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Year 2 Flashcards

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1
Q

What is evidence based medicine

A

Princess of identifying and using most up to date and relevant evidence to inform decisions for individual patient problems

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2
Q

Process of evidence based medicine

A

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

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3
Q

Which factors influence infection

A

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)

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4
Q

Infections in health care

A

Nosocomial infections
Uti pneumonia lower respiratory tract infection surgical wounds septicemia
Rare ones eg chicken pox tb mrsa

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5
Q

90/10 gap

A

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

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6
Q

What is R0

A

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)

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7
Q

List some internal immunization programmes

A

Expanded programme on immunization (EPI)
Global polio eradication initiative (GPEI)
Global alliance for vaccines and immunization (GAVI)

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8
Q

Calman hine report

A

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

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9
Q

Consequences of calman hine report

A

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

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10
Q

What is the national cancer survivorship initiative

A

Partnership with cancer charities clinicians and patients considered a range of approaches for improving services and support available for cancer survivors

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11
Q

Importance of hair

A

Individual and group identity
Symbol of femininity
Stigma
Shows sickness status

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12
Q

What is surveillance

A

Systematic collection collation and analysis of data and dissemination of results so appropriate measures can be taken

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13
Q

Purpose of surveillance

A

Early warning system for impending public health emergencies
Document impact of an intervention or track progress towards specific goals
Monitor and clarify epidemiology

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14
Q

Role of WHO in public health

A

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

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15
Q

Functions of a clinical record

A

Support patient Care
Improve future patient care
Social purposes at request of patients
Medico-legal document

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16
Q

ABCDE method of breaking bad news

A 
Advanced preparation
Building a relationship
Communicate well
Deal with patient reactions
Encourage and validate emotions
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17
Q

SPIKES method of breaking bad news

A 
Setting up 
Perception
Invitation 
Knowledge 
Emotions
Strategy and summary
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18
Q

Role of midwife in postnatal care

A 
Screeening/identification of at risk clients 
Lifestyle changes
Mental health services 
Health promotion
Information-bonding breast feeding
Reassurance and support 
Safeguarding
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19
Q

Sensitivity

A

Proportion of positive correctly identified

True positives /(true positives+false negatives)

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20
Q

Specificity

A

Proportion if negatives correctly identified

True negatives/ true negatives+ false positives

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21
Q

Limitations of screening

A 
Expensive 
Adverse effects (stress radiation exposure discomfort )
Stress caused by false positive
False sense of security by false negatives which delay final diagnosis
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22
Q

Four resources used when making a clinical decision

A

P atient preferences
A vailable resources
R esearch evidence
C linical expertise

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23
Q

Positive predictive value

A

Probability that subjects with a positive screening test truly have the disease
True positives / all positives

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24
Q

Negative predictive value

A

Probability of subjects with a negative screening test truly don’t have the disease
True negative / all negative

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25
Q

Near miss

A

Situation which events arise during clinical care but fail to develop further
Can report it at the national reporting and learning system

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26
Q

What are the free travel vaccines available

A

Diphtheria polio tetantus typhoid hepatitis a cholera

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27
Q

Paper records

A

Continuous portable writer identified legibility issues must be dated and signed

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28
Q

Electronic records

A

Problem orientated searchable structured safer prescribing clinical decision support software

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29
Q

Adverse event

A

Unintended even resulting from clinical care and causing patient harm

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30
Q

Near miss

A

Situation in which events arise during clinical care but fail to develop further

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31
Q

Types of errors

A

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

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32
Q

What to do when adverse incidents occur

A

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

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33
Q

Purpose of surveillance

A

Serve as an early warning system for health emergencies
Document the impact of an intervention
Monitor and clarify epidemiology of health problems

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34
Q

Length bias

A

The overestimating of survival duration among screening-detected cases due to an increase of slowly progressing cases

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35
Q

Active failures

A

Unsafe acts committed by people in direct contact with the patient
Usually short lived and predictable

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36
Q

Latent error

A

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

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37
Q

Types of violations

A

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)

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38
Q

Mental health problems in post natal period

A 
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
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39
Q

Summary hospital level mortality indicator

A

Ratio between actual number of patients who die within 30 days of discharge compared to expected to die average

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40
Q

Male screening programmes

A 
Newborn and infamy physical exam 
Newborn blood spot
Newborn hearing 
Diabetic eye 
Bowel cancer
Abdominal aortic aneurysm (age65)
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41
Q

Primary care records

A

Advanced computer systems
Paper light
Limited access for community teams

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42
Q

Serious incidents

A

Opportunity for learning very large
Warrant and use resources to investigate and act
Serious consequences to patients or staff

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43
Q

Four areas of child development

A

Gross motor
Find motor and vision
Hearing speech language
Social skills and behavior

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44
Q

The midwives act 1902

A

The normality of child bearing and calling doctors as soon as abnormality occurs
Equal access to midwives of all socioeconomic standings

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45
Q

Four areas of development

A

Frods motor
Fine motor
Hearing speech language
Social skills / Behaviour

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46
Q

Development checks

A

Neonatal examination
6-8wk gp fheck
1 yr check by health visitor
2-2.5yr check by hv

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47
Q

Development red flags

A 
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
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48
Q

Leading cause of death in young people

A

Suicide

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49
Q

Patient death causes

A

Poor clinical monitoring
Diagnostic error
Inadequate drug/ treatment (acts of commission)

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50
Q

Acts of ommision

A

Failure to treat according to test evidence

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51
Q

PICO

A

Population
Intervention
Comparison
Outcome

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52
Q

Match pico to study design

A 
Diagnosis -cross sectional study
Aetiology- cohort study
Prognosis/ cohort study
Therapy- RCT
Evaluation/acceptance- qualitative research
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53
Q

Three main questions for evaluating a study

A

Are the results valid
What are the results
Can i apply the results to this patients care

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54
Q

Theories of nhs waiting lists

A

Backlog
Demand management (waiting acts as deterrent to prevent frivolous use)
Allows resources to be fully used -no waste
Underfunding and inefficiency

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55
Q

Individualised multifactorial intervention

A

Strength and balance training
Home hazard assessment and intervention
Vision assessment and referral
Medication review

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56
Q

Falls prevention programme

A

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

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57
Q

Palliative care services

A

Generalists- primary health care team, nursing home, secondary services, social services
Specialist- specialist nurse and physicians, hospices, marie curie nurses

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58
Q

District nurse

A

Primary health care team
Community based
Hands on skills

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59
Q

Practice nurse

A

PHCT
Practice baded
Hands on

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60
Q

Marie curie nurse

A

Community based
Arranged by district nurse
Specialist palliative care skills
Hand on

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61
Q

Macmillan nurse

A

Community or hospital based
Specislist care
Advice support and resource

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62
Q

Publication bias

A

Non publication of study results because of strength or direction of finding
Can result in overestimation of treatment benefits

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63
Q

Performance bias

A

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

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64
Q

Lead time bias

A

Overestimation of survival due to early detection of screening rather than clinical presentation
Eg survival following diagnosis

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65
Q

Population attributable risk

A

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

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66
Q

Risk decision analysis steps

A 
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
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67
Q

Food frequency questionnaires

Pros and cons

A

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

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68
Q

Decision analytic approach benefits

A

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

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69
Q

Cardiophobic

A

Anxiety disorder characteristic of repeated chest pains and palpitations accompanied with fear of heart attack and dying

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70
Q

Da costas syndrome

A

‘Irritable heart’
Dyspnoea fatigue rapid pulse palpitations chest pain
Mostly with exertion
Associated with exhaustion and emotional strain

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71
Q

Population strategy pros and cons

A

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

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72
Q

Types of singlular economic health evaluations

A

All called partial evaluation
Outcome description (consequences only)
Cost description (cost only)
Cost-outcome description (both)

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73
Q

Types of economic health evaluation where two or more alternatives compared

A

Partial evaluation- effectiveness analysis (consequences only)
Partial evaluation- cost analysis (costs only)
Both is full economic evaluation

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74
Q

Types of full economic evaluation

A

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

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75
Q

Two ways evaluations can be conducted

A

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

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76
Q

Cost minimisation analysis

A

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

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77
Q

Cost effective analysis

A

Effects measured in most appropriate uni dimensional natural unit or health profiles
Cost per unit effect
Eg renal failure cost per life saved

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78
Q

Where does cea data come from

A

Evaluation alongside rct usually only one year time limit

Modelling-data from literature, meta analysis needs to be non biased

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79
Q

Incremental cost effectiveness ratio

A

(Cost of intervention- cost of control)/

Effectiveness of intervention- control

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80
Q

Cea advantages and disadvantages

A

Straightforward to carry out and easy to understand

But narrow uni dimensional measure of effect so can’t compare alternatives measured in different units

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81
Q

Qaly league table approach problems

A 
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
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82
Q

Cost benefit analysis adavantages

A

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

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83
Q

CBA issues

A

How do we value a life or health outcome
Must measure time being spent
Most comprehensive but rarely undertaken

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84
Q

Which economic evaluation is preferred choice

A

Cost utility analysis

NICE recommends it where costs measured in pounds and outcomes in qalys

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85
Q

Zoonosis

A

Objects or materials likely to carry infection

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86
Q

Basic reproductive number

A

R0
Number of cases each particular case generates
Affected by rates of contacts probability of transmission and duration of infectiousness

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87
Q

Effective reproduction rate

A

R

Estimated number of secondary cases per infectious case in a population of susceptible and non susceptible hosts

88
Q

Endemic disease

A

Found in a specific region or within a specific demographic

89
Q

6 global causes make up 70% of childhood deaths

A 
Lower respiratory tract infections 
Infections 
Diarrheal illness 
Malaria
HIV
Measles
Neonatal infections
90
Q

Examples of inactivated vaccines

A

Hep a
IPV
Some flu vaccines
Rabies

91
Q

Examples of recombinant vaccines

A

Hep b
Hpv
Men b

92
Q

Conjugate vaccines examples

A

Hib
Men c
Pcv

93
Q

Vaccine safety things

A

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

94
Q

What is sojourn time?

A 
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)
95
Q

order of food outbreak investigation

A

preliminary steps
intermediate steps
collecting data
environmental investigation

96
Q

preliminary phase

A

is there an outbreak?
confirming diagnosis
what is nature and extent of outbreak

97
Q

intermediate steps

A 
who is ill and how many
case finding
whats the cause
is proper care being arranged
what immediate action can be taken
98
Q

collecting data

A 
time person place
number affected
symptoms
common factors 
food histories
storing data
99
Q

environmental investigation

A

revisit food path
hazard analysis and critical control points
dont tell pls show
samples of food surfacae and equipment swabs
catering staff

100
Q

outbreak outliers

A 
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
101
Q

analytical epidemiological studies

A

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

102
Q

establishing causality (8 things)

A

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

103
Q

Wernicke-Korsakoff syndrome

A 
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
104
Q

Food safety policy

A

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

105
Q

haccp

A

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.

106
Q

blame culture

A

individuals cover up errors for fear of retribution - reduces focus on true causes of failure

107
Q

What is MPS

A

enhanced person matching algorithm that increases number of link able records when incomplete records have been submitted

108
Q

MPS good clinical record

A

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

109
Q

three core principles of nhs

A

meet the needs of patients
focus on clinical needs rather than ability to pay
be free at point of delivery

110
Q

care quality commission

A

assess quality of healthcare
license healthcare
produce policies by unannounced visits and routine data use

111
Q

child welfare steps-how to stop child mortality

A

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

112
Q

The Children Act 1989

A

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.

113
Q

Children and Families Act 2014

A

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

114
Q

The Education Act 2002

A

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

115
Q

child morbidity and mortality stats

A

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

116
Q

medical model of birth

A

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

117
Q

social model of birth

A

 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

118
Q

social/cultural issues of pregnancy

A

 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

119
Q

barriers to MDT working

A 
 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
120
Q

epidemiology on chd

A

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

121
Q

population attributable risk

A

How much of the disease in the population is attributable to a particular exposure
PAR = Risk in population - Risk in unexposed

122
Q

population attributable fraction

A

the proportional reduction in population disease or mortality would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario.

123
Q

Prevention paradox

A

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?

124
Q

10 principles of screening

A

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

125
Q

how to measure waiting times

A

average waiting time (mean or median)
proportion who waited longer than x number of days
average wait of people currently on list

126
Q

measurement issues

A 
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
127
Q

theories of nhs waiting lists

A

backlog- implies needs of emergency funds
demand management- waiting acts as a ‘price’ to deter frivolous use
allows nhs resources to be fully employed

128
Q

What situations are associated with an increased risk of error?

A

Unfamiliarity with the task, inexperience, shortage of time, inadequate checking, poor procedures, poor human equipment interface

129
Q

Demand-side policies

A

These policies when it comes to waiting times consider:
o Explicit guidelines to prioritise patients
o Subsidise private insurance

130
Q

supply side policies

A

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

131
Q

combined policies

A

These policies when it comes to waiting times consider:
o Waiting-time guarantees
o With sanctions
o With choice and competition

132
Q

what is confounding

A

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

133
Q

four ways to deal with confounding

A

restriction
matching
stratification
adjusting

134
Q

restriction method

A

removing the data which contains the cofunder

but less data and difficult when theres other cofounders

135
Q

matching method

A

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

136
Q

stratification

A

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

137
Q

adjusting

A

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

138
Q

multiple variable regression

A

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

139
Q

what is quality improvement

A

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

140
Q

quality improvement cycle

A

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

141
Q

CQUIN - how they get hospitals to change quality

A

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

142
Q

Quality outwork framework in gp

A

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

143
Q

the research cycle

A

clinical problem
basic research
applied research
clinical care

144
Q

1) clinical problem

A 
Observation, association, prognosis 
Person ( patient ) 
Population 
Why is this a problem and for who 
Priority setting partnership PPI
145
Q

2)basic research

A

Lab based

Biochem, genetics, physiology, in vitro, experimental models

146
Q

3)applied research

A 
Questions determines type of study 
Intervention  = comparative study 
Prognosis = Cohort 
Diagnosis = Comparative 
Satisfaction = Survey / qualitative study 
Value = Cost- effectiveness study
147
Q

4)clinical care

A 
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
148
Q

positive likelihood ratio

A

sensitivity/(1-specificity)

149
Q

negative likelihood ratio

A

(1-sensitivity)/specificity

150
Q

‘intention to treat’

analysis

A

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.

151
Q

why is assessing the quality of trials by two authors good practice

A

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

152
Q

what is meta analysis

A

A statistical technique for quantitatively combining the
results of multiple studies that measure the same outcome
into a single pooled or summary estimate.

153
Q

difference between deductive and inductive

A

deductive is intended to give logically conclusive support for the conclusion, as
opposed to giving the conclusion probable support which is inductive

154
Q

what makes an argument valid

A

The conclusion follows logically from the premises
It is impossible for the premises to be true and the
conclusion to be false

155
Q

What is meant by saying an argument is sound?

A

An argument is sound if the conclusion follows logically from premises that are in fact true

156
Q

audit cycle

A 
identify problem
set standards
collect data
assess conformity of current practice to standards
implement change
re audit
157
Q

theories of decision making

A

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

158
Q

3 moral theories

A

(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

159
Q

What statistical test to use to get the p value

A

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

159
Q

What statistical test to use to get the p value

A

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

159
Q

What statistical test to use to get the p value

A

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

160
Q

What are the 6 key areas for action in the cancer reform strategy (2007)?

A

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

161
Q

‘Improving outcomes: A strategy for cancer (2011)’?

A

Prevention and early diagnosis
Quality of life and patient experience
Better treatments
Reducing inequalities

162
Q

independent cancer taskforce (2015)

A

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

163
Q

What is sojourn time?

A

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

164
Q

What is overdiagnosis bias?

A

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

165
Q

How can you decide ways to distribute healthcare?

A 
QALY 
waiting list
likelihood to pay
likelihood to comply to treatment 
lifestyle choices
166
Q

Name some statutes (laws) that oblige doctors to disclose information

A

Public Health Act 1984
Road Traffic Act 1988
Prevention of terrorism act 1989

167
Q

What is the MBRRACE report (2014)?

A

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

168
Q

What is ‘quality’ in relation to health care

A

The extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional
knowledge

169
Q

what are key consumer protection agencies

A

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

170
Q

How can consumer protection be improved?

A

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

171
Q

What was the main outcome of the human fertilisation and embryology act (1990)

A

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)
‘

172
Q

What were some of the criticisms of the ‘welfare criterior’

A

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

173
Q

What provisions, if any, should be made for doctors who conscientiously object
What are the 3 views

A

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

174
Q

What are the barriers to implementation of research informed practice

A

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

175
Q

direct vs indirect standardization

A

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

176
Q

What are the stages in decision analysis?

A

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

177
Q

what do square and circle nodes mean on decision tree

A

Square node-Indicated decision, represents choice between actions
Circle node-Indicated chance (probability), represents uncertainty, potential outcomes of each decision

178
Q

How do you calculate expected utility

A

Expected utility = utility value x

probability

179
Q

sensitive analysis

A

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

180
Q

preference sensitive and probability sensitive decisions

A

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

181
Q

What are the benefits of using decision analysis to make decisions

A

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

182
Q

What are the negatives of using decision analysis to make decisions

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 presentation framing effects e.g.survival/death
The approach is reductionist

183
Q

What is the ICF model of disability?

A

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

184
Q

What are Bowlby’s 4 stages of grief

A

numbness
yearning/pining and anger
despair and disorganisation
reorganisation

185
Q

What is Worden’s tasks of mourning

A

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

186
Q

What is pathological grief

A

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

187
Q

What is the myth of the neutral therapist

A

Idea that psychotherapists will ‘leak’ their personal views regardless of their intention
This will come across in their questioning/direction of questioning

188
Q

What are some examples of CLinical decision system

A

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

189
Q

absolute risk reduction

A

risk without treatment- risk with treatment
IF >0 then risk increase <0 risk decrease

190
Q

relative risk/risk ratio

A

probability of event in exposed/unexposed
ART/ARC

191
Q

odds ratio

A

probabily of event occuring/ p not occuring in the SAME group

192
Q

absolute risk

A

number of events in group/ number of people in group

193
Q

NNT

A

1/ARR

194
Q

NNH

A

1/risk increase

195
Q

formal fallacy

A

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

196
Q

informal fallacy

A

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)

197
Q

Ad Hominen Move

A

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

198
Q

Begging the Question

A

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.

199
Q

Argument of Authority

A

Statement or position or argument that is simply true based on someone in authority stating it.

200
Q

Strawman Fallacy

A

Misrepresenting someone argument with a distorted, exaggerated, or misrepresented version of the position of the argument
exaggerating, clutching at straws

201
Q

confounding

A
  • distortion (or potential for distortion) of association between outcome and exposure by third factor which has an association with both exposure and outcome
202
Q

incomplete follow up of participants effect

A
  • 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
203
Q

95% confidence interval

A

Indication that ‘95% confident’ that the risk in population (‘true effect’) lies within this range of values.

204
Q

Current self harm epidemiology patterns

A

Predominant problem in younger groups
Females more than male
Pain killers- paracetamol is most common ingested substances
Alcohol commonly associated
Psychiatric illness in 10%

205
Q

Give examples of two things you will look for to relate it to your population

A

Description of study sample
Patter of exposures similar to local population

206
Q

What does adjusted mean in a study

A

Accounted for con founders

207
Q

Key issue of recruitment in case control

A

Must come from same population (cases and controls)

208
Q

Mental health act year

A

1983

209
Q

Equality act year

A

2010

210
Q

Mental capacity act and revised year

A

2005 and revised 2007 allows planning of treatment for younger ages

211
Q

Bacillus cereus incubation

A

1-6 hrs

212
Q

Staph aureus incubation

A

2-4

213
Q

Écolo incubation

A

12-48

214
Q

Salmonella

A

12-72

215
Q

Canpylobacter

A

48-96

Health And Society (1 decks)

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