Theme C Flashcards
What are the analytical methods for collecting population research?
Trials - RCTS
What are the descriptive methods for collecting population research?
Survey
Case report
Case series
What are the observational methods for collecting population research?
Cohort
Case control
Describe a case control study
Observational
Begin with cases (people with the disease or outcome) and the controls (those without the disease or outcome)
Look into the past to look for risk factors or absence of risk factors
Describe cohort studies
Observational
Start with people who do not have the disease
Classify whether they are in the risk factor group or no risk factor
After a period of time look to see who has the disease / outcome
What are the problems associated with observational studies?
Confounding
Bias
What are some of the problems with measuring diet?
Random error
Homogeneity of exposure
Bias
Confounding
How can you measure diet?
Food disappearance data (national level)
Household surveys
Individual surveys
(24 hour recall, food frequency, diet diary, bio markers)
Pros and cons of diet diaries
Records diet as eaten
More flexible
Better estimate of energy and absolute intake
Requires effort to complete
Expensive to code
Alters diet while diary completed
What is internal validity?
Extent to which a causal conclusion based on the study is warranted.
Extent to which a study minimises systematic error
What is external validity?
Extent to which the results of the study can be generalised to other situations and other people
What can limit the generality of study findings?
- Situational specifics e.g. time, location, researcher, extent of measurement, treatment administration
- Pretest - if cause effect relationship are only found in pretest
- Post test - if cause effect relationship are only found in post test
- Reactivity - if effects only ocurred as an effect of studying the situation
- Rosenthal effects - inferences about cause-consequence relationships may not be generalisable to other researchers
Why do we need evidence based medicine?
Increasing medical knowledge Limited time to read Inadequacy of traditional sources Disparity between diagnostic skills/ clinical judgement Can improve medical practice
What are the four components for an evidence based decision?
Evidence from research
Clinical expertise
Patient preference
Available resources
What are the different types of research study?
Cohort Case control Randomised control trias Qualitative approaches Diagnostic and screening studies Systematic reviews
What is a cohort study appropriate for?
Prognosis
Cause
What is a case control study appropriate for?
Cause
What is a RCT appropriate for?
treatment interventions
benefits and harm
cost effectiveness
What is a qualitative study appropriate for?
Patients and/or practitioners perspective
What is the process for evidence based medicine?
- Convert the need for information into an answerable questions
- Identifying best evidence to answer that question
- Understanding it
- Critically appraising evidence for validity, impact and applicability
- Integrating critical appraisal with clinical expertise, patient circumstances and service constraints
- Evaluating effectiveness of steps 1-5
What is a background question?
General knowledge about a disorder
Who/what/where/when…. disorder
What is a foreground question?
Specific knowledge about managing patients with a disorder
Patient/problem
Intervention
Comparison intervention
Clinical outcomes
What is the control of communicable diseases based on?
Surveillance
Preventative measures
Outbreak investigation
Appropriate control measures
What are the host factors that influence infection?
Age Gender Alcoholism Drug abuse Co-existing diseases Port of entry Immuno-state Nutrition Genetic make up Cell receptors
Define outbreak
An epidemic limited to localised increase in the incidence of disease e.g. village, town
Define epidemic
The occurrence in a community or region of cases of an illness, specific health related behaviour, or other health related events clearly in excess than normal expectancy
Define pandemic
An epidemic occurring over a very wide area, crossing international boundaries and usually affecting a large number of people
Define surveillance
Systemic collection, collation and analysis of data and dissemination of the results so that appropriate control measures can be taken
What happens in outbreak investigation and control?
- Establish existence of outbreak and verify diagnosis
- Identify and count cases or exposure
- Time, place, person
- Formulate hypothesis and test
- Additional studies
- Evaluate control measures through surveillance
- Communicate findings
Define health care associated infections
Are those arising as a result of health care interventions, either in patients undergoing these interventions or in healthcare workers involved in interventions
What are the factors affecting the risk of acquiring a health care associated infecton?
Underlying disease Extremes of age Breach of defence mechanisms Exposure to infection Hospital pathogens Antibiotic resistance
What is the incidence of health care associated infections?
9% of in patients
1 billion per year costs
15,000 deaths a year
What are the common sites of hospital infections?
GI 22% Respiratory 20% Urinary tract 19% Surgical site 13% Skin 10% Blood stream 6%
What prevention strategies are part of the infection control programme?
- Advisory service
- Surveillance of hospital associated infections
- Detection investigation and control of outbreaks
- Policies and procedures to prevent infection
- Dissemination and implementation of national policy
- Education and training
- Monitoring clinical practice
What are some of the current policies and procedures for infection control?
- Screening of patients (MRSA)
- Barrier nursing-isolation of infected patients
- Sharp disposal
- Sterilisation and decontamination of instruments
- Procedures for use of medical devices
- Hand washing
- Hand sanitiser stations
What are the objectives of vaccinations?
Protect individuals from specific disease
Protect populations
What is the vaccination goal?
To reduce mortality and morbidity from vaccine preventable infections
What are the aims of vaccines?
Selective protection of vulnerable Eradication Elimination Prevent deaths Prevent infection Prevent transmission Prevent clinical cases
Who is included in a susceptible population (vaccination)?
- Any person who is not immune to a particular pathogen and is said to be susceptible
- A person may be susceptible because they have never encountered the infection or vaccine against it before
- A person may be susceptible because are unable to amount an immune response
- A person may be susceptible because vaccination is contraindicated for them
What is Ro?
Ro is the average number of secondary infections produced by a typical infective agent in a totally susceptible population
Ro does not fluctuate in short term, is not affected by vaccination and is a property of the infectious agent
What does Ro depend on?
Bug characteristics:
Infectivity of organism
Duration of infectiousness
Population characteristics:
Demographics
Population density
What is R?
Effective reproduction number
Average number of secondary infections produced by a typical infective agent
In a homogenously mixing population, where s is the proportion susceptible
R= Ro x s
How do mass vaccination programmes impact the disease?
Reduce the size of susceptible population Reduce number of cases Reduce risk of infection on population Reduce contract of susceptible to cases Lengthening of epidemic cycle Increase mean age of infection
What is the epidemic threshold?
R = 1
What happens if R>1?
Number of cases increases
What happens if R<1?
Number of cases decreases
What is required to eliminate a disease?
R<1
What is herd immunity?
Level of immunity in population which protects the whole population because the disease stops spreading in the community
Why is herd immunity important?
Only way to effectively eliminate an infection
Will never achieve 100% personal protection with vaccination
Less than 100% vaccine efficacy
Less than 100% vaccine uptake
How do you calculate critical vaccination coverage?
H = herd immunity threshold s* = critical proportion susceptible
H = 1-s*
How is vaccine efficacy calculated?
VE = vaccine efficacy AR = attack rate
VE% = AR (unvaccinated) - AR (vaccinated) x 100
What factors determine whether a disease is a burden?
Number of cases
Morbidity
Mortality
What effects how much a disease will be prevented?
Age-specific burden in relation to age of immunisation
Vaccine effectiveness
Likely coverage
Indirect effects of immunisation on disease transmission
What are the possible negative effects of the vaccine programme?
Risk from vaccine
Programme errors
Interference with existing strategys
What needs to be taken into account when implementing a new vaccine?
- Is the disease a public health problem?
- Are there other ways to control the disease?
- Impact of new vaccine
- Vaccine safety
- Vaccination schedule
- How much disease will be prevented?
- Side effects?
- Additional resources required
- Cost effectiveness
How do you implement a new vaccination program?
Pilots e.g. Hib in Gambia
Phased introduction e.g. pneumococcal UK
Global vaccination e.g. small pox
When do you vaccinate?
- Most likely to maximise uptake e.g. term time in school ages
- Greatest impact on disease burden e.g. seasonal diseases
- Use of multiple vaccines
When choosing the strategy for vaccination, what do you need to consider?
- Risk of exposure
- Risk of disease/complication
- Susceptibility
- Vaccine features (safety, side effects, efficacy)
- Acceptability/ timing issues
Why is international collaboration of vaccination necessary?
- Inequity in access to immunisation services
- Low political commitment and under investment in some countries
- Higher costs of service delivery
- Lack of commercial incentives for manufacturers to develop vaccines
- Some countries can’t guarantee vaccine quality
What are the elements of academic research?
Theory
Techniques
Methodology
Define epistemology
A theory of knowledge and knowledge production
e.g. where does knowledge come from and who has it
Define methodology
The practice and process of doing research including the role of the researcher
Define method
A technique or gathering date
e.g. questionnaire, interview, documentary analysis
Define positivism
A way of thinking that considers the social world and can be observed and studied using the methods of physical sciences
Researcher - value free, objective and neutral
Define interpretivism
Considers that the social world consists of multiple, subjective realities
Social interaction is studied in its natural surroundings
Researcher acknowledges their influence on the process through reflexivity
Define bad news
Any news that drastically and negatively alters the patient’s view of his or her future
What can clinicians worry about when delivering bad news?
- Uncertainty about patient expectations
- Fear of destroying patients hope
- Fear of their own inadequacy
- Not feeling prepared to manage patients emotional reactions
- Embarrassment having previously painted an optimistic picture
What are some of the distancing strategies used when breaking bad news?
Avoidance Normalisation Premature reassurance False reassurance Switching Jollying along
How should bad news be broken?
Advance preparation Build a relationship Communicate well Deal with patient reactions Encourage and validate emotion
OR
Setting up Perception Invitation Knowledge Emotions Strategy and summary
How should you deal with anger?
Recognise someones anger
Don’t dismiss it
Remain calm
What is risk transition?
As a country develops, the disease that affect the population shift from primarily communicable (infectious) to primary non-communicable
Improvements in medial care
Aging population
Public health interventions
What is primary prevention?
Aims to reduce exposure
What is secondary prevention?
Aims to identify those with pre-clinical disease to influence progression of disease
What is tertiary prevention?
Aims to modify outcomes of disease
What are the most common cancers in males?
Prostate
Lung
Bowel
What are the most common cancers in females?
Breast
Lung
Bowel
What cancers have the highest mortality?
Lung Bowel Breast Prostate Pancreas
What are the most common cancers occurring in children?
Leukaemia Brain tumour Neuroblastoma Lymphoma Retinoblastoma
What is the lifetime incidence of cancer?
1 in 3
What percentage of people die from cancer?
1 in 4
25%
How many people each year die of cancer?
270,000
What are some of the potential causes of UK poor performance in cancer treatment?
Differences in data collection Age differences Differences in stage of presentation Differences in social class Differences in access to treatment
What are the conclusions and consequences of the Eurocare-2 report?
Cancer survival in 80s and 90s was one of the worst in Europe
Expert Advisory Group formed in 1995 - Calman-Hine report
What was advised in the Calman-Hine report?
- All patients to have access to a uniformly high quality of care
- Public and professional education to recognise early symptoms of cancer
- Patients, families and carers should be given clear information about treatment options and outcomes
- The development of cancer services should be patient centred
- Primary care should be central to cancer care
- The psychosocial needs of cancer sufferers and carers to be recognised
- Cancer registration and monitoring of outcomes essential
What are the Calman-Hine solutions?
3 levels of care
- Primary care
- Cancer units serving DGHs (250,000)
- Cancer centres serving population in excess of one million
Why do we have MDTs with cancer treatment?
- Modern management of cancer involves many disciplines
- Allied health professionals e.g. nurses, physiotherapists, speech therapists etc. play an important role
- Delivery of cancer care is often fragmented over several hospital sites
- Better outcomes for patients managed in MDTs
Who is involved in an cancer care MDT?
Physician Surgeon Oncologist Radiologist Histopathologist Specialist nurse MDT co-ordinator Physiotherapist Dietician Palliative care Chaplain
What is the function of an MDT in cancer care?
- discuss every new diagnosis of cancer within their site
- decide on management plan for every patient
- inform primary care of that plan
- designate a key worker for that patient
- develop referral, diagnosis and treatment guidelines for their tumour sites according to local and national guidelines
- Audit
What strategy was developed to tackle cancer?
NHS Cancer plan (2000)
What are the aims of the NHS cancer plan?
- To save more lives
- To ensure people with cancer get the right professional support and care as well as the best treatments
- To tackle the inequalities in health (unskilled workers twice as likely to die from cancer)
- Build for a future through investment in cancer work force, through strong research and through preparation for the genetics revolution
What are cancer networks?
Organisational model for cancer services.
Serve 1-2 million
Brings together health services
What are the activities of a cancer network?
- Development of strategic plans
- Implementation of national policies
- delivery of improvements in the care of patients with cancer
- coordinate and support network activityies in relation to the pathway of patients within a specific tumour site
- Provides resources to enable network audits and research
- Provide a channel for communication across partners within the network
What were the 6 areas for action in the cancer reform strategy?
- Prevention
- Earlier diagnosis
- Ensuring better treatment
- Living with cancer and beyond
- Reducing cancer inequalities
- Delivering care in the most appropriate setting
What are the 4 key drivers for delivery of cancer care?
- Using information to drive quality and choice
- Stronger commissioning
- Funding world class cancer care
- Planning for the future
What is the purpose of critical reflection?
- Develop skills in life-long learning
- develop self-awareness with regards to attitudes, beliefs and values
- develops skills in understanding, analysing and questioning your practice and experiences
- understand and evaluate perspective of others
- identify strengths, weaknesses and training gaps
What is ethical reasoning?
The process of critical evaluation of ethical and legal aspects
Why is ethical reasoning important?
- understand and evaluate arguments
- know when to protest or challenge other people behaviour or practice
- make the right decisions as doctors
- explain and justify decisions that you make
- make decisions that you are able to live by and justify to yourself
What is a moral argument?
Argument that seeks to support a moral claim of some kind
What are the functions of the clinical record?
- Provide a record of patient’s contact with health care providers
- Act as an aide memoire and facilitate communication with and about patients
- Primarily they exist to support patient care
- Contains information useful for clinical audit, financial planning, management and research aimed at improving patient care in the future
- Range of social purposes at the request of patients
- To inform many people
- Support method and structure to history and examination
- ensure clarity of diagnosis
- enable structure and comprehensive monitoring
- Maintain consistent explanation for the patient
- ensure continuity of care
What is the contents of clinical records?
- Presenting symptoms and reasons for seeking health care
- Relevant clinical findings and diagnosis
- Options for care and treatment discussed with patient
- Risk and benefits of care
- Decisions about care and treatment including evidence of patients agreement
- Action taken and outcomes
What are the differences in the clinical record in primary and secondary care?
Primary - patient oriented, paper light, low tech content, correspondance rich
Secondary - imaging heavy, paper oriented, disease oriented
What is the law and policy on maintaining clinical records?
GMC - Clear, accurate, legible and contemporaneous patient records
What are the principles of the Data Protection Act 1998? (8)
- Personal data shall be processed fairly and lawfully
- Personal data shall be obtained only for one or more specified lawful purposes
- Personal data should be adequate, relevant and not excessive in relation to the purpose for which they are processed
- Personal data shall be accurate and kept up to date
- Data should not be kept for longer than necessary
- Processed in accordance with rights under the act
- Measures shall be taken against unauthorised processing and against destruction or damage
- It should not be transferred
What are the objective of NHS connecting for health?
- to improve patient choice and the quality and convenience of care
- ensure that clinicians have the right information at the right time to deliver care
- to deliver 21st century IT support for a modern, efficient NHS
Why is the body a problem?
- Bodies are sacred
- They cannot be treated the same as other objects
- They are the seat of the soul or the self
What is a body dysmorphic disorder?
A mismatch between inside and outside
Subjective and objective body image
What are the positive ways in which medicine changes bodies/
Plastic surgery for scarring
Re-constructive surgery
Drug treatments for skin conditions
What are the negative ways in which medicine changes bodies?
Drug side affects e.g. Thalidamide
Cosmetic surgery problems
Reproduction techniques
What are the types of body transtitions?
Ageing Accident/injury scars Hair loss Cancer Diabetes Lupus Menopause Pregnancy Skin disorder Stroke
What are the disadvantages of screening?
May face difficulty with - employment - insurance Ethical issues - passing on disorder to chidren
What are the advantages of diagnosis?
- Immediately life saving
- MDT support
- Bridge to transplantation
- Relieves loneliness and isolation
- Opportunity for further social involvement
What are the impacts of dialysis?
- Often have multiple medical problems
- Frequent hospital admissions
- Depression and psychological illness common
- Heavy burden on time (travel and clinics)
- Limitation of travel because of treatment
- Restrictions on fluid intake and diet
- Employment difficulties
- Cost to health provider
What is screening?
The systematic application of a test or inquiry to identify individuals at sufficient risk OR risk of a specific disorder to warrant further investigation or direct preventative action amongst people who have not sought medical attention
What level of prevention is screening?
Most is secondarY
Why should we screen?
- Opportunities for primary prevention are limited
- Opportunities for treatment are limited
- Screening gives potential for early and more effective treatment
When screening what is required from the condition?
- Important health problem
- Natural history of the condition should be understood e.g. should be a detectable risk factor and latent period
- Cost effective primary prevention should have been impletmented
When screening, what is required from the test?
- Simple, safe, precise, validated test
- Distribution of test values should be known
- Suitable cut off point agreed
- Test should be acceptable
- Agreed policy on further management
When screening, what is required from the treatment?
- effective treatment
- evidence that earlier treatment gives better outcomes
- clinical management of condition should be optimised prior to screening programme
When screening, what is required from the programme?
- RCT evidence that the programme is effective in reducing mortality or morbidity
- evidence that the whole programme is acceptable to professionals and public
- Benefit should outweigh harm
- Opportunity cost of programme should be economically balanced in relation to health care spending
- Plan for quality assurance
What is length bias?
Screening over-represents less aggressive disease
overestimation of survival benefit due to the detection of slowly growing lesions by screening tests, perhaps including lesions that will never cause mortality.
What is the consequence of length bias?
- Disease with a longer sojourn are easier to catch in the screening net
- Individuals with disease detected by screening automatically have a better prognosis than those who present with symptoms
- If you only compare individuals that chose to be screened against those who didn’t - distorted view
What is lead time?
Length of time between detection of a disease and its usual presentation and diagnosis
What is lead time bias?
bias that occurs when two tests for a disease are compared, and one test diagnoses the disease earlier, but there is no effect on the outcome of the disease
May appear to prolong survival but only diagnosed earlier
What is the consequence of lead time bias?
Survival is inevitably longer following diagnosis through screening because of the extra lead time
Appropriate measure of effectiveness is lost
What is good about “good” screening?
Early detection of disease means the risk of death or illness can be reduced in some people
What is bad about “good” screening?
Some people get tests, diagnosis and treatment with no benefit
Some people get ill or die despite a negative screening test
What are the relevant considerations for reproductive ethics?
- Interests of parents, procreative autonomy
- Interests of future child, welfare based
- Interests of third parties, including the state
What is assisted reproductive technology?
Any treatment or procedures involving in vitro handling of human oocytes and sperm or embryos for the purpose of achieving pregnancy
What are the ethical objections to the use of IVF?
- Involves destruction of embryos - some think that they have a moral status
- Harmful for those trying to conceive - risk of mortality and morbidity and loss success rate
- Unnatural - poor argument
What are the chance of success of IVF?
32% under 35 27% = 35-37 21% = 38-39 13% = 40-42 5% = 43-44 2% = 45+
What is the right to an open future?
Children will have a maximally open future.
Sometimes used to justify not allowing a selection of embryos that will grow into persons with serious disablities
What is the Human Fertilisation and Embryology Act 1990?
A woman will not be provided with fertility treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment
- Supportive parenting (2008)
Why is the welfare criterion in ART criticised?
- Might be unfair as unfertile couples do not have to meet this criterion
- Predicting the welfare of children is very difficult
- Research suggests that a father is not always required for a child to flourish
What IVF is available for those aged 23-39 on the NHS?
Up to 3 cycles on the NHS
What is PGD?
Screening of cells from implantation preimplantation embyros for detection of genetic or chromosomal disorders before embryo transfer
What are the uses of PGD?
Avoid genetic disease
Sex selection
Saviour siblings
What are the criteria to qualify for an abortion?
- less than 24 weeks
- Involve greater risk to continue the pregnancy - 3. Injury to physical or mental health of pregnant woman, existing children or family
- Termination prevents grave permanent injury to physical or mental health of woman
- Continuance would risk the life of the pregnant woman
- substantial risk that the child would suffer from physical or mental abnormalities
What is the pro-life argument?
Against abortion
- Abortion ends the life of a foetus
- Human foetus has moral status of a person
- Wrong to end a persons life
- Abortion morally wrong
What are the views of the moral status of a foetus?
- Identify as a human organism
- The potential to be a person
- Identity as a person
- Conferred moral status
What are the methods used to study drug safety?
Animal experiments Clinical trials Epidemiological methods - Spontaneous reporting - Post marketing surveillance - Cohort studies - Case control studies Meta-analysis
What is an adverse event?
An unintended event resulting from clinical care causing patient harm
What is a near miss event?
A situation in which events or omissions, arising during clinical care fail to develop further, whether or not as the result of compensating action, thus preventing injury to a patient
What is the iceberg model of errors?
- Misadventure - death/sever harm
- No harm event - potential for harm is present
- Near miss - unwanted consequences were prevented because of recovery
Only see actual harm, can miss the true scale of errors
Name some examples of adverse events in healthcare?
Wrong site surgery Medication errors Pressure ulcers Wrong diagnosis Failure to treat Patient fa Hospital acquired infection Medicine adverse effects
How many adverse events are heir in the NHS hospital sector per year?
850,000
What are the causes of serious obstetrics adverse events?
- Mismanagement of forceps-assisted delivery
- Inadequate supervision by senior staff
- Senior staff not recognising gravity of a problem
- Poor record keeping
- Onset of labour not correctly diagnosed
- Mothers not moved into delivery suite in time
- Inadequate foetal heart monitoring
- Signs for foetal distress missed or ignored
What was outlined in the Berwick report?
- The quality of patient care should be above all else
- Patient safety problems exist throughout
- Improvement requires system of support
- Patient and carers need to be engaged and empowered at all times
- Usually systems, procedures, conditions, environment and constraints and NOT STAFF that lead to safety incidents
What are the solutions of the Berwick report?
- Wide systemic change
- Abandon blame as a tool
- Work with patients and carers to achieve health care goals
- Use quantitative targets with caution
- Ensure responsibility for functions related to safety
What is the Keogh Review?
- Assessing patient safety needs hard data and soft intelligence
- Safety processes are often in place but not understood, therefore not implemented
- Findings of patient safety investigations need to be widely shared
- The at risk population needs to be easily identified and flagged
What are HSMR?
Hospital standardised mortality ratios
Why can comparing Hospital standardised mortality ratios be misleading?
- Random variation
- Definitions and coding
- Case mix (over adjustment and under adjustment of risk)
- Variations in planned place of death
- Relationship with quality of care
What percentage of deaths is preventable?
5.2%
12,000 deaths per year
What are the causes of adverse events?
- Active failure (focuses on errors of individual at frontline)
- System failure (concentrates on conditions under which an individual works)
- Equipment failure (when equipment is maintained and used appropriately)
What is the Swiss Cheese Model?
- Every step in a process has the potential for failure
- An error may allow a problem to pass through one layer
- The other layers act as a defence
- Each layer is a defence against potential error impacting outcome
What is an active failure?
Unsafe acts committed by people in direct contact with patient
- Usually short lived
- Often unpredictable
Errors or violations
What are the 3 types of errors?
Knowledge based
Rule based
Skills based
What is a skills based error?
Attention slips and memory lapses. Involved the unintended deviation of actions from what may have been a good plan
What is a rule-based error?
Encounter relatively familiar problem but apply the wrong rule .
Misapplication of good rule or application of a bad rule
What is a knowledge based error?
Forming wrong plans as the result of inadequate knowledge or experience
What are violations?
Deliberate deviations from a regulated code of practice or procedure. They occur because people break the rules intentionally
What are the 5 types of violations?
Routine Optimising Situational Reasoned Malicious
What is a routine violation?
A violation that has become normal behaviour within a peer group
What is an optimising violation?
The motive is to improve a work situation (e.g. in boring or repetitive job)
What is a situational violation?
Context dependent e.g. time pressure or low staffing level
What is a reasoned violation?
Deliberate deviation from protocol thought to be in the patient best interest at the time
What is a malicious violation?
Deliberate act intended to harm someone or the organisation
What is a latent error?
Develop over time and lay dormant until they combine with other factors or active failures to cause an adverse event
- Long lived
- Can be identified and removed before they cause an adverse event
- Training of staff
- Working environmental conditions
What is the blame culture?
Individuals cover up error for fear of retribution
Reduces focus on true causes of failure because of the emphasis on individual actions at the expense of the role of underlying systems
NHS is an example
What is the human factors approach?
Acknowledges the universal nature of human fallibility and the inevitability of error
Assumes that errors will occur
Designs things in the workplace to try to minimise the likelihood of error or its consequence
What situations are associated with an increased risk of error?
*Unfamiliarity with a task
*Inexperience
Shortage of time
Inadequate checking
Poor procedures
Poor human equipment interface
- especially with lack of supervision
What are some of the individual factors that predispose to error?
Fatigue Stress Hunger Illness Language Cultural factors Hazardous attitudes
How can human factors thinking be applied to the work environment?
- Avoidance reliance on memory
- Make things visible
- Review and simplify processes
- Standardise common processes and procedures
- Routinely uses checklists
- Decrease the reliance on vigilance
What are the 9 classifications of the contributory factors framework?
- Patient factors
- Staff factors
- Task factors
- Communication factors
- Equipment
- Work equipment
- Organisational factors
- Education and training factors
- Team factors
Why are children of particular concern ethically and legally speaking?
- Dependent/reliant on other people to take care of them or act in their best interests
- May have undeveloped decision making capacities, including respect to understanding
- May possess underdeveloped value systems
- Limited powers with respect to defending their rights
What are the rules for an under 16 year old making a decision?
- If Gillick competent the consent of patient is sufficient
- If not competent, parental responsibility is sufficient
- Those with parental responsibility have a legal obligation to act in child’s best interests
- If parents fail to consent then the courts should be involved
- In emergency , doctors should treat
What are the rules for decision making at 16-17 years old?
- Presumed consent at 16
- Consent must be obtained
- If someone under 18 refuses - treatment given if approved by parents or courts
Who has parental responsibility?
Mother Father if married Father if they have acquired responsibility Adopted parents Guardian appointed by parents Local authority name in a care order
What is Gillick competence?
The parental right yield tot he child’s right to make his own decisions when he reaches a sufficient understanding and intelligence to be capable of making up his own mind
When assessing best interests of a child what should you consider?
- Views of child
- Views of parents
- Views of others close to the child
- Cultural or religious beliefs
- Views of healthcare professionals
- Which option will least restrict the child’s future options
What is the principle of parental autonomy?
Parents have the right to make decisions regarding their children
Can be over-ridden by courts if necessary
What are some of the complex treatment issues?
- Withholding and withdrawing treatment
- Procedures undertaken for religious, cultural or social reasons
- Jehovahs Witness parents and children needing blood products
- Donation and use of organs
- Saviour siblings
- Childhood immunisation and parents who do not want children to be vaccinated
What is the harm principle?
The only purpose for which power can be rightfully exercised over any member of a civilised community against his will is to prevent harm to others
What are the criteria required to provide sexual health services to under 16?
- they can understand all aspects of advice and implications
- you can’t persuade them to tell their parents
- in relation to contraception and STIs, the person is likely to have sex without treatment
- physical or mental health is likely to sugger unless they receive treatment
- best interests for them to receive treatment without parental knowledge
What are the types of medical errors?
- Medication - wrong drug, wrong dose
- Surgery - wrong procedure
- Infection control
Why is consumer protection necessary?
- Medicine has weak evidence base
- Large variation in clinical practice: doctors do give different treatments to patients with similar needs and personal characteristics
- Failure to measure success
What data is available to improve patient safety?
- Hospital episode statistics (HES) - detais referring GP, procedures given, duration of stay, discharge/death
- Patient reported outcome measurement (PROMs) - before procedure and after, quality of life measurement
- Reference cost data
- Summary hospital level mortality indicator (SHMI)
What is SHMI?
Summary hospital level mortality indicator
Actual mortality rates within 30 days of discharge compared to expected mortality given hospital characteristics
Numbers are small and data may be corrupted
What are the key agencies involved in consumer protection agencies?
- Care Quality Commissions (CQC)
- Monitor
- National Patient Safety Agency
- National Institute for Health and Clinical Excellence (NICE)
What is the care quality commission?
- Regulates quality and financial performance of all health social care providers, public and private
- Licensing all providers of health and social care
- Policing - unannounced visits and use of routine data (HES)
What is Monitor?
- Regulator of foundation trusts since 2004
- Collaborates with CQC and National Audit Office
- Responsible for competition policy and setting hospital tariffs
How are families changing?
Increase in smaller, singe and step parenting families
- Decreased birth rate
- Later marriage
- later child bearing
- Working mothers
What are some of the religious and cultural beliefs regarding pregnancy and child birth?
- Pollution (unwashed baby, blood, placenta, cord)
- Cleansing practices
- Internal examinations and male practitioners
- Circumcision
- The month
- Naming the baby
What has changed in terms of childbirth practices?
- Public to private
- Natural to medical
- Home to hospital
- Midwife to Doctors and nurses
What do people want from hospital (childbirth)?
- Pain relief
- Doctors attendance
- Safety
- Cleanliness
- Higher status
- Being cared for after birth
What are the social movements in maternity care?
Increased choice for women Greater control over own labour Home like environment Mother not separated from newborn Women having more say
BUT still medical control
What are the major causes of death in children under 5?
- Pneumonia
- Diarrhoea
- Malaria
- Neonatal pneumonia/sepsis
- Preterm delivery
- Birth asphyxia
What are the risk factors for childhood pneumonia?
Low birth weight Malnutrition Non-breastfed children Overcrowded housing Indoor air pollution
How do you minimise risks to newborns?
- Quality care and nutrition during pregnancy
- Safe delivery by a skilled birth attendant
- Maternal immunisation
- Quality neonatal care
What was the first child survival revolution?
- Led by UNICEF in 80s
Concentrated on
- Growth monitoring
- Oral rehydration therapy
- Breast feeding
- Immunisation
What was the second child survival revolution?
Millennium development goals - 8 goals
What are the 8 goals of the Millennium development goals?
- eradicate extreme poverty and hunger
- achieve universal primary education
- Promote gender equality and empower women
- Reduce child mortality
- Improve maternal health
- Combat HIV/AIDS
- Ensure environmental stability
- Global partnership for development
What are the 4 risk factor categories for childhood death?
- Service need and provision
- Wider family and environmental factors
- Factors intrinsic to the child
- Factors around parental care
What are the 4 Golden rules for talking with children?
- Ask only those questions which are needed
- Wherever appropriate, use open rather than closed questions
- Avoid using “why” questions
- Never ask questions just to satisfy own curiosity
Why are teenagers less likely to visit the GP?
- Confidentiality
- Communication
- Lack of empathy
- Perception of judgemental attitude of physicians
Rutihauser (2003)
What difficulties can affect the nature of communication with children?
- Major life impact
- New school/ domestic situation/ area/ parent illness/ recent bereavement
- Having a bad day
- Anxious/scared/angry
- Feeling unwell
What are the components of social and emotional development outlined by Berk (2000)?
- Emotional communication
- Understanding of self
- Ability to manage feelings
- Knowledge about other people
- Interpersonal skills
- Friendships
- Intimate relationships
- Moral reasoning and behaviour
What are the 5 stages in Erikson’s Psychosocial stages (1950)?
0-1yr = Basic trust vs mistrust (trust gained from warm nuturing care vs. neglect)
1-3 yr = Autonomy vs shame. (child encouraged to use new skills vs shaming child)
3-6yr = Initiative vs. guilt. (childs initiative supported vs. controlling parents)
6-11yr = Industry vs. inferiority. (Ability to work and co-operate with other vs. incompetence)
Teens = Identity vs. confusion (search for values and goals vs confusion over identity)
What are the Piaget’s stages of cognitive development?
Stage 1 (0-1m) = reflex activity
Stage 2 (1-4m) = self-investigation
Stage 3 (4-8m) = co-ordination and reaching out
Stage 4 (8-12m) = goal directed behaviour
Stage 5 (12-18m) = experimentation
Stage 6 = (18-24m) problem solving and mental combinations
Pre-operational period (2-7y) = symbolic functions emerge + reasoning
Period of concrete operations (7-11y) - logical opeations applied to concrete problems
What are the 8 different intelligences outined by Gardner’s (1973)?
- Linguistic
- Musical
- Logico-mathematical
- Spatial
- Bodily-kinesthetic
- Interpersonal
- Intrapersonal (self awareness)
- Naturalist
What are the indicators of social well being?
- Social competence (social skills)
- Rewarding personal and social relationships with others
- Communication skills
- Appropriate social behaviour
What are the indicators of social dysfunction?
- Victimised, ostracised, stigmatied by others
- poor relationships with others
- Social withdrawal
- Inappropriate social behaviour
What are the indicators of emotional wellbeing?
- Stable and secure attachments to significant others (parents)
- Emotions appropriate to context
- Positive self-esteem
- Generally happy and optimistic outlook on life
What are the indicators of emotional dysfunction?
- Unstable and insecure attachments to parents
- Emotions inappropriate to context
- Poor self esteem
- Anxiety and depression
What are the indicators of cognitive functioning?
- Functioning at age appropriate level
- Appropriate progess in cognitive development
- Child has positive and realistic perception of cognitive abilities
- Given opportunities to reach individual potential
What are the indicators of cognitive dysfunction?
- Underachievement or limited cognitive ability
- Lack of expected progress in cognitive development
- Child has negative perception of cognitive abilities
- May require special education to reach potential
What do the GMC guidelines state on personal beliefs and professionalism?
- Must not express personal beliefs to patients in ways that exploit their vulnerability or likely to cause them distress
- Must not refuse or delay treatment because you believe that a patient’s actions or lifestyle contributed to their condition
- Must not unfairly discriminate against patients or colleagues by allowing your beliefs to affect your professional relationships or the treatment
What is conscientious objection?
To object to something because it conflicts with one’s moral or religious beliefs
Where does the GMC lie on conscientious objection?
You may choose to opt out of providing a particular procedure because of personal beliefs and values as long as it doesn’t result in direct or indirect discrimination against a group of patients.
You must do you best to make sure patients are aware of your objection in advance
You should be open with employers, partners or colleagues
What should you do if you conscientiously object to something?
- Tell patient that you do not provide the procedure
- Tell patient they have the right to discuss condition and options for treatment with another doctor.
- Make sure patient has enough information to arrange to see another doctor
Define research
A structured activity which is intended to provide new knowledge which is generalisable and intended for wider dissemination
What is the Nuremberg Code (1947)?
Resulted from the subsequent Nuremberg Trials at the end of the second world war.
Comprises a set of research ethics principles for human experimentation
- Voluntary consent of human subject essential
- Avoid all unnecessary physical and mental suffering and injury
- Conducted only be scientifically qualified persons
What is the Helsinki Declaration (1964)?
Research ethics principles
Requirement that any form of human research is subject to independent ethical review and oversight by a properly covened committee
What are the general research ethic principles?
- Project useful
- increase in knowledge
- Benefits outweigh risks
- Risks as low as possible
- Informed and voluntary consent
- Competent participants
- Maximal confidential
- Findings reported and recorded
When is research ethics approval required?
- Research with human participants, human tissue or personal data
If in doubt = get advice
Why is approval from the research ethics committee needed?
- Ensures research accords with strict ethical principals (protecting participants from harm)
- Protects researchers
- Minimises potential for claims of negligence
- Protects integrity and reputation
- Condition for grant funding
- Legal requirement in some cases
When is NHS ethics review required?
Research that involves:
- patients and users of NHS
- Relatives or carers of patients of the NHS
- access to data, organs or other bodily material of NHS patients
- Foetal material and IVF in NHS patients
- recently dead in NHS premises
- Use or access to NHS premises
What do research ethics committee consider in an application?
- Scientific and ethical importance of the study
- The likelihood that the study will achieve its aims
- Risks involved
- Use of vulnerable groups
- Methods of recruitments
- Consent procedure
- Patient information sheet
- Confidentiality and protection of data
- Feedback to participants
- Destruction of samples of data
Define consent for research
Consent is asking someone’s permission to involve them in the research project and letting them decide for themselves.
Must be informed and voluntary
What should be on the information sheet for participants of a study?
- Purpose of study
- Why they have been chosen?
- Do you have to take part?
- What will happen
- What will I have to do
- What procedure is being tested
- What are the alternatives for diagnosis or treatment
- What are the side effects of any treatment?
- Risks of taking part
- possible benefits
- what if something goes wrong
- What will happen to results
- Who is organising and funding
- who to contact for more information
What contributes valid consent for a trial?
- not putting direct pressure on patients or volunteers to participate
- not offering inducements
- not threatening sanctions if they leave the study
What the medical research council (MRC) guidelines on confidentiality?
- All information is confidential
- All research is to be approved by REC
- All personal information must be coded and anonymised as far as possible
What is the best study to use for diagnosis?
Cross sectional analytic study
What is the best study for establishing aetiology?
Cohort study
Population based case-control study
What is the best study for establishing prognosis?
Cohort study
What is the best study for establishing treatment?
Randomised control trial
Systematic review
What does appraisal assess a study for?
- Bias
- Applicability
- Value
What are the 3 steps for critical appraisal?
- are the results valid
- What are the results?
- Can I apply the results to this patient’s care
When looking at the result of a therapy/ RCT, what should you look at?
Relative risk reduction
Absolute risk reduction
Confidence intervals
Number needed to treat
When looking at the results of a study looking at diagnosis what should you look at?
Sensitivity Specificity Positive predictive value Negative predictive value Likelihood ratio
When looking at the results of a study looking at aetiology what should you look at?
Relative risk
Odds ratio
Number needed to harm
What questions need to be asked as part of a critical appraisal? (of a review)
- Did the review ask a clearly focused question?
- Did the review include the right type of study?
- Did the reviewer try to identify all relevant studies?
- Did the reviewers assess the quality of the included studies?
- If the results of the studies have been combined, was it reasonable to do so?
- How are the results presented and what is the main result?
- How precise are these results?
- Can the results be applied to the local population?
- Were all important outcomes considered?
- Should policy or practice change as a result of the evidence contained in this review?
Critical appraisal
Did the review ask a clearly focused question?
What should be considered?
- population studied
- intervention given or exposure
- outcomes considered
Critical appraisal
Did the review include the right type of study?
What should be considered?
- address the reviews question
- have an appropriate study design?
Critical appraisal
Did the reviewers try to identify all relevant studies?
What should be considered?
- which bibliographic databases were used?
- was there follow-up reference lists?
- if there was personal contact with experts?
- if the reviewers searched for unpublished studies
- if the reviewer searched for non-English language studies
Critical appraisal
Did the reviewers access the quality of the included studies?
What should be considered?
- Clear pre-determined strategy was used to determine which studies were included.
Look for
- a scoring system
- more than one assessor
Critical appraisal
Was it reasonable to combine results?
What should be considered?
- Are the results of each study clearly displayed
- the results were similar from study to study
- tests for heretogenity
- the reasons for any variations are discussed
Results should not be combined if the results are dissimilar.
Should be if similar - provides stronger evidence
Critical appraisal
How are the results presented and what is the main result?
What should be considered?
- how are results expressed e.g. odds ratio, relative risk
- how large this size of result is and how meaningful it is
- how you would sum up the bottom-line result of the review in a sentence
Critical appraisal
How precise are these results?
What should be considered?
- if a confidence interval was reported, would your decision about the intervention be the same at the upper and lower limit?
- if a p value is reported
Critical appraisal
Can the results be applied to the local population?
What should be considered?
- population sample covered in the view (is it different to your population in ways that would alter the results)
- your local setting differs from that of the review
- you can provide the same intervention in your setting
Critical appraisal
Were all important outcomes considered?
What should be considered?
- individual
- policy makers
- professionals
- family/carers
- wider community
What are the psychological components of pain?
- Behavioural (fear avoidance)
- Cognitive (somatisation/catastrophising)
- Affective (anxiety/depression)
What are the positive and negative meanings of pain for the sufferer? SOCIAL
Positive
- Sympathy, support, attention
Negative
- Loss of income, altered role within family unit
What are the biopsychosocial aspects of pain?
Bio - physiological dysfunction and neurophysiological changes
Pyscho - illness behaviour, beliefs, coping strategies, emotions, distress
Social - culture, social interactions, sick role
What is the relationship between taking time off work and returning to work?
The longer a person is off work, the less likely they are to return
6m = 50%
1 year = 25%
2 year = 0
What assessment tools can be used to assess pain?
Visual analogue score Verbal rating score Brief pain inventory HAD score McGill pain score LANSS score
What are the treatments for pain (psychosocial approach)?
Eduction
- Healthcare professional or focus group
- Coping strategies
- Cognitive behavioural therapy
- Mindfulness
- Pain management programme
- CBT
What is mindfulness?
Meditation technique aimed at focusing the mind on the present moment
Relaxed and non judgemental awareness of thoughts, feelings and sensations
Why do we have waiting lists?
- Limitless demand for health
- Limited resources for health care
- Supply is finite
- Creates scarcity
What are the ways to ration healthcare?
By ability to pay (US)
By need
What are the different waits within the NHS?
GP appointment specialist appoinment agreed elective procedure waiting room A and E Emergency admission Ambulance
How can wait be measured in NHS?
- Average or median waiting time
- Proportion waiting longer than x days
- Average or median wait of people currently on waiting list
- Proportion of people currently on waiting list waiting longer than x days
- Size of waiting list
- Time to clear list
What are the different theories of NHS waiting lists?
- Backlog (occasional emergency injection of funds)
- Demand management (wait acts as price, deter frivolous use)
- NHS resources fully employed
- Irrelevant
- Inevitable
- Caused by underfunding
- Caused by inefficiency
- Selfishness
What causes a reduction of waiting time?
More doctors
More specialists
More expenditure
Activity based remuneration for doctors and/or hospitals
Describe the history of maximum inpatient waiting times under the labour government?
Started at 15 months down to 3 months
Describe the history of maximum outpatient waiting times under the labour government?
26 weeks to 14 weeks
Describe the history of maximum waiting times for cancer treatment under the labour government?
2 months to 1 month
What policies were introduced in 2000-2008 regarding hospital waiting times?
4 hour maximum A and E wait
1 month for cancer treatment
Inpatient and outpatient maximum waiting times
Hospitals given an overall performance score based on these
What are some of the down sides to monitoring the success of the NHS via perfomance indicators?
- Unmeasured performance suffers
- Adverse behaviour response (patients waiting in ambulance instead of emergency room)
- Data manipulation and fraud
- Sacrifice of professional autonomy
What happened in 2010 after the change in government (NHS)
Waiting time targets relaxed or abandoned
Targets and terror to competition and choice
Maintained reductions without targets
What national policies are in place to reduce waiting times?
- Payment by results (fixed price for every patient episode)
- Patient choice (patients offered a choice of providers to introduce competition)
- Clincal commissioning groups (incentives for GPs to avoid admissions)
What are some of the policies to increase supply of surgery?
- Additional funding (waiting time fund for backlog)
- Increasing productivity (day case, better use of theatres, incentives for consultants (weekend pay))
- Booking patients (single lists)
- Use of new providers (private)
- Diagnosis and treatment centres
- Increasing patient choice (increasing competition)
- Incentives to reduce waiting times (bonuses)
What are some policies to reduce demand for surgery?
Incentives for GPs
Clinical guidelines
Encourage use of private sector
Encourage private health insurance
What are some possible criteria for managing waiting lists?
- Clinical urgency
- Clinical severity
- Potential health gain
- Productivity and economic loss
- Equity weighting (poverty)
- Spare capacity
- Length of time waiting
What are the current challenges in managing waiting lists?
18 week referral to hospital treatment
Changing priorities for NHS policy
Nicholson challenge
Saving 15-20 billion
Changes in referral and treatment threshold
Why should you support patients decision making?
- Patients are happier
- It enables them to exercise self-determination and respect autonomy
- Likely to facilitate other positive goods, including trust and strong doctor-patient relationships
- Professional and legal requirement
What are the 5 key principles of the mental capacity act 2005?
- Assumed to have capacity unless established otherwise
- Should not be treated as unable to make decisions unless all steps to help have been taken
- Not to be treated as unable to make a decision just because they make an unwise decision
- Any decision made under the act must be made in his best interests
- Act needs to be done in the way which is least restrictive of the person’s rights and freedom
What methods can be used to support patients in their decision-making?
- Using a different form of communication
- Providing information in a more accessible form
- treating the medical condition which may be affecting capacity
- having a structured programme to improve a person’s capacity
What is the main purpose of mental capacity determination?
To distinguish between patients who should and should not retain decisional authority regarding aspects of their treatment or care
What are the criteria for capacity?
- to understand information relevant to the decision
- to retain information
- to use or weigh that info as part of the process of making the decision
- to communicate their decision
What is advanced care planning?
It is the process of discussing and planning ahead in anticipation of deterioration in a patient’s condition
- Advances statement of wishes
- Advanced decisions to refuse treatments (advanced directives)
What is the purpose of advanced directives?
Extend considerations of patient autonomy to situations in which the patient no longer has mental capacity
Can only refuse treatment, not demand it
What are the criteria for advanced decisions?
- Over 18
- Patient lacks capacity at the time when treatment is to be given
- Patient competent when making the advaned directive
- Properly informed
- Statement clearly applicable to situation
- Has not withdrawn
- The person has not appointed an attorney to make the decisions
- Person has not done anything in consistent with the directive
What are the criteria for refusing life-saving treatment?
- must be in writing
- must be signed by the maker
- signature must be witnessed and signed by witness
- document must be verified by a statement that AD is to apply to a specified treatment “even if life at risk”
- Statement must be signed by maker and a witness
What are the pros of advance directives?
- Respects patient’s choice/autonomy
- Encourages openness and forward planning
- Gives patients legal right to refuse treatment
- Patients will become less anxious about unwanted treatments
- Lower healthcare costs as people will want less aggressive treatment
What are the cons of advance directives?
- Difficult to verify that the patients opinion has not changed since AD
- Difficulty ascertaining circumstances are what the patient foresaw
- Possibility of coercion
- Possibility of mistaken diagnosis
What is the incidence of falls?
30% over 65y
45% 80-89
55% 90+
3x higher in institutions
What are the consequence of falls?
- 10% result in serious injury
- 1-2% is a hip fracture
- Multiple minor injuries (contusions, lacerations)
- Long lie (hypothermia, pressure sores, pneumonia)
- Psychological problems
- Increase dependency and disability
- Impact on carers
- Institutionalisation
What are the psychological problems of falls?
- Fear of falling
- Self imposed activity restriction
- Social isolation
- Depression
What is a QALY?
To measure the burden of disease across different diseases = QALY is a measurement
1 QALY = 1 year in perfect health
What methods are available to prevent hip fractures?
- Fall prevention
- Bone protection
- Bisphosphonates
- Vitamin D/ calcium
- HRT
NOT hip protectors
What are the risk factors for hip fracture?
- Age
- Female
- Low BMI
- Family history
- Prior history of wrist fracture
- Smoking
- Ethnicity
- Steroid use
- Muscle weakness
- History of falls
- Gait deficit
- Balance of deficit
- Visual deficit
- Arthritis
- Impaired ADL
- Depression
- Cognitive impairment
- Age 80+
What medical conditions increase risk of fall?
Parkinsons's Stroke Hypotension Depression Epilepsy Dementia Eye disease Incontinence Osteoarthritis RA Peripheral neuropathy
What is the National Service Framework for Older people?
NSF 2001 -
Aim to reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen
What are the big 5 complementary therapies?
Acupuncture Chiropractic Herbal medicine Homeopathy Osteopathy
What are the barriers to more complementary therapy on the NHS?
- Regulatory issues
- Financial concerns within NHS
- Tribalism
- Inertia (resistance to change)
- Mixed evidence of effectiveness
What is an effectiveness gap>
A clinical area where available treatments are not fully effective or satisfactory for any reason including lack of efficacy, adverse effects, acceptability to patients, compliance or economic or any other reason
What do chiropractors mainly treat?
Back, neck and shoulder problems
Joint, posture and muscle problems
Leg pain and sciatica
Sports injuries
What do osteopaths mainly treat?
- Back pain
- Repetitive strain injury
- Changes to posture in pregnancy
- Postural problems causing by driving or work strain
- the pain of arthritis and sports injuries
What are the ways in which confounding can be addressed in design and analysis?
- Restriction
- Matching
- Stratification
- Multiple varibale regression
What is restriction to prevent confounding?
Restriction is a method that limits participation in the study to individuals who are similar in relation to the confounder. For example, a study restricted to non-smokers only will eliminate any confounding effect of smoking.
What is matching to reduce confounding?
Used in case-control studies
Create a comparison group matched on the possible confounder
USed for age and sex
Still need to consider confounding in analysis
What is stratification to reduce confounding?
Stratification allows the association between exposure and outcome to be examined within different strata of the confounding variable. For example by age, sex or alcohol consumption.
Stratification allows for the assessment of modifying effects as well as controlling for confounding factors.
Adjusting is the final step - a weighted average of the effect seen in each stratum
What are the limits to stratification?
To take into account 4 confounders, it would require 32 strata
What is the prevention paradox?
The majority of people who suffer a [stroke] are not at high risk of [stroke]
75% have normal blood pressure
What is the prevention paradox when targeting high risk groups?
Larger potential benefit to the individual
Smaller effect on population rate of stroke
Many conditions that you treat are asymptomatic
Many of the treatments have side effects
What is the prevention paradox when targeting the population?
Large potential benefit to community
Low potential benefit to individual
Why are research-based recommendations important?
- Personal experience is biased
- Research reports findings for many more patients than can hope to see in personal experience
- Research involves application of scientific method to minimise bias
- Recommendations have been assessed for their cinical and cost effectiveness
What are the features of recommendations (from research) that will increase their adoption?
- Easy to follow
- Compatible with existing norms and values
- Knowledge, people must be aware of new recommendation
- Be from a reliable source
- No resistance from patients
- Using already available equipment
What is an educational outreach?
Use of a trained person who meets providers in their practice settings to give information with the intent of changing their behaviour
What methods can be used to spread information about a new recommendation?
- Distribution of published or printed recommendations
- Educational meetings e.g.
- Conferences
- Lectures
- Workshops
- Educational outreach
- Local opinion leaders
- Audit and feedback
- Reminders on computer or paper
What are computerised decision support systems?
System that compares patient characteristics with a knowledge base then guides a health provider by offering patient-specific and situation specific advice
What is the true cost effectiveness of a technology?
Cost effectiveness (£/unit of benefit) PLUS the costs of changing behaviour
Name some reasons why a physician would not following the handwashing criteria?
Individual professional
- Irritates hand
- Takes too much time
- Seldom see complications
- Lack of hard evidence
Team/Unit
- Nobody controlling
- Management not interested
Hospital
- Not feasible in normal work
- No guidelines in hospital
- Absence of facilities
How many people in the UK have dementia?
800,000
What are the benefits to an early diagnosis?
- If reversible/treatment best to find out early
- Opens the door for future care
- Can help people take control of lives and plan ahead
- NO RESEARCH
- Priority on early diagnosis than post-diagnostic interventions
What is the impact of diagnosis on the patient? (dementia)
- Denial (with or without insight). Attributes to old age. Often accompanied by anger
- Grief reaction
- Acceptance/ positive coping stratgies
What can determine the response to the news of diagnosis of dementia?
- Insight
- Stage of illness
- Ability to remember and process information
- Type of dementia
- Previous personality
- Relationship and support
What is the impact of diagnosis on carers? (dementia)
- Confirmation of something they have long suspected
- Fear
- Anger
- Grief
What can determine the response to the news of the diagnosis of dementia?
- Understanding of illness
- Patients reaction
- Nature of relationship with patient
What are the benefits to getting a diagnosis?
- Know what it is that you are dealing with
- Access to treatments
- Access to support services
- Information/education
- Planning for the future e.g. financial affairs
- Assess and manage risks e.g. driving
How can the diagnosis of dementia effect the spouse/partner?
- Relationship becomes skewed
- Practical
- Emotional
- Physical/ sexual
- Financial
- Relationships
How can the diagnosis of dementia effect the parent/child?
- Role reversal
- Competing demands
- Conflict between family members
- Effect on young children
How can the diagnosis of dementia effect the health of the carers?
- Increased stress
- Increased physical care
- Poor sleep
- Constant vigilance
- Loss of support of partner
- Unable to take time off sick
What can help carers?
- Careful management of co-morbid illness
- Support and stimulation for patient
- Support and respite care for families
- Day care
- Befriending e.g. Alzeheimers society
- Education
- Medication
What are the Behavioural and psychological symptoms of dementia
- Restlessness
- Physical aggression
- Wandering
- Sexual disinhibition
- Repeated questioning
- Screaming
- Swearing
- Anxiety
- Depressive mood
- Withdrawal
- Hallucinations
- Delusions and psychosis
What is
- end of life care?
- end of life care pathway?
- end of life care drugs?
- Can be the last year or more of life
- last 48 hours of life
- Terminal patients
Define palliative care?
Palliative care is the active holistic care of patients with advanced, progressive illness
What is the goal of palliative care?
Achievement of the best quality of life for patients and their families
What are the key principles of DNACPR?
- CPR is a medical treatment that cannot be demanded by patients or their family
- To offer futile treatments is ethically inappropriate
Who is specialist palliative care provided for?
Patients and carers with unresolved symptoms and complex psychosocial issues, with complex end of life and bereavement issues
Who is specialist palliative care provided by?
Health care professionals for whom palliative care is their core work.
Undergone relevant training increasingly provided by accredited specialist
Nurse, doctor, physio, OT, chaplain
What are the generalist palliative care services?
- Primary health care team
- Nursing home
- Secondary care
- Social services
What are the specialist palliative care services?
- Clinical nurse specialists
- Specialist physicians in palliative care
- Hospices
- Marie Curie nurses
What palliative care services are provided by the NHS?
- Community clinical nurse specialist
- Hospital clinical nurse specialist
- Some consultants
- Some in patient units
- Macmillian
What palliative care services are provided by the voluntary sector?
- Hosptice services
- Most in patient beds
- Marie curie/sue ryder
- Marie curie nurses
- Macmillan
What different nurses are involved in palliative care?
- District
- Practice
- Marie curie
- Macmillan
What is spirituality?
Umbrella term
- Religious or faith framework
Includes
- Meaning to life
- Purpose
- Hope
- Sense of person hood
What questions can be used to encourage a patient to discuss spiratual things?
- Where do you turn when life gets tough?
- How have you coped with difficult things in the past?
- Do you have faith or a belief?
- Does death worry you?
What are the psychosocial risk factors for cardiac and respiratory conditions?
- Anxiety
- Depression
- Anger/hostility
- Socioeconomic status
- Work/ marital stress
- Caregiver strain
- Lack of social support
How does chronic stress causes cardiovascualr problems?
- Increase in HPA
- Increase in sympathetics
- Increase altered behaviours
- ANS dysfunction
- Insulin resistance
- Central obesity
- Hypertension
- Inflammation
- Platelet activation
- Decrease bone density
What is ICIDH?
International classification of impairments, disabilities and handicaps
Takes into account all dimensions of disease
- Disease
- Impairment (functional loss)
- Disability (activity limitations)
- Handicap (social disadvantage)
What is the Kubler-Ross Grief model 1969?
Denial Anger Bargaining Depression Acceptance
What is the dual process model of grief?
Stroebe and Schut
2 components - loss oriented and restoration orientated
Switch between
Loss
- Grief work
- Breaking bonds, ties, relocation
- Denial/avoidance
Restoration
- attending to life changes
- doing new things
- new roles/identities
What is Da Costa’s syndrome?
Cardiophobia
Dyspnoea Fatigue Rapid pulse Palpitations Chest pain
Pyschological (anxiety/panic disorder) associated with exhaustion and emotional situation)
Not due to they physical disease of the heart
What are the psychological sequale that follows disease?
- Emotional/ affective
- Cognitive/ thoughts
- Behavioural/ lifestyle
What modifies how people deal with serious disease?
- Personality (Type A/ mental toughness)
- Existing psychopathology (anxiety/ depression)
- Personal control
- Self esteem/self confidence
- Current stress
What are the issues are dealt with in rehabilitation?
- Clinical symptoms
- On going education
- Misconceptions
- Informal psychological assessment
- Anxiety management/ counselling/ CBT
- Facilitate lifestyle changed
- Promote return to normal activity
What is the health belief model?
psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals
It suggests that people will take a health related action if:
- If a person thinks that a negative condition can be avoided
- Taking that action will avoid the negative condition
- Feel confident and successful carrying out action
What is the transtheoretical model of behaviour change?
- Pre-contemplative (no intention)
- Contemplative (thinking, open to suggestions)
- Preparations (change imminent)
- Action (made changes)
- Maintenance (change established)
What are the factors that influence rehabilitation?
Age Gender Social deprivation Co-existing physical illness and severity Health and illness beliefs Intelligence/education Past family history Other people Culture Media
How can rehabilitation be facilitated?
Education
- Cognitive approaches e.g. goal-setting, cognitive techniques
- Social support
- Reinforcement (feeback, self monitoring, patient autonomy)
- Client - practioner relationship (communication)
What is the link between CHD mortality and social position?
- Lower social postion
= increased risk
What are the risk factors for cardiovascualr disease?
Age gender FH smoking hypertension cholestrol diabetes physical inactivity obesity diet socio-economic status psychosocial alcohol ethnicity
What is the prevention paradox?
A preventative measure that brings benefits to the community offers little to each participating individual
What are the positives of the high risk treatment strategy?
- Appropriate to the individual
- Motivated subject
- Motivated clinician
- Cost effective resourceuse
- Benefit: risk (high)
What are the negatives to the high risk treatment strategy?
- Screening difficult
- Palliative and temporary
- Limited potential
- Behaviourly inappropriate
- Labelling
What are the positives to the population strategy?
- Large potential
- Behaviourally appropriate
What are the negatives to the population treatment strategy?
- Population paradox (small individual benefit)
- Poor motivation
- Benefit: risk (low)
How are thresholds for treating risk factors determined?
Driven by weighing the balance between costs and benefits:
- costs to individuals (another tablet?)
- cost to population
- absolute benefits
What is decision analysis?
Systematic, explicit, quantitative way of making decisions in health care that can lead to enhanced communication about clinical controversies and better decisions
It assumes:
- decision process is logical and rational
- a rational decision maker will choose the option to maximise utility
What are the stages of decision analysis?
- Structure the problem as a decision tree, identifying choices, information and preferences
- Assess the probability of every choice branch
- Assess the utility of every outcome state
- Identify option that maximuses expected utility
- Conduct a sensitivity analysis to explore effect of varying judgements
- Toss up if 2 options have same EU
On a decision tree what does a square node represent?
- Decision node
- Represents choice between actions
e.g. What do I do?
On a decision tree what does a circle node represent?
- Chance node
- Represents uncertainty
- Potential outcomes of each decision
e.g. noting, give treatment, find out more information
What are utility measures?
- measure of desirability of all possible outcomes in the decision tree
- Provide a numerical value attached to beliefs and feelings
What is EQ-5D?
standardised instrument for use as a measure of health outcome
- Mobility
- Looking after myself
- Doing usual activities
- Having pain or discomfort
- Feeling worried, sad or unhappy
Give examples of utility measures
- QALY (quality adjusted life years)
- Rating scales
- Standard gamble
- Time trade off
What is a QALY?
1 year in perfect health
Considers quantity and qaulity of life
How is expected utility calculated?
- Values are placed in decision tree
- Expected value for each brach calculated by multiplying utility with probability
- Expected values for each branch are added to give expected utility for each decision option
What are the benefits to decision analysis?
- Makes all assumptions in a decision explicit
- Allows examination of the process of making a decision
- Integrates evidence into the decision making process
- Insight gained during process may be more important
- Can be used for individual decisions, population level decisions and for cost effectiveness analysis
What are the limitations of decision analysis?
Probability estimates
- required data sets to estimate probability may not exist
- subjective probability estimates are subject to bias
Utility measures
- Individuals may be asked to rate a state of health they have not experienced
- Different techniques will result in different numbers
- Subject to framing effects
- Approach is reductionist
What is the Parkes 4 stages of normal grief?
- Numbness
- Yearning
- Disorganisation
- Reorganisation
What are the features of acute grief?
- somatic or bodoily distress
- preoccupation with the image of the deceased
- guilt relating to deceased
- hostile reactions
- inability to function as one had before the loss
- development of traits of the deceased in own behaviour
What are the Wordens’ tasks of mourning?
- Accept the reality of the loss
- Work through the pain of grief
- Adjust to an environment in which the deceased is missing
- Emotionally relocate the deceased and move on with life
What is pathological grief?
- extended grief reaction (getting stuck)
- mummification and denial
- major depressive disorder >2 months after loss
What are the food safety concerns?
- food borne illness
- nutritional adequacy
- environmental contaminants
- naturally occurring contaminants
- pesticide residues
- food additives
What are the methods of prevention for food poisoning?
- Public education
- Staff training
- Food inspectors
- Bad PR
- Proper equipment well maintained
- Good raw materials
What are the principal sources of food poisoning outbreaks in UK?
Catering premises
Institutions
Catered functions
Other
What is the public health act?
Allows exclusion from work of people that pose an increased risk of spreading GI infections
- persons of doubtful personal hygiene
- children in nursery or pre school
- people whose work involved food prep
- health and social care staff
What is the food safety act?
1990
Defines food and enforcement authorities and their responsibilities
- premises must be registered
- inspections
- obligations to ensure safety
- powers of enforcement
What is Hazard Analysis Critical Control Point? HACCP
Compulsory procedure within good manufacturing practice
- analysis of potential food hazards
- identify where hazards can occur
- deciding which points are critical for food safety
- implementing effective control and monitoring
- reviewing this
What are the 4 components in an evidence based approach?
- Question formulation
- Literature search
- Appraisal of evidence
- Clinical decision
What are clinical decision support systems?
Designed to aid clinician decision making
- can be computerised
- may be paper based
- may be reminder systems
Give some examples of clinical decision support systems?
- Reminder systems (CSC Primary care)
- Screening
- Vaccination
- Testing
- Medication Use
- Identification of risky behaviour - Diagnostic systems
- Match patient signs and symptoms to database
- Model individual patient data against epidemiological data
- Can provide hypotheses or estimates of probability of different potential diagnoses - Prescribing
- Advice on drug dosage - Disease management
- Can provide info to assist monitoring of patients
Define sensitivity
Proportion of people with target disorder who have positive test
True positives / true positive+false negative
Define specificity
Proportion of people without the target disorder who have a negative test
True negative/ true negative+false positive
Why use a clinical decision support system?
Can improve practioner performance in
- diagnosis
- disease management
- prescribing/ dosing
- rates of vaccinations, screening
What may hinder the use of clinical decision support systems?
- earlier negative experience of IT
- potential harm to doctor-patient relationship
- obscured responsibilitie
- reminders increase workload
What are the aims of patient decision aids?
- understand probable outcomes of options by providing info relevant to decision
consider personal value they place on benefits vs. harms by clarifying preferences - help them feel supported in decision making
- help them move through steps in making a decision
- help them participate in deciding about health care
Define equality
Being the same in quantity, amount, value, intensity
Define equity
Fairness or impartiability; even handedness
Where is justice involved in healthcare?
- Prioritisation and rationing of services
- Allocation of sparce health resources
- Health service funding
- Research prioritisation and participation
- More specific allocatory decisions e.g. organs
What is a QALY?
Quality adjusted life year
Assign a utility value to a state of health and then multiplying that by the number of years expected to be lived in that state
What are the objections to QALY based assessments?
- Difficulties relating to measurement
- Measuring value/quality of life
- Who should make the decisions, bias
- Double jeopardy objection
- Total cost per QALY for funding care of patients with terminal illnesses likely to be highest
- QALY may favour life years over individaul lives
- Ageist - the older you are the fewer QALys you have left
What is the argument for QALYs not being ageist?
It does not aim to discriminated against elderly
Treated the same no matter what age
What is the double jeopardy objection?
A person who needs treatment for something may lose out if they have another condition that affects quality of life
What is a needs-based assessment?
Make resource allocations decisions on basis of need
What are some objections to needs-based approaches for resource allocation?
- How do you measure need
- Whose needs count
- What needs are relevant
- Meeting need is not the only thing to consider
- Not everyone will choose the difference principle
- Bottomless pit objection - very worst off will absorb almost all of our healthcare and make them SLIGHTLY better off
What criteria can be used for making resource choices?
- QALY
- Need
- Age
- Place on waiting list
- Likelihood of complying with treatment
- types of lifestyle choices that the patient has made
- ability of patients to pay
What are the arguments for lifestyle-based assessments for resource allocation?
- those who behave in ways that contribute to their ill health are less deserving than those that avoid it
- those who engage in behaviours that contribute to ill health and are aware of dangers have FORFEITED their right to receive treatment
- more likely to be deterred from behaviours if they know what the consequences are
- those who do not contribute to own ill health will have longerlasting health
What are the arguments against lifestyle-based assessments for resource allocation?
- May have lacked knowledge or voluntariness regarding their risk taking
- Unfair to punish
- Unclear whether it would work as deterrent
- Not the role of a healthcare professional to deter patients in this way
- Refusing treatment on the basis of lifestyle choice is against GMC
What is the rule of rescue?
- Provide aid to identified victims of illness or accident
- Public are more sympathetic towards a named person who is dying
- not capsured by QALYs
What is economic evaluation?
Value both inputs (opportunity costs) and outputs (health outcomes or health gains) of healthcare interventions and policies
Means of assessing whether changes in resource allocation are potentially efficient- supplement or replace the price mechanism
AID to decision making (not substitute)
Why is economic evaluation important?
- Increasing healthcare expenditure means need to evaluate medical care
- Increasing health care reforms so need to evaluate health policies
What do clinical evaluations investigate?
Efficacy
Effectiveness
What do economic evaluations investigate?
Efficacy
When making decisions about resource allocation what should be considered?
- Opportunity cost of choices
- Benefit of their choice
How do you measure cost?
A cost is the value of what you give up
- cost to NHS?
- Patient
- Carer
- Society
How do you measure benefit?
- Health gain e.g. increase in life length/ quality
- Social gains for community
- Health/social gains of family
What are the different types of economic evaluation?
Depends on the outcome measure used
- Cost minimisation analysis (CMA)
- Cost effectiveness analysis (CEA)
- Cost utility analysis (CUA)
- Cost benefit analysis (CBA)
What is cost minimisation analysis?
Relevant only if the effectiveness/outcome of the alternatives under comparison has been demonstrated to have equivalent effect/benefit for the patient
Least cost alternative is the most efficient
What is cost effectiveness analysis?
Includes cost and outcomes - natural unit
Comparison between treatments in an area where effectiveness is unequal
Only used when alternatives result in same outcome measure
What is cost utility analysis?
Combines multiple outcomes in a single measure of utility e.g. QALY
Allows comparisons between alternatives in different therapeutic categories with different natural outcomes
What is cost benefit analysis?
Links cost and outcomes by expressing both in monetary units
Forces an explicit decision about whether the intervention is worth its cost
e.g. willingness to pay is a measure
What are the 3 stages to costing in economic evaluation?
- Identification
- Measurement
- Valuation of inputs into healthcare
What costs to include
What is the function of sensitivity analysis?
Do changes in assumptions affect the study results?
Alter key parameters to determine the effect
- Determines whether the preference for a programme changes as the value of variables used are changed
How do you deal with time in health economic evaluation?
Greater weight is given to current over future costs
Future costs and benefits must be discounted to their present value
What are 2 generic measures for measuring and valuing outcomes in quality of life?
SF36 EQ 5D (NICE recommended)
What are the key features of a good economic evaluation?
- Well defined question
- Relevant alternatives or comparators
- Good clinical relevance
- Relevant range of costs and consequences identified
- Accurate measurement of costs and consequences
- Credible valuation of costs and consequences
- Adjustment for differential timing (discounting)
- Incremental analysis
- Sensitivity analysis of the results
- Clear discussion of the relevance of the results
Whhy are health economics important?
- All healthcare systems have limited resources
- Healthcare systems are inefficient
- Inefficiency reduces clinicians capacity to meet the health needs of patients
- Efficiency is not the only objective of poliy makers
How can expenditure in healthcare be controlled?
- Private insurers are poor purchasers
- Governments impose cash limits
- Private systems by price
- Public systems by need
How is the NHS budget divided amongst countries?
barnett formula
What is the principle of allocation of care according to need?
Targeting resources at those activities that give the greatest patient health gain for the £ spent
Maximise population health gain from the available budget
What is technical efficiency?
Maximise production of goods or services
What is allocative efficiency?
Production of most desired/ worthwhile goods and services at least cost
How do you incentivise changes in clinical behaviour?
Penalties vs. bonuses
Financial vs. non-financial incentives
QOF in GP land
Define body dysmporphic disorder
A mismatch between the inside and the outside or the subjective and objective body image
Describe the disability and stigma caused by incontinence
Distress Embarrassment Inconvenience Threat to self esteem Loss of personal control Desire for normalisation
