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Year 2 - Theme C > Theme C > Flashcards

Theme C Flashcards

0
Q

What are the analytical methods for collecting population research?

A

Trials - RCTS

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1
Q

What are the descriptive methods for collecting population research?

A

Survey
Case report
Case series

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2
Q

What are the observational methods for collecting population research?

A

Cohort

Case control

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3
Q

Describe a case control study

A

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

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4
Q

Describe cohort studies

A

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

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5
Q

What are the problems associated with observational studies?

A

Confounding

Bias

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6
Q

What are some of the problems with measuring diet?

A

Random error
Homogeneity of exposure
Bias
Confounding

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7
Q

How can you measure diet?

A

Food disappearance data (national level)
Household surveys
Individual surveys
(24 hour recall, food frequency, diet diary, bio markers)

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9
Q

Pros and cons of diet diaries

A

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

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10
Q

What is internal validity?

A

Extent to which a causal conclusion based on the study is warranted.
Extent to which a study minimises systematic error

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11
Q

What is external validity?

A

Extent to which the results of the study can be generalised to other situations and other people

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12
Q

What can limit the generality of study findings?

A
  1. Situational specifics e.g. time, location, researcher, extent of measurement, treatment administration
  2. Pretest - if cause effect relationship are only found in pretest
  3. Post test - if cause effect relationship are only found in post test
  4. Reactivity - if effects only ocurred as an effect of studying the situation
  5. Rosenthal effects - inferences about cause-consequence relationships may not be generalisable to other researchers
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13
Q

Why do we need evidence based medicine?

A 
Increasing medical knowledge
Limited time to read
Inadequacy of traditional sources
Disparity between diagnostic skills/ clinical judgement
Can improve medical practice
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14
Q

What are the four components for an evidence based decision?

A

Evidence from research
Clinical expertise
Patient preference
Available resources

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15
Q

What are the different types of research study?

A 
Cohort
Case control
Randomised control trias
Qualitative approaches
Diagnostic and screening studies
Systematic reviews
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16
Q

What is a cohort study appropriate for?

A

Prognosis

Cause

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17
Q

What is a case control study appropriate for?

A

Cause

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18
Q

What is a RCT appropriate for?

A

treatment interventions
benefits and harm
cost effectiveness

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19
Q

What is a qualitative study appropriate for?

A

Patients and/or practitioners perspective

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20
Q

What is the process for evidence based medicine?

A
  1. Convert the need for information into an answerable questions
  2. Identifying best evidence to answer that question
  3. Understanding it
  4. Critically appraising evidence for validity, impact and applicability
  5. Integrating critical appraisal with clinical expertise, patient circumstances and service constraints
  6. Evaluating effectiveness of steps 1-5
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21
Q

What is a background question?

A

General knowledge about a disorder

Who/what/where/when…. disorder

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22
Q

What is a foreground question?

A

Specific knowledge about managing patients with a disorder

Patient/problem
Intervention
Comparison intervention
Clinical outcomes

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23
Q

What is the control of communicable diseases based on?

A

Surveillance
Preventative measures
Outbreak investigation
Appropriate control measures

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24
Q

What are the host factors that influence infection?

A 
Age
Gender
Alcoholism
Drug abuse
Co-existing diseases
Port of entry
Immuno-state
Nutrition
Genetic make up
Cell receptors
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25
Q

Define outbreak

A

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

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26
Q

Define epidemic

A

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

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27
Q

Define pandemic

A

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

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28
Q

Define surveillance

A

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

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29
Q

What happens in outbreak investigation and control?

A
  • 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
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30
Q

Define health care associated infections

A

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

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31
Q

What are the factors affecting the risk of acquiring a health care associated infecton?

A 
Underlying disease
Extremes of age
Breach of defence mechanisms
Exposure to infection
Hospital pathogens
Antibiotic resistance
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32
Q

What is the incidence of health care associated infections?

A

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

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33
Q

What are the common sites of hospital infections?

A 
GI 22%
Respiratory 20%
Urinary tract 19%
Surgical site 13%
Skin 10%
Blood stream 6%
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34
Q

What prevention strategies are part of the infection control programme?

A
  • 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
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35
Q

What are some of the current policies and procedures for infection control?

A
  • 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
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36
Q

What are the objectives of vaccinations?

A

Protect individuals from specific disease

Protect populations

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37
Q

What is the vaccination goal?

A

To reduce mortality and morbidity from vaccine preventable infections

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38
Q

What are the aims of vaccines?

A 
Selective protection of vulnerable
Eradication
Elimination
Prevent deaths
Prevent infection
Prevent transmission
Prevent clinical cases
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39
Q

Who is included in a susceptible population (vaccination)?

A
  • 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
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40
Q

What is Ro?

A

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

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41
Q

What does Ro depend on?

A

Bug characteristics:
Infectivity of organism
Duration of infectiousness

Population characteristics:
Demographics
Population density

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42
Q

What is R?

A

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

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43
Q

How do mass vaccination programmes impact the disease?

A 
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
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44
Q

What is the epidemic threshold?

A

R = 1

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45
Q

What happens if R>1?

A

Number of cases increases

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46
Q

What happens if R<1?

A

Number of cases decreases

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47
Q

What is required to eliminate a disease?

A

R<1

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48
Q

What is herd immunity?

A

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

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49
Q

Why is herd immunity important?

A

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

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50
Q

How do you calculate critical vaccination coverage?

A 
H = herd immunity threshold
s* = critical proportion susceptible

H = 1-s*

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51
Q

How is vaccine efficacy calculated?

A 
VE = vaccine efficacy
AR = attack rate

VE% = AR (unvaccinated) - AR (vaccinated) x 100

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52
Q

What factors determine whether a disease is a burden?

A

Number of cases
Morbidity
Mortality

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53
Q

What effects how much a disease will be prevented?

A

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

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54
Q

What are the possible negative effects of the vaccine programme?

A

Risk from vaccine
Programme errors
Interference with existing strategys

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55
Q

What needs to be taken into account when implementing a new vaccine?

A
  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
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56
Q

How do you implement a new vaccination program?

A

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

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57
Q

When do you vaccinate?

A
  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
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58
Q

When choosing the strategy for vaccination, what do you need to consider?

A
  1. Risk of exposure
  2. Risk of disease/complication
  3. Susceptibility
  4. Vaccine features (safety, side effects, efficacy)
  5. Acceptability/ timing issues
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59
Q

Why is international collaboration of vaccination necessary?

A
  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
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60
Q

What are the elements of academic research?

A

Theory
Techniques
Methodology

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61
Q

Define epistemology

A

A theory of knowledge and knowledge production

e.g. where does knowledge come from and who has it

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62
Q

Define methodology

A

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

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63
Q

Define method

A

A technique or gathering date

e.g. questionnaire, interview, documentary analysis

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64
Q

Define positivism

A

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

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65
Q

Define interpretivism

A

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

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66
Q

Define bad news

A

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

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67
Q

What can clinicians worry about when delivering bad news?

A
  • 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
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68
Q

What are some of the distancing strategies used when breaking bad news?

A 
Avoidance
Normalisation
Premature reassurance
False reassurance
Switching
Jollying along
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69
Q

How should bad news be broken?

A 
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
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70
Q

How should you deal with anger?

A

Recognise someones anger
Don’t dismiss it
Remain calm

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71
Q

What is risk transition?

A

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

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72
Q

What is primary prevention?

A

Aims to reduce exposure

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73
Q

What is secondary prevention?

A

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

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74
Q

What is tertiary prevention?

A

Aims to modify outcomes of disease

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75
Q

What are the most common cancers in males?

A

Prostate
Lung
Bowel

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76
Q

What are the most common cancers in females?

A

Breast
Lung
Bowel

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77
Q

What cancers have the highest mortality?

A 
Lung
Bowel
Breast
Prostate
Pancreas
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78
Q

What are the most common cancers occurring in children?

A 
Leukaemia
Brain tumour
Neuroblastoma
Lymphoma
Retinoblastoma
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79
Q

What is the lifetime incidence of cancer?

A

1 in 3

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80
Q

What percentage of people die from cancer?

A

1 in 4

25%

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81
Q

How many people each year die of cancer?

A

270,000

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82
Q

What are some of the potential causes of UK poor performance in cancer treatment?

A 
Differences in data collection
Age differences
Differences in stage of presentation
Differences in social class
Differences in access to treatment
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83
Q

What are the conclusions and consequences of the Eurocare-2 report?

A

Cancer survival in 80s and 90s was one of the worst in Europe

Expert Advisory Group formed in 1995 - Calman-Hine report

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84
Q

What was advised in the Calman-Hine report?

A
  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
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85
Q

What are the Calman-Hine solutions?

A

3 levels of care

  • Primary care
  • Cancer units serving DGHs (250,000)
  • Cancer centres serving population in excess of one million
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86
Q

Why do we have MDTs with cancer treatment?

A
  • 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
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87
Q

Who is involved in an cancer care MDT?

A 
Physician
Surgeon
Oncologist
Radiologist
Histopathologist
Specialist nurse
MDT co-ordinator
Physiotherapist
Dietician
Palliative care
Chaplain
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88
Q

What is the function of an MDT in cancer care?

A
  • 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
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89
Q

What strategy was developed to tackle cancer?

A

NHS Cancer plan (2000)

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90
Q

What are the aims of the NHS cancer plan?

A
  • 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
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91
Q

What are cancer networks?

A

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

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92
Q

What are the activities of a cancer network?

A
  • 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
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93
Q

What were the 6 areas for action in the cancer reform strategy?

A
  • Prevention
  • Earlier diagnosis
  • Ensuring better treatment
  • Living with cancer and beyond
  • Reducing cancer inequalities
  • Delivering care in the most appropriate setting
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94
Q

What are the 4 key drivers for delivery of cancer care?

A
  • Using information to drive quality and choice
  • Stronger commissioning
  • Funding world class cancer care
  • Planning for the future
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95
Q

What is the purpose of critical reflection?

A
  • 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
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96
Q

What is ethical reasoning?

A

The process of critical evaluation of ethical and legal aspects

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97
Q

Why is ethical reasoning important?

A
  • 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
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98
Q

What is a moral argument?

A

Argument that seeks to support a moral claim of some kind

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99
Q

What are the functions of the clinical record?

A
  • 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
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100
Q

What is the contents of clinical records?

A
  • 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
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101
Q

What are the differences in the clinical record in primary and secondary care?

A

Primary - patient oriented, paper light, low tech content, correspondance rich

Secondary - imaging heavy, paper oriented, disease oriented

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102
Q

What is the law and policy on maintaining clinical records?

A

GMC - Clear, accurate, legible and contemporaneous patient records

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103
Q

What are the principles of the Data Protection Act 1998? (8)

A
  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
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104
Q

What are the objective of NHS connecting for health?

A
  • 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
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105
Q

Why is the body a problem?

A
  • Bodies are sacred
  • They cannot be treated the same as other objects
  • They are the seat of the soul or the self
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106
Q

What is a body dysmorphic disorder?

A

A mismatch between inside and outside

Subjective and objective body image

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107
Q

What are the positive ways in which medicine changes bodies/

A

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

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108
Q

What are the negative ways in which medicine changes bodies?

A

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

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109
Q

What are the types of body transtitions?

A 
Ageing
Accident/injury scars
Hair loss
Cancer
Diabetes
Lupus
Menopause
Pregnancy
Skin disorder
Stroke
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110
Q

What are the disadvantages of screening?

A 
May face difficulty with
- employment
- insurance
Ethical issues
- passing on disorder to chidren
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111
Q

What are the advantages of diagnosis?

A
  • Immediately life saving
  • MDT support
  • Bridge to transplantation
  • Relieves loneliness and isolation
  • Opportunity for further social involvement
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112
Q

What are the impacts of dialysis?

A
  • 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
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113
Q

What is screening?

A

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

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114
Q

What level of prevention is screening?

A

Most is secondarY

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115
Q

Why should we screen?

A
  • Opportunities for primary prevention are limited
  • Opportunities for treatment are limited
  • Screening gives potential for early and more effective treatment
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116
Q

When screening what is required from the condition?

A
  • 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
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117
Q

When screening, what is required from the test?

A
  • 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
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118
Q

When screening, what is required from the treatment?

A
  • effective treatment
  • evidence that earlier treatment gives better outcomes
  • clinical management of condition should be optimised prior to screening programme
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119
Q

When screening, what is required from the programme?

A
  • 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
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120
Q

What is length bias?

A

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.

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121
Q

What is the consequence of length bias?

A
  • 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
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122
Q

What is lead time?

A

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

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123
Q

What is lead time bias?

A

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

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124
Q

What is the consequence of lead time bias?

A

Survival is inevitably longer following diagnosis through screening because of the extra lead time

Appropriate measure of effectiveness is lost

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125
Q

What is good about “good” screening?

A

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

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126
Q

What is bad about “good” screening?

A

Some people get tests, diagnosis and treatment with no benefit

Some people get ill or die despite a negative screening test

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127
Q

What are the relevant considerations for reproductive ethics?

A
  • Interests of parents, procreative autonomy
  • Interests of future child, welfare based
  • Interests of third parties, including the state
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128
Q

What is assisted reproductive technology?

A

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

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129
Q

What are the ethical objections to the use of IVF?

A
  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
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130
Q

What are the chance of success of IVF?

A 
32% under 35
27% = 35-37
21% = 38-39
13% = 40-42
5% = 43-44
2% = 45+
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131
Q

What is the right to an open future?

A

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

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132
Q

What is the Human Fertilisation and Embryology Act 1990?

A

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)

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133
Q

Why is the welfare criterion in ART criticised?

A
  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
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134
Q

What IVF is available for those aged 23-39 on the NHS?

A

Up to 3 cycles on the NHS

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135
Q

What is PGD?

A

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

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136
Q

What are the uses of PGD?

A

Avoid genetic disease
Sex selection
Saviour siblings

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137
Q

What are the criteria to qualify for an abortion?

A
  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
  3. Termination prevents grave permanent injury to physical or mental health of woman
  4. Continuance would risk the life of the pregnant woman
  5. substantial risk that the child would suffer from physical or mental abnormalities
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138
Q

What is the pro-life argument?

A

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
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139
Q

What are the views of the moral status of a foetus?

A
  1. Identify as a human organism
  2. The potential to be a person
  3. Identity as a person
  4. Conferred moral status
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140
Q

What are the methods used to study drug safety?

A 
Animal experiments
Clinical trials
Epidemiological methods
- Spontaneous reporting
- Post marketing surveillance
- Cohort studies
- Case control studies
Meta-analysis
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141
Q

What is an adverse event?

A

An unintended event resulting from clinical care causing patient harm

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142
Q

What is a near miss event?

A

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

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143
Q

What is the iceberg model of errors?

A
  • 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

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144
Q

Name some examples of adverse events in healthcare?

A 
Wrong site surgery
Medication errors
Pressure ulcers
Wrong diagnosis
Failure to treat
Patient fa
Hospital acquired infection
Medicine adverse effects
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145
Q

How many adverse events are heir in the NHS hospital sector per year?

A

850,000

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146
Q

What are the causes of serious obstetrics adverse events?

A
  • 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
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147
Q

What was outlined in the Berwick report?

A
  • 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
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148
Q

What are the solutions of the Berwick report?

A
  • 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
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149
Q

What is the Keogh Review?

A
  • 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
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150
Q

What are HSMR?

A

Hospital standardised mortality ratios

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151
Q

Why can comparing Hospital standardised mortality ratios be misleading?

A
  • 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
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152
Q

What percentage of deaths is preventable?

A

5.2%

12,000 deaths per year

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153
Q

What are the causes of adverse events?

A
  • 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)
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154
Q

What is the Swiss Cheese Model?

A
  • 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
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155
Q

What is an active failure?

A

Unsafe acts committed by people in direct contact with patient

  • Usually short lived
  • Often unpredictable

Errors or violations

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156
Q

What are the 3 types of errors?

A

Knowledge based
Rule based
Skills based

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157
Q

What is a skills based error?

A

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

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158
Q

What is a rule-based error?

A

Encounter relatively familiar problem but apply the wrong rule .

Misapplication of good rule or application of a bad rule

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159
Q

What is a knowledge based error?

A

Forming wrong plans as the result of inadequate knowledge or experience

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160
Q

What are violations?

A

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

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161
Q

What are the 5 types of violations?

A 
Routine
Optimising
Situational
Reasoned
Malicious
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162
Q

What is a routine violation?

A

A violation that has become normal behaviour within a peer group

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163
Q

What is an optimising violation?

A

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

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164
Q

What is a situational violation?

A

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

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165
Q

What is a reasoned violation?

A

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

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166
Q

What is a malicious violation?

A

Deliberate act intended to harm someone or the organisation

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167
Q

What is a latent error?

A

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
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168
Q

What is the blame culture?

A

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

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169
Q

What is the human factors approach?

A

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

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170
Q

What situations are associated with an increased risk of error?

A

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

  • especially with lack of supervision
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171
Q

What are some of the individual factors that predispose to error?

A 
Fatigue
Stress
Hunger
Illness
Language
Cultural factors
Hazardous attitudes
172
Q

How can human factors thinking be applied to the work environment?

A
  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
173
Q

What are the 9 classifications of the contributory factors framework?

A
  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
174
Q

Why are children of particular concern ethically and legally speaking?

A
  • 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
175
Q

What are the rules for an under 16 year old making a decision?

A
  • 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
176
Q

What are the rules for decision making at 16-17 years old?

A
  • Presumed consent at 16
  • Consent must be obtained
  • If someone under 18 refuses - treatment given if approved by parents or courts
177
Q

Who has parental responsibility?

A 
Mother
Father if married
Father if they have acquired responsibility
Adopted parents
Guardian appointed by parents
Local authority name in a care order
178
Q

What is Gillick competence?

A

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

179
Q

When assessing best interests of a child what should you consider?

A
  • 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
180
Q

What is the principle of parental autonomy?

A

Parents have the right to make decisions regarding their children

Can be over-ridden by courts if necessary

181
Q

What are some of the complex treatment issues?

A
  • 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
182
Q

What is the harm principle?

A

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

183
Q

What are the criteria required to provide sexual health services to under 16?

A
  • 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
184
Q

What are the types of medical errors?

A
  • Medication - wrong drug, wrong dose
  • Surgery - wrong procedure
  • Infection control
185
Q

Why is consumer protection necessary?

A
  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
186
Q

What data is available to improve patient safety?

A
  • 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)
187
Q

What is SHMI?

A

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

188
Q

What are the key agencies involved in consumer protection agencies?

A
  1. Care Quality Commissions (CQC)
  2. Monitor
  3. National Patient Safety Agency
  4. National Institute for Health and Clinical Excellence (NICE)
189
Q

What is the care quality commission?

A
  • 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)
190
Q

What is Monitor?

A
  • Regulator of foundation trusts since 2004
  • Collaborates with CQC and National Audit Office
  • Responsible for competition policy and setting hospital tariffs
191
Q

How are families changing?

A

Increase in smaller, singe and step parenting families

  • Decreased birth rate
  • Later marriage
  • later child bearing
  • Working mothers
192
Q

What are some of the religious and cultural beliefs regarding pregnancy and child birth?

A
  • Pollution (unwashed baby, blood, placenta, cord)
  • Cleansing practices
  • Internal examinations and male practitioners
  • Circumcision
  • The month
  • Naming the baby
193
Q

What has changed in terms of childbirth practices?

A
  • Public to private
  • Natural to medical
  • Home to hospital
  • Midwife to Doctors and nurses
194
Q

What do people want from hospital (childbirth)?

A
  • Pain relief
  • Doctors attendance
  • Safety
  • Cleanliness
  • Higher status
  • Being cared for after birth
195
Q

What are the social movements in maternity care?

A 
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

196
Q

What are the major causes of death in children under 5?

A
  1. Pneumonia
  2. Diarrhoea
  3. Malaria
  4. Neonatal pneumonia/sepsis
  5. Preterm delivery
  6. Birth asphyxia
197
Q

What are the risk factors for childhood pneumonia?

A 
Low birth weight
Malnutrition
Non-breastfed children
Overcrowded housing
Indoor air pollution
198
Q

How do you minimise risks to newborns?

A
  • Quality care and nutrition during pregnancy
  • Safe delivery by a skilled birth attendant
  • Maternal immunisation
  • Quality neonatal care
199
Q

What was the first child survival revolution?

A
  • Led by UNICEF in 80s

Concentrated on

  • Growth monitoring
  • Oral rehydration therapy
  • Breast feeding
  • Immunisation
200
Q

What was the second child survival revolution?

A

Millennium development goals - 8 goals

201
Q

What are the 8 goals of the Millennium development goals?

A
  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
202
Q

What are the 4 risk factor categories for childhood death?

A
  • Service need and provision
  • Wider family and environmental factors
  • Factors intrinsic to the child
  • Factors around parental care
203
Q

What are the 4 Golden rules for talking with children?

A
  • 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
204
Q

Why are teenagers less likely to visit the GP?

A
  • Confidentiality
  • Communication
  • Lack of empathy
  • Perception of judgemental attitude of physicians

Rutihauser (2003)

205
Q

What difficulties can affect the nature of communication with children?

A
  • Major life impact
  • New school/ domestic situation/ area/ parent illness/ recent bereavement
  • Having a bad day
  • Anxious/scared/angry
  • Feeling unwell
206
Q

What are the components of social and emotional development outlined by Berk (2000)?

A
  • Emotional communication
  • Understanding of self
  • Ability to manage feelings
  • Knowledge about other people
  • Interpersonal skills
  • Friendships
  • Intimate relationships
  • Moral reasoning and behaviour
207
Q

What are the 5 stages in Erikson’s Psychosocial stages (1950)?

A

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)

208
Q

What are the Piaget’s stages of cognitive development?

A

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

209
Q

What are the 8 different intelligences outined by Gardner’s (1973)?

A
  • Linguistic
  • Musical
  • Logico-mathematical
  • Spatial
  • Bodily-kinesthetic
  • Interpersonal
  • Intrapersonal (self awareness)
  • Naturalist
210
Q

What are the indicators of social well being?

A
  • Social competence (social skills)
  • Rewarding personal and social relationships with others
  • Communication skills
  • Appropriate social behaviour
211
Q

What are the indicators of social dysfunction?

A
  • Victimised, ostracised, stigmatied by others
  • poor relationships with others
  • Social withdrawal
  • Inappropriate social behaviour
212
Q

What are the indicators of emotional wellbeing?

A
  • Stable and secure attachments to significant others (parents)
  • Emotions appropriate to context
  • Positive self-esteem
  • Generally happy and optimistic outlook on life
213
Q

What are the indicators of emotional dysfunction?

A
  • Unstable and insecure attachments to parents
  • Emotions inappropriate to context
  • Poor self esteem
  • Anxiety and depression
214
Q

What are the indicators of cognitive functioning?

A
  • 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
215
Q

What are the indicators of cognitive dysfunction?

A
  • 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
216
Q

What do the GMC guidelines state on personal beliefs and professionalism?

A
  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
217
Q

What is conscientious objection?

A

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

218
Q

Where does the GMC lie on conscientious objection?

A

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

219
Q

What should you do if you conscientiously object to something?

A
  • 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
220
Q

Define research

A

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

221
Q

What is the Nuremberg Code (1947)?

A

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
222
Q

What is the Helsinki Declaration (1964)?

A

Research ethics principles

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

223
Q

What are the general research ethic principles?

A
  • 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
224
Q

When is research ethics approval required?

A
  • Research with human participants, human tissue or personal data

If in doubt = get advice

225
Q

Why is approval from the research ethics committee needed?

A
  • 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
226
Q

When is NHS ethics review required?

A

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
227
Q

What do research ethics committee consider in an application?

A
  • 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
228
Q

Define consent for research

A

Consent is asking someone’s permission to involve them in the research project and letting them decide for themselves.

Must be informed and voluntary

229
Q

What should be on the information sheet for participants of a study?

A
  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
230
Q

What contributes valid consent for a trial?

A
  • not putting direct pressure on patients or volunteers to participate
  • not offering inducements
  • not threatening sanctions if they leave the study
231
Q

What the medical research council (MRC) guidelines on confidentiality?

A
  • All information is confidential
  • All research is to be approved by REC
  • All personal information must be coded and anonymised as far as possible
232
Q

What is the best study to use for diagnosis?

A

Cross sectional analytic study

233
Q

What is the best study for establishing aetiology?

A

Cohort study

Population based case-control study

234
Q

What is the best study for establishing prognosis?

A

Cohort study

235
Q

What is the best study for establishing treatment?

A

Randomised control trial

Systematic review

236
Q

What does appraisal assess a study for?

A
  • Bias
  • Applicability
  • Value
237
Q

What are the 3 steps for critical appraisal?

A
  1. are the results valid
  2. What are the results?
  3. Can I apply the results to this patient’s care
238
Q

When looking at the result of a therapy/ RCT, what should you look at?

A

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

239
Q

When looking at the results of a study looking at diagnosis what should you look at?

A 
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Likelihood ratio
240
Q

When looking at the results of a study looking at aetiology what should you look at?

A

Relative risk
Odds ratio
Number needed to harm

241
Q

What questions need to be asked as part of a critical appraisal? (of a review)

A
  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?
242
Q

Critical appraisal
Did the review ask a clearly focused question?
What should be considered?

A
  • population studied
  • intervention given or exposure
  • outcomes considered
243
Q

Critical appraisal
Did the review include the right type of study?
What should be considered?

A
  • address the reviews question

- have an appropriate study design?

244
Q

Critical appraisal
Did the reviewers try to identify all relevant studies?
What should be considered?

A
  • 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
245
Q

Critical appraisal
Did the reviewers access the quality of the included studies?
What should be considered?

A
  • Clear pre-determined strategy was used to determine which studies were included.

Look for

  • a scoring system
  • more than one assessor
246
Q

Critical appraisal
Was it reasonable to combine results?
What should be considered?

A
  • 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

247
Q

Critical appraisal
How are the results presented and what is the main result?
What should be considered?

A
  • 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
248
Q

Critical appraisal
How precise are these results?
What should be considered?

A
  • 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
249
Q

Critical appraisal
Can the results be applied to the local population?
What should be considered?

A
  • 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
250
Q

Critical appraisal
Were all important outcomes considered?
What should be considered?

A
  • individual
  • policy makers
  • professionals
  • family/carers
  • wider community
251
Q

What are the psychological components of pain?

A
  • Behavioural (fear avoidance)
  • Cognitive (somatisation/catastrophising)
  • Affective (anxiety/depression)
252
Q

What are the positive and negative meanings of pain for the sufferer? SOCIAL

A

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

253
Q

What are the biopsychosocial aspects of pain?

A

Bio - physiological dysfunction and neurophysiological changes

Pyscho - illness behaviour, beliefs, coping strategies, emotions, distress

Social - culture, social interactions, sick role

254
Q

What is the relationship between taking time off work and returning to work?

A

The longer a person is off work, the less likely they are to return

6m = 50%
1 year = 25%
2 year = 0

255
Q

What assessment tools can be used to assess pain?

A 
Visual analogue score
Verbal rating score
Brief pain inventory
HAD score
McGill pain score
LANSS score
256
Q

What are the treatments for pain (psychosocial approach)?

A

Eduction
- Healthcare professional or focus group

  • Coping strategies
  • Cognitive behavioural therapy
  • Mindfulness
  • Pain management programme
  • CBT
257
Q

What is mindfulness?

A

Meditation technique aimed at focusing the mind on the present moment

Relaxed and non judgemental awareness of thoughts, feelings and sensations

258
Q

Why do we have waiting lists?

A
  • Limitless demand for health
  • Limited resources for health care
  • Supply is finite
  • Creates scarcity
259
Q

What are the ways to ration healthcare?

A

By ability to pay (US)

By need

260
Q

What are the different waits within the NHS?

A 
GP appointment
specialist appoinment
agreed elective procedure
waiting room
A and E
Emergency admission
Ambulance
261
Q

How can wait be measured in NHS?

A
  • 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
262
Q

What are the different theories of NHS waiting lists?

A
  • 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
263
Q

What causes a reduction of waiting time?

A

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

264
Q

Describe the history of maximum inpatient waiting times under the labour government?

A

Started at 15 months down to 3 months

265
Q

Describe the history of maximum outpatient waiting times under the labour government?

A

26 weeks to 14 weeks

266
Q

Describe the history of maximum waiting times for cancer treatment under the labour government?

A

2 months to 1 month

267
Q

What policies were introduced in 2000-2008 regarding hospital waiting times?

A

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

268
Q

What are some of the down sides to monitoring the success of the NHS via perfomance indicators?

A
  • Unmeasured performance suffers
  • Adverse behaviour response (patients waiting in ambulance instead of emergency room)
  • Data manipulation and fraud
  • Sacrifice of professional autonomy
269
Q

What happened in 2010 after the change in government (NHS)

A

Waiting time targets relaxed or abandoned

Targets and terror to competition and choice

Maintained reductions without targets

270
Q

What national policies are in place to reduce waiting times?

A
  • 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)
271
Q

What are some of the policies to increase supply of surgery?

A
  • 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)
272
Q

What are some policies to reduce demand for surgery?

A

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

273
Q

What are some possible criteria for managing waiting lists?

A
  • Clinical urgency
  • Clinical severity
  • Potential health gain
  • Productivity and economic loss
  • Equity weighting (poverty)
  • Spare capacity
  • Length of time waiting
274
Q

What are the current challenges in managing waiting lists?

A

18 week referral to hospital treatment

Changing priorities for NHS policy

Nicholson challenge
Saving 15-20 billion

Changes in referral and treatment threshold

275
Q

Why should you support patients decision making?

A
  • 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
276
Q

What are the 5 key principles of the mental capacity act 2005?

A
  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
277
Q

What methods can be used to support patients in their decision-making?

A
  • 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
278
Q

What is the main purpose of mental capacity determination?

A

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

279
Q

What are the criteria for capacity?

A
  • 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
280
Q

What is advanced care planning?

A

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)
281
Q

What is the purpose of advanced directives?

A

Extend considerations of patient autonomy to situations in which the patient no longer has mental capacity

Can only refuse treatment, not demand it

282
Q

What are the criteria for advanced decisions?

A
  • 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
283
Q

What are the criteria for refusing life-saving treatment?

A
  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
284
Q

What are the pros of advance directives?

A
  • 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
285
Q

What are the cons of advance directives?

A
  • 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
286
Q

What is the incidence of falls?

A

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

287
Q

What are the consequence of falls?

A
  • 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
288
Q

What are the psychological problems of falls?

A
  • Fear of falling
  • Self imposed activity restriction
  • Social isolation
  • Depression
289
Q

What is a QALY?

A

To measure the burden of disease across different diseases = QALY is a measurement

1 QALY = 1 year in perfect health

290
Q

What methods are available to prevent hip fractures?

A
  • Fall prevention
  • Bone protection
  • Bisphosphonates
  • Vitamin D/ calcium
  • HRT

NOT hip protectors

291
Q

What are the risk factors for hip fracture?

A
  • 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+
292
Q

What medical conditions increase risk of fall?

A 
Parkinsons's
Stroke
Hypotension
Depression
Epilepsy
Dementia
Eye disease
Incontinence
Osteoarthritis
RA
Peripheral neuropathy
293
Q

What is the National Service Framework for Older people?

A

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

294
Q

What are the big 5 complementary therapies?

A 
Acupuncture
Chiropractic
Herbal medicine
Homeopathy
Osteopathy
295
Q

What are the barriers to more complementary therapy on the NHS?

A
  • Regulatory issues
  • Financial concerns within NHS
  • Tribalism
  • Inertia (resistance to change)
  • Mixed evidence of effectiveness
296
Q

What is an effectiveness gap>

A

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

297
Q

What do chiropractors mainly treat?

A

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

298
Q

What do osteopaths mainly treat?

A
  • 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
299
Q

What are the ways in which confounding can be addressed in design and analysis?

A
  • Restriction
  • Matching
  • Stratification
  • Multiple varibale regression
300
Q

What is restriction to prevent confounding?

A

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.

301
Q

What is matching to reduce confounding?

A

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

302
Q

What is stratification to reduce confounding?

A

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

303
Q

What are the limits to stratification?

A

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

304
Q

What is the prevention paradox?

A

The majority of people who suffer a [stroke] are not at high risk of [stroke]

75% have normal blood pressure

305
Q

What is the prevention paradox when targeting high risk groups?

A

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

306
Q

What is the prevention paradox when targeting the population?

A

Large potential benefit to community

Low potential benefit to individual

307
Q

Why are research-based recommendations important?

A
  • 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
308
Q

What are the features of recommendations (from research) that will increase their adoption?

A
  • 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
309
Q

What is an educational outreach?

A

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

310
Q

What methods can be used to spread information about a new recommendation?

A
  • 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
311
Q

What are computerised decision support systems?

A

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

312
Q

What is the true cost effectiveness of a technology?

A

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

313
Q

Name some reasons why a physician would not following the handwashing criteria?

A

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
314
Q

How many people in the UK have dementia?

A

800,000

315
Q

What are the benefits to an early diagnosis?

A
  • 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
316
Q

What is the impact of diagnosis on the patient? (dementia)

A
  • Denial (with or without insight). Attributes to old age. Often accompanied by anger
  • Grief reaction
  • Acceptance/ positive coping stratgies
317
Q

What can determine the response to the news of diagnosis of dementia?

A
  • Insight
  • Stage of illness
  • Ability to remember and process information
  • Type of dementia
  • Previous personality
  • Relationship and support
318
Q

What is the impact of diagnosis on carers? (dementia)

A
  • Confirmation of something they have long suspected
  • Fear
  • Anger
  • Grief
319
Q

What can determine the response to the news of the diagnosis of dementia?

A
  • Understanding of illness
  • Patients reaction
  • Nature of relationship with patient
320
Q

What are the benefits to getting a diagnosis?

A
  • 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
321
Q

How can the diagnosis of dementia effect the spouse/partner?

A
  • Relationship becomes skewed
  • Practical
  • Emotional
  • Physical/ sexual
  • Financial
  • Relationships
322
Q

How can the diagnosis of dementia effect the parent/child?

A
  • Role reversal
  • Competing demands
  • Conflict between family members
  • Effect on young children
323
Q

How can the diagnosis of dementia effect the health of the carers?

A
  • Increased stress
  • Increased physical care
  • Poor sleep
  • Constant vigilance
  • Loss of support of partner
  • Unable to take time off sick
324
Q

What can help carers?

A
  • 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
325
Q

What are the Behavioural and psychological symptoms of dementia

A
  • Restlessness
  • Physical aggression
  • Wandering
  • Sexual disinhibition
  • Repeated questioning
  • Screaming
  • Swearing
  • Anxiety
  • Depressive mood
  • Withdrawal
  • Hallucinations
  • Delusions and psychosis
326
Q

What is

  1. end of life care?
  2. end of life care pathway?
  3. end of life care drugs?
A
  1. Can be the last year or more of life
  2. last 48 hours of life
  3. Terminal patients
327
Q

Define palliative care?

A

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

328
Q

What is the goal of palliative care?

A

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

329
Q

What are the key principles of DNACPR?

A
  • CPR is a medical treatment that cannot be demanded by patients or their family
  • To offer futile treatments is ethically inappropriate
330
Q

Who is specialist palliative care provided for?

A

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

331
Q

Who is specialist palliative care provided by?

A

Health care professionals for whom palliative care is their core work.

Undergone relevant training increasingly provided by accredited specialist

Nurse, doctor, physio, OT, chaplain

332
Q

What are the generalist palliative care services?

A
  • Primary health care team
  • Nursing home
  • Secondary care
  • Social services
333
Q

What are the specialist palliative care services?

A
  • Clinical nurse specialists
  • Specialist physicians in palliative care
  • Hospices
  • Marie Curie nurses
334
Q

What palliative care services are provided by the NHS?

A
  • Community clinical nurse specialist
  • Hospital clinical nurse specialist
  • Some consultants
  • Some in patient units
  • Macmillian
335
Q

What palliative care services are provided by the voluntary sector?

A
  • Hosptice services
  • Most in patient beds
  • Marie curie/sue ryder
  • Marie curie nurses
  • Macmillan
336
Q

What different nurses are involved in palliative care?

A
  • District
  • Practice
  • Marie curie
  • Macmillan
337
Q

What is spirituality?

A

Umbrella term
- Religious or faith framework

Includes

  • Meaning to life
  • Purpose
  • Hope
  • Sense of person hood
338
Q

What questions can be used to encourage a patient to discuss spiratual things?

A
  • 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?
339
Q

What are the psychosocial risk factors for cardiac and respiratory conditions?

A
  • Anxiety
  • Depression
  • Anger/hostility
  • Socioeconomic status
  • Work/ marital stress
  • Caregiver strain
  • Lack of social support
340
Q

How does chronic stress causes cardiovascualr problems?

A
  • Increase in HPA
  • Increase in sympathetics
  • Increase altered behaviours
  • ANS dysfunction
  • Insulin resistance
  • Central obesity
  • Hypertension
  • Inflammation
  • Platelet activation
  • Decrease bone density
341
Q

What is ICIDH?

A

International classification of impairments, disabilities and handicaps

Takes into account all dimensions of disease

  • Disease
  • Impairment (functional loss)
  • Disability (activity limitations)
  • Handicap (social disadvantage)
342
Q

What is the Kubler-Ross Grief model 1969?

A 
Denial
Anger
Bargaining
Depression
Acceptance
343
Q

What is the dual process model of grief?

A

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
344
Q

What is Da Costa’s syndrome?

A

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

345
Q

What are the psychological sequale that follows disease?

A
  • Emotional/ affective
  • Cognitive/ thoughts
  • Behavioural/ lifestyle
346
Q

What modifies how people deal with serious disease?

A
  • Personality (Type A/ mental toughness)
  • Existing psychopathology (anxiety/ depression)
  • Personal control
  • Self esteem/self confidence
  • Current stress
347
Q

What are the issues are dealt with in rehabilitation?

A
  • Clinical symptoms
  • On going education
  • Misconceptions
  • Informal psychological assessment
  • Anxiety management/ counselling/ CBT
  • Facilitate lifestyle changed
  • Promote return to normal activity
348
Q

What is the health belief model?

A

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
349
Q

What is the transtheoretical model of behaviour change?

A
  • Pre-contemplative (no intention)
  • Contemplative (thinking, open to suggestions)
  • Preparations (change imminent)
  • Action (made changes)
  • Maintenance (change established)
350
Q

What are the factors that influence rehabilitation?

A 
Age
Gender
Social deprivation
Co-existing physical illness and severity
Health and illness beliefs
Intelligence/education
Past family history
Other people
Culture
Media
351
Q

How can rehabilitation be facilitated?

A

Education

  • Cognitive approaches e.g. goal-setting, cognitive techniques
  • Social support
  • Reinforcement (feeback, self monitoring, patient autonomy)
  • Client - practioner relationship (communication)
352
Q

What is the link between CHD mortality and social position?

A
  • Lower social postion

= increased risk

353
Q

What are the risk factors for cardiovascualr disease?

A 
Age
gender
FH
smoking
hypertension
cholestrol
diabetes
physical inactivity
obesity
diet
socio-economic status
psychosocial
alcohol
ethnicity
354
Q

What is the prevention paradox?

A

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

355
Q

What are the positives of the high risk treatment strategy?

A
  • Appropriate to the individual
  • Motivated subject
  • Motivated clinician
  • Cost effective resourceuse
  • Benefit: risk (high)
356
Q

What are the negatives to the high risk treatment strategy?

A
  • Screening difficult
  • Palliative and temporary
  • Limited potential
  • Behaviourly inappropriate
  • Labelling
357
Q

What are the positives to the population strategy?

A
  • Large potential

- Behaviourally appropriate

358
Q

What are the negatives to the population treatment strategy?

A
  • Population paradox (small individual benefit)
  • Poor motivation
  • Benefit: risk (low)
359
Q

How are thresholds for treating risk factors determined?

A

Driven by weighing the balance between costs and benefits:

  • costs to individuals (another tablet?)
  • cost to population
  • absolute benefits
360
Q

What is decision analysis?

A

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
361
Q

What are the stages of decision analysis?

A
  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
362
Q

On a decision tree what does a square node represent?

A
  • Decision node
  • Represents choice between actions

e.g. What do I do?

363
Q

On a decision tree what does a circle node represent?

A
  • Chance node
  • Represents uncertainty
  • Potential outcomes of each decision

e.g. noting, give treatment, find out more information

364
Q

What are utility measures?

A
  • measure of desirability of all possible outcomes in the decision tree
  • Provide a numerical value attached to beliefs and feelings
365
Q

What is EQ-5D?

A

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
366
Q

Give examples of utility measures

A
  • QALY (quality adjusted life years)
  • Rating scales
  • Standard gamble
  • Time trade off
367
Q

What is a QALY?

A

1 year in perfect health

Considers quantity and qaulity of life

368
Q

How is expected utility calculated?

A
  • 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
369
Q

What are the benefits to decision analysis?

A
  • 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
370
Q

What are the limitations of decision analysis?

A

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
371
Q

What is the Parkes 4 stages of normal grief?

A
  1. Numbness
  2. Yearning
  3. Disorganisation
  4. Reorganisation
372
Q

What are the features of acute grief?

A
  • 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
373
Q

What are the Wordens’ tasks of mourning?

A
  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
374
Q

What is pathological grief?

A
  • extended grief reaction (getting stuck)
  • mummification and denial
  • major depressive disorder >2 months after loss
375
Q

What are the food safety concerns?

A
  1. food borne illness
  2. nutritional adequacy
  3. environmental contaminants
  4. naturally occurring contaminants
  5. pesticide residues
  6. food additives
376
Q

What are the methods of prevention for food poisoning?

A
  • Public education
  • Staff training
  • Food inspectors
  • Bad PR
  • Proper equipment well maintained
  • Good raw materials
377
Q

What are the principal sources of food poisoning outbreaks in UK?

A

Catering premises
Institutions
Catered functions
Other

378
Q

What is the public health act?

A

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
379
Q

What is the food safety act?

A

1990
Defines food and enforcement authorities and their responsibilities

  • premises must be registered
  • inspections
  • obligations to ensure safety
  • powers of enforcement
380
Q

What is Hazard Analysis Critical Control Point? HACCP

A

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
381
Q

What are the 4 components in an evidence based approach?

A
  1. Question formulation
  2. Literature search
  3. Appraisal of evidence
  4. Clinical decision
382
Q

What are clinical decision support systems?

A

Designed to aid clinician decision making

  • can be computerised
  • may be paper based
  • may be reminder systems
383
Q

Give some examples of clinical decision support systems?

A
  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
384
Q

Define sensitivity

A

Proportion of people with target disorder who have positive test

True positives / true positive+false negative

385
Q

Define specificity

A

Proportion of people without the target disorder who have a negative test

True negative/ true negative+false positive

386
Q

Why use a clinical decision support system?

A

Can improve practioner performance in

  • diagnosis
  • disease management
  • prescribing/ dosing
  • rates of vaccinations, screening
387
Q

What may hinder the use of clinical decision support systems?

A
  • earlier negative experience of IT
  • potential harm to doctor-patient relationship
  • obscured responsibilitie
  • reminders increase workload
388
Q

What are the aims of patient decision aids?

A
  • 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
389
Q

Define equality

A

Being the same in quantity, amount, value, intensity

390
Q

Define equity

A

Fairness or impartiability; even handedness

391
Q

Where is justice involved in healthcare?

A
  • Prioritisation and rationing of services
  • Allocation of sparce health resources
  • Health service funding
  • Research prioritisation and participation
  • More specific allocatory decisions e.g. organs
392
Q

What is a QALY?

A

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

393
Q

What are the objections to QALY based assessments?

A
  • 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
394
Q

What is the argument for QALYs not being ageist?

A

It does not aim to discriminated against elderly

Treated the same no matter what age

395
Q

What is the double jeopardy objection?

A

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

396
Q

What is a needs-based assessment?

A

Make resource allocations decisions on basis of need

397
Q

What are some objections to needs-based approaches for resource allocation?

A
  • 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
398
Q

What criteria can be used for making resource choices?

A
  • 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
399
Q

What are the arguments for lifestyle-based assessments for resource allocation?

A
  • 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
400
Q

What are the arguments against lifestyle-based assessments for resource allocation?

A
  • 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
401
Q

What is the rule of rescue?

A
  • Provide aid to identified victims of illness or accident
  • Public are more sympathetic towards a named person who is dying
  • not capsured by QALYs
402
Q

What is economic evaluation?

A

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)

403
Q

Why is economic evaluation important?

A
  • Increasing healthcare expenditure means need to evaluate medical care
  • Increasing health care reforms so need to evaluate health policies
404
Q

What do clinical evaluations investigate?

A

Efficacy

Effectiveness

405
Q

What do economic evaluations investigate?

A

Efficacy

406
Q

When making decisions about resource allocation what should be considered?

A
  • Opportunity cost of choices

- Benefit of their choice

407
Q

How do you measure cost?

A

A cost is the value of what you give up

  • cost to NHS?
  • Patient
  • Carer
  • Society
408
Q

How do you measure benefit?

A
  • Health gain e.g. increase in life length/ quality
  • Social gains for community
  • Health/social gains of family
409
Q

What are the different types of economic evaluation?

A

Depends on the outcome measure used

  • Cost minimisation analysis (CMA)
  • Cost effectiveness analysis (CEA)
  • Cost utility analysis (CUA)
  • Cost benefit analysis (CBA)
410
Q

What is cost minimisation analysis?

A

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

411
Q

What is cost effectiveness analysis?

A

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

412
Q

What is cost utility analysis?

A

Combines multiple outcomes in a single measure of utility e.g. QALY

Allows comparisons between alternatives in different therapeutic categories with different natural outcomes

413
Q

What is cost benefit analysis?

A

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

414
Q

What are the 3 stages to costing in economic evaluation?

A
  • Identification
  • Measurement
  • Valuation of inputs into healthcare

What costs to include

415
Q

What is the function of sensitivity analysis?

A

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
416
Q

How do you deal with time in health economic evaluation?

A

Greater weight is given to current over future costs

Future costs and benefits must be discounted to their present value

417
Q

What are 2 generic measures for measuring and valuing outcomes in quality of life?

A 
SF36
EQ 5D (NICE recommended)
418
Q

What are the key features of a good economic evaluation?

A
  • 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
419
Q

Whhy are health economics important?

A
  • 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
420
Q

How can expenditure in healthcare be controlled?

A
  • Private insurers are poor purchasers
  • Governments impose cash limits
  • Private systems by price
  • Public systems by need
421
Q

How is the NHS budget divided amongst countries?

A

barnett formula

422
Q

What is the principle of allocation of care according to need?

A

Targeting resources at those activities that give the greatest patient health gain for the £ spent

Maximise population health gain from the available budget

423
Q

What is technical efficiency?

A

Maximise production of goods or services

424
Q

What is allocative efficiency?

A

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

425
Q

How do you incentivise changes in clinical behaviour?

A

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

426
Q

Define body dysmporphic disorder

A

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

427
Q

Describe the disability and stigma caused by incontinence

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

Year 2 - Theme C (1 decks)

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