the key points to learn Flashcards
components of consent
capacity informed voluntary not coerced not manipulated valid
valid consent components
current
specific
in date
capacity
to act reasoned decision communicate decision understand decision retain memory
clinical negligence
duty of care duty was breached caused/materially contributed to damage damage was reasonably foreseeable and had negative consequences and effects = on balance of probability
how long can you sue for?
3yrs to sue - from moment you first knew something was wrong
- children until 21
how long should you keep records for?
min 11yrs
children until 25
epidemiology
study of pops to determine the freq and distribution of disease
roles of epidemiology
monitor infectious diseases monitor non-infectious diseases study NH of diseases investigate RFs of diseases health needs assessment development of preventive programmes evaluation of interventions health service planning
incidence
number of new individuals who contract a disease during a particular period of time
where are incidence estimates obtained from?
longitudinal studies/derived from registers
limitations of DMF
teeth ext for reasons other than caries
influenced by access e.g. IP surface
diff in differentiating FS from Rxs - underestimate caries
influenced by past disease activity
threshold criteria of disease can vary (must specify)
cannot be used for root caries
types of epidemiological study
descriptive (observational)
analytic (observational)
intervention/experimental
descriptive (observational) study
measures of disease freq - incidence, prevalence
analytic (observational) study
case control
cohort
intervention/experimental study
RCT
prevalence
number of existing cases
where are prevalence estimates obtained from?
CS studies/derived from registers
advantages of sampling
reduced number of individuals to be sampled
reduced cost
higher response rate
higher quality of info collected
types of sampling
simple random sample systematic stratified cluster multi-stage
errors in sampling
sampling/selection bias response/info bias measurement error observer variation - intra - you - inter loss to follow up
public health definition
the science and practice of preventing diseases, promoting health and improving QOL through the organised efforts of society
aims of public health
tackle inequalities
improve reach of services
dimensions of HC quality
person-centred safe efficient equitable effective timely
Kerr report
inverse care law
reactive (should be anticipatory)
criteria for a public health problem
prevalence of condition
impact of condition on individual level
impact on wider society e.g. £
condition preventable and effective txs are available
main roles of public health
epidemiology health needs assessment preventing disease and health improvement addressing health inequalities policy development development and implementation of local health strategies service development - clinical pathways pt safety improving governance systems and QI evaluating health services teaching and training research
protected characteristics
Equality Act 2010 age disability gender gender reassignment pregnancy and maternity marriage and civil partnership religion and belief sexual orientation race/ethnicity
reasonable adjustments
evidence levels from high to low
SRs and meta-analyses RCTs cohort case-control CS ecological studies case series and case reports ideas, editorials and opinions
design elements of RCTs
inclusion/exclusion criteria
comparison/control group
randomisation
blinding/masking
allocation concealment (selection bias)
technique to prevent selection bias by concealing the allocation sequence from those assigning participants to intervention groups, until moment of assignment
prevents researchers from influencing which participants are assigned to a given intervention group
advantage of RCTs
provide strongest and most direct epidemiologic evidence for causality. Gold standard
disadvantages of RCTs
more difficult to design and conduct than observational studies
- ethical issues
- feasibility
- £
still some risk of bias and generalisability often limited
not suitable for all research Qs
CIs VofND
diff = 0 ratio = 1
CIs
quantify level of uncertainty
tells us the range of values that a true pop tx effect is likely to lie
overlaps/contains VofND - insufficient evidence for a diff
odds ratio
intervention odds/control odds
relative risk reduction
starting-modified/starting risk x100
absolute risk reduction
starting - modified risk
NNT
1/ARD
round up
ARD
difference in risk between groups
risk ratio
risk in tx group/risk in placebo group
risk
number of events of interest/total number of observations
odds
number of events of interest/number without the event
aims
broad goals
objectives
specific and define what participants achieve at end of intervention
educational objectives
knowledge: increase in level of knowledge
affective: change in behaviour/beliefs
behaviours: acquisition of new skills/competencies
SMART objective
Specific Measurable Appropriate Realistic Time-related
planning framework
identify needs and priorities set aims and objectives decide best way to achieve aims identify resources plan evaluation methods set action plan ACTION - implement your plan and evaluation
what % of budget is often set aside for evaluation?
10-15%
3 Es of evaluation
efficiency
effectiveness
economy
3 Es of evaluation - efficiency
assess what has been achieved, did intervention have desired effect
3 Es of evaluation - effectiveness
measure impact and whether was worthwhile
3 Es of evaluation - economy
cost-effectiveness and whether time/labour and money were well-spent
purpose of evaluation
inform future plans
justify decisions to others
types of evaluation
impact - immediate effects
process
outcome - longer-term
research methods used in evaluation
semi-structured interviews observation focus groups self-response surveys interview-based surveys telephone interviews = use of both qualitative/quantitative useful
what was the ottawa charter?
1st conference in health promotion
aspects of the ottawa charter
building healthy public policy creating supportive env strengthening community action developing personal skills re-orientating health services
concentration for cleaning blood spills
10 000ppm
concentration for cleaning other spills
1000ppm
consulting styles
directing
following
guiding
domestic abuse response
Ask Validate "you don't deserve to be hit" Document Refer - Scottish Domestic Abuse Helpline - Rape Crisis Scotland
how long should you keep a consignment note for?
3yrs
what should the consignment note contain?
description, destination, quantity, origin, transport
principles of waste disposal
segregation
storage
disposal
document
F supplements for <0.3ppm F ion level in drinking water - <6m
nil
F supplements for <0.3ppm F ion level in drinking water - 6m-3yrs
0.25mg
F supplements for <0.3ppm F ion level in drinking water - 3-6yrs
0.5mg
F supplements for <0.3ppm F ion level in drinking water - 6-16yrs
1mg
F supplements for <0.6ppm F ion level in drinking water - <6m
nil
F supplements for <0.6ppm F ion level in drinking water - 6m-3yrs
nil
F supplements for <0.6ppm F ion level in drinking water - 3-6yrs
0.25mg
F supplements for <0.6ppm F ion level in drinking water - 6-16yrs
0.5mg
F supplements for >0.6ppm F ion level in drinking water
nil
OARS - communicating behaviour change
Open Qs - how are you managing...? Affirmation - you've managed to keep up Reflective listening Summary - advice ask permission to discuss health behaviour
cycle of behaviour change
precontemplation contemplation preparation action maintenance = at all stages possible relapse
VBA
Ask
Advise
Act
“drip effect”
Brief 5As
Ask Advise Assess Assist Arrange follow-up
how does F work?
reduces demineralisation
makes E more resistant to acid attack
increases remineralisation
can stop bacterial metabolism (at high conc) to produce less acid
OH effects of smoking
staining PDD reduced sensation infection risk delayed healing halitosis caries black hairy tongue oral cancers
general effects of smoking
cancers COPD chest infections skin - wrinkling miscarriage asthma
nicotine addiction
7-10s to hit brain
binds to nicotinic acetylcholine receptor - stimulates dopamine release = satisfaction
drop in nicotine levels = craving and withdrawal
triangle of nicotine addiction
emotional attachment
habit
neurochemical changes (chemical addiction)
e-cigs
stimulate tobacco smoking through vapourised nicotine delivery without burning conventional tobacco
how effective are e-cigs at helping smokers to quit?
moderately effective
harm reduction hand to mouth habit maintained psychosocial aspect of addiction maintained reduction in withdrawal symptoms control of dosage
disadvantages of e-cigs
safety
gateway theory: uptake of cigs
renormalisation of cigs
signs of nicotine poisoning
nausea and vomiting
dizziness
headache
nicotine withdrawal
irritability anxiety headaches craving depression disturbed sleep weight gain
champix
active ingredient varenicline
- stimulates nicotinic receptors - relieves craving and withdrawal symptoms
- also blocks nicotine from acting on nicotinic receptors - prevents rewarding and enjoyable effects of nicotine
= not NRT
behaviour change wheel COM-B stages
identify target behaviour(s) assess underlying reasons - COM-B ways to change/maintain behaviour - barriers and facilitators techniques (BCTs) implement and evaluate - inc feasibility (APEASE)
APEASE feasibility
Acceptability Practicability Effectiveness Affordability Safety (SEs) Equity
chronic heavy drinking oral issues
oral cancer oral ulceration glossitis angular cheilitis gingivitis - nutritional deficiency trauma xerostomia (dehydration) poor wound healing and OM erosion bruxism
sources of behaviour
capability - physical - psychological opportunity - social - physical motivation - automatic - reflective
aspects of the com b behaviour change wheel
sources of behaviour
intervention fcts
policy
chronic heavy drinking medical issues
GIT - acute gastritis - liver problems - GI bleeding - malnutrition - cancers heart - arrhythmias - cardiomyopathy - hypertension traumatic injuries skin, muscles, nerves and bones - osteoporosis blood - macrocytosis - thrombocytopenia - leucopenia Obs-Gyn problems other - poor wound healing, bleeding - immune system - mental health
what do screening tests do?
identify people who need more comprehensive assessment for substance misuse disorders
doesn’t make involved diagnosis/assessment
oral cancer and alcohol
ethanol metabolite acetaldehyde promotes tobacco initiated tumours
damages DNA and alters oncogene production
alcohol facilitates absorption of carcinogenic substances across mucosa
- partly due to thinning (nutritional deficiency)
alcohol screening tests
AUDIT
FAST
CAGE
types of drinking
hazardous
harmful
dependent
brief motivational interventions
Feedback Responsibility Advice Menu of options Empathic Self-efficacy
CMO low risk guidelines
don’t regularly drink >14 units per week
- spread evenly over ≥3 days
heavy drinking sessions - increased risk of death from long-term illnesses and accidents and injuries
risk of illnesses (inc cancer) increases with any amount you drink on a regular basis
if want to cut down - have several drink free days each week
single occasion drinking guidelines
limit total amount
drink more slowly with food, alternate with water
avoid risky places and activities
make sure you have people you know around you
ensure you can get home safely
3 common risk indices
absolute
relative (/)
attributable (-)
mainstream smoke
smoker inhales then exhales
sidestream smoke
wafts off end of lit cigarette, more dangerous - more carcinogen
3rd hand smoke
carcinogen laden residue that builds up on surfaces
confounding variable
variable which for some reason was left uncontrolled
multiple variables not one exerting influence on outcome of study
null hypothesis
when making definitive statement impossible to prove therefore a false statement can be made (null) which is then disproven
p value
probability of obtaining results at least as extreme as the results actually observed during the test, assuming that the null hypothesis is correct
- how likely it is to get a result like this if the null hypothesis is true
could you get this result from luck?
<0.05 data is significant
CASP
Critical Appraisal Skills Programme
CASP components
A - are the results valid?
B - results?
C - will the results help locally?
intention to treat ITT
analyse the data as though the switchers were still in the new agent group
more conservative (preferred)
pragmatic - in real life this will happen
drop outs - can input data
per protocol
analyse data according to tx actually received
efficacy to explain the effects of the intervention itself
both groups need to be treated exactly the same apart from the factor you are investigating
care bundle
a set of EB interventions that when used together significantly improves outcomes
aims to ensure pts receive optimum care at every contact
split mouth design advantages
each participant acts as own control - reduce inter-individual variation
both control and intervention exposed to same env
therefore fewer participants required to obtain same study power as parallel group
every participant receives each intervention therefore good for determining preferences
split mouth design disadvantages
carry across effects “leakage”
selection of pts (need to have matching carious teeth) might limit external validity
statistical analysis more complicated, isn’t usually done
pt can’t be blinded
bundle
data collection tool to sample whether optimum care is being delivered
factors contributing to adverse events
human
structural
clinical
QI/clinical governance
systematic approach to maintaining and improving the quality of pt care within a health system
CG components
education and training (CPD) clinical audit clinical effectiveness (EBD) research and development openness: Duty of Candour risk management - to pts and practitioners
clinical guidelines
systematically developed statements which assist in the decision making about appropriate HC for specific clinical conditions
aims of clinical guidelines
improve quality of HC
provide recommendations for tx and care
be used to develop standards for clinical audit
be used in education and training of HCPs
help pts make informed decisions
improve communication between pt and HCP
how much CPD?
100 hours verifiable CPD within 5yr cycle and at least 10hrs verifiable every 2yrs
CPD highly recommended topics (pt safety)
MEs: at least 10hrs per cycle, at least 2hrs pa
disinfection and decon ≥5hrs every cycle
radiography and radiation protection: at least 5hrs per cycle
other CPD recommended areas
ethical and legal issues
complaints handling
oral cancer: early detection
safeguarding
clinical audit definition
a QI process that seeks to improve pt care and outcomes through SR of care against explicit criteria and the implementation of change
uses of clinical audit
observe gaps in knowledge learning attitudes protocol training
clinical audit stages
select/identify problem/topic set criteria observe practice and collect data analyse data, determine any deviation from standard identify any areas of change required make changes
SEA
identify event collect info set meeting to discuss meet and undertake structured analysis implement changes and monitor progress write up SEA report seek external feedback
2 things to do after audit cycle
implement changes
repeat audit
need
what people could benefit from
demand
what people want
supply
what is provided
considering need
normative felt expressed comparative unmet
influences on need, supply, demand
current research agenda medical knowledge £ historical patterns medical influence: prevention or tx? public and political pressure media social and educational influence
= not static
SDNAP objectives
health needs assessment 1 - examine and describe the pop 2 - identify needs of pop 3 - examine current service provision 4 - identify how gaps can be met
DPH
health protection
health promotion
healthcare PH
7 special HBs and one PH body
PH Scotland HIS SAS NHS National Waiting Times Centre State Hospitals Board for Scotland NHS24 NES NSS
stages of HC planning
cyclical constant process
assessment of need options decisions on policy available resources implementation evaluation (review)
OHIP 2018 key domains
focus on prevention reduce oral health inequalities meet needs of an ageing pop more services on high st improving info for pts quality assurance and improvement workforce finance
SPIKES
setting perception information/invitation knowledge empathy summarise and strategy
diversity
acknowledgement of alterity
equity
equal outcome
categories of discrimination
direct indirect associative perceived harassment victimisation instruction to discriminate
stress physiology
endocrine system
hypothalamus
increased cortisol
stress RFs
demand control support relationships role change
burnout
process where a prev committed professional disengages from their work in response to stress and strain experienced in the job
exhausted
dissatisfaction with themselves
negative indifferent or cynical attitude
MBI 3 scales: Maslach Burnout Inventory
emotional exhaustion
depersonalisation
personal accomplishment
resilience
process of adapting well in the face of adversity, trauma, tragedy and threats
4 basic ingredients of resilience
awareness
thinking
reaching out
fitness
complaints stages
frontline resolution (≤5 WDs) investigation ( ≤20 WDs) independent external review - NHS - SPSO (pt has 12m) - private - HIS or DCS - 6m
values
subcategory of beliefs
determinants of what we are likely to do
hierarchy - can conflict
value clarification
criteria of a value
chosen freely chosen from alternatives chosen after thoughtful consideration of consequences of alternatives we prize this choice we affirm it to others act upon it act upon it repeatedly
values and conscience intertwined
act on our conscience because of our values
values also form our conscience
troubled conscience
acting against our value system
how are values expressed?
in our voluntary actions
moral distress
others’ decisions trouble us
are values related to ethics?
may/may not be
primary sources
single research source
secondary sources
multiple papers, synthesising together
SRs
literature review that uses systematic methods to collect secondary data, critically appraise research studies and synthesise studies
designed to provide a complete, exhaustive summary of current evidence relative to a research Q
often quicker and cheaper than embarking on a new study
key characteristics of a SR
1 - well-formulated Q 2 - comprehensive data search 3 - unbiased selection and abstraction process 4 - assessment of papers 5 - synthesis of data
non-systematic reviews
typically invited contributions created by experts to provide an overview or broad summary of what is happening in a particular field
nature means they are susceptible to bias
authors may not clearly state the methodology used, and may be selective in presenting evidence to support a particular, pre-existing view
SRs vs single studies
save readers time
provide reliable evidence
resolve inconsistencies
identify gaps (catalyst for better studies)
identify when Qs have been fully answered
explore differences between studies
why are SRs important?
reduce large quantities of information into manageable portions formulate policy and develop guidelines efficient use of resources increased power/precision limit bias and improve accuracy
authors for SRs
≥2
topic expert
methodological expert
study protocol for SRs
in advance set out what they plan to do methodologically (so you don’t deviate from procedures during it)
the process for SRs
authors study protocol specific Q search strategy inclusion/exclusion criteria critical appraisal synthesis
SRs specific Q
using PICO
SRs search strategy
comprehensive and repeatable
multiple electronic databases
published and unpublished literature
- research studies that haven’t been published - hard to find
look quite a long way back not just really recent ones
ideally without language restrictions
SRs inclusion/exclusion criteria
specific
agreed in advance
SRs critical appraisal
systematic and thorough
risk of bias
SRs synthesis
qualitative (narrative) synthesis
quantitative pooling of data in meta-analysis
- relative precision and quality of the included studies
SRs well-formulated Q
PICO
inclusion criteria
how reliable are SRs?
depends
- methodological quality of the included studies
- quality of the SR itself
- how well was the review conducted?
- AMSTAR2/ROBIS - checklists to assess how well SR
has been done
Cochrane
evidence tool to enhance healthcare knowledge and decision making
for anyone interested in using high quality info to make health decisions
global independent network
gathers and summarises the best evidence from research - informed choices
does not accept commercial or conflicted funding
SR - where should all of the steps be described?
in the review protocol
what is the first step in the SR process?
protocol development
- it should be registered
declaration of helsinki
every clinical trial must be registered in a publically accessible database before recruitment of the first subject
reporting bias SRs
statistically significant ‘positive’ results are:
- more likely to get published - publication bias
- more likely to be published rapidly - time lag bias
- more likely to be published in english - language bias
- more likely to be cited by others - citation bias
unbiased selection and abstraction process SRs
selection of relevant papers
data extraction to a predefined data extraction form
conducted independently by at least 2 reviewers - done in duplicate
- if don’t agree can get a 3rd to adjudicate
clear description of reasons for exclusion
adequate description of inc studies
details of studies funding sources
assessment of papers
how well studies have been designed and conducted (methodologically)
independently by at least 2 reviewers
- if don’t agree can get a 3rd to adjudicate
results of assessment should be reflected in analysis
‘quality’ assessment tools
composite scales
component approach
‘quality’ assessment tools - composite scales
assign numerical value to individual items to provide overall estimate of quality
problematic - can get same score for different reasons
‘quality’ assessment tools - component approach
assess relevant methodological aspects individually e.g. randomisation, blinding, drop outs
preferred
risk of bias assessment
bias determines extent to which results of studies can be believed
a study conducted to the highest possible standards can still have risk of bias
direction of bias: causes overestimation or underestimation of tx effect
magnitude of bias
study risk of bias table
each author does independently then come together to compare
judge each category as low/unclear/high risk and include comment re support for judgement
random sequence generation (selection bias) allocation concealment (selection bias) blinding - outcome assessors blinding - participants incomplete outcome data (attrition bias) selective reporting (reporting bias) other bias
can form a summary table and a summary graph
SR synthesis of data
appropriate pooling
- qualitative (narrative)
- quantitative (MA) - inappropriate when data are sparse
or when heterogeneity exists
clear presentation of individual studies inc in the review
MA potential advantages
an increase in power
an improvement in precision
the ability to answer Qs not posed by individual studies
MAs have potential to mislead and should only be undertaken when:
minimal differences in characteristics across studies
same outcome measure
data in each study are available - data needs to be extractable
SRs - why use risk of bias?
in practice, impossible to measure the amount of bias in a study
so do risk of bias assessment
dealing with risk of bias
variation in risk of bias may be an explanation for heterogeneity between results of different studies - sensitivity analyses
a significant risk of bias in included studies should give rise to cautious conclusions in a SR
- you want them to be a low risk of bias
what is a MA?
the process of using statistical methods to combine the results of different studies
aim - integrate findings, pool data - identify the overall trend of results
optional part of a SR
calculates a tx effect based on pooled data from a group of studies
estimates a common tx effect across studies
improves the precision of a point estimate by using all available data - getting more participants
different types of data
dichotomous (binary)
continuous
= whatever type - calculate a single summary statistic to represent the effect found in each study - usually 95% CIs
choice of summary statistic for dichotomous data
odds ratio risk ratio %/relative risk reduction risk difference or absolute risk reduction NNT
choice of summary statistic for continuous data
weighted mean difference: when all outcomes are using the same scale
standardised mean difference: for when all the studies are assessing the exact same outcome but do it in a variety of ways
weighting studies
more weight given to studies which give us more info:
- more participants
- more events (e.g. prevalence of disease)
- lower variance
- may not be able to tell from plot whether variation is lower
types of heterogeneity
clinical
methodological
statistical
clinical heterogeneity
variation in participants, interventions, outcomes, study design
methodological heterogeneity
variation in methods used in studies e.g. quality of allocation concealment
statistical heterogeneity
excessive variation in the results of studies
variation in tx effects above that expected by chance
identifying heterogeneity visually
if studies are estimating the same thing we would expect CIs to overlap to a large extent
statistical heterogeneity may appear in forest plots as poor overlap of CIs
- if CIs don’t overlap - can say there is a lot of
heterogeneity
look for outliers
interpretation of forest plot
if the CI crosses the line of no effect, this is equivalent to saying that there is insufficient evidence for a difference in the effects of the 2 interventions
cumulative meta-analysis
updates as each trial becomes available
recalculate RR and CI
chi squared test of heterogeneity
p <0.1 demonstrates statistically significant heterogeneity
- may not be appropriate to pool data
I squared statistic
% variation due to heterogeneity rather than chance
<50% acceptable
represents level of statistical heterogeneity
sensitivity analysis
does result change according to small variations in data and methods
- choice of tx effects of method for pooling
- inclusion/exclusion of dubious data
- inclusion/exclusion of trials
should set out plans in protocol if going to include/exclude some data from meta-analysis
- study quality/reasons that make it different to others - see if it makes a difference
a common sensitivity analysis is to repeat the analysis taking out lower quality trials
Cochrane GRADE
Grading of Recommendations Assessment Development and Evaluation evaluates the quality of the body of evidence (MA) high, mod, low, v low e.g. certainty, heterogeneity, risk of bias
subgroup analysis
where it is suspected in advance that certain features may alter the effect of an intervention
e.g. gender, age groups, specific disease subtypes (mild/mod/severe)
need to predefine subgroups before you start - can’t do it when you see the results
fixed effects
assumes that the studies are so similar that they are effectively different parts of one large study
assumes that the ‘true’ answer for each study is the same
random effects
assumes that the studies are slightly different
assumes that the ‘true’ answer for each study will be slightly different from the ‘true’ answer of the others
wider CI
more conservative - prefer it unless really good reason to believe fixed effects
5 factors that can lower quality
high or unclear risk of bias
inconsistency between studies (heterogeneity)
indirectness (PICO)
imprecision - numbers and CIs
publication bias - likely that negative/null results not published?
summary of findings table
summary of key findings from a SR presents: - quality of evidence - magnitude of the effect - reasons behind judgements format: - PICO - outcomes - results
improving reporting standards
CONSORT
EQUATOR
COMET
CONSORT
evidence-based minimum set of recommendations for reporting RCTs
shown to improve quality of reporting
EQUATOR
enhancing the quality and transparency of health research
COMET
core outcome measures in effectiveness trials
- stipulate which outcomes should be used in all clinical trials
disadvantage of cochrane reviews
don’t incorporate human factors e.g. seeking HC, tx compliance, if they don’t change their behaviour etc
registered trials
Trials registries - gov
international committee of medical journal editors (ICMJE)
declaration of helsinki
