Theme C Flashcards

Question

Define outbreak

Answer 1

An epidemic limited to localised increase in the incidence of disease e.g. village, town

Answer 2

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

Answer 3

An epidemic occurring over a very wide area, crossing international boundaries and usually affecting a large number of people

Answer 4

Systemic collection, collation and analysis of data and dissemination of the results so that appropriate control measures can be taken

Answer 5

- 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

Answer 6

Are those arising as a result of health care interventions, either in patients undergoing these interventions or in healthcare workers involved in interventions

Answer 7

``` Underlying disease Extremes of age Breach of defence mechanisms Exposure to infection Hospital pathogens Antibiotic resistance ```

Answer 8

9% of in patients 1 billion per year costs 15,000 deaths a year

Answer 9

``` GI 22% Respiratory 20% Urinary tract 19% Surgical site 13% Skin 10% Blood stream 6% ```

Answer 10

- 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

Answer 11

- 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

Answer 12

Protect individuals from specific disease Protect populations

Answer 13

To reduce mortality and morbidity from vaccine preventable infections

Answer 14

``` Selective protection of vulnerable Eradication Elimination Prevent deaths Prevent infection Prevent transmission Prevent clinical cases ```

Answer 15

- 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

Answer 16

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

Answer 17

Bug characteristics: Infectivity of organism Duration of infectiousness Population characteristics: Demographics Population density

Answer 18

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

Answer 19

``` 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 ```

Answer 20

Number of cases increases

Answer 21

Number of cases decreases

Answer 22

Level of immunity in population which protects the whole population because the disease stops spreading in the community

Answer 23

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

Answer 24

``` H = herd immunity threshold s* = critical proportion susceptible ``` H = 1-s*

Answer 25

``` VE = vaccine efficacy AR = attack rate ``` VE% = AR (unvaccinated) - AR (vaccinated) x 100

Answer 26

Number of cases Morbidity Mortality

Answer 27

Age-specific burden in relation to age of immunisation Vaccine effectiveness Likely coverage Indirect effects of immunisation on disease transmission

Answer 28

Risk from vaccine Programme errors Interference with existing strategys

Answer 29

1. Is the disease a public health problem? 2. Are there other ways to control the disease? 3. Impact of new vaccine 4. Vaccine safety 5. Vaccination schedule 6. How much disease will be prevented? 7. Side effects? 8. Additional resources required 9. Cost effectiveness

Answer 30

Pilots e.g. Hib in Gambia Phased introduction e.g. pneumococcal UK Global vaccination e.g. small pox

Answer 31

1. Most likely to maximise uptake e.g. term time in school ages 2. Greatest impact on disease burden e.g. seasonal diseases 3. Use of multiple vaccines

Answer 32

1. Risk of exposure 2. Risk of disease/complication 3. Susceptibility 4. Vaccine features (safety, side effects, efficacy) 5. Acceptability/ timing issues

Answer 33

1. Inequity in access to immunisation services 2. Low political commitment and under investment in some countries 3. Higher costs of service delivery 4. Lack of commercial incentives for manufacturers to develop vaccines 5. Some countries can't guarantee vaccine quality

Answer 34

Theory Techniques Methodology

Answer 35

A theory of knowledge and knowledge production e.g. where does knowledge come from and who has it

Answer 36

The practice and process of doing research including the role of the researcher

Answer 37

A technique or gathering date e.g. questionnaire, interview, documentary analysis

Answer 38

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

Answer 39

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

Answer 40

Any news that drastically and negatively alters the patient's view of his or her future

Answer 41

- 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

Answer 42

``` Avoidance Normalisation Premature reassurance False reassurance Switching Jollying along ```

Answer 43

``` 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 ```

Answer 44

Recognise someones anger Don't dismiss it Remain calm

Answer 45

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

Answer 46

Aims to reduce exposure

Answer 47

Aims to identify those with pre-clinical disease to influence progression of disease

Answer 48

Aims to modify outcomes of disease

Answer 49

Prostate Lung Bowel

Answer 50

Breast Lung Bowel

Answer 51

``` Lung Bowel Breast Prostate Pancreas ```

Answer 52

``` Leukaemia Brain tumour Neuroblastoma Lymphoma Retinoblastoma ```

Answer 53

1 in 4 | 25%

Answer 54

``` Differences in data collection Age differences Differences in stage of presentation Differences in social class Differences in access to treatment ```

Answer 55

Cancer survival in 80s and 90s was one of the worst in Europe Expert Advisory Group formed in 1995 - Calman-Hine report

Answer 56

1. All patients to have access to a uniformly high quality of care 2. Public and professional education to recognise early symptoms of cancer 3. Patients, families and carers should be given clear information about treatment options and outcomes 4. The development of cancer services should be patient centred 5. Primary care should be central to cancer care 6. The psychosocial needs of cancer sufferers and carers to be recognised 7. Cancer registration and monitoring of outcomes essential

Answer 57

3 levels of care - Primary care - Cancer units serving DGHs (250,000) - Cancer centres serving population in excess of one million

Answer 58

- 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

Answer 59

``` Physician Surgeon Oncologist Radiologist Histopathologist Specialist nurse MDT co-ordinator Physiotherapist Dietician Palliative care Chaplain ```

Answer 60

- 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

Answer 61

NHS Cancer plan (2000)

Answer 62

- 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

Answer 63

Organisational model for cancer services. Serve 1-2 million Brings together health services

Answer 64

- 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

Answer 65

- Prevention - Earlier diagnosis - Ensuring better treatment - Living with cancer and beyond - Reducing cancer inequalities - Delivering care in the most appropriate setting

Answer 66

- Using information to drive quality and choice - Stronger commissioning - Funding world class cancer care - Planning for the future

Answer 67

- 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

Answer 68

The process of critical evaluation of ethical and legal aspects

Answer 69

- 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

Answer 70

Argument that seeks to support a moral claim of some kind

Answer 71

- 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

Answer 72

- 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

Answer 73

Primary - patient oriented, paper light, low tech content, correspondance rich Secondary - imaging heavy, paper oriented, disease oriented

Answer 74

GMC - Clear, accurate, legible and contemporaneous patient records

Answer 75

1. Personal data shall be processed fairly and lawfully 2. Personal data shall be obtained only for one or more specified lawful purposes 3. Personal data should be adequate, relevant and not excessive in relation to the purpose for which they are processed 4. Personal data shall be accurate and kept up to date 5. Data should not be kept for longer than necessary 6. Processed in accordance with rights under the act 7. Measures shall be taken against unauthorised processing and against destruction or damage 8. It should not be transferred

Answer 76

- 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

Answer 77

- Bodies are sacred - They cannot be treated the same as other objects - They are the seat of the soul or the self

Answer 78

A mismatch between inside and outside Subjective and objective body image

Answer 79

Plastic surgery for scarring Re-constructive surgery Drug treatments for skin conditions

Answer 80

Drug side affects e.g. Thalidamide Cosmetic surgery problems Reproduction techniques

Answer 81

``` Ageing Accident/injury scars Hair loss Cancer Diabetes Lupus Menopause Pregnancy Skin disorder Stroke ```

Answer 82

``` May face difficulty with - employment - insurance Ethical issues - passing on disorder to chidren ```

Answer 83

- Immediately life saving - MDT support - Bridge to transplantation - Relieves loneliness and isolation - Opportunity for further social involvement

Answer 84

- 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

Answer 85

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

Answer 86

Most is secondarY

Answer 87

- Opportunities for primary prevention are limited - Opportunities for treatment are limited - Screening gives potential for early and more effective treatment

Answer 88

- 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

Answer 89

- 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

Answer 90

- effective treatment - evidence that earlier treatment gives better outcomes - clinical management of condition should be optimised prior to screening programme

Answer 91

- 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

Answer 92

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.

Answer 93

- 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

Answer 94

Length of time between detection of a disease and its usual presentation and diagnosis

Answer 95

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

Answer 96

Survival is inevitably longer following diagnosis through screening because of the extra lead time Appropriate measure of effectiveness is lost

Answer 97

Early detection of disease means the risk of death or illness can be reduced in some people

Answer 98

Some people get tests, diagnosis and treatment with no benefit Some people get ill or die despite a negative screening test

Answer 99

- Interests of parents, procreative autonomy - Interests of future child, welfare based - Interests of third parties, including the state

Answer 100

Any treatment or procedures involving in vitro handling of human oocytes and sperm or embryos for the purpose of achieving pregnancy

Answer 101

1. Involves destruction of embryos - some think that they have a moral status 2. Harmful for those trying to conceive - risk of mortality and morbidity and loss success rate 3. Unnatural - poor argument

Answer 102

``` 32% under 35 27% = 35-37 21% = 38-39 13% = 40-42 5% = 43-44 2% = 45+ ```

Answer 103

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

Answer 104

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)

Answer 105

1. Might be unfair as unfertile couples do not have to meet this criterion 2. Predicting the welfare of children is very difficult 3. Research suggests that a father is not always required for a child to flourish

Answer 106

Up to 3 cycles on the NHS

Answer 107

Screening of cells from implantation preimplantation embyros for detection of genetic or chromosomal disorders before embryo transfer

Answer 108

Avoid genetic disease Sex selection Saviour siblings

Answer 109

1. less than 24 weeks 2. Involve greater risk to continue the pregnancy - 3. Injury to physical or mental health of pregnant woman, existing children or family 4. Termination prevents grave permanent injury to physical or mental health of woman 5. Continuance would risk the life of the pregnant woman 6. substantial risk that the child would suffer from physical or mental abnormalities

Answer 110

Against abortion 1. Abortion ends the life of a foetus 2. Human foetus has moral status of a person 3. Wrong to end a persons life 4. Abortion morally wrong

Answer 111

1. Identify as a human organism 2. The potential to be a person 3. Identity as a person 4. Conferred moral status

Answer 112

``` Animal experiments Clinical trials Epidemiological methods - Spontaneous reporting - Post marketing surveillance - Cohort studies - Case control studies Meta-analysis ```

Answer 113

An unintended event resulting from clinical care causing patient harm

Answer 114

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

Answer 115

- 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

Answer 116

``` Wrong site surgery Medication errors Pressure ulcers Wrong diagnosis Failure to treat Patient fa Hospital acquired infection Medicine adverse effects ```

Answer 117

- 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

Answer 118

- 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

Answer 119

- 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

Answer 120

- 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

Answer 121

Hospital standardised mortality ratios

Answer 122

- 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

Answer 123

5.2% | 12,000 deaths per year

Answer 124

- 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)

Answer 125

- 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

Answer 126

Unsafe acts committed by people in direct contact with patient - Usually short lived - Often unpredictable Errors or violations

Answer 127

Knowledge based Rule based Skills based

Answer 128

Attention slips and memory lapses. Involved the unintended deviation of actions from what may have been a good plan

Answer 129

Encounter relatively familiar problem but apply the wrong rule . Misapplication of good rule or application of a bad rule

Answer 130

Forming wrong plans as the result of inadequate knowledge or experience

Answer 131

Deliberate deviations from a regulated code of practice or procedure. They occur because people break the rules intentionally

Answer 132

``` Routine Optimising Situational Reasoned Malicious ```

Answer 133

A violation that has become normal behaviour within a peer group

Answer 134

The motive is to improve a work situation (e.g. in boring or repetitive job)

Answer 135

Context dependent e.g. time pressure or low staffing level

Answer 136

Deliberate deviation from protocol thought to be in the patient best interest at the time

Answer 137

Deliberate act intended to harm someone or the organisation

Answer 138

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

Answer 139

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

Answer 140

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

Answer 141

*Unfamiliarity with a task *Inexperience Shortage of time Inadequate checking Poor procedures Poor human equipment interface * especially with lack of supervision

Answer 142

``` Fatigue Stress Hunger Illness Language Cultural factors Hazardous attitudes ```

Answer 143

1. Avoidance reliance on memory 2. Make things visible 3. Review and simplify processes 4. Standardise common processes and procedures 5. Routinely uses checklists 6. Decrease the reliance on vigilance

Answer 144

1. Patient factors 2. Staff factors 3. Task factors 4. Communication factors 5. Equipment 6. Work equipment 7. Organisational factors 8. Education and training factors 9. Team factors

Answer 145

- 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

Answer 146

- 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

Answer 147

- Presumed consent at 16 - Consent must be obtained - If someone under 18 refuses - treatment given if approved by parents or courts

Answer 148

``` Mother Father if married Father if they have acquired responsibility Adopted parents Guardian appointed by parents Local authority name in a care order ```

Answer 149

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

Answer 150

- 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

Answer 151

Parents have the right to make decisions regarding their children Can be over-ridden by courts if necessary

Answer 152

- 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

Answer 153

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

Answer 154

- 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

Answer 155

- Medication - wrong drug, wrong dose - Surgery - wrong procedure - Infection control

Answer 156

1. Medicine has weak evidence base 2. Large variation in clinical practice: doctors do give different treatments to patients with similar needs and personal characteristics 3. Failure to measure success

Answer 157

- 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)

Answer 158

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

Answer 159

1. Care Quality Commissions (CQC) 2. Monitor 3. National Patient Safety Agency 4. National Institute for Health and Clinical Excellence (NICE)

Answer 160

- 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)

Answer 161

- Regulator of foundation trusts since 2004 - Collaborates with CQC and National Audit Office - Responsible for competition policy and setting hospital tariffs

Answer 162

Increase in smaller, singe and step parenting families - Decreased birth rate - Later marriage - later child bearing - Working mothers

Answer 163

- Pollution (unwashed baby, blood, placenta, cord) - Cleansing practices - Internal examinations and male practitioners - Circumcision - The month - Naming the baby

Answer 164

- Public to private - Natural to medical - Home to hospital - Midwife to Doctors and nurses

Answer 165

- Pain relief - Doctors attendance - Safety - Cleanliness - Higher status - Being cared for after birth

Answer 166

``` 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

Answer 167

1. Pneumonia 2. Diarrhoea 3. Malaria 4. Neonatal pneumonia/sepsis 5. Preterm delivery 6. Birth asphyxia

Answer 168

``` Low birth weight Malnutrition Non-breastfed children Overcrowded housing Indoor air pollution ```

Answer 169

- Quality care and nutrition during pregnancy - Safe delivery by a skilled birth attendant - Maternal immunisation - Quality neonatal care

Answer 170

- Led by UNICEF in 80s Concentrated on - Growth monitoring - Oral rehydration therapy - Breast feeding - Immunisation

Answer 171

Millennium development goals - 8 goals

Answer 172

1. eradicate extreme poverty and hunger 2. achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS 7. Ensure environmental stability 8. Global partnership for development

Answer 173

- Service need and provision - Wider family and environmental factors - Factors intrinsic to the child - Factors around parental care

Answer 174

- 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

Answer 175

- Confidentiality - Communication - Lack of empathy - Perception of judgemental attitude of physicians Rutihauser (2003)

Answer 176

- Major life impact - New school/ domestic situation/ area/ parent illness/ recent bereavement - Having a bad day - Anxious/scared/angry - Feeling unwell

Answer 177

- Emotional communication - Understanding of self - Ability to manage feelings - Knowledge about other people - Interpersonal skills - Friendships - Intimate relationships - Moral reasoning and behaviour

Answer 178

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)

Answer 179

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

Answer 180

- Linguistic - Musical - Logico-mathematical - Spatial - Bodily-kinesthetic - Interpersonal - Intrapersonal (self awareness) - Naturalist

Answer 181

- Social competence (social skills) - Rewarding personal and social relationships with others - Communication skills - Appropriate social behaviour

Answer 182

- Victimised, ostracised, stigmatied by others - poor relationships with others - Social withdrawal - Inappropriate social behaviour

Answer 183

- Stable and secure attachments to significant others (parents) - Emotions appropriate to context - Positive self-esteem - Generally happy and optimistic outlook on life

Answer 184

- Unstable and insecure attachments to parents - Emotions inappropriate to context - Poor self esteem - Anxiety and depression

Answer 185

- 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

Answer 186

- 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

Answer 187

1. Must not express personal beliefs to patients in ways that exploit their vulnerability or likely to cause them distress 2. Must not refuse or delay treatment because you believe that a patient's actions or lifestyle contributed to their condition 3. Must not unfairly discriminate against patients or colleagues by allowing your beliefs to affect your professional relationships or the treatment

Answer 188

To object to something because it conflicts with one's moral or religious beliefs

Answer 189

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

Answer 190

- 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

Answer 191

A structured activity which is intended to provide new knowledge which is generalisable and intended for wider dissemination

Answer 192

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

Answer 193

Research ethics principles Requirement that any form of human research is subject to independent ethical review and oversight by a properly covened committee

Answer 194

- 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

Answer 195

- Research with human participants, human tissue or personal data If in doubt = get advice

Answer 196

- 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

Answer 197

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

Answer 198

- 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

Answer 199

Consent is asking someone's permission to involve them in the research project and letting them decide for themselves. Must be informed and voluntary

Answer 200

1. Purpose of study 2. Why they have been chosen? 3. Do you have to take part? 4. What will happen 5. What will I have to do 6. What procedure is being tested 7. What are the alternatives for diagnosis or treatment 8. What are the side effects of any treatment? 9. Risks of taking part 10. possible benefits 11. what if something goes wrong 12. What will happen to results 13. Who is organising and funding 14. who to contact for more information

Answer 201

- not putting direct pressure on patients or volunteers to participate - not offering inducements - not threatening sanctions if they leave the study

Answer 202

- All information is confidential - All research is to be approved by REC - All personal information must be coded and anonymised as far as possible

Answer 203

Cross sectional analytic study

Answer 204

Cohort study | Population based case-control study

Answer 205

Cohort study

Answer 206

Randomised control trial | Systematic review

Answer 207

- Bias - Applicability - Value

Answer 208

1. are the results valid 2. What are the results? 3. Can I apply the results to this patient's care

Answer 209

Relative risk reduction Absolute risk reduction Confidence intervals Number needed to treat

Answer 210

``` Sensitivity Specificity Positive predictive value Negative predictive value Likelihood ratio ```

Answer 211

Relative risk Odds ratio Number needed to harm

Answer 212

1. Did the review ask a clearly focused question? 2. Did the review include the right type of study? 3. Did the reviewer try to identify all relevant studies? 4. Did the reviewers assess the quality of the included studies? 5. If the results of the studies have been combined, was it reasonable to do so? 6. How are the results presented and what is the main result? 7. How precise are these results? 8. Can the results be applied to the local population? 9. Were all important outcomes considered? 10. Should policy or practice change as a result of the evidence contained in this review?

Answer 213

- population studied - intervention given or exposure - outcomes considered

Answer 214

- address the reviews question | - have an appropriate study design?

Answer 215

- 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

Answer 216

- Clear pre-determined strategy was used to determine which studies were included. Look for - a scoring system - more than one assessor

Answer 217

- 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

Answer 218

- 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

Answer 219

- 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

Answer 220

- 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

Answer 221

- individual - policy makers - professionals - family/carers - wider community

Answer 222

- Behavioural (fear avoidance) - Cognitive (somatisation/catastrophising) - Affective (anxiety/depression)

Answer 223

Positive - Sympathy, support, attention Negative - Loss of income, altered role within family unit

Answer 224

Bio - physiological dysfunction and neurophysiological changes Pyscho - illness behaviour, beliefs, coping strategies, emotions, distress Social - culture, social interactions, sick role

Answer 225

The longer a person is off work, the less likely they are to return 6m = 50% 1 year = 25% 2 year = 0

Answer 226

``` Visual analogue score Verbal rating score Brief pain inventory HAD score McGill pain score LANSS score ```

Answer 227

Eduction - Healthcare professional or focus group - Coping strategies - Cognitive behavioural therapy - Mindfulness - Pain management programme - CBT

Answer 228

Meditation technique aimed at focusing the mind on the present moment Relaxed and non judgemental awareness of thoughts, feelings and sensations

Answer 229

- Limitless demand for health - Limited resources for health care - Supply is finite - Creates scarcity

Answer 230

By ability to pay (US) | By need

Answer 231

``` GP appointment specialist appoinment agreed elective procedure waiting room A and E Emergency admission Ambulance ```

Answer 232

- 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

Answer 233

- 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

Answer 234

More doctors More specialists More expenditure Activity based remuneration for doctors and/or hospitals

Answer 235

Started at 15 months down to 3 months

Answer 236

26 weeks to 14 weeks

Answer 237

2 months to 1 month

Answer 238

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

Answer 239

- Unmeasured performance suffers - Adverse behaviour response (patients waiting in ambulance instead of emergency room) - Data manipulation and fraud - Sacrifice of professional autonomy

Answer 240

Waiting time targets relaxed or abandoned Targets and terror to competition and choice Maintained reductions without targets

Answer 241

- 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)

Answer 242

- 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)

Answer 243

Incentives for GPs Clinical guidelines Encourage use of private sector Encourage private health insurance

Answer 244

- Clinical urgency - Clinical severity - Potential health gain - Productivity and economic loss - Equity weighting (poverty) - Spare capacity - Length of time waiting

Answer 245

18 week referral to hospital treatment Changing priorities for NHS policy Nicholson challenge Saving 15-20 billion Changes in referral and treatment threshold

Answer 246

- 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

Answer 247

1. Assumed to have capacity unless established otherwise 2. Should not be treated as unable to make decisions unless all steps to help have been taken 3. Not to be treated as unable to make a decision just because they make an unwise decision 4. Any decision made under the act must be made in his best interests 5. Act needs to be done in the way which is least restrictive of the person's rights and freedom

Answer 248

- 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

Answer 249

To distinguish between patients who should and should not retain decisional authority regarding aspects of their treatment or care

Answer 250

- 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

Answer 251

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)

Answer 252

Extend considerations of patient autonomy to situations in which the patient no longer has mental capacity Can only refuse treatment, not demand it

Answer 253

- 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

Answer 254

1. must be in writing 2. must be signed by the maker 3. signature must be witnessed and signed by witness 4. document must be verified by a statement that AD is to apply to a specified treatment "even if life at risk" 5. Statement must be signed by maker and a witness

Answer 255

- 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

Answer 256

- 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

Answer 257

30% over 65y 45% 80-89 55% 90+ 3x higher in institutions

Answer 258

- 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

Answer 259

- Fear of falling - Self imposed activity restriction - Social isolation - Depression

Answer 260

To measure the burden of disease across different diseases = QALY is a measurement 1 QALY = 1 year in perfect health

Answer 261

- Fall prevention - Bone protection - Bisphosphonates - Vitamin D/ calcium - HRT NOT hip protectors

Answer 262

- 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+

Answer 263

``` Parkinsons's Stroke Hypotension Depression Epilepsy Dementia Eye disease Incontinence Osteoarthritis RA Peripheral neuropathy ```

Answer 264

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

Answer 265

``` Acupuncture Chiropractic Herbal medicine Homeopathy Osteopathy ```

Answer 266

- Regulatory issues - Financial concerns within NHS - Tribalism - Inertia (resistance to change) - Mixed evidence of effectiveness

Answer 267

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

Answer 268

Back, neck and shoulder problems Joint, posture and muscle problems Leg pain and sciatica Sports injuries

Answer 269

- 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

Answer 270

- Restriction - Matching - Stratification - Multiple varibale regression

Answer 271

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.

Answer 272

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

Answer 273

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

Answer 274

To take into account 4 confounders, it would require 32 strata

Answer 275

The majority of people who suffer a [stroke] are not at high risk of [stroke] 75% have normal blood pressure

Answer 276

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

Answer 277

Large potential benefit to community | Low potential benefit to individual

Answer 278

- 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

Answer 279

- 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

Answer 280

Use of a trained person who meets providers in their practice settings to give information with the intent of changing their behaviour

Answer 281

- 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

Answer 282

System that compares patient characteristics with a knowledge base then guides a health provider by offering patient-specific and situation specific advice

Answer 283

Cost effectiveness (£/unit of benefit) PLUS the costs of changing behaviour

Answer 284

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

Answer 285

- 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

Answer 286

- Denial (with or without insight). Attributes to old age. Often accompanied by anger - Grief reaction - Acceptance/ positive coping stratgies

Answer 287

- Insight - Stage of illness - Ability to remember and process information - Type of dementia - Previous personality - Relationship and support

Answer 288

- Confirmation of something they have long suspected - Fear - Anger - Grief

Answer 289

- Understanding of illness - Patients reaction - Nature of relationship with patient

Answer 290

- 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

Answer 291

- Relationship becomes skewed - Practical - Emotional - Physical/ sexual - Financial - Relationships

Answer 292

- Role reversal - Competing demands - Conflict between family members - Effect on young children

Answer 293

- Increased stress - Increased physical care - Poor sleep - Constant vigilance - Loss of support of partner - Unable to take time off sick

Answer 294

- 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

Answer 295

- Restlessness - Physical aggression - Wandering - Sexual disinhibition - Repeated questioning - Screaming - Swearing - Anxiety - Depressive mood - Withdrawal - Hallucinations - Delusions and psychosis

Answer 296

1. Can be the last year or more of life 2. last 48 hours of life 3. Terminal patients

Answer 297

Palliative care is the active holistic care of patients with advanced, progressive illness

Answer 298

Achievement of the best quality of life for patients and their families

Answer 299

- CPR is a medical treatment that cannot be demanded by patients or their family - To offer futile treatments is ethically inappropriate

Answer 300

Patients and carers with unresolved symptoms and complex psychosocial issues, with complex end of life and bereavement issues

Answer 301

Health care professionals for whom palliative care is their core work. Undergone relevant training increasingly provided by accredited specialist Nurse, doctor, physio, OT, chaplain

Answer 302

- Primary health care team - Nursing home - Secondary care - Social services

Answer 303

- Clinical nurse specialists - Specialist physicians in palliative care - Hospices - Marie Curie nurses

Answer 304

- Community clinical nurse specialist - Hospital clinical nurse specialist - Some consultants - Some in patient units - Macmillian

Answer 305

- Hosptice services - Most in patient beds - Marie curie/sue ryder - Marie curie nurses - Macmillan

Answer 306

- District - Practice - Marie curie - Macmillan

Answer 307

Umbrella term - Religious or faith framework Includes - Meaning to life - Purpose - Hope - Sense of person hood

Answer 308

- 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?

Answer 309

- Anxiety - Depression - Anger/hostility - Socioeconomic status - Work/ marital stress - Caregiver strain - Lack of social support

Answer 310

- Increase in HPA - Increase in sympathetics - Increase altered behaviours - ANS dysfunction - Insulin resistance - Central obesity - Hypertension - Inflammation - Platelet activation - Decrease bone density

Answer 311

International classification of impairments, disabilities and handicaps Takes into account all dimensions of disease - Disease - Impairment (functional loss) - Disability (activity limitations) - Handicap (social disadvantage)

Answer 312

``` Denial Anger Bargaining Depression Acceptance ```

Answer 313

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

Answer 314

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

Answer 315

- Emotional/ affective - Cognitive/ thoughts - Behavioural/ lifestyle

Answer 316

- Personality (Type A/ mental toughness) - Existing psychopathology (anxiety/ depression) - Personal control - Self esteem/self confidence - Current stress

Answer 317

- Clinical symptoms - On going education - Misconceptions - Informal psychological assessment - Anxiety management/ counselling/ CBT - Facilitate lifestyle changed - Promote return to normal activity

Answer 318

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: 1. If a person thinks that a negative condition can be avoided 2. Taking that action will avoid the negative condition 3. Feel confident and successful carrying out action

Answer 319

- Pre-contemplative (no intention) - Contemplative (thinking, open to suggestions) - Preparations (change imminent) - Action (made changes) - Maintenance (change established)

Answer 320

``` Age Gender Social deprivation Co-existing physical illness and severity Health and illness beliefs Intelligence/education Past family history Other people Culture Media ```

Answer 321

Education - Cognitive approaches e.g. goal-setting, cognitive techniques - Social support - Reinforcement (feeback, self monitoring, patient autonomy) - Client - practioner relationship (communication)

Answer 322

- Lower social postion | = increased risk

Answer 323

``` Age gender FH smoking hypertension cholestrol diabetes physical inactivity obesity diet socio-economic status psychosocial alcohol ethnicity ```

Answer 324

A preventative measure that brings benefits to the community offers little to each participating individual

Answer 325

- Appropriate to the individual - Motivated subject - Motivated clinician - Cost effective resourceuse - Benefit: risk (high)

Answer 326

- Screening difficult - Palliative and temporary - Limited potential - Behaviourly inappropriate - Labelling

Answer 327

- Large potential | - Behaviourally appropriate

Answer 328

- Population paradox (small individual benefit) - Poor motivation - Benefit: risk (low)

Answer 329

Driven by weighing the balance between costs and benefits: - costs to individuals (another tablet?) - cost to population - absolute benefits

Answer 330

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

Answer 331

1. Structure the problem as a decision tree, identifying choices, information and preferences 2. Assess the probability of every choice branch 3. Assess the utility of every outcome state 4. Identify option that maximuses expected utility 5. Conduct a sensitivity analysis to explore effect of varying judgements 6. Toss up if 2 options have same EU

Answer 332

- Decision node - Represents choice between actions e.g. What do I do?

Answer 333

- Chance node - Represents uncertainty - Potential outcomes of each decision e.g. noting, give treatment, find out more information

Answer 334

- measure of desirability of all possible outcomes in the decision tree - Provide a numerical value attached to beliefs and feelings

Answer 335

standardised instrument for use as a measure of health outcome 1. Mobility 2. Looking after myself 3. Doing usual activities 4. Having pain or discomfort 5. Feeling worried, sad or unhappy

Answer 336

- QALY (quality adjusted life years) - Rating scales - Standard gamble - Time trade off

Answer 337

1 year in perfect health | Considers quantity and qaulity of life

Answer 338

- 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

Answer 339

- 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

Answer 340

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

Answer 341

1. Numbness 2. Yearning 3. Disorganisation 4. Reorganisation

Answer 342

- 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

Answer 343

1. Accept the reality of the loss 2. Work through the pain of grief 3. Adjust to an environment in which the deceased is missing 4. Emotionally relocate the deceased and move on with life

Answer 344

- extended grief reaction (getting stuck) - mummification and denial - major depressive disorder >2 months after loss

Answer 345

1. food borne illness 2. nutritional adequacy 3. environmental contaminants 4. naturally occurring contaminants 5. pesticide residues 6. food additives

Answer 346

- Public education - Staff training - Food inspectors - Bad PR - Proper equipment well maintained - Good raw materials

Answer 347

Catering premises Institutions Catered functions Other

Answer 348

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

Answer 349

1990 Defines food and enforcement authorities and their responsibilities - premises must be registered - inspections - obligations to ensure safety - powers of enforcement

Answer 350

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

Answer 351

1. Question formulation 2. Literature search 3. Appraisal of evidence 4. Clinical decision

Answer 352

Designed to aid clinician decision making - can be computerised - may be paper based - may be reminder systems

Answer 353

1. Reminder systems (CSC Primary care) - Screening - Vaccination - Testing - Medication Use - Identification of risky behaviour 2. 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 3. Prescribing - Advice on drug dosage 4. Disease management - Can provide info to assist monitoring of patients

Answer 354

Proportion of people with target disorder who have positive test True positives / true positive+false negative

Answer 355

Proportion of people without the target disorder who have a negative test True negative/ true negative+false positive

Answer 356

Can improve practioner performance in - diagnosis - disease management - prescribing/ dosing - rates of vaccinations, screening

Answer 357

- earlier negative experience of IT - potential harm to doctor-patient relationship - obscured responsibilitie - reminders increase workload

Answer 358

- 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

Answer 359

Being the same in quantity, amount, value, intensity

Answer 360

Fairness or impartiability; even handedness

Answer 361

- Prioritisation and rationing of services - Allocation of sparce health resources - Health service funding - Research prioritisation and participation - More specific allocatory decisions e.g. organs

Answer 362

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

Answer 363

- 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

Answer 364

It does not aim to discriminated against elderly Treated the same no matter what age

Answer 365

A person who needs treatment for something may lose out if they have another condition that affects quality of life

Answer 366

Make resource allocations decisions on basis of need

Answer 367

- 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

Answer 368

- 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

Answer 369

- 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

Answer 370

- 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

Answer 371

- Provide aid to identified victims of illness or accident - Public are more sympathetic towards a named person who is dying - not capsured by QALYs

Answer 372

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)

Answer 373

- Increasing healthcare expenditure means need to evaluate medical care - Increasing health care reforms so need to evaluate health policies

Answer 374

Efficacy | Effectiveness

Answer 375

- Opportunity cost of choices | - Benefit of their choice

Answer 376

A cost is the value of what you give up - cost to NHS? - Patient - Carer - Society

Answer 377

- Health gain e.g. increase in life length/ quality - Social gains for community - Health/social gains of family

Answer 378

Depends on the outcome measure used - Cost minimisation analysis (CMA) - Cost effectiveness analysis (CEA) - Cost utility analysis (CUA) - Cost benefit analysis (CBA)

Answer 379

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

Answer 380

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

Answer 381

Combines multiple outcomes in a single measure of utility e.g. QALY Allows comparisons between alternatives in different therapeutic categories with different natural outcomes

Answer 382

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

Answer 383

- Identification - Measurement - Valuation of inputs into healthcare What costs to include

Answer 384

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

Answer 385

Greater weight is given to current over future costs Future costs and benefits must be discounted to their present value

Answer 386

``` SF36 EQ 5D (NICE recommended) ```

Answer 387

- 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

Answer 388

- 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

Answer 389

- Private insurers are poor purchasers - Governments impose cash limits - Private systems by price - Public systems by need

Answer 390

barnett formula

Answer 391

Targeting resources at those activities that give the greatest patient health gain for the £ spent Maximise population health gain from the available budget

Answer 392

Maximise production of goods or services

Answer 393

Production of most desired/ worthwhile goods and services at least cost

Answer 394

Penalties vs. bonuses Financial vs. non-financial incentives QOF in GP land

Answer 395

A mismatch between the inside and the outside or the subjective and objective body image

Answer 396

``` Distress Embarrassment Inconvenience Threat to self esteem Loss of personal control Desire for normalisation ```