctors actually do to help individuals change their health behaviours?

Answer 167

Work with patients priorities
Aim for easy changes over time
Set and record goals
Plan explicit coping strategies – e.g. avoid relapses by planning for stressful times
Review progress regularly (this is very important) – e.g. the annual diabetes check
Remember the public health impact of lots making making small differences to lots of individuals

Question 168

What is the role of NCSCT?

Answer 168

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

Evidence-based tobacco control programmes and smoking cessation interventions

Question 169

What is the impact of smoking on health?

Answer 169

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

Question 170

What is the economical impact of smoking?

Answer 170

£5 billion to the NHS a year
Avg. smoker spends £2,900 on smoking a year
Loss in productivity from smoking breaks
Increased absenteeism

Cleaning up cigarette butts - £342 million
Loss of economic output from death of smokers and passive smokers

Question 171

What is the difference between an infectious disease and a communicable disease?

Answer 171

Infectious disease = any disease caused by an infection

Communicable disease = disease that can spread from one person to another

Question 172

What are the mechanisms by which communicable disease can be spread?

Answer 172

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

Question 173

What makes a communicable disease of public health importance?

Answer 173

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)

Question 174

What is a notifiable disease?

Answer 174

A disease who’s name is on a lost of Public Health diseases that must be notified of

Question 175

What is notification of disease?

Answer 175

If a registered medical practitioner becomes aware or suspects that a patient is suffering from a notifiable disease or food poisoning

Send a notification as soon as possible, even if there is just suspicion of a notifiable disease

Question 176

What type of illnesses need notifying?

Answer 176

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

If you are ever worried about something – if in doubt notify
Use common sense – chickenpox itself is not notifiable but if a nurse on a cancer ward has chickenpox then that is a large risk to a lot of people

Question 177

Who needs to be notified?

Answer 177

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

Question 178

Which infections do ordinary doctors need not notify about?

Answer 178

Health Care Associated Infections (HCAIs)

Sexually transmitted infections

These are notified by GUM and I.D. departments
The only exception to this is Hepatitis B

Question 179

How is notification carried out?

Answer 179

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

Question 180

Give some examples of some diseases that must be notified urgently

Answer 180

Acute meningitis – if bacterial, meningococcal septicaemia
Acute poliomyelitis
Anthrax
Botulism
Cholera
Diphtheria
Typhoid
Food poisoning – if in outbreaks or clusters
Measles

Question 181

Give some examples of communicable diseases that need to be notified, but not urgently

Answer 181

Acute encephalitis
Leprosy
Mumps
Rubella
Typhus
Whooping cough (if not diagnosed during acute phase – if diagnosed during acute phase it’s urgently notifiable)

Question 182

How is communicable disease notification performed?

Answer 182

Fill in the form on the hospital computer system

Question 183

What are some causes of infectious bloody diarrhoea?

Answer 183

Campylobacter

Shigella

E.Coli

Question 184

Legionnaires disease is not communicable, but why is it still important to notify?

Answer 184

Infectious disease from a common infective source – so there is a chance it’ll make a lot of other people ill

Air conditioning, hot tubs, saunas, jet washers (anywhere you can aerosolise water)

Question 185

Why would you notify about notifiable diseases?

Answer 185

Legal requirement
Good medical practice
It’s a clinical governance issue if you don’t
Because it leads to action – which might be urgent
Allows surveillance – need to know how commonly the disease is happening
Monitoring of immunisation programmes - to see if they are successful by noting a drop in prevalence after introduction of vaccinations

Question 186

What is the role of consultant in communicable disease control (CCDC)?

Answer 186

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

Question 187

Which is the strain of E.Coli that we need to know about?

Answer 187

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

Question 188

What is the aim of outbreak control?

Answer 188

To identify and control the source of infection and the route of transmission to prevent spread of infection (further cases)

Where, what caused it, prevent others getting it

Question 189

Define cluster

Answer 189

An aggregation of cases – may or may not be linked

Question 190

Define suspected outbreak

Answer 190

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

Question 191

Define confirmed outbreak

Answer 191

Link confirmed through investigation (epidemiological/microbiological)

Question 192

How should outbreaks be managed?

Answer 192

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

Question 193

Define food poisoning

Answer 193

Any disease of an infectious or toxic nature caused by or thought to be caused by the consumption of food or water

Includes all food or water borne illness, regardless of the presenting symptoms and signs
Includes illness caused by toxic chemicals
Excludes allergies and food intolerances

Question 194

What action needs to be taken for food poisoning?

Answer 194

Identify affected cohort
Identify source
? Close restaurant
People sampling
Food sampling
Questionnaire

Question 195

What is the role of schools in infectious disease breakouts?

Answer 195

Requirement to keep children away from school

Requirement for school to provide a list of attendees

Question 196

What may the court require if there’s an communicable disease outbreak?

Answer 196

Seizure or destruction of objects that could be infectious
Isolation or quarantine of people
Disinfection/decontamination
Closure of premises

Question 197

What are the levels of Maslow’s hierarchy of needs?

Answer 197

(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

Question 198

What are the causes of homelessness?

Answer 198

Relationship breakdown
Mental illness
Domestic abuse
Disputes with parents
Bereavement - more than half say they have “no family ties”
Drugs
Alcohol
No money
No job

Question 199

What are some major health problems faced by homeless adults?

Answer 199

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

Question 200

What are some barriers to healthcare for travellers?

Answer 200

Reluctance of GPs to register travellers and to visit traveller sites
Poor reading and writing skills – many are illiterate
Communication difficulties
Too few permanent sites
Mistrust of professionals
Lack of choice

Question 201

What are some barriers to healthcare for homeless people?

Answer 201

Difficulties with access to healthcare – opening times, appointment & procedures location, perceived +/- actual discrimination
Lack of integration between primary care services and other agencies - housing, social services, criminal justice system
Other things on their mind – people do not prioritise their health when there are more immediate survival issues
May not know where to go
May not be able to get there

Question 202

Define asylum seeker

Answer 202

A person who has made an application for refugee status

Question 203

Define refugee

Answer 203

A person granted asylum and refugee status, usually means leave to remain for 5 years and then re-apply

Question 204

What is humanitarian protection?

Answer 204

Failed to demonstrate claim for asylum but face serious threat to life if returned. Usually 3 years then re-apply

Question 205

How do asylum seekers live?

Answer 205

No choice dispersal
Vouchers/70% of income support sum
NASS support package
Full access to NHS
Not allowed to work

Question 206

What are some physical health problems affecting asylum seekers?

Answer 206

Common illness
Illness specific to country of origin
Injuries from war and travelling
No previous health surveillance/neonatal screening/immunisatoins
Malnutrition
Torture and sexual abuse
Infestations
Communicable disease/blood borne disease
Untreated chronic disease/congenital problems

Question 207

What are some mental health problems that affect asylum seekers?

Answer 207

PTSD
Depression
Sleep disturbance
Psychosis
Self-harm

Question 208

What is meant by ’error’?

Answer 208

An unintended outcome

Question 209

What are some common issues with accidents/safety in healthcare?

Answer 209

Wrong diagnosis 🡪 wrong plan
Medication reconciliation – if they have forgotten to reconcile the medication list then patients could end up with duplicates, medications that interact etc.
High concentration medication solutions
Patient identification
Patient care handovers

Question 210

Why is safety compromised so often in healthcare?

Answer 210

Healthcare is a complex, high risk environment
Resource intensive
System, patient and practitioner interaction
Responsibilities are often shared
Practitioners often take risks unknowingly

Question 211

What are the 4 different ways in which errors can be classified?

Answer 211

Intention

Action

Outcome

Context

Question 212

Describe how error can be classified based on intention

Answer 212

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

Question 213

Describe how an error can be classified based on action

Answer 213

Generic factors – e.g. omission, intrusion, wrong order

Task specific factors – wrong blood vessels/organ/side, bad knots in surgery

Question 214

Describe how an error can be classified based on outcome

Answer 214

Near miss
Successful detection and recovery
Death/injury/loss of function
Prolonged intubation/stay in ICU
Cost of litigation
Unplanned transfer

Question 215

Describe how an error can be classified based on context

Answer 215

Anticipations and perseverations
Interruptions and distractions
Nature of procedure
Team factors
Organisation factors
Equipment and staffing issues
Accumulation of stressors

Question 216

What are the 2 different perspectives on error?

Answer 216

The person approach – focus on the individual

The system approach – focus on the working conditions

Question 217

Describe the person approach perspective on error

Answer 217

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

Question 218

Describe the system approach perspective on error

Answer 218

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

Question 219

What are some strategies that can be used to reduce errors and harm?

Answer 219

Simplification and standardisation of clinical processes
Checklists and aide memoires – SBAR
Information technology
Team training
Risk management programmes
Mechanisms to improve uptake of evidence based treatment patterns

Question 220

What are some tools used for risk identification?

Answer 220

Incident reporting
Complaints and claims
Audit, service evaluation and benchmarking
External accreditation
Active measurement/compliance

Question 221

What is the definition of a never event? Give some examples

Answer 221

Serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented

Examples:
Surgery – wrong site/implant, retained item (swab etc.)
Medication – wrong preparation/route (the intrathecal vincristine situation)
Mental health – suicide

Question 222

What are the 4 main leadership styles?

Answer 222

Inspirational

Transactional

Laissez-faire (letting things take their own course without interfering)

Transformational – inclusive leadership is distributed throughout all levels of an organisation

Question 223

What are the mechanisms underlying inhumane behaviour?

Answer 223

Bystander effect – number of bystanders (lack of leadership?), ambiguity, similarity of bystandar to victim

Pressing situational factors can override explicitly announced value systems

Unwillingness to speak out against prevailing view (i.e. afraid to whilstle blow)

Question 224

What are the 10 basic types of error? Give an example of each

Answer 224

Sloth – not bothering to check results accurately, inadequate documentation
Fixation and loss of perspective – early unshakeable focus on a diagnosis, inability to see bigger picture
Communication breakdown – unclear instructions of plans, not listening to or considering other’s opinions
Poor team working – some out of their depth, some underutilised
Playing the odds – choosing the common and dismissing the rare
Bravado – working beyond your competence/without adequate supervision (opposite holds true for timidity)
Ignorance – lack of knowledge, not knowing what you don’t know
Mis-triage – over/underestimating the seriousness of a situation
Lack of skill – lack of appropriate skills, teaching or practice
System error – environmental, technology, equipment or organisation features. Inadequate safeguards built in to the system

Question 225

Which skill, attribute or behaviour is missing in each type of basic error?

Answer 225

Sloth – conscientiousness
Fixation and loss of perspective – open mindedness, situational awareness
Communication breakdown – effective communication
Poor team working – good team work
Playing the odds – probability assessment
Bravado/timidity – humility (accurate self-evaluation)
Ignorance – self-awareness
Mis-triage – prioritisation
Lack of skill – effective technical skills
System error - good system design

Question 226

Define negligence

Answer 226

Failure to take proper care over something

A breach of duty of care which results in damage

Question 227

What are the factors that contribute to negligence?

Answer 227

System failure

Human factors

Judgement failure (defective decision making)

Neglect

Poor performance

Misconduct

Question 228

Give an example of how system failure can lead to negligence?

Answer 228

Computer system may shut down, losing patient’s notes
If the patient is unconscious and unable to communicate, important information may be lost at a critical moment

Hackers could get into computer systems and remove confidential information
Letting confidentiality be broken in this way could be considered negligence

Question 229

Describe how human factors could lead to negligence

Answer 229

Personal factors – i.e. they are having a bad day and it causes them to make mistakes at work
Teamwork problems - miscommunication, not liking people in the team
Working environment
Decision density – i.e. leaving one person to make all the decisions puts a lot of pressure on that person and would make them more likely to make a mistake

Question 230

Describe how judgement failure can lead to negligence?

Answer 230

Defective decision making
Analytical or intuitive
Wrong amount of type of information
Wrong decision making strategy
Bias

Question 231

Describe how neglect can lead to negligence

Answer 231

Not showing sufficient care
Falling below expected standard
Often a chain of minor failures
May be multidisciplinary – communication and assumptions
May or may not lead to harm

Question 232

Describe how poor performance can lead to negligence

Answer 232

Repeated minor mistakes
Not learning from mistakes
Usually extends beyond attitude to patient care – timekeeping, reliability, sickness, scruffy appearance

Question 233

Describe how misconduct can lead to negligence

Answer 233

Deliberate harm
Covering up errors
Fraud/theft/abuse – falsely claiming sickness or expenses, drug or alcohol misuse
Improper relationships – i.e. with other staff members, patients etc.

Question 234

What 4 questions need to be asked when negligence is suspected?

Answer 234

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?

Question 235

What are 2 tests that can be used to decide whether there was a breach in a duty of care?

Answer 235

Bolam test = would a group of responsible doctors do the same?

Bolitho test = would it be reasonable of them to do so?

Question 236

What factors influence how much money a patient will get from a successful negligence claim?

Answer 236

Loss of income

Cost of extra care

Pain and suffering

Question 237

What are the factors that make up the tripartite model of types of learning?

Answer 237

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

Question 238

What are the 4 types of learner?

Answer 238

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

Question 239

What is it important to do about these learning styles?

Answer 239

Choose activities which best match your learning style

Identify least dominant style so that you can strengthen these

Question 240

What are the features of Kolb’s learning cycle?

Answer 240

Experience (activist)
Review, reflect on experience (reflection)
Conclusions from experience (theorist)
What can I do differently next time? (pragmatist)

Question 241

How should a skill be taught?

Answer 241

Breaking the task down into smaller components

Utilising an internal commentary

See one, do one, teach one

Question 242

What are the key responsibilities of small group teachers?

Answer 242

Managing the group, activities and the learning

Facilitate the learning – leading discussions, asking open-ended questions, guiding process and task, enabling active participation of learners and engagement with ideas

Question 243

What are the 4 fundamental questions that a small group teacher must ask themselves?

Answer 243

Who am I teaching? Numbers, level, names

What am I teaching? The topic or subject, the type of expected learning (knowledge, skills, behaviours)

How will I teach it?

How will I know if the students understand/understood?

Question 244

What are the 7 types of question strategies?

Answer 244

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?

Question 245

Why is it important to teach diversity?

Answer 245

Better outcomes for patients – more likely to adhere to treatment, fewer tests and referrals

More satisfying doctor-patient encounters – patients more satisfied with their care, better able to understand their problems, fewer complaints

Question 246

What is the “iceberg” model of culture?

Answer 246

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

Question 247

Define culture

Answer 247

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

Question 248

Define ethnocentrism

Answer 248

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

Question 249

Define stereotype

Answer 249

Involves generalisations about the ’typical’ characteristics of members of a group

Question 250

Define prejudice

Answer 250

Attitude towards another person based solely on their membership of a group

Question 251

Define discrimination

Answer 251

Actual positive or negative actions towards the objects of prejudice

Question 252

What is Kleinman’s explanatory model of illness?

Answer 252

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?

Question 253

Why have rationing needs increased in terms of resource allocation?

Answer 253

(question is essentially asking why we need to ration resources more strictly)

Shift from acute illness to chronic long term

Normal physiological events medicalised

Increase in choice and increase in expensive drugs

Question 254

What is meant by rationing?

Answer 254

Resource is refused because of lack of affordability rather than clinical ineffectiveness

Question 255

What are the 3 allocation theories?

Answer 255

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

Question 256

What are some problems that arise from increasing health promotion and check up programmes?

Answer 256

Despite reaching out to everyone, there is much better uptake in higher income groups

Question 257

What are the human rights articles that are frequently engaged in healthcare?

Answer 257

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

Question 258

What are the benefits of using social media as a doctor?

Answer 258

Establishing wider and more diverse social and professional networks
Engaging with the public and colleagues in debates
Facilitating public access to accurate health information
Improving patient access to services

Question 259

What are the risks of using social media as a doctor?

Answer 259

Loss of personal privacy
Potential breaches of confidentiality
Online behaviour that may be perceived as unprofessional, offensive or inappropriate by others
Risks of posts being reported by the media or sent to employers

Question 260

What are the GMC duties of a doctor?

Answer 260

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

Question 261

What are the main principles to consider when dressing a wound?

Answer 261

Remove excess exudate and toxic components
Maintain a high humidity at the wound-dressing interface (needs to be a warm, moist environment)
Allow gaseous exchange
Provide thermal insulation
Impermeable to bacteria
Allow for changes without trauma
Be acceptable to the patient
Highly absorbent (for heavily exudative wounds)
Cost-effective
Mechanical protection
Comfortable and mouldable
Be able to be sterilised

Question 262

How does a moist wound environment affect the wound?

Answer 262

Increases the rate of epithelial migration
Reduces lag phase between epithelial cell proliferation and differentiation
Encourages collagen synthesis
Promotes formation of capillary loops
Decreases length of inflammatory phase
Reduces pain and trauma due to dressing adherence
Promotes breakdown of necrotic tissue
Speeds wound contraction

Question 263

What are the 4 phases of wound healing?

Answer 263

Vascular response

Inflammatory response

Proliferation

Maturation

Question 264

What are the 5 features of inflammation?

Answer 264

Rubor (redness)
Calor (heat)
Dolor (pain)
Tumour (swelling)
Loss of function

Question 265

What is meant by primary, secondary and tertiary intention with respect to wound healing?

Answer 265

Primary intention – little or no tissue loss, wound edges directly opposed (linear scarring)

Secondary intention – wound edges not oppose, would allowed to granulate, epithelialisation occurs from edge of hair follicle remnants in the base of the wound

Tertiary intention – wound is purposefully left open e.g. infection, foreign body, initially cleaned, debrided and observed. Surgically closed later

Question 266

What are some general patient factors which act as a barrier to healing?

Answer 266

Elderly
Diabetes – microvascular disease, neuropathy, raised glucose
Malnutrition
Malignancy
Renal or hepatic failure
Drugs
Immunosuppression
Vitamin deficiencies

Question 267

What are some local wound factors which act as a barrier to healing?

Answer 267

Site
Infection
Oedema
Vascular insufficiency
Previous radiotherapy

Question 268

What are the 5 main types of wound dressing?

Answer 268

Hydrogel
Alginate
Hydrocolloid
Foams
Non-adherent dressings

Question 269

What is the definition of domestic abuse?

Answer 269

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

Question 270

What are the 3 main ways in which domestic abuse presents to healthcare?

Answer 270

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

Question 271

What is the role of a doctor if they suspect a case of domestic abuse?

Answer 271

Try and speak to them alone (i.e. away from their partner and away from their children)
Document EVERYTHING THEY SAY
Document what their injuries look like
Only report to the police if it’s safe to do so - focus on safety
Tell them you can help them and point them in the right direction for proper support
Display posters about helplines etc. in your GP surgery
Ask direct questions – be non-judgement and reassuring

Question 272

Which tool can be used to assess domestic abuse?

Answer 272

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

Question 273

What do you do if you think someone is at medium/standard risk of domestic abuse?

Answer 273

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

Question 274

What do you do if you believe someone is high risk for domestic abuse?

Answer 274

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

Question 275

What is the role of the domestic homicide review?

Answer 275

A review of the circumstances in which the death of a person aged 16 or over has or appears to have resulted from violence, abuse or neglect

Includes suicides if you think domestic abuse contributed to the suicide

Question 276

What is the definition of an evaluation (of health services)?

Answer 276

Evaluation is the assessment of whether a service achieves its objectives

Question 277

What are the 3 things that make up the framework for a health service evaluation?

Answer 277

Structure

Process

Outcome

Question 278

What sort of things would be evaluated for structure in a health service evaluation?

Answer 278

Buildings – locations where a particular clinic is provided

Staff – number of vascular surgeons per 1000 population

Equipment – number of ICU beds in a hospital

Question 279

What sort of things would be evaluated for process in a health service evaluation?

Answer 279

What is done… e.g.:
Number of patients seen in A&E
Number of operations performed (may be expressed as a rate)

Question 280

What sort of things would be evaluated to assess outcomes in a health service evaluation?

Answer 280

Mortality
Morbidity
Quality of life/PROMS
Patient satisfaction

The 5 D’s can also be used – death, disease, disability, discomfort, dissatisfaction

Question 281

What are some examples of PROMS questionnaires used in primary care?

Answer 281

Oxford Hip Score and Oxford knee score
EQ-5D
Aberdeen varicose vein questionnaire

Question 282

What are some issues with health outcomes in an evaluation?

Answer 282

Link (cause and effect) between health service provided and health outcome may be difficult to establish as many other factors may be involved
Time lag between service provided and outcome may be long
Large sample sizes may be needed to detect statistically significant effects
Data may not be available
There may be issues with data quality

Question 283

When assessing the quality of health services, Maxwell’s classification lists 6 dimensions. List the 6 dimensions

Answer 283

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?

Question 284

What are the 2 different methods which can be used for evaluation?

Answer 284

1. Qualitative – interviews, focus groups
2. Quantitative – routinely collected data, review of records, surveys,
   epidemiological methods

Question 285

Although using measures of health outcomes is desirable in evaluation of health services, there are potential limitations. Explain why it may be difficult to attribute a health outcome to the service provided?

Answer 285

Other factors can affect it – wealth, socioeconomic status

Link may be difficult to establish between service provided and outcomes
Time lag
Sample sizes inadequate

Question 286

What is thought to be one of the main reasons of an increase in alcohol related liver disease in the UK?

Answer 286

Thought to be largely due to an increase in binge drinking

Question 287

How much alcohol is the recommended number of units per week?

Answer 287

14 units for both men and women

Question 288

How much alcohol is in a unit?

Answer 288

8 grams

Question 289

What is the calculation for number of units of alcohol?

Answer 289

Litres x %

So in 1 litre of 12% vodka - 12 units
In a 250ml glass of 14% wine – 1 litre would be 14 units so it’s 14/4 = 3.5

Question 290

Name some aetiological/risk factors for drinking problems?

Answer 290

Family
Religion
Personality
physical health/gender
Occupation
Availability of alcohol
Peer group
Advertising

Question 291

Why are more women drinking now than ever?

Answer 291

More socially acceptable
More disposable income
More drinks marketed at women 🡪 cocktails
More drinking places aimed at women customers 🡪 themed bars, well decorated

Question 292

What are some social and psychological risk factors for problem drinking?

Answer 292

Drinking within the family
Childhood problem behaviour relating to impulse control – introducing children to it early does NOT decrease their risk, it increases it
Early use of alcohol, nicotine and drugs
Poor coping responses to life events
Depression as a cause, not as a result of problem drinking – drink to help themselves feel better

Question 293

What is the link between socioeconomic deprivation and problem drinking?

Answer 293

Adverse effects of alcohol exacerbated amongst lower socioeconomic groups – i.e. if a CEO is too hungover to drive to work, they can pay for a taxi. But someone of a lower class may not be able to afford a taxi to work so may get fired
Low socioeconomic status – less likely to have good support from friends and family
Vicious cycle – low mood from lack of social support causes them to drink which isolates them even more

Question 294

What are the most common causes of death due to alcohol?

Answer 294

Accidents and violence – drink driving!
Malignancies – all types of cancer, not just liver
Cerebrovascular disease – strokes
Coronary heart disease

Alcohol 🡪 raises BP and triglycerides

Question 295

What are some other health problems caused by alcohol?

Answer 295

GI issues
Liver disease
CVD
Neurological – Wernicke’s, Korsakoff’s
MSK – gout
Birth defects – foetal alcohol syndrome
Gynae cancers
Kidney and bladder cancers

Question 296

How is alcoholic fatty liver disease managed?

Answer 296

Completely reversible if alcohol is withdrawn

Question 297

Why is it important to check clotting profile in alcoholics?

Answer 297

Liver makes the clotting factors
Severe hepatitis is a medical emergency – causing ascites, bleeding and encephalopathy

Also at risk of oesophageal varices

Question 298

Which types of cancer have been associated with alcohol?

Answer 298

Head and neck – mouth, larynx, pharynx, oeseophageal

GI – liver, stomach, colon, rectum, pancreas

Breast and gynae

Question 299

What are some features of fetal alcohol syndrome?

Answer 299

Microcephaly
Upturned nose
Hypoplastic (underformed) jaw
Short palpebral fissure
Smooth philtrum
Thin upper lip
Epicanthic folds

Question 300

What are some important questions to ask in an alcohol history?

Answer 300

CAGE and AUDIT screening tools

How much do you drink?
What do you drink?
Who do you drink with? Where?
Occupation?
Steady regular drinking or binging at weekends?
Debts?
What does your partner think about your drinking?

Question 301

What are some general/supportive measures of treatment for alcoholics?

Answer 301

Most importantly = address other health problems they may have
Consider vitamin supplementation – Thiamine (B1) as alcoholics do not eat well
Assess IHD risk
Consider osteoporosis risk

Question 302

Why is it NOT necessary to take a blood sample for alcohol level in alcoholics?

Answer 302

It’s a transient measure so is not helpful in chronic alcohol abuse

Question 303

What things should be included in motivational interviewing about alcohol use?

Answer 303

Potential harm caused
Reasons for changing behaviour – health and wellbeing, relationships
Cover obstacles to change – life stresses, lonelieness
Strategies to combat obstacles
Goals

Question 304

Which medications can be used in relapse prevention for alcoholics?

Answer 304

Disulfram (ANTABUSE) – gives them horrible flushing and hangovers

Acamprosate – GABA blocker

Naltrexone

Question 305

What are the symptoms of alcohol dependence syndrome?

Answer 305

Cluster of 3 of the following in a 12 month period:

Tolerance
Physiological withdrawal
Difficulty controlling drinking (onset, amount, stopping)
Neglect of social and other areas of life
Spending more time obtaining and using alcohol
Continued use despite negative physical and psychological effects

Question 306

What are the symptoms of delirium tremens?

Answer 306

Toxic confusional state as a result of alcohol withdrawal

Clouding of consciousness/confusion/seizures
Hallucinations – any sensory modality
Marked tremor

Question 307

How is delirium tremens treated?

Answer 307

Chlordiazepoxide to prevent fitting

Supportive fluids

Pabrinex

Question 308

What is a cohort study?

Answer 308

Prospective
Looks at an exposed and non-exposed population
To see whether either of them experience a particular outcome

Question 309

What is a case control study?

Answer 309

RETROSPECTIVE

Looks at a control group and a case group (i.e. one of them has a disease and one group doesn’t)
Comparing which ones of them were exposed to a particular exposure or not

Question 310

What are some determinants of health?

Answer 310

Genes
Environment – social and economic, physical (mould etc.)
Lifestyle
Healthcare

Wider determinants – inequalities in health, primary, secondary and tertiary prevention

Question 311

What is the difference between equity and equality?

Answer 311

Equity = what is fair and just (i.e. on a moral level)

Equality = concerned with equal shares (i.e. on a financial level)

Question 312

What are the 2 types of equity?

Answer 312

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)

Question 313

What are the dimensions of health equity?

Answer 313

Spatial – geographical

Social – age, gender, socioeconomic status, ethnicity

Question 314

How can health equity be examined?

Answer 314

Supply of healthcare
Access to healthcare
Utilisation of healthcare
Healthcare outcomes
Health status
Resource allocation
Wider determinants of health

Question 315

What are the 3 domains of Public Health practice?

Answer 315

Health improvement – education, housing, lifestyles, community

Health protection – infectious disease, chemicals/poisons, emergencies, environmental health hazards

Improving services (health care) – service planning, audit and evaluation, clinical governance

Question 316

What’s the difference between the 3 different types of prevention?

Answer 316

Primary - stop something before it happens (lifestyle, education, immunisations)

Secondary – catch disease in early/pre-symptomatic stage (breast cancer screening)

Tertiary - aims to prevent complications of the disease (diabetic eye clinic, stroke clinic)

Question 317

Explain the swiss cheese model of negligence

Answer 317

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