Year 2 Health and Society 3 2 Flashcards
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What is evidence-based decision making (EBDM)?
Process for identifying and using most up-to-date (and relevant) evidence to inform decisions for individual patient problems
What does EBDM involve? (4 key aspects)
- Patient preferences- Available resources, - Research evidence, - Clinical expertise
Why is decision making in medicine important?
- Doctors make decisions constantly, - The decisions have effects on patients, families, and society, - Having an understanding of decision making, and the role of evidence, can help improve medical practice
Why do we need EBDM?
- Limited time to read, - Inadequacy of ‘traditional’ sources of information - textbooks are often out of date, - Disparity between diagnostic skills/clinical judgement (which increase over time) and up-to-date knowledge/clinical performance (which decrease)
What are the different types of research studies and when are they each appropriate? (6 main types)
- Cohort studies - prognosis, cause, - Case-control studies - cause, - Randomised controlled trials - treatment interventions, benefit and harm, cost effectiveness, - Qualitative approaches - patients and/or practitioners perspectives, - Diagnostic and screening studies - identification, - Systematic reviews - summary of evidence for a specific question
What is the process of EBDM? (5 steps)
- Converting the need for information into an answerable question, 2. Identifying the best evidence to answer that question, 3. Critically appraising the evidence for its validity, impact, and applicability, 4. Integrating the critical appraisal with clinical expertise and the patient’s unique circumstances, 5. Evaluating our effectiveness and efficiency in carrying out the previous steps and seeking ways to improve
What are the 4 steps in the approach to smoking cessation?
- Health education and general information to enhance motivation for quitting (light smokers), 2. Brief advice from a health professional to quit smoking (light smokers), 3. Advice, nicotine replacement, follow-up by a specialist (moderately motivated, medium dependence smokers), 4. Specialised counselling rooms and agencies working with group sessions (high dependence smokers)
What is antibiotic resistance?
Bacteria change so antibiotics no longer work in people who need them to treat infections
What are the reasons for the widespread use of antibiotics? (2 reasons)
- Increase in global availability, - Uncontrolled sale in many low or middle income countries
What are some of the causes of antibiotic resistance? (5 causes)
- Use in livestock for growth promotion, - Releasing antibiotics into the environment during pharmaceutical manufacturing, - Volume of antibiotics prescribed, - Missing doses when taking antibiotics, - Inappropriate prescribing of antibiotics
How can antibiotic resistance be prevented? (5 ways)
- Using antibiotics only when prescribed by a doctor, - Completing the full prescription, - Never sharing antibiotics or using leftover prescriptions, - Only prescribing antibiotics when they are needed, - Using the right antibiotics to treat the illness
Which factors influence infection? (5 main factors)
- Infectious agents - ability to reproduce, survival, ability to spread, infectivity, pathogenicity, - Environment - contamination, other humans, animals, water, - Mode of transmission - droplet, airborne, aerosol, direct consumption, faecal-oral route, blood-borne, sexual contact, zoonosis, - Portal of entry - mouth, nose, ears, genital tract, skin, urinary tract, - Host factors - chronic illness, nutrition, age, immunity, lifestyle (e.g. smoking, drugs, etc.)
What are the most important infectious diseases in the UK? (9 diseases)
- Diphtheria, - Haemophilus influenza, - Measles, - Mumps, - Rubella, - Poliomyelitis, - Pneumococcal disease, - Tetanus, - Whooping cough
What are the most important infectious diseases in developing countries? (4 diseases)
- Pneumonia, - Chronic diarrhoea (due to several causes), - Malaria, - HIV/AIDS
What is surveillance?
Systematic collection, collation and analysis of data and dissemination of the results so that appropriate control measures can be taken
What is the purpose of surveillance? (3 main points)
- Serve as an early warning system for impending public health emergencies, - Document the impact of an intervention, or track progress towards specific goals, - Monitor and clarify the epidemiology of health problems, to allow priorities to be set and to inform public health policy and strategy
Which infectious disease are becoming more common in the UK and why?
Hospital acquired infections (e.g. MRSA, STIs, mumps)
Which infectious diseases are associated with exposure to healthcare?
- Nosocomial infections, - More common examples (60%): UTIs, pneumonia, lower respiratory tract infections (LRTIs), septicaemia, - Less common examples (40%) but more dangerous: chicken pox, TB, legionella, MRSA
What can be done to reduce the risk of nosocomial infections? (3 main steps)
- Prevention - hand washing, infection control programmes, advisory service, surveillance (mandatory for MRSA), sterilisation and decontamination of instruments, - Detection, investigation and control of outbreaks - screening, barrier nursing/isolation of infected patients, sharps disposal, - Policies and procedures to prevent and control infection - dissemination and implementation of policies, education and training, monitor clinical practice
What is global health?
- Health of global population, - Improving health and achieving equality in health for all people worldwide, - Emphasises trans-national health issues, determinants and solutions
What is international health?
Health defined by geography (nation wealth), problems (e.g. infections, water sanitation), instruments (e.g. infection control aid), and a recipient and donor relationship
What are the major functions of global health? (4 key points)
- To provide health-related public goods - research, standards, guidelines, - To manage cross-national externalities through epidemiological surveillance, information sharing, and coordination, - To mobilise global solidarity for populations facing deprivation and disasters, - To convene stakeholders to reach consensus on key issues, setting priorities, negotiating rules, facilitating mutual accountability, and advocating for health in other policy-making arenas
What is the motivation for global health? (2 key aspects)
- Increased awareness of global health disputes, - Enthusiasm to make a difference across international boundaries
What is the ‘90/10 gap’ (commission on health research for development - 1990)?
Less than 10% of worldwide resources devoted to health research were put towards health in developing countries, where over 90% of all preventable deaths worldwide occurred
What is the solution for the ‘90/10 gap’? (4 steps)
- Regulation of the quality of imported food, medicines, manufactured goods, and inputs, - Getting timely access to information about the global spread of infectious disease, - Procurements of sufficient vaccine and drug supplies in a pandemic, - Ensuring a sufficient corps of well-trained health personnel
What impact has travel and migration had on diseases seen in the UK? (5 impacts)
- Help spread infectious diseases, - Transmission of behaviour and culture increases risk of non-communicable diseases, - May introduce a disease to a new population - widespread and deadly effects, - More in contact with animals - increase in animal diseases (zoonosis), - Migrants may bring diseases to countries that have not been exposed
What is WHOs definition of environment, in relation to health?
- All the physical, chemical and biological factors external to a person, and all the related behaviours, - Environmental health consists of preventing or controlling disease, injury, and disability related to the interactions between people and their environment
What is an outbreak?
Sudden increase in occurrences of a disease in a community, which has never experienced the disease before or when causes of the disease occur in numbers greater than expected in a defined area
What is an epidemic?
Occurrence of a group of illnesses of similar nature and derived from a common source, in excess of what would be normally expected in a community or region
What is a pandemic?
Worldwide epidemic (outbreak -> epidemic -> pandemic)
How can we prevent epidemics? (5 steps)
- Insure developing countries against the threat of a pandemic, - Funds and international responders sent to country with outbreak to reduce human suffering, - Development of vaccines, - Fast, early, planned response means less spread, - Monitor disease to prevent future outbreaks
What is the role of WHO in public health? (6 key aspects)
- Providing leadership on matters critical to health and engaging in partnerships where joint action is needed, - Shaping the research agenda and stimulating the generation, translation, and dissemination of valuable knowledge, - Setting norms and standards and promoting and monitoring their implementation, - Articulating ethical and evidence-based policy options, - Providing technical support, catalysing change, and building sustainable institutional capacity, - Monitoring the health situation and assessing health trends
What general intervention strategies are possible for HIV/AIDS? (6 strategies)
- Introduction of blood donor and product screening, - Promotion and distribution of condoms at affordable prices , - Peer education for high risk groups e.g. sex workers, - Promotion of safer sexual behaviour at the population level, - Diagnosis and treatment of STDs, - HIV voluntary counselling and testing
What are the determinants of effective outcomes of intervention? (3 main determinants)
- Economics - many developing countries can only spend a few dollars per annum per capita on healthcare, - Priorities - ‘developed world academic’ analyses of cost-effectiveness may not reflect the developing world realities, - Setting - countries where true reductions in incidence and prevalence have occurred (e.g. Uganda) may be characterised by openness in political leadership towards HIV/AIDS and other cultural factors
What are the current problems and issues?
- Africa struggles against debt, trade restrictions and inadequate aid provisions, - Global fund în under-resourced, - US politics are retrogressive and harmful
What are the public health objectives of vaccination? (7 objectives)
- To reduce mortality and morbidity from vaccine preventable infections, - To prevent outbreaks and epidemics, - To contain an infection in a population, - To reduce the number of infections, - To interrupt transmission to humans, - To generate herd immunity, - To eradicate an infectious agent
What are the 2 most effective developments in healthcare to protect population health?
- Clean drinking water, - Vaccination
What factors influence the utility of immunisation/vaccination as an approach to disease prevention? (9 points)
- Disease burden, - Risk of exposure to the disease, - Age, health status, vaccination history, - Special risk factors, - Reactions to previous vaccine doses, allergies, - Risk of infecting others, - Cost, - Other ways of controlling the disease, - Impact on public perception
What is required for a disease to be eradicate using vaccination? (3 requirements)
- Where no other reservoirs of the infection exist in animals or environment, - Where consequences of infection are very high, - Where scientific and political prioritisation exists
Give examples of diseases that have been eradicated
- Smallpox, - Polio
What is herd immunity?
- Level of immunity in the population which protects the whole population, - Herd immunity only applies to diseases which are passes from person to person, - Provides indirect protection to unvaccinated as well as direct effect to the vaccinated, - A disease can therefore be eradicated even if some people remain susceptible
What is R0?
- Basic reproduction rate, - The average number of individuals directly infected by an infectious case during the infectious period, in a totally susceptible population (number of secondary cases following introduction of infection)
What factors affect R0? (3 main factors)
- The rate of contacts in the host population, - The probability of infection being transmitted during contact, - The duration of infectiousness
What is effective reproduction rate (R)?
Estimates the average number of secondary cases per infectious case in a population made up of both susceptible and non-susceptible hosts
What is the equation for effective reproduction rate?
R = R0x (x is the fraction of the host population which is susceptible e.g. half population is 0.5), R >1 = number of cases increases, R <1 = number of cases decreases, needs to be maintained for elimination, R =1 = epidemic threshold
What is the equation for herd immunity?
H = (R0 -1) / R0
What is a susceptible population? (4 key points)
- Any person who is not immune to a particular pathogen is said to be susceptible, - A person may be susceptible because they have never encountered the infection or the vaccine against it before, - A person may be susceptible because they are unable to mount an immune response, - A person may be susceptible because vaccination is contraindicated for them
What is WHOs role in vaccination?
- Makes recommendations for countries on vaccination policy, - Supports less able countries with vaccination strategy implementation, - Works through the international health regulations to ensure the maximum security against the international spread of disease with a minimum interference with world traffic
List some international immunisation programmes
- Expanded programme on immunisation (EPI), - Global polio eradication initiative (GPEI), - Global alliance for vaccines and immunisation (GAVI)
How are new vaccination programmes implemented? (who, how and when)
- Who - to protect the vulnerable, contain outbreak, eradicate disease, - How - pilots, phased introduction, global vaccination, - When - greatest impact on disease burden
What is shared decision making and why is it important?
- Conversation between patient and their health care professional to reach a health care choice together, - Important when - there is more than one reasonable option, no one option has a clear advantage, the possible benefits/harms of each option affect patients differently
What are the pros of vaccination? (8 points)
- Can save lives, - Ingredients are safe in the amount used, - Adverse reactions are rare, - Herd immunity, - Save children and parents time and money, - Protect future generations, - Eradication of diseases, - Economic benefits for society
What are the cons of vaccination? (7 points)
- Can cause serious and sometimes fatal side effects, - Contain harmful ingredients, - Government should not intervene in personal medical choices, - Can contain ingredients some people object to e.g. chicken eggs, - Unnatural, - Pharmaceutical companies main goal is to make profit, - Some diseases that vaccines target are relatively harmless in many cases e.g. rotavirus
What factors influence decision making? (6 factors)
- Lifestyle, - Perception of health, - Beliefs about childhood diseases, - Risk perception of the diseases, - Perceptions about vaccine effectiveness and vaccine components , - Trust in institution
What is the population vs individual interest debate?
- For the individual - protection by ‘herd immunity’ may be safest option as avoids risk of vaccine, - For the community - avoidance of vaccination leads to reduced coverage so diminishes herd immunity
Which websites can be used to find out if a person needs travel vaccines?
- NHS fitfortravel, - The National Travel Health Network and Centre (NaTHNaC)
What are some of the free and private travel vaccines available?
- Free - diphtheria, polio, tetanus, typhoid, hepatitis A, cholera, - Private - hepatitis B, Japanese encephalitis, meningitis, rabies, TB, yellow fever
What factors should be consider when deciding to get travel vaccinations? (8 factors)
- The country or countries you’re visiting , - When you’re travelling, - Where you’re staying , - How long you’ll be staying, - Your age and health, - What you’ll be doing during stay , - If you’re working as an aid worker, - If you’re working in a medical setting, - If you’re contact with animals
What are the 5 common cancers (incidence) in adult men and women in the UK (list in order)?
- Breast/prostate, 2. Lung, 3. Bowel, 4. Melanoma, 5. Non-Hodgkin lymphoma
What are the 5 most common causes of cancer mortality for adult men and women combined in the UK (list in order)?
- Lung, 2. Bowel, 3. Prostate/breast, 4. Pancreas, 5. Oesophagus
What are the most common cancers in children?
Leukaemias
What is the most common causes of cancer mortality in children?
Brain, CNS and intracranial tumours
How do the patterns of cancer in the UK differ from that seen in a developing country?
Mortality is higher in UK (29%)
What is the role of legal and lifestyle changes in reducing incidence and mortality of cancer? (3 main points)
- Prevention - legal and lifestyle changes, vaccinations, - Screening - early detection and diagnosis, - Disease management - improving treatments and quality of life
What is meant by difficult (bad) news?
Bad/difficult news is defined as any news that drastically and negatively alters the patient’s (or their relatives) view of his or her future
What factors can affect the impact of news on a patient? (7 factors)
- Institutionalised beliefs, - Personality types, - Gender, - Culture/race, - Religion, - Patients knowledge, - Relatives
What anxieties might health care professionals have about breaking bad news? (5 points)
- Uncertainty about the patient’s expectations, - Fear of destroying the patient’s hope, - Fear of their own inadequacy in the face of controlling disease, - Not feeling prepared to manage the patients anticipated emotional reactions, - Embarrassment at having previously painted too optimistic a picture for the patient
What is the ABCDE method of breaking bad news?
A - Advanced preparation, B - Building a relationship, C - Communicate well, D - Deal with patient reactions, E - Encourage and validate emotions
What is the SPIKES method of breaking bad news?
S - Setting up , P - Perception, I - Invitation, K - Knowledge, E - Emotions, S - Strategy and summary
What emotions may a patient feel when they receive difficult news? (5 main emotions)
- Grief, - Distress, - Denial, - Anger, - Agitation/restlessness
How can cancer change partner relationships? (6 changes)
- Change in roles, - Change in responsibilities, - Change in physical needs, - Change in emotional needs, - Change in sexuality and intimacy, - Change in future plans
What were the conclusions and consequences of the Eurocare-II report?
- Despite limitations of the methodology, cancer survival in the UK in the 1980-90s was one of the worst in Europe, - Expert advisory group formed to the chief medial officer in 1995 which generated the calman-hine report
What were the conclusions and consequences of the Calman-Hine report (1995)? (6 points)
(The Calman-Hine report examined cancer services in the UK, and proposed a restructuring of cancer services to achieve more equitable level of access to high levels of expertise throughout the country.), , - All patients to have access to a uniformly high quality of care, - Public and professional education to recognise early symptoms of cancer, - Patients, families and carers should be given clear information about treatment options and outcomes, - The development of cancer services should be patient-centred, - Primary care to be central to cancer care, - The psychosocial needs of cancer sufferers and carers to be recognised
What are the Calman-Hine solutions?
There should be 3 levels of care:, - Primary care, - Cancer units serving district general hospitals - treat common cancers, diagnostic procedures, common surgery, non-complex chemo, - Cancer centres (populations in excess of 1 million) - treat rare cancers, radiotherapy, complex chemo, , Key to managing patients would be the MDT
What is a national service framework? (3 main points)
- Set national standards and define service models for a service or care group, - Put in place programmes to support implementation, - Establish performance measures against which progress within agreed timescales would be measured
What are the main aims of the NHS cancer plan (2000)?
- Save more lives, - Ensure people with cancer get the right professional support, care and treatments, - Tackle the inequalities in health e.g. unskilled workers are 2x more likely to die from cancer as professionals, - Build for the future - investment in cancer workforce, strong research, preparation for the genetics revolution, , NHS plan followed by several improving outcomes guidance (NICE) which relate to the organisation of services for a particular cancer., , - 2000 manual of cancer - >300 standards relating to the delivery of cancer treatment including provisions of chemotherapy, radiotherapy, etc., - 2004 manual of cancer (manual of quality measures) - >900 new measures
What are the 6 key areas for action in the cancer reform strategy (2007)?
- Prevention - smoking, obesity, alcohol, etc., - Screening - diagnosing cancer earlier, - 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 the most appropriate setting - locally where possible, services should be centralised where necessary
Which cancers are screened for?
- Cervical, - Breast, - Bowel
What is the national cancer survivorship initiative?
Partnership with cancer charities, clinicians and patients, considered a range of approaches to improving services and support available for cancer survivors
What were the main outcomes from ‘Improving outcomes: A strategy for cancer (2011)’? (4 outcomes)
- Prevention and early diagnosis - focus on lifestyle factors, screening, diagnostic tests, - Quality of life and patient experience - patient experience surveys, more 1:1 support roles, risky stratified pathway of care, following assessment and care planning, - Better treatments - cancer drugs fund, reducing variation in radiotherapy, reaffirmed MDTs and national audits, - Reducing inequalities
What are some of the inequalities experiences amongst cancer patients? (5 examples)
- White cancer patients report a more positive experience than other ethnic groups, - Younger people are the least positive about their experience, particularly around understanding completely what was wrong with them, - Men are generally more positive about their care than women, particularly around staff and staff working together, - Non-heterosexual patients reported less positive experience, especially in relation to communication and being treated with respect and dignity, - People with rarer forms of cancer in general reported a poorer experience of their treatment and care then people with more common forms of cancer
What are the outcomes from the independent cancer Taskforce (2015)? (6 outcomes)
- Spearhead a radical upgrade in prevention and public health, - Drive a national ambition to achieve earlier diagnosis, - Establish patient experiences being on a par with clinical effectiveness and safety, - Transform our approach to 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 body image?
- Perceptions, thoughts, and behaviours related to one’s appearance, - The body is a bearer of values and a means of representing our identity to others - it shows who we are to others
What is biographical distribution?
- Chronic illness leads to a loss of confidence in the body, - From this follows a loss of confidence in social interaction or self-identify
Give examples of diseases/symptoms/treatments/side-effects which affect body image (6 examples)
- Scars, - Prosthetic device - e.g. leg, - Mastectomy, - Impact on sexuality - function, pain, appearance, - Stoma, - Hair loss, - Weight loss/weight gain
What is the importance of hair?
- An important site for individual and group identity, - A way of ‘doing gender’ - a symbol of felinity? hair loss not so bad for men, - Stigma - patients have some choices as to whether they will be stigmatised, - Patient control of their status as sick - can be managed through ‘normal’ appearance (wigs, beanies, scarves)
What are the functions of the clinical record? (4 points)
- Support patient care, - Improve future patient care, - Social purposes at the request of patients, - Medico-legal document
What should be recorded in a clinical record? (7 key aspects)
- Presenting symptoms and reasons for seeking health care, - Relevant clinical findings, - Diagnosis and important differentials, - Options for care and treatment, - Risk and benefits of care and treatment, - Decisions about care and treatment, - Action taken and outcomes
What are the differences between paper and electronic records?
- Paper - continuous, portable, writer identified, legibility issues, must be dated and signed, - Electronic - problem orientated, searchable, structured, safer prescribing, clinical decision support software
What is the use of records in audit, research and management?
- Support clinical audit, - Facilitates clinical governance, - Facilitates risk management, - Support clinical research
What is duty of care?
Legal obligation which is imposed on an individual requiring adherence to a standard of reasonable care while performing any acts that could foreseeable harm others
What is negligence?
- Negligence is a failure to exercise the care that a reasonably prudent person would exercise in like circumstances, - You have to make decisions that adheres to your duty of care as a doctor and could not be considered negligent
What are the 4 ethical principles?
- Beneficence - duty to do good, - Non-maleficence - duty to cause no harm, - Autonomy - patient has the right to make their own decision, Justice - fair, equitable treatment for all
What are the ethical theories? (3 main theories)
- Consequentialism/utilitarianism - the correct moral response is related to the outcome or consequence of the act, - Deontology - places value on the intentions of the individual and focuses on rules, obligations and duties, - Virtue ethics - right living is derived from the moral character of the agent
How do you evaluate an argument? (2 steps)
- Get clear on the logical form of the argument, 2. Query - valid and sound
Why might an argument be invalid? (4 reasons)
- Different premises may express different concepts, - Confusing necessary with sufficient, and vice-versa, - Insensitive to the way in which claims are qualified, - Argument begs the question
Why might an argument be unsound? (3 reasons)
- Argument is invalid, - Argument is valid but one or more premise is false - makes a false/controversial moral/empirical claim, - An unsound argument doesn’t mean there will be an unsound conclusion
What should be avoided in arguments? (5 points)
- Straw man fallacy - simply ignoring the person’s actual position and substituting it for a distorted, exaggerated or misrepresented version of that position, - Ab hominem - directed against a person rather than the position they are maintaining, - Appealing to emotion, - Begging the question, - Argument from fallacy - conclusion must be false because the premises are false (not necessarily)
What is a moral argument?
- Seek to support a moral claim of some kind, - Argument need not succeed but to be an argument it must at least provide supporting reasons for the claim in question
What is a deductive argument?
- Purely logic, - “This means this, therefore this means this”
What is an inductive argument?
Making an argument based on observation, more probable conclusions (seeing is believing but you may not have seen everything)
What are MDTs in cancer care and why are they needed?
- Modern management of cancer - involves many disciplines, surgical and non-surgical, oncology, - Allied health professionals e.g. nurses, physiotherapists, speech therapists, etc., - Delivery of cancer care is often fragmented over several hospital sites - need to streamline and co-ordinate various components of care, - Probably better outcomes for patients managed in MDTs
Who is in a cancer MDT (core and extended)?
Core (medical staff):, - Physicians, - Surgeons, - Oncologist, - Radiologist, - Histopathologist, - Specialist nurses, - MDT coordinator, , Extended:, - Physiotherapist, - Dietician, - Palliative care, - Chaplin
What are the functions of MDTs in cancer care? (6 key functions)
- Discuss every new diagnosis of cancer within their site, - Decide on a management plan for every patient, - Inform primary care of that plan, - Designate a key worker for that patient, - Develop referral, diagnosis and treatment guidelines for their tumour sites, - Audit
What is sensitivity?
- True positives, - Measures the proportion of positives that are correctly identified
What is the equation for sensitivity?
Sensitivity = true positives / (true positives + false negatives)
What is specificity?
- True negatives, - Measures the proportion of negatives that are correctly identified
What is the equation for specificity?
Specificity = true negatives / (true negatives + false positives)
What is a diagnostic test?
Any kind of medical test performed to aid in the diagnosis or detection of disease
What are the uses of diagnostic tests? (4 uses)
- Diagnosis, - Monitoring, - Screening, - Prognosis
How is sensitivity and specificity important in informing diagnosis?
The importance of a diagnostic accuracy testing is directly proportional to the tests potential to cause patient consequences and harm
What does true positive mean?
Test indicates disease when there is disease
What does true negative mean?
Test indicates no disease when there is no disease
What does false positive mean?
Test indicates disease when there is no disease
What does false negative mean?
Test indicates no disease when there is disease
What is positive predictive value?
The probability that subjects with a positive screening test truly have the disease
What is negative predictive value?
The probability that subject with a negative screening test truly don’t have the disease
What is the likelihood ratio?
The likelihood that a given test result would be expected in a patient with the target disorder compared to the likelihood that the same result would be expected in a patient without the target disorder
What is screening?
Systematic application of a test or inquiry, to identify individuals at sufficient risk of a specific disorder to warrant further investigation or direct preventive action, amongst persons who have not sought medical attention on account of symptoms of that disorder
What is the purpose of screening? (3 purposes)
- Opportunities for primary prevention are limited, - Opportunities for treatment are limited, - Screening gives potential for early and more effective treatment
What is commonly screened for? (8 examples)
- Cancer - colorectal cancer, breast cancer, cervical cancer, - PPD test - tuberculosis, - Prenatal tests - foetal abnormalities, - Newborn bloodspot test - PKU, cystic fibrosis, etc., - Ophthalmoscopy or digital photography and image grading - diabetic retinopathy, - Ultrasound scan - abdominal aortic aneurysm, - Screening for metabolic syndrome, - Screening for potential hearing loss in newborns
What are the limitations of screening?
- Cost and use of medical resources on a majority of people who do not need treatment, - Adverse effects of screening procedure - stress, anxiety, discomfort, radiation exposure, - Stress and anxiety caused by a false positive result, - Unnecessary investigation and treatment of false positive results, - Stress and anxiety caused by prolonging knowledge of an illness without any improvement in outcome, - A false sense of security caused by false negatives, which may delay final diagnosis
What are the pros and cons of good screening?
Pros - early detection of disease means the risk of death or illness can be reduced for some people, , Cons - Some people get tests, diagnosis ad treatment with no benefit; some people get ill or die despite a negative screening test
What areas should be evaluated when deciding what should be screened for? (4 areas)
- Condition - important? epidemiology, natural history of condition, detectable risk factor, latent period, cost-effective, - Test - simple, safe, precise, validated, cut-off agreed, acceptable, - Treatment - effective evidence based treatment, - Programme - RCT evidence of reduction in mortality or morbidity, benefit outweigh harm, opportunity cost, quality assurance
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, - Length of sojourn time = long - better prognosis
What is length bias?
Overestimation of survival duration among screening-detected cases by the relative excess of slowly progressing cases
What are the consequences of length bias?
- Diseases with a longer sojourn time are ‘easier to catch’ in the screening net, - On average, individuals with diseases detected through screening ‘automatically’ have a better prognosis than people who present with symptoms/signs, - If we simply compare individuals who choose to be screened with those who don’t we get a distorted picture
What is lead time bias?
Overestimation of survival duration among screen-detected cases (relative to those detected by signs and symptoms) when survival is measured from diagnosis
What are the consequences of lead time bias?
- Survival is inevitably longer following diagnosis through screening because of the ‘extra’ lead time, - Because of this the appropriate measure of effectiveness is deaths prevented, not survival
What is over diagnosis bias?
- Overestimation of survival duration among screen-detected cases caused by inclusion of pseudo disease - 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
What is PSA testing and what can cause elevated PSA?
- Prostate-specific antigen (PSA) - protein produced by cells of the prostate gland, - Elevated in - prostate cancer, BPH, prostatitis, UTI, exercise
What are the advantages of PSA screening?
- Can help detect tumours with no symptoms, - Allows estimation of prostate size and stage, - Helps doctor predict response to treatment, - Can be used to monitor men who are at increased risk
What are the disadvantages of PSA screening?
- Early detection may not reduce the chance of dying from prostate cancer, - Over-diagnosis -> over-treatment, - May give false-positive - other conditions can increase PSA, not specific enough, - May give false-negative
What are some of the impacts of incontinence on a patient?
- Distress, - Embarrassment, - Inconvenience, - Threat to self esteem, - Loss of personal control, - Desire for normalisation, - Loss of interest in sex, - Difficulty sleeping (especially with nocturia)
What impact might chronic dialysis have on a patient?
- Regular hospital admissions, - Restriction of leisure time, - May have to give up job, - Increased dependence on dialysis, - Uncertainness about the future, - Fatigue, - Limitations of liquids and foods, - Disrupts family and friend relationships, - Depression, - Lower self-esteem
What 4 sources are used when making a clinical decision?
- Patient preferences, - Available resources, - Research evidence, - Clinical expertise
What is opportunity cost?
- The loss of other alternative when one alternative is chosen, - The amount of money that is alienated by choosing to use it for one project than another
What is distributive justice?
How we distribute resources the are finite in a fair way
How can you decide ways to distribute healthcare? (5 factors)
- QALY calculation, - Waiting list, - Likelihood of complying with treatment, - Lifestyle choices of patient, - Ability to pay
What is confidentiality?
Pledge of agreement to not divulge or disclose information about patients to others
Why is it important to maintain confidentiality? (6 points)
- Improves trust between patient and doctor, - Respects autonomy, - Prevents patient harm, - Virtuous, - Human rights act, - GMC requirements
When can confidentiality be breached?
- Statute (law), - Consent by patient, - Public best interest
Name some statutes (laws) that oblige doctors to disclose information
- Public Health Act 1984, - Road Traffic Act 1988, - Prevention of Terrorism Act 1989
Define patient safety
Coordinated efforts to prevent harm to patients cause by the process of health care itself
What is an adverse event/
Unintended event resulting from clinical care and causing patient harm
What is a near miss?
A situation in which events or omissions arising during clinical care fail to develop further
Describe the Swiss cheese model of accident causation
Although many layers of defence lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur
What are the main causes of error at an individual and a system level?
- Individual error - errors of individuals, blames individual for forgetfulness, inattention or moral weakness, - System error - conditions under which an individual works, tries to build defences to eliminate errors or mitigate their effect
What are active failures?
- Unsafe acts committed by people in direct contact with the patient, - Usually short lived, often unpredictable
What is latent error?
- Develop over time until they combine with other factors or active failures to casein adverse event, - Long lived and often can be identified and removed before they cause an adverse event
What are the different types of errors? (3 types)
- Knowledge based - such as forming wrong intentions or plans as a result of inadequate knowledge/experience, - Rule based - encounter relatively familiar problems but apply wrong rule, either misapplication of a good rule or application of a bad rule, - Skills based - attention slips and memory lapses, involve the unintended deviation of actions from what may have been a good plan; people are prone to these types of errors, mainly due to interruption or distraction
What are violations?
- Deliberate deviation from some regulated code of practice or procedure, - They occur because people intentionally break the rules
What are the types of violation? (4 types)
- Routine - regularly performed shortcuts due to system, process or task being poorly designed or actions; may become tacitly accepted practice over time, - Reasoned - occasional reasoned deviation from a protocol or procedure which we believe we have good reason for making (e.g. time constraints), may be in patient’s best interests, - Reckless - deliberate deviations from a protocol/code of conduct and include acts where opportunity for harm is foreseeable and ignored, although harm may never be intended, - Malicious - deliberate deviations from a protocol/code of conduct, where the intention is to cause harm
What systems are in place in the NHS to try and prevent errors occurring? (3 systems)
- National Patient Safety Agency (NPSA) 2001 - coordination of reporting and learning from mistakes that affect patient safety, - National Reporting and Learning System (NRLS) 2004 - national system for anonymous reporting go patient safety incidents, including near misses; all trusts now have local system for reporting, linked to the national system; also has an E-form for reporting incidents anonymously directly to the NPSA, - Medicines and Healthcare Products Regulatory Agency (MHRA) - ensures medicines, healthcare products and medical equipment meet appropriate standards of safety, quality, performance and effectiveness and that they are used safely; monitoring of medicines and acting on safety concerns; responsible for adverse incident reporting system for medical devices
How do we know if a hospital is safe?
- Hospital mortality data, - Data on other measures of safety - reports of never events and serious incidents, NHS safety thermometer, patent safety dashboards, - Monitoring and inspections by regulators - care quality commission (CQC), NHS Improvement
What situations are associated with an increased risk of error? (6 examples)
- Unfamiliarity with the task, - Inexperience, - Shortage of time , - Inadequate checking, - Poor procedures, - Poor human equipment interface
What should we do when adverse incidents occur? (5 steps)
- Report it - incident reporting systems, - Assess its seriousness, - Analyse why it occurred - root cause analysis, - Be open and honest with the affected patient and apologise - duty of candour, - Learn from the event and put in place action to reduce risk of repeat
Why do children go to A&E?
- Accidental injury, - Asthma, - Respiratory illness, - Infective process, - Rashes, - Appendicitis
Why are males more likely to die than females?
- Higher suicide rates, - Violence related incidents, - Road traffic accidents, - Behavioural differences between males and females - more likely to take part in ‘risky’ behaviour
What is the most common cause of external deaths in adolescents?
Traffic accidents (>50%)
Why does poverty increase the chance of getting ill?
- Poor nutrition, - Overcrowding, - Lack of clean water, - Harsh realities that may make putting your health at risk the only way to survive or keep your family safe
Why does poor health increase poverty?
- Reducing a family’s work productivity, - Leading family to sell assets to cover the costs of treatment
What are the implications of chronic illness in children?
- Affects physical, mental and social development, - Repeated absence at school, - Affect on parents and siblings, - Financial effect (family and community), - Can be lifelong
What conditions are screened for before birth? (3 main tests)
Antenatal screening tests identify major abnormalities, - Alpha fetoprotein - raised in neural tube defects and some GI abnormalities, - Downs test - alpha fetoprotein and HCG, - Ultrasound - growth check, cardiac abnormalities, diaphragmatic hernia
What tests are done neonatally? (2 tests)
- Blood spot test - PKU, cystic fibrosis, sickle cell disease, congenital hypothyroidism, - Physical examination
What are the timings for screening and developmental surveillance?
- Antenatal screening (12th week of pregnancy), - Neonatal examination, - New baby review (14 days), - 6-8 week check, - 1 year check, - 2-2.5 year check
What is the purpose of the 6-8 week postnatal check?
- Take history, - Assess psychological and social situation, - Examination of mother - abdomen, vaginal exam (sometimes), BMI, - Examination of baby - weight, head circumference, appearance and movement, hips, heart, spine, eyes, - Health promotion - immunisations, breast-feeding, reducing risk of SIDS, car safety, - Assessment of parenting and emotional attachment
What is looked for in the heart examination at the 6-8 week postnatal check?
- Look for cyanosis, ventricular heave, respiratory distress, tachypnea, - Feel apex beat, - Listen or murmurs
What is developmental dysplasia of hip (DDH)?
Ball and socket joint of hip doesn’t form properly - too shallow so femoral head is loose and can dislocate
What are the tests for developmental dysplasia of hip (DDH)?
- Barlows test - flex and adduct hip then push hip posteriorly, positive test causes femoral head to slip out of the acetabulum , - Ortolanis test - gently abduct hip, puts dislocated hip back in place
What are the normal vital signs of a healthy baby?
- Respiratory rate - 30-60 breaths per minute, - Heart rate - 100-160 beats per minute, - Temperature - 37 degrees celsius
What immunisations should be given in the first year of life?
- 8 weeks - 6-in-1 vaccine (1st dose), rotavirus vaccine (1st dose), MenB vaccine (1st dose), - 12 weeks - 6-in-1 vaccine (2nd dose), pneumococcal (PCV) vaccine, rotavirus vaccine (2nd dose), - 16 weeks - 6-in-1 vaccine (3rd dose), MenB vaccine (2nd dose), - 1 year - Hip/MenC vaccine (1st dose), MMR (1st dose), PCV vaccine (2nd dose), MenB (3rd dose)
What is puerperium?
- Postnatal period, - Period of about 6-8 weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition
What are the main aims of antenatal care? (6 aims)
- Monitor progress of pregnancy to optimise maternal and foetal health, - Develop a partnership between the other and health professionals, - Exchange information that promotes choice - about lifestyle, location of birth, etc., - Recognise deviations from the norm and refer appropriately, - Increase understanding of public health issues, - Provide opportunities to prepare for birth and parenthood
Which key documents influence antenatal care provisions?
- MBRRACE-UK (mothers and babies - reducing risk through audits and confidential enquiries across the UK), - NICE antenatal care guideline (2008, modified 2014), - Evidence based practice, - Local policy/guidelines for practice, - Midwifery 2020, - National maternity review ‘Better births’
What were the key themes of the national maternity review ‘Better births’? (7 themes)
- Personalised care, - Continuity of care, - Safer care, - Better postnatal and perinatal mental health care, - Multi-professional working, - Working across boundaries, - A fairer payment system
What tests are done at antenatal visits? (3 main tests)
- Physical examination - weight, BP, urinalysis, - Blood tests - FBC, antibodies, ABO and Rh, HIV, - Psychosocial and emotional support - general wellbeing, work, financial, anxiety
What are some of the risk factors for adverse outcomes to pregnancy?
- Chronic or acute disease - may be complicated with pregnancy, - Proteinuria - could indicate renal pathology, - Significant increase BP readings - pre-eclampsia, may lead to eclampsia (fits and convulsions), - Significant oedema - hypertensive disorder?, - Uterus large or small for gestational age - lots of conditions affect these, - Malpresentation - cephalic or breach, - Infection - increases risk of miscarriage/stillbirth, - Social or psychological factors - mental health problems can lead to antenatal depression/postnatal depression
What are the different forms of pregnancy loss? (4 types)
- Spontaneous miscarriage - loss of pregnancy before 24 completed weeks of pregnancy, - Ectopic pregnancy - fertilised ovum implants outside uterus (embryo grows in Fallopian tube or even abdomen), - Termination of pregnancy, - Stillbirth - born after 24 weeks and does not show any sign of life
What is the MBRRACE-UK report (2014)?
- Mother and Babies Reducing Risk through Audits and Confidential Enquiries across the UK, - 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 of women who died had known mental health problems before they died
What are common causes of death in the postnatal period? (4 causes)
- Infection, - Haemorrhage, - Thrombosis, - Hypertensive disorders (eclampsia)
What physical health and wellbeing issues might a woman experience in the postnatal period? (9 examples)
- Perineal care - infection, inadequate repair, wound breakdown/non-healing, - Urinary retention , - Dyspareunia - difficult or painful sex, - Headache, - Fatigue, - Backache, - Constipation, - Haemorrhoids, - Breast and nipples - redness, painful, cracked, mastitis
What mental health problems may be experienced in the postnatal period?
- 50-80% ‘The blues’ - very weepy over small things, time-limited, recovers very quickly, if it continues then begins o worry about postnatal depression, - 10-15% Postnatal depression - tiredness, worthlessness, low mood, - 0.2% Puerperal psychosis - severe episodes of mental illness that begins suddenly, mania, depression, confusion, hallucinations, delusions
What was the main outcome of the Peel Committee Report (1970)?
Sufficient facilities should be made available for 100% of childbearing women to give birth in hospital
What are the risks associated with Caesarean section? (3 main risks)
- General anaesthesia, danger of Mendelsohns’ syndrome (aspiration pneumonia), paralytic ileus, - Surgical techniques, quite radical abdominal surgery, risk to other internal organs from surgical trauma, - Childbearing risks for further births
What is the medical model of birth?
- Birth seen as a dangerous journey, only normal in retrospect, therefore assume the worst, - Low threshold for intervention (to fix defective bodies)
What is the social model of birth?
Birth is seen as a normal physiological process which women are uniquely designed to achieve
What are some of the cultural issues during 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 mother’s plans, - Social disapproval for pregnancy out of wedlock and teenagers
What was the outcome of the Midwives’ Act (1902)?
- Established normality in childbearing as the midwife’s role - refer to doctors as soon as abnormality occurs, - This ensures equal access to midwives and doctors for childbearing women of all socioeconomic standing
What are the benefits of institutionalised childbirth? (5 points)
- Standardisation of care, - Access to good facilities to support childbirth, - Availability of populations of childbearing women and infants for the purposes of midwifery and obstetric training, - Faster access to emergency care, - Access of effective obstetric analgesia
What ar the risks of institutionalised childbirth? (5 points)
- Medicalisation, - Depersonalisation of birth, - Lack of privacy, - Inflexibility of labour and birth practices, - Limitation of resources
What is the role of doctors in welfare?
- You must consider the safety and welfare of children and young people, whether or not you routinely see them as patients, - identifying signs of abuse or neglect early and taking action quickly are important in protecting children and young people, - Know what to do if you are concerned that a child or young person is at risk of, or is suffering, abuse or neglect, - Act on any concerns about a child or young person who may be at risk of, or suffering, abuse or neglect
What are the indicators of a successful breastfeed?
- Baby - audible and visible swallowing, sustained rhythmic suck, relaxed arms and head, moist mouth, regular soaked nappies, - Mother - breast softening, no compression of nipples at end of feed, relaxed
What problems may occur with breastfeeding?
- Nipple pain, - Engorgement, - Mastitis, - Inverted nipple, - Ankyloglossia (tongue ties), - Sleepy baby
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
Why is there a heavy emphasis on quality management in healthcare?
Quality management produces improved quality, reduced costs, increased productivity and an increased market share
Why is consumer protection necessary? (3 medical practice deficiencies)
- Medicine has a weak evidence base, - Large variations in clinical practice - doctors do give different treatments to patients with similar needs and personal characteristics, - Failure to measure success outcomes in healthcare
What data are available to improve patient safety? (3 sources)
- Hospital episode statistics (HES) - details referring GP, procedures given, duration of stay and discharge/death, lack of basic national data in primary care, - Patient reported outcome measurements (PROMs) - before procedure and after procedure quality of life measurement slowly developing, - Reference cost data - cost data are poor