Year 2 Flashcards
What is evidence based medicine
Princess of identifying and using most up to date and relevant evidence to inform decisions for individual patient problems
Process of evidence based medicine
Need for info into an answerable question
Identifying best evidence to answer it
Critically appraising the evidence for validity impact and applicability
Interstates critical appraisal with clinical expertise and patients unique circumstances
Evaluating effectiveness and efficiency and seeking ways to improve
Which factors influence infection
Infectious agents (ability to survive and spread, infectivity, pathogenicity)
Environment (contamination humans animals water)
Mode of transmission (airborne blood sexual contact direct consumption)
Portal of entry (mouth nose skin gi)
Host factors (illness nutrition age lifestyle)
Infections in health care
Nosocomial infections
Uti pneumonia lower respiratory tract infection surgical wounds septicemia
Rare ones eg chicken pox tb mrsa
90/10 gap
Less than 10% of worldwide resources devoted to health research put towards health in developing countries where over 90% of all preventable deaths worldwide occur
What is R0
Basic reproduction rate
Average number of individuals directly infected by an infectious case during infectious period in a totally susceptible population (number of secondary cases following an infection)
List some internal immunization programmes
Expanded programme on immunization (EPI)
Global polio eradication initiative (GPEI)
Global alliance for vaccines and immunization (GAVI)
Calman hine report
Examined cancer services in uk and proposed restructuring of cancer services to achieve a more equitable access to high levels of expertise throughout the country
Consequences of calman hine report
All patients having equal access to high quality of care
Public and professional education to recognize early symptoms of cancer
Patients families and carers given clear info on treatment options and outcomes
Patient centred
Primary care to be central to cancer care
Psychological needs of patients and carers to be recognized
What is the national cancer survivorship initiative
Partnership with cancer charities clinicians and patients considered a range of approaches for improving services and support available for cancer survivors
Importance of hair
Individual and group identity
Symbol of femininity
Stigma
Shows sickness status
What is surveillance
Systematic collection collation and analysis of data and dissemination of results so appropriate measures can be taken
Purpose of surveillance
Early warning system for impending public health emergencies
Document impact of an intervention or track progress towards specific goals
Monitor and clarify epidemiology
Role of WHO in public health
Providing leadership and engaging in partnerships where joint action needed
Shaping research agenda
Setting norms and standards and promoting and monitoring them
Articulating ethical and evidence based policy options
Providing technical support
Monitoring health situations and trends
Functions of a clinical record
Support patient Care
Improve future patient care
Social purposes at request of patients
Medico-legal document
ABCDE method of breaking bad news
Advanced preparation Building a relationship Communicate well Deal with patient reactions Encourage and validate emotions
SPIKES method of breaking bad news
Setting up Perception Invitation Knowledge Emotions Strategy and summary
Role of midwife in postnatal care
Screeening/identification of at risk clients Lifestyle changes Mental health services Health promotion Information-bonding breast feeding Reassurance and support Safeguarding
Sensitivity
Proportion of positive correctly identified
True positives /(true positives+false negatives)
Specificity
Proportion if negatives correctly identified
True negatives/ true negatives+ false positives
Limitations of screening
Expensive Adverse effects (stress radiation exposure discomfort ) Stress caused by false positive False sense of security by false negatives which delay final diagnosis
Four resources used when making a clinical decision
P atient preferences
A vailable resources
R esearch evidence
C linical expertise
Positive predictive value
Probability that subjects with a positive screening test truly have the disease
True positives / all positives
Negative predictive value
Probability of subjects with a negative screening test truly don’t have the disease
True negative / all negative
Near miss
Situation which events arise during clinical care but fail to develop further
Can report it at the national reporting and learning system
What are the free travel vaccines available
Diphtheria polio tetantus typhoid hepatitis a cholera
Paper records
Continuous portable writer identified legibility issues must be dated and signed
Electronic records
Problem orientated searchable structured safer prescribing clinical decision support software
Adverse event
Unintended even resulting from clinical care and causing patient harm
Near miss
Situation in which events arise during clinical care but fail to develop further
Types of errors
Knowledge- wrong doings due to inadequate knowledge or experience
Rule based- misapplication of a good rule or application of a bad rule
Skills based-attention slips and memory lapses
What to do when adverse incidents occur
Report it incident reporting systems
Assess its seriousness
Analyze why it occurred (root cause analysis)
Be open and honest with affected patients and apologize (duty of candor)
Learn from event and put in place actions to reduce risk of repeat
Purpose of surveillance
Serve as an early warning system for health emergencies
Document the impact of an intervention
Monitor and clarify epidemiology of health problems
Length bias
The overestimating of survival duration among screening-detected cases due to an increase of slowly progressing cases
Active failures
Unsafe acts committed by people in direct contact with the patient
Usually short lived and predictable
Latent error
Develop over time until they combine with other factors or active failures to cause an adverse event
Long lived and can be removed before they cause an adverse event
Types of violations
Routine (regularly performed has become a norm)
Reasoned (reasoned, done for patients best interests)
Reckless (deliberate deviations from protocol but not intended to cause harm)
Malicious (deliberate deviations intended to cause harm)
Mental health problems in post natal period
Baby blues (50-80%)- acute stress reaction treated with reassurance Postnatal depression (10-15%) low mood for more than two weeks tcas and ssris Postnatal psychosis (0.2%) thoughts of harming themselves or the baby and delusions etc ECT therapy
Summary hospital level mortality indicator
Ratio between actual number of patients who die within 30 days of discharge compared to expected to die average
Male screening programmes
Newborn and infamy physical exam Newborn blood spot Newborn hearing Diabetic eye Bowel cancer Abdominal aortic aneurysm (age65)
Primary care records
Advanced computer systems
Paper light
Limited access for community teams
Serious incidents
Opportunity for learning very large
Warrant and use resources to investigate and act
Serious consequences to patients or staff
Four areas of child development
Gross motor
Find motor and vision
Hearing speech language
Social skills and behavior
The midwives act 1902
The normality of child bearing and calling doctors as soon as abnormality occurs
Equal access to midwives of all socioeconomic standings
Four areas of development
Frods motor
Fine motor
Hearing speech language
Social skills / Behaviour
Development checks
Neonatal examination
6-8wk gp fheck
1 yr check by health visitor
2-2.5yr check by hv
Development red flags
No smile at 8 weeks Not holding objects at 5 months Not sitting at 12 months Not walking at 18 months Not pointing at objects at 2 years
Leading cause of death in young people
Suicide
Patient death causes
Poor clinical monitoring
Diagnostic error
Inadequate drug/ treatment (acts of commission)
Acts of ommision
Failure to treat according to test evidence
PICO
Population
Intervention
Comparison
Outcome
Match pico to study design
Diagnosis -cross sectional study Aetiology- cohort study Prognosis/ cohort study Therapy- RCT Evaluation/acceptance- qualitative research
Three main questions for evaluating a study
Are the results valid
What are the results
Can i apply the results to this patients care
Theories of nhs waiting lists
Backlog
Demand management (waiting acts as deterrent to prevent frivolous use)
Allows resources to be fully used -no waste
Underfunding and inefficiency
Individualised multifactorial intervention
Strength and balance training
Home hazard assessment and intervention
Vision assessment and referral
Medication review
Falls prevention programme
Discuss what changes a person is willing to make
Address fear of falling and encourage activity
Educate
Measures to prevent falling
How to cope if they fall
Palliative care services
Generalists- primary health care team, nursing home, secondary services, social services
Specialist- specialist nurse and physicians, hospices, marie curie nurses
District nurse
Primary health care team
Community based
Hands on skills
Practice nurse
PHCT
Practice baded
Hands on
Marie curie nurse
Community based
Arranged by district nurse
Specialist palliative care skills
Hand on
Macmillan nurse
Community or hospital based
Specislist care
Advice support and resource
Publication bias
Non publication of study results because of strength or direction of finding
Can result in overestimation of treatment benefits
Performance bias
Unequal provision of healthcare between treatment and control group apart from treatment being tested
Eh placebo group receiving additional therapies or patients changing their health behaviours
Lead time bias
Overestimation of survival due to early detection of screening rather than clinical presentation
Eg survival following diagnosis
Population attributable risk
Risk of disease will increase as exposure prevalence of relative risk increases
Eg more people who smoke the more risk of cvd attributable to smoking in population
Risk decision analysis steps
Decision tree Assess probability Assess utility Identify option that maximises utility Could conduct sensitivity analysis If two options have same expected utility then it’s a toss up
Food frequency questionnaires
Pros and cons
Pros: it captures usual diet and less work to code/complete
Cons: doesn’t record actual diet as eaten, overestimation of fruit and veg , poor measure of energy intake and less flexible
Decision analytic approach benefits
Makes all assumptions in a decision explicit
Allows examination of the process of making a decision
Integrated research evidence
Can be used for individual decisions, population level decisions and cost effective analysis
Cardiophobic
Anxiety disorder characteristic of repeated chest pains and palpitations accompanied with fear of heart attack and dying
Da costas syndrome
‘Irritable heart’
Dyspnoea fatigue rapid pulse palpitations chest pain
Mostly with exertion
Associated with exhaustion and emotional strain
Population strategy pros and cons
Pros : large potential as targeting many people
Cons: population paradox- small perceived individual benefit, poor motivation and can cause compliance issues. Benefit for risks is low
Types of singlular economic health evaluations
All called partial evaluation
Outcome description (consequences only)
Cost description (cost only)
Cost-outcome description (both)
Types of economic health evaluation where two or more alternatives compared
Partial evaluation- effectiveness analysis (consequences only)
Partial evaluation- cost analysis (costs only)
Both is full economic evaluation
Types of full economic evaluation
Cost effectiveness- single common variable measures eg life years gained
Cost utility- quantity and quality of life eg qalys
Cost benefit- all effects measured outcomes valued by money spent
Two ways evaluations can be conducted
Conducted alongside RCT or non randomised studies eg before and after . These collect primary data
Rely on secondary data or existing studies eg technology assessment reviews for NICE
Cost minimisation analysis
Not full for of economic evaluation
Assumes health effects to be equal in each alternative
Appropriate when prior evidence suggests there is no or little difference in outcomes between the options
Cost effective analysis
Effects measured in most appropriate uni dimensional natural unit or health profiles
Cost per unit effect
Eg renal failure cost per life saved
Where does cea data come from
Evaluation alongside rct usually only one year time limit
Modelling-data from literature, meta analysis needs to be non biased
Incremental cost effectiveness ratio
(Cost of intervention- cost of control)/
Effectiveness of intervention- control
Cea advantages and disadvantages
Straightforward to carry out and easy to understand
But narrow uni dimensional measure of effect so can’t compare alternatives measured in different units
Qaly league table approach problems
Used in cost utility analysis Maximises efficiency within nhs budget But methods underlying cost/qaly estimates may differ between studies Opportunity cost ignored Lowest qaly ones may be ignored
Cost benefit analysis adavantages
Allows comparison across programmes with different health outcomes
Allows comparison with non health care interventions so can be used to allocate a global budget
Overall public sector efficiency needs a standardised price per unit of outcome that funders are willing to pay
CBA issues
How do we value a life or health outcome
Must measure time being spent
Most comprehensive but rarely undertaken
Which economic evaluation is preferred choice
Cost utility analysis
NICE recommends it where costs measured in pounds and outcomes in qalys
Zoonosis
Objects or materials likely to carry infection
Basic reproductive number
R0
Number of cases each particular case generates
Affected by rates of contacts probability of transmission and duration of infectiousness
Effective reproduction rate
R
Estimated number of secondary cases per infectious case in a population of susceptible and non susceptible hosts
Endemic disease
Found in a specific region or within a specific demographic
6 global causes make up 70% of childhood deaths
Lower respiratory tract infections Infections Diarrheal illness Malaria HIV Measles Neonatal infections
Examples of inactivated vaccines
Hep a
IPV
Some flu vaccines
Rabies
Examples of recombinant vaccines
Hep b
Hpv
Men b
Conjugate vaccines examples
Hib
Men c
Pcv
Vaccine safety things
Once a vaccine is being used in uk ius monitored by mhra for rare side effects
Anyone can report a suspected adverse reaction through yellow card scheme
What is sojourn time?
The duration of a disease before clinical symptoms become apparent but during which it is detectable by a screening test. Its clinical relevance is that it represents the duration of the temporal window of opportunity for early detection Length of sojourn time short-: Rapidly progressing disease, poorer prognosis (SHORTER DETECTABLE PERIOD) Length of sojourn time long: Better prognosis (LONGER DETECTABLE PERIOD)
order of food outbreak investigation
preliminary steps
intermediate steps
collecting data
environmental investigation
preliminary phase
is there an outbreak?
confirming diagnosis
what is nature and extent of outbreak
intermediate steps
who is ill and how many case finding whats the cause is proper care being arranged what immediate action can be taken
collecting data
time person place number affected symptoms common factors food histories storing data
environmental investigation
revisit food path
hazard analysis and critical control points
dont tell pls show
samples of food surfacae and equipment swabs
catering staff
outbreak outliers
cases that dont appear related but could be significant as they may represent baseline level of illness outbreak source case exposed earlier than others case with long incubation period eg cholera story
analytical epidemiological studies
in absence of lab confirmation this may be used to identify source of out break
compare food history of ill and well people
point source outbreak- cohort study
common source outbreak- case control study
establishing causality (8 things)
Temporal : risk precedes outcome
Specific : associated with disease it causes
Consistent : does this in other countries / groups of ppl
Strong : strong association good indicator of causality
Dose response : more the exposure the more likely the outcome
Modifiable : If you stop the exposure the risk goes back to base line
Plausible : is it likely
Coherent : needs to be consistent with the science
Wernicke-Korsakoff syndrome
Complication of thiamine deficiency and neurotoxicity from alcohol Medical emergency mortality of 10-20% treatment should not be delayed on investigations Altered mental state and mild memory impairment Oculomotor abnormality ( nystagmus, ocular palsies ) Cerebella dysfunction ( ataxia ) Management, oral thymine High risk = 3 days parental thymine Suspected = parental thiamine twice daily for 5 days
Food safety policy
Food is not intrinsically safe. Food concerns (1) food borne illness (2) nutritional adequacy (3) Environmental contaminants (4) Naturally occurring contaminants (5) Pesticide residues (6) Food additives
haccp
hazard analysis and critical control points
Good manufacturing practice guidelines covers all aspects of food production and labeling and storage
Analysis of hazards.
Identification of points where hazards may occur. Deciding which point are critical to food safety. Implementing control and monitoring procedures. Reviewing hazards at critical points at intervals especially when there has been a change in operation.
blame culture
individuals cover up errors for fear of retribution - reduces focus on true causes of failure
What is MPS
enhanced person matching algorithm that increases number of link able records when incomplete records have been submitted
MPS good clinical record
allow a clinician to reconstruct a consultation or patient contact without relying on memory. It will include:
Comprehensive history, examination of patient, systems examines, all important findings, differential diagnosis, investigations, referral, information given to patient, consent, treatment, follow-up arrangements, progress
three core principles of nhs
meet the needs of patients
focus on clinical needs rather than ability to pay
be free at point of delivery
care quality commission
assess quality of healthcare
license healthcare
produce policies by unannounced visits and routine data use
child welfare steps-how to stop child mortality
Reduce risk of preterm birth and LBW and promote maternal health
Improve recognition and management of serious illness across the health service
Implement policies for common causes of death from accidents and injuries
Improve management of chronic diseases, including mental health
The Children Act 1989
To allow children to be healthy.
Allowing children to remain safe in their environments.
Helping children to enjoy life.
Assist children in their quest to succeed.
Help make a contribution – a positive contribution – to the lives of children.
Help achieve economic stability for our children’s futures.
Children and Families Act 2014
aims to ensure that greater protection is available for children who have been classed as vulnerable. eg foster care or additional needs.
The Act also ensures that a Education, Health and Care Plan is produced for children with additional needs
The Education Act 2002
places a duty on educational settings such as schools and colleges to ensure that the safeguarding and welfare of children are paramount to the way in which their establishment functions.
And to make sure staff receive adequate training on safeguarding and welfare
child morbidity and mortality stats
Preterm birth and low birth weight are major risk factors including
Maternal age, smoking, socio-economic disadvantage
After infancy, injury is most frequent cause of death >75% in 10-18 year bracket
Suicide remains the leading cause of death in young people in the UK, these have not declined in 30yrs
infants most deaths>adolescents>young children
medical model of birth
Birth is seen as a dangerous journey that is only normal in retrospect, therefore assume the
worst. There is a low threshold for intervention (to fix the defective bodies)
Induction of labour
Strict time thresholds for progression
Cesarean
Epidural anaesthesia
Continuous electronic foetal monitoring
Frequent assessment of progress in labour
Labour in an obstetric unit
social model of birth
Birth is a normal physiological process, which women are uniquely designed to
achieve.
Support the capability of the women’s body
Home from home environment
Use of different positions to give birth
Use of other supportive measures such as bath for pain management and pool for
labour and birth
Watchful waiting/patients
social/cultural issues of pregnancy
Unintended pregnancy - Delay in seeking prenatal care and having a premature
baby, higher levels of stress and depression
Pregnancy may or may not fit with the mothers plans
Social disapproval/stigma for pregnancy out of wedlock and teenagers and too old people
barriers to MDT working
Separate documentation Poor working relationship Lack of awareness and appreciation of the roles and responsibilities of others Limited time and resources Overlapping of roles and duplication of services Poor communication Lack of information sharing Lack of collaboration Lack of trust and confidence in the abilities of other agencies Increased workload Lack of appropriately trained staff Constant re-organisation
epidemiology on chd
More ppl die of CVD globally that any other disease
28% of deaths in the UK for men are from CVD
26% of deaths in the UK for women are from CVD
Rates of death have halved in the UK from 1990-2019
Over 75% of CVD deaths are in low to middle income countries
Heavy smokers have a 32x risk of non-smokers of dying from lung cancer
population attributable risk
How much of the disease in the population is attributable to a particular exposure
PAR = Risk in population - Risk in unexposed
population attributable fraction
the proportional reduction in population disease or mortality would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario.
Prevention paradox
A large number of people exposed to a small risk generate many more cases than the small number exposed to high risk. Therefore should strategies to reduce risk only target high risk individuals or the population as a whole?
10 principles of screening
Should be an important health problem
Should be accepted treatment for those identified with that disease
Facilities for diagnosis should be available
Should be a recognizable latent or early symptomatic stage
Should be a suitable test or examination
Test should be accepted by the population
Natural history and development of the disease should be understood
Should be an agreed policy on whom to treat as patients
The cost of funding ( including diagnosis and treatment ) should be economically balanced in relation to possible expenditure on medical care as a whole
Case-finding should be a continuing process not a ‘once and for all’ project
how to measure waiting times
average waiting time (mean or median)
proportion who waited longer than x number of days
average wait of people currently on list
measurement issues
outpatient vs inpatient waiting gp referral wt of treated patients vs on the list waiting time by specialty or procedure mean vs median elective vs emergency
theories of nhs waiting lists
backlog- implies needs of emergency funds
demand management- waiting acts as a ‘price’ to deter frivolous use
allows nhs resources to be fully employed
What situations are associated with an increased risk of error?
Unfamiliarity with the task, inexperience, shortage of time, inadequate checking, poor procedures, poor human equipment interface
Demand-side policies
These policies when it comes to waiting times consider:
o Explicit guidelines to prioritise patients
o Subsidise private insurance
supply side policies
These policies when it comes to waiting times consider:
o Increased production in the public sector by funding extra activity
o Contracting with private sector
o Sending patients abroad
o Increased productivity by producing activity-based financing
o Increased choice of providers
o Improved management of waiting lists
combined policies
These policies when it comes to waiting times consider:
o Waiting-time guarantees
o With sanctions
o With choice and competition
what is confounding
Confounding is an apparent relationship between an exposure and an outcome that is false; that is, it implies a causal relationship that actually does not exist
four ways to deal with confounding
restriction
matching
stratification
adjusting
restriction method
removing the data which contains the cofunder
but less data and difficult when theres other cofounders
matching method
most common in case control
match the number of confounders in each group
good for string cofounders such as age and sex
still need to consider cofounding in analysis
stratification
Possible in analysis. Analyze exposure : outcome association in different sub-groups of the confounder
eg make table for pie eaters and calculate risk and make one for non pie eaters and calculate risk
adjusting
Last step for stratification is - Adjust for confounding if number of variables involved is relatively small
Recombine the results to get an adjusted measure of effect
This is effectively a weighted average of the effect seen in each stratum ( adjusted risk ratio )
crude ratio vs adjusted risk ratio eg 1
multiple variable regression
you do not need to be able to do this, just understand
y = a + bx
Y = vertical axis
a= intercept of data on the y axis
b= gradient of the data on the graph
x= horizontal axis
You can plot confounders on the axis so there will be multiple b’s lines with different gradients
y= a + (b1x1) + (b2+2) +(b3x3)
B1x1 = jogging
B2x2 = smoking
B3x3 = drinking ect..
The coefficients of the multiple explanatory variables (x1 x2 x3) can be used to estimate measure like risk ratios, odds ratios ect.
The coefficients of the regressions compensate for confounding in the same way as stratification. They allow for ‘adjustment‘ of estimates for confounding
what is quality improvement
Interactive and iterative
Engage participants across organizational levels
Foster environment where improvement and innovation and viewed as normal
Empowering staff to strive for change
Provide knowledge and methods to implement change
Remove barriers to change
quality improvement cycle
Plan: set goals, predict, plan data collection
Do: test the plan, document the problem, reassure and revise
Study : complete data analysis, review lessons and decide action
Act: implement evaluate and decide next cycle
CQUIN - how they get hospitals to change quality
Improve staff health and wellbeing
Reduce the impact of serious infections
Improve transition out of children and young people metal health services
Support proactive and safe discharge
Prevent ill health by reducing risky behaviors e.g smoking and alcohol
Quality outwork framework in gp
Annual reward and incentive programme detailing GP proactive achievement results
Compared delivery and quality of care against previous years
Enables commissioners to reward ‘excellence’ across key domains e.g public health, patient experience, quality and productivity
the research cycle
clinical problem
basic research
applied research
clinical care
1) clinical problem
Observation, association, prognosis Person ( patient ) Population Why is this a problem and for who Priority setting partnership PPI
2)basic research
Lab based
Biochem, genetics, physiology, in vitro, experimental models
3)applied research
Questions determines type of study Intervention = comparative study Prognosis = Cohort Diagnosis = Comparative Satisfaction = Survey / qualitative study Value = Cost- effectiveness study
4)clinical care
Getting evidence into practice gaps : Identify the need for knowledge Discovery of that new knowledge Synthesis of knowledge Application of knowledge Development of routine clinical actions
positive likelihood ratio
sensitivity/(1-specificity)
negative likelihood ratio
(1-sensitivity)/specificity
‘intention to treat’
analysis
In such an analysis, participants in a trial are analysed
within the group they were allocated in randomisation,
even if they have not completed the trial or changed
treatment.
why is assessing the quality of trials by two authors good practice
Assessing quality is important because studies with
weaker designs will be less valid and can overestimate
effects.
Using two independent reviewers to assess quality
makes it less likely that errors will be made.
Using pre-agreed criteria helps make the process
objective and transparent
what is meta analysis
A statistical technique for quantitatively combining the
results of multiple studies that measure the same outcome
into a single pooled or summary estimate.
difference between deductive and inductive
deductive is intended to give logically conclusive support for the conclusion, as
opposed to giving the conclusion probable support which is inductive
what makes an argument valid
The conclusion follows logically from the premises
It is impossible for the premises to be true and the
conclusion to be false
What is meant by saying an argument is sound?
An argument is sound if the conclusion follows logically from premises that are in fact true
audit cycle
identify problem set standards collect data assess conformity of current practice to standards implement change re audit
theories of decision making
Normative - what you should be doing, according to social or professional norms
Descriptive - what are you doing
Prescriptive - how can we improve what we are doing
3 moral theories
(1) Consequentialism
The morally right action is the one that achieves the best outcome overall
Act utilitarianism : morality of an action is determined by the effect on people regardless of the action
Rule utilitarianism : morality is determined if the person followed the general rule or conduct that leads normally leads to the best outcome
(2) Duty ethics - deontology
Acts are morally right if they accord with moral rules or duties.
Therefore an act may be right even if it leads to worse consequences overall - may derive from divine revelation e.g 10 commandments
(3) Virtue ethics
Morally right action is the one a virtuous person would perform in the circumstances
Virtues are those traits, dispositions and ways of thinking needed for human happiness or flourishing e.g honesty, open-mindedness
What statistical test to use to get the p value
Quantitative data
Two groups > Independent T-test, adjust using multiple regression
One group ( paried ) > Paired T-Test
Qualitative data
Two groups > Chi-squared/ odds ratios, adjust using logistic regression
One group ( paired ) > Mcnemar test
What statistical test to use to get the p value
Quantitative data
Two groups > Independent T-test, adjust using multiple regression
One group ( paried ) > Paired T-Test
Qualitative data
Two groups > Chi-squared/ odds ratios, adjust using logistic regression
One group ( paired ) > Mcnemar test
What statistical test to use to get the p value
Quantitative data
Two groups > Independent T-test, adjust using multiple regression
One group ( paried ) > Paired T-Test
Qualitative data
Two groups > Chi-squared/ odds ratios, adjust using logistic regression
One group ( paired ) > Mcnemar test
What are the 6 key areas for action in the cancer reform strategy (2007)?
Prevention-Smoking, obesity, alcohol etc
Diagnosing cancer earlier-Screening
Ensuring better treatment-Reduced waiting times, increase in radiotherapy capacity, new cancer drugs be referred to NICE, chemotherapy audits
Living with and beyond cancer-National cancer survivorship initiative
Reducing cancer inequalities
Delivering care in best setting-Locally where possible, services should be centralised where necessary
‘Improving outcomes: A strategy for cancer (2011)’?
Prevention and early diagnosis
Quality of life and patient experience
Better treatments
Reducing inequalities
independent cancer taskforce (2015)
radical upgrade in prevention and public health
Drive a national ambition to achieve earlier diagnosis
Establish patient experience as being on a par with clinical effectiveness and safety
support people living with and beyond cancer
Make the necessary investments required to deliver a modern high-quality service
Overhaul process for commissioning, accountability and provision
What is sojourn time?
duration of disease before clinical symptoms become apparent but during which it is detectable by a screening test.
Its clinical relevance is that it represents the duration of the temporal window of opportunity for early detection.
Length of sojourn time short-
Rapidly progressing disease, poorer prognosis
Length of sojourn time long- Better prognosis
What is overdiagnosis bias?
Overestimation of survival duration among screen-
detected cases caused by inclusion of pseudodisease- subclinical disease that would not become overt before the patient dies of other causes.
Occurs when screen-detected cancers are either non-growing or so slow-growing
that they never would cause medical problems
How can you decide ways to distribute healthcare?
QALY waiting list likelihood to pay likelihood to comply to treatment lifestyle choices
Name some statutes (laws) that oblige doctors to disclose information
Public Health Act 1984
Road Traffic Act 1988
Prevention of terrorism act 1989
What is the MBRRACE report (2014)?
Looked at standards of care and mortality and morbidity rates
2/3 of mothers died from medical and mental health problems, 1/3 from direct causes
3/4 women who died had known mental health problems before they died
What is ‘quality’ in relation to health care
The extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional
knowledge
what are key consumer protection agencies
Care Quality Commission (CQC)-Regulates ‘quality’ and financial performance of all
health and social care providers, public and private, provides regulatory framework,licenses all providers of health and social care
NHS Improvement (formerly ‘Monitor’)-Ensures financial obligations are met in terms of balancing income and expenditure
National Institute for
Health and Clinical Excellence (NICE)-
Set standards for treatment
How can consumer protection be improved?
Appraisal by peers
Revalidation by the GMC
Medical audit as a compulsory
part of routine practice and annual job planning
GP and consultant contracts- Increasing transparency in comparative performance
in relation to activity, costs, and patient-reported outcomes
Transparency and accountability
What was the main outcome of the human fertilisation and embryology act (1990)
A woman shall 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
(including the need of that child for a father)
‘
What were some of the criticisms of the ‘welfare criterior’
Fertile couples don’t have to meet this criterion
Predicting the welfare of future children is very difficult
Research suggests not the case that a father is always required for a child to flourish
What provisions, if any, should be made for doctors who conscientiously object
What are the 3 views
Objections should always be respected-
The autonomy of the medical provider is
paramount, no-one should be made to do something that goes against their strongly held personal beliefs
Objections should never be respected- Women’s interests should always take
priority, sometimes argued that if doctors
don’t like this then shouldn’t have chosen
medicine as a profession
Objections can sometimes be respected
(this is the position of the GMC)-
It might be possible for women’s interests to be met while at the same time not requiring
doctors to do something that would cause them a great deal of distress e.g. perhaps can refer patients to abortion services or provide patients with information
What are the barriers to implementation of research informed practice
Characteristics of the
recommendations- Easy to follow, compatible with existing norms, need for new skills, complexity of recommendations
Characteristics of the adopters- Knowledge, attitudes, skills and abilities
Characteristics of the organisation- Limitations and constraints, organisational culture
Characteristics of the environment- Social influence
direct vs indirect standardization
direct standardisation? Required we know the age-
specific rates of mortality in all populations under study
indirect standardisation?Only requires that we know the total number of deaths and the age structure of the
study population
When is indirect standardisation preferable?
Small numbers in particular age groups
What are the stages in decision analysis?
1)Structure the problem as a decision tree-
Identifying choice, information (what is
and is not known) and preferences
2.Assess the probability (chance) of every choice branch
3.Assess (numerically) the utility of every outcome
4.Identify the option that maximises expected utility
5.(Possibly) Conduct a sensitive analysis to explore effect of varying judgements
what do square and circle nodes mean on decision tree
Square node-Indicated decision, represents choice between actions
Circle node-Indicated chance (probability), represents uncertainty, potential outcomes of each decision
How do you calculate expected utility
Expected utility = utility value x
probability
sensitive analysis
Sensitive analysis explores what would happen if the probabilities or utility values were slightly different to the ones you are using
Calculate effect of uncertainty on
decision
preference sensitive and probability sensitive decisions
Preference sensitive- The person might feel strongly about the side effects of the
treatment
Probability sensitive -Sensitive to changes in the chance of different outcomes
What are the benefits of using decision analysis to make decisions
Makes all assumptions in a decision explicit
Allows examination of the process of making a decision
Integrates research evidence into the decision process
Insight gained during process may be more important than the generated numbers
Can be used for individual decisions, population level decisions and for cost-effectiveness analysis
What are the negatives of using decision analysis to make decisions
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 presentation framing effects e.g.survival/death
The approach is reductionist
What is the ICF model of disability?
Functioning and disability are multi-dimensional concepts relating to:
Body functions and structures
Physiological functions and anatomical parts
of body, including cardiac and respiratory systems
Activities
Participation of people in life
Environmental factors
What are Bowlby’s 4 stages of grief
numbness
yearning/pining and anger
despair and disorganisation
reorganisation
What is Worden’s tasks of mourning
Accepting the reality of the loss e.g. come to terms with the person being ‘gone’
Work through the pain of grief
Adjust to an environment in which the deceased is missing
Emotionally relocate the deceased and move on with life
What is pathological grief
Extended grief reactions- Getting stuck in one of the phases (normally each phase is
about 6 months)
Can be in denial for an extended period of time
-Exhibit mummification (not changing things in dead persons room for example)
Major depressive disorders >2 months after loss
What is the myth of the neutral therapist
Idea that psychotherapists will ‘leak’ their personal views regardless of their intention
This will come across in their questioning/direction of questioning
What are some examples of CLinical decision system
Reminder systems- Screening, vaccination, testing, medication use
Decision systems (diagnosis and treatment)-
Model individual patient data against epidemiological data
Prescribing -Advice on drug and dosage, highlights potential drug interactions
Condition management-Assists monitoring patients
absolute risk reduction
risk without treatment- risk with treatment
IF >0 then risk increase <0 risk decrease
relative risk/risk ratio
probability of event in exposed/unexposed
ART/ARC
odds ratio
probabily of event occuring/ p not occuring in the SAME group
absolute risk
number of events in group/ number of people in group
NNT
1/ARR
NNH
1/risk increase
formal fallacy
Formal – Premises are true but within the structure of the argument does not relate to the conclusion. error in reasoning
Example of a Formal Fallacy
All Dogs are Animals
All Cats are Animals
Therefore, all dogs are cats
informal fallacy
error in content of argument
Example of an Informal Fallacy
All feathers are light
Light is not dark
So, all feathers are not dark
(incorrect use of word light)
Ad Hominen Move
Shifting the argument from the point in question to an irrelevant aspects of the person who is making the argument
eg ur moms a whore
Begging the Question
An argument in which the conclusion, or point of dispute, has already been assumed in the reasons given in favour of the conclusion. A circular argument.
Argument of Authority
Statement or position or argument that is simply true based on someone in authority stating it.
Strawman Fallacy
Misrepresenting someone argument with a distorted, exaggerated, or misrepresented version of the position of the argument
exaggerating, clutching at straws
confounding
- distortion (or potential for distortion) of association between outcome and exposure by third factor which has an association with both exposure and outcome
incomplete follow up of participants effect
- Incomplete follow up allows for selection bias
- Incomplete follow-up may reduce the power of the study even if it is non-differential between exposure groups
- Differential follow-up will lead to bias
95% confidence interval
Indication that ‘95% confident’ that the risk in population (‘true effect’) lies within this range of values.
Current self harm epidemiology patterns
Predominant problem in younger groups
Females more than male
Pain killers- paracetamol is most common ingested substances
Alcohol commonly associated
Psychiatric illness in 10%
Give examples of two things you will look for to relate it to your population
Description of study sample
Patter of exposures similar to local population
What does adjusted mean in a study
Accounted for con founders
Key issue of recruitment in case control
Must come from same population (cases and controls)
Mental health act year
1983
Equality act year
2010
Mental capacity act and revised year
2005 and revised 2007 allows planning of treatment for younger ages
Bacillus cereus incubation
1-6 hrs
Staph aureus incubation
2-4
Écolo incubation
12-48
Salmonella
12-72
Canpylobacter
48-96
