Health and Society Yr2

What general intervention strategies are possible for HIV/AIDS?
- blood donor and product screening
- affordable condoms
- education for high risk groups
- promotion of safe sex at a population level
- diagnosis and treatments of STDs
- HIV voluntary counselling and testing
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Determinants of effective outcomes of intervention?
- 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 t
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Current problems/issues?
- debt, inadequate aid
- under resourced global fund
- US politics are retrogressive and harmful
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What are public health objectives of vaccination?
- reduce morbidity and mortality
- prevent outbreaks and epidemics
- contain infections
- interrupt transmission
- generate herd immunity
- eradicate infectious agent
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What is required for a disease to eradicated using vaccination?
- no other reservoirs exist in animals or environment
- where consequences of infection are very high
- where scientific and political prioritisation exist
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Which diseases have been eradicated?
- Polio
- Smallpox
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Describe herd immunity
- level of immunity in a population which protects the whole population
- only applies to diseases passed from person to person
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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)
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What factor affect R0
- rate of contacts in host population
- probability of transmission
- duration of infectiveness
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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
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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
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What is the equation for herd immunity?
• H = (R0-1)/ R0
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What is a susceptible population
- any person not immune
- never before encountered?
- unable to amount immune response?
- vaccine contraindicated?
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What is WHOs role in vaccination?
- Reccommndations to countries on tax policy
- supports less able countries with implmentation
- works through international health regulations to ensure max security
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List some international immunisation programmes:
- Extended programme of immunisation EPI
- Global polio Eradication Initiative (GPEI)
- Global Alliance for Vaccines and Immunisation (GAVI)
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What is shared decision making and why is it important?
- reach health care choice together
- important when there is more than one reasonable option
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Pros of vaccination?
- Saves lives
- ingredients are safe in the amounts used
- adverse reactions are rare
- herd immunity
- save children and parents time and money
- protect future generations
- eradication of disease
- economic benefits for society
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- side effects
- harmful ingredients
- person medical choices
- can contain ingredients that people object to e.g. egg
- unnatural
- profit
- relatively harmless diseases
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What factors affect decision making?
- lifestyle
- perception of health
- beliefs about childhood diseases
- risk perception of the diseases
- perceptions about vaccine effective and vaccine components
- trust in institution
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What is the population vs individual interest debate?
- For individual- 'herd immunity' prtection best option as avoids risk of vaccine
- community - avoidance of vaccine disminishes her immunity
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What websites can be used to find out if travel vaccines are needed?
- NHSfitfortravel
- The National Travel Health Network and Centre (NaTHNaC)
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What are some free travel vaccines?
- Diptheria, polio, tetanus, typhoid, hep A, cholera
- Private = Hep B, Japanese encephalitis, meningitis, rabies, TB, yellow fever
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What factors should be considered when deciding to get travel vaccinations?
- the country
- when you're travelling
- where you're staying
- how long for
- age and health
- what you'll be doing
- if you're working a an aid worker
- if you're in contact with animals
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Most common cancers on adult men and women?
1. breast/prostate
2. lung
3. bowel
4. melanoma
5. non-hodgkin lymphoma
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5 most common causes of cancer mortality in men and women?
1. Lung
2. Bowel
3. Prostate, breast
4. Pancreas
5. Oesophagus
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most common cancers in children
- leukaemia
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- most common causes of cancer mortality In children
- brain, CNS and intracranial tumours
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How do patterns of cancer differ from those in developing countries?
- Higher in UK (29%)
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- Role of legal and lifestyle changes in reducing incidence and mortality of cancer
- prevention - legal and lifestyle changes, vaccinations
- screening - early detection and diagnosis
- Disease management - improving treatments and quality of life
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What is meant by bad news
- drastically and negatively alters patients (relatives) views of their future
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What factors affect the impact of news on a patient?
- institutional beliefs, personality types, gender, culture, religion, patients knowledge, relatives (support)
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What anxieties may healthcare professionals have about breaking bad news
- uncertainly about patients expectations
- fear of destroying patients hope
- fear of their own inadequacy in face of controlling the disease
- not feeling prepared for emotional response
- previously being too optimistic
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- advanced preparation
- building relationship
- communicate well
- deal with reactions
- encourage and validate emotions
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- setting up
- perception
- invitation
- emotions
- strategy and summary
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What emotions may a patient feel when they receive bad news?
- grief, distress, denial, anger, agitated/restless
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How can cancer change partner relationships
- change in roles/responsibilities
-change in physical needs
- change in emotional needs
- change in sexuality and intimacy
- change in future plans
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Conclusions and consequences of Eurocare-II report?
- Despite limitations of mythology, cancer survival in the UK 1980s-90s was one of the worst in Europe
- Expert advisory group formed to the chief medical officer in 19995 generated the calman-hine report
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consequences and conclusions of calman-hine report (1995)
- examined cancer services in UK, proposed a restructuring of cancer services to achieve more equitable level of access to high levels of expertise throughout the country
- access to uniformly high quality care
- public and professional education to recog
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What are the Calman-Hine solutions
-3 levels of care
- primary care
- cancer units serving district general hospitals
- cancer centres (populations in excess of 1MIL)
- key to managing patients is MDT
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What is national service framework
- national standards and define service models for service or care group
- programs to support implementation
- establish performance measures against which progress within agreed timescales would be measured
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Aims of NHS cancer plan?
- save more lives
- sneer they get the right support, care and treatments
- tackle health inequalities
- build for the future
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NICE CANCER guidelines?
- 2000 manual of cancer - 300 standards
- 2004 manual of cancer - over 900 new measures
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what are the 6 key areas for action in the cancer reform startergy?
- diagnosis early
- ensuring better treatment
- living with and beyond cancer
- delivering care in most appropriate setting
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Which cancers are screened for?
- cervical, bowel, breast
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what is the national cancer survivorship initiative
- partnership with cancer charities, clinicians and patients, range of approaches to improving services and support available for cancer survivors
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main outcomes from 'Improving outcomes: A strategy for cancer (2011)'?
- white cancer patients report a more positive experience
- younger people least positive about their experience, particularly around understanding completely what was wrong with them
- men generally more positive about their care than women
- non-hete
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Outcomes from independent cancer Taskforce (2015).
-Spearhead a radical upgrade in prevention and public health
- Drive a national ambition to achieve earlier diagnosis
- establish patient experience as being on par with clinical effectiveness
- transform approach to support people living with and beyo
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what is body image
- perceptions, thoughts, and behaviours related to ones specific appearance
- body is bearer of values and a means of representing our identity to others - it shows who we are to others
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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-identity
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What is the purpose of hair
- important site of individual and group identity
- symbol of femininity
- stigma
- patient control over their status as sick
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Functions of clinical record?
- support patent care
- improve future patient care
- social purposes at the request of patients
- medico-legal document
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What should be recorded on clinical records?
- Presenting symptoms
- clinical findings
- diagnosis and important differentials
- options for care and treatment
- risk and benefit of care and treatment
- decisions about care and treatment
- action taken and outcomes
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Differences between paper and electronic records
Paper - continuous, portable, writer indentififed, legibility issues, must be dated and signed
Electronic - problem orientated, searchable, structured, safer prescribing, clinical decision support software
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What is the use of record in audit, research and management?
- support clinical audit
- facilitates clinical governance
- facilitates risk management
- support clinical research
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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 foreseeably harm others
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What is negligence?
- failure to exercise the care that a reasonably prudent person would exercise in like circumstances
- make decisions that adhere duty as a doctor
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- correct moral response is related to the outcome or consequence of the act
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Places value on the intentions of the individual and focuses on rules, obligations and duties
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Virtue ethics?
Right living is derived from the moral character of the agent
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How do you evaluate an argument?
- clear on logical form of argument
- query - valid and sound
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why might an argument be invalid?
- 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
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Why might an argument be unsound?
- Argument is invalid
- Argument is valid but one or more premise is false
- an unsound argument doesn't mean there will be an unsound conclusion
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What should be avoided in arguments?
- staw man fallacy - substituting persons position for distorted, exaggerated or misrepresented version
- ab hominem - directing against a person, not their position
- appealing to emotion
- begging the questions
- argument from fallacy - conclusion must
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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 some supporting reasons for the claim in question
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What is a deductive argument?
- purely logic
- this means this, therefore this...
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What is an inductive argument?
- making an argument based on an observation, more probable conclusions (seeing is believing but you may not have seen everything)
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What are mDTs in cancer care and why are they needed?
-fragmented over several hospital sites
- better outcomes
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functions of MDT in cancer care?
- discuss every new diagnosis of cancer within their site
- decide on management plan for every patient
- inform primary care of that plan
- designate a key worker
- develop referral, diagnosis and treatment guidelines for their tumour sites
- audit
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What is sensitivity?
- true positives
- measures proportion of positives correctly identified
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equation for sensitivity?
= true pos / (true pos + false neg)
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What is specificity?
- true neg
- measures proportion of neg correctly identified
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uses of diagnostic tests?
- diagnosis
- screening
- monitoring
- prognosis
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how is sensitivity and specificity important in diagnosis
• The importance of a diagnostic accuracy in testing is directly proportional to the tests potential to cause patient consequences and harm.
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What is positive predictive value?
- probability that subjects with a positive screening test truly have the disease
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What is the likelihood ratio?
- 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
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What is commonly screened for
- cancer
- prenatal tests
- newborn bloodspot test
- ultrasound scan - abo aneurysm
- metabolic syndrome
- hearing loss in newborn
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What are the limitations of screening
- cost and use of medical resources
- adverse effects of screening procedure
- stress and anxiety caused by false positive
- prolonged knowledge of an illness without an improvement in outcome
- false sense of security caused by false negatives, which
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- what are the pros and cons of good screening
- pros - early detection, decreases risk of death

- cons - no benefit, ill despite screening
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-what areas should be evaluated when deciding what should be screened for?
- condition - important? natural history of condition, detectable risk factor, latent period, cost-effective
- test - simple, safe, validated
- treatment
- programme - RCT evidence of reduction in mortality or morbidity, benefit outweigh harm, opportunit
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what is sojourn time
- duration of a disease before clinical symptoms become apparent, but during which it is detectable
- temporal window of opportunity for detection
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what is length bias
- overestimation of survival duration among screening - detected cases by the relative excess of slowly progressing cases
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What are the consequences of length bias
- diseases with a longer sojourn time are easier to catch in the screening net
- scereened = automatic better prognosis
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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.
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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
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What is over diagnosis bias?
• Overestimation of survival duration among screen-detected cases caused by inclusion of pseudodisease - subclinical disease that would not become overt before the patient dies of other causes.
• Occurs when screen-detected cancers are either non-growin
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What is PSA testing and what can cause elevated PSA?
- prostate specific antigen, protein produced by cells of the prostate gland
- elevated in - prostate cancer, BPH, prostates, UTI
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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 increased risk
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What are the disadvantages of PSA screening
- early detection may not reduce chance of death
- over treatment
- may give false- positive, other conditions can increase PSA, not specific enough
- may give false- negative
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consequences of incontinence
- distress
- embarrassment
- inconveniance
- self esteem
- loss of personal control
- desire for normalisation
- loss of interest in sex
- difficulty sleeping
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what impact might chronic dialysis have on patients
- hospital admissions
- restriction of leisure time
- may have to give up job
- increased dependance on dialysis
- uncertainness about the future
- fatigue
- limitation of liquids and foods
- depression
- lower-self esteem
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What 4 sources are used when making a clinical decision
- patient preferences
- available resources
- research evidence
- clinical expertise
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what is opportunity cost?
the loss of other alternatives when one alternative is chose
the amount of money that is alienated by choosing to use it for one project rather than another
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What is distributive justice
how can we distribute resources that are finite in a fair way
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how can you decide ways to distribute healthcare
- QALY calculation
- waiting list
- likelihood of complying with treatment
- lifestyle choices of patient
- ability to pay
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What is confidentiality
- pledge of agreement to not divulge or disclose information about patients to others
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why is It important to maintain confidentiality
improves trust between patient and doctor
respects autonomy
prevents patient harm
human rights act
GMC requirement
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when can confidentiality be breached
consent by patient
public best interest
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name some statutes that oblige doctors to disclose information
public health act 1984
Road traffic act 1988
prevention of terrorism act 1989
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define patient safety
coordinated efforts to prevent harm to patients caused by the process of health care itself
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what is an adverse event
unintended event resulting from clinical care and causing patient harm
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what is a near miss
a situation I which events arise during clinical care but fail to develop further
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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
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what are the main causes of error at an individual and a system level
individ - blames individual for forgetfulness, inattention or moral weakness
systematic - condition under which the individual works
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what are active failures
unsafe acts committed by people in direct contact with the patient
usually short lived, often unpredictable
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what is latent error
develop over time until they combine with other factors or active failures to cause an adverse event
- long lived often can be identified and removed before they cause an adverse event
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What are the different types of errors?
- knowledge based
- rule based
- skills based
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What are violations
- deliberate deviation from one regulated code of practice or procedure
- people intentionally breaking rules
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Types of violations?
routine- shortcuts sue to system being poorly designed (may be in patients best interest)
Reasoned - believe we have a good reason (e.g. time restraints)
Reckless - deliberate deviations from a protocol/code of conduct include acts where opportunity for h
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What systems are in place in the NHS to try and prevent error occurring
National Patient Safety Agency - 2001 - coordination of reporting and learning from mistakes that affect patient safety
- National Reporting and learning system - 2004, anonymous reporting
- Medicines and Healthcare - products Regulatory Agency - ensur
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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 (CDQ), NHS improvement
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What situations are associated with an increased risk of error
unfamiliarity with the task
- inexperience
- shortage of time
- inadequate checking
- poor procedures
- poor human equipment interface
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What should we do when adverse incidents happen
- report it
- assess its seriousness
- analyse why it occurred
- be open and honest (DUTY OF CANDOUR)
-learn from the event and put in place actions to reduce risk of repeat
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What are the common causes of death and contact with hospital/primary care in children in developing countries
- infection, diarrhoea, malaria, HIV, malnutrition, kwashiorkor, sanitation,, water supply, food hygiene
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what are the common causes of death and contact with hospital/primary are in children in developed countries?
congenital abnormalities, infections, respiratory disorders, trauma, malignancy, neurological disease
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Why do children go to A&E
accidental injury, asthma, respiratory illness, infective process, rashes, appendicitis
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Why are males more likely to die than females
- higher suicide rates
- violence related
- road traffic accidents
- 'risky' behaviour
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What is the most common cause of external deaths in adolecscents
traffic accidents
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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
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- why does poor health increase poverty
- reducing a family work productivity
- leading family to sell assets to cover cost of treatment
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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 affect (family and community)
- can be lifelong
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What conditions are screened for at birth
- antenatal screening tests
- alpha fetoprotein (neural tube defects, GI abnormalities)
- Downs test (alpha fetoprotein and HCG)
- Ultrasound
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What tests are done neonatally
- Blood spot test (PKU, cystic fibrosis, sickle cell disease, congenital hypothyroidism
- physical examination
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What are the timings for screening and developmental surveillance?
Anetanatal screening (12th week of pregnancy)
Neonatal examination
new baby review
6-8 wk check
1 yr check
2-2.5 year check
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What is the purpose of the 6-8 week postnatal check
take history
assess psychological and social situation
examination of mother (abdomen, vaginal exam, BMI)
Examination of baby (weigh, head circumference, appearance and movement
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What is the purpose of the 6-8 week postnatal check
- take history
- assess psychological and social situation
- examination of mother (BMI)
- health promotion
- assessment of parenting and emotional attachment
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what is looked for in the heart examination at 6-8 week check
- cyanosis, ventricular heave, respiratory distress, tachypnoea
- feel apex beat
- listen for murmurs
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What is developmental dysplasia of the hip
ball and socket join of hip doesn't form properly too shallow so femoral head is loose and can dislocate
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What are the tests for DDH
Barlow's test (Flex and adduct hip then push posteriorly, positive test causes the femoral head to slip out of the acetebaulmum)
Ortolanis test - gently abduct hip, puts dislocated hip back in place
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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
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what immunisations should be given in the first year
8 wks - 5 in 1 vaccine, PCV vaccine, Men B, rotavirus
12 wks - 5in1 vaccine, rotavirus
16 weeks - 5in1 vaccine, PCV vaccine, Men B 2
1 year - Hip, Men C vaccine, MMR vaccine, PCV vaccine, Men B vaccine 3
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What is puerperium
- postnatal period
- period of about 6-8 weeks after childbirth during which the mothers reproductive organs return to their original non-pregnant condition
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What are the main aims of antenatal care?
- monitor progress of pregnancy to optimise maternal and health professional
- develop a partnership between woman and health professional
- exchange information that promotes choice
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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
• Nation
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What were the key themes of the national maternity review 'Better births?'
- personalised care
- continuity of care
- safer care
- better postnatal and perinatal mental health care
- multi-professional working
- a fairer payment system
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What tests are done at antenatal visits?
- physical examination - wight, BP, urinalysis
- Blood tests - FBC, antibodies, ABO and Rh, HIV
- Psychosocial and emotional support - general wellbeing, work, financial, anxiety
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What are some of the risk factors for adverse outcomes in pregnancy?
- chronic or acute disease (may be complicated with pregnancy)
- proteinuria (renal)
- significant bP (pre-eclampsia can lead to eclampsia)
- significant oedema
- uterus size
- malpresentation (cephalic or breach)
- infection
- sociological/psychologica
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What are the different forms of pregnancy loss
- spontaneous miscarriage (before 24 wks)
- ectopic (outside uterus)
- termination of pregnancy
- still born after 24 wks)
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What is the MBRACE report 2014
- looked at standards of care and mortality rates
- 2/3 of mothers dies from medical and mental health problems, 1/3 from direct causes
- 3/4 women who died had known mental health problems
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what are the common causes of death is postnatal period
infection, haemorrhage, thrombosis, hypertensive disorders (eclampsia)
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What physical heath and wellbeing issues might a woman experience in the postnatal period?
- perineal care - infection, inadequate repair, wound breakdown/non-healing
- urinary retention
- dyspareunia (difficult painful sex)
- headache
- fatigue
- backache
- constipation
- haemorrhoids
- breast and *******, redness, pain, cracked
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what mental health problems may be experienced in the postnatal period
- 50-80% baby blues - weepy, time limited, recover quickly
- 10-15% postnatal depression - tiredness, worthlessness, low mood
- 0.2% puerperal psychosis - severe episodes of mental illness that begins suddenly, mania, depression, confusion, hallucinations
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what are the main outcomes of the peel committee report (1970)
sufficient facilities should be made available for 100% of childbearing women to give birth in hospital
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What are the risk associated with caesarean section
- general anaesthesia, danger of medelsohns syndrome (aspiration pneumonia), paralytic ileum
- surgical techniques, radical, riks to other organs
- childbearing risk for further births
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what is the medical model of birth
birth seen as dangerous journey, only normal in retrospect, therefore assume the worse
low threshold for intervention
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what is the social model of birth
normal physiological process, women are uniquely designed to achieve
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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 mothers plans
- social disapproval for pregnancy out of wedlock and teenagers
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what is the outcome of the midwives act (1902)
established normality in childbearing as the midwife's role - refer to doctors as soon as abnormality occurs
- ensures equal access to midwives and doctors for childbearing women of all socioeconomic standing
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What are the benefits of institutionalised childbirth?
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 analge
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What are the risks of institutionalised childbirth
- medicalisation
- depersonalisation of birth
- lack of privacy
- inflexibility in labour and birth practices
- limitation of resources
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What is the role of doctors in welfare?
- must consider the safety and welfare of children and young people, wether or not they are your patient
- identifying signs of abuse or neglect early and taking action
- knowing what to do when concerned about welfare
- act on any concerns
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What are the indicators of successful breast-feeding
- baby - audible and visible swallowing, sustained rhythmic sucking, relaxed arms and head, moist mouth, regular soaked *******
women - breast softening, no compression of ******* at end of feed, relaxed
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what problems may occur with breastfeeding
****** pain
inverted ******
ankylosis (tongue ties)
sleepy baby
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What is quality in relation to healthcare?
• The extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
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why is there a heavy emphasis on quality management in healthcare
- improved quality, reduced cost, increased productivity and an increased market share
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Why is consumer protection necessary?
Medical practice has 3 deficiencies internationally:
- weak evidence base
- large variations is clinical practice
- failure to measure success outcomes
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What data are available to improve patient safety?
- hospital episode statistics (details referring GO, procedures given, duration of stay and discharge/death, lack basic nutritional data in primary care
- patient reported outcome measures (PROMs) - before procedure and after procedure quality of life mea
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What is the summary hospital level mortality indicator? (SHMI)
- The ratio between the actual number of patients who die within 20 days of discharge compared with the number that would be expected to die on the basis of average
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What are the key consumer protection agencies
acre quality commission
NHS improvement (ensures financial obligations are met)
National Institute for Health and Clinical Excellence
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Who enforces the NICE guidelines?
• Royal Colleges
• Professional audit
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How can consumer protection be improved?
• Appraisal by peers
• Revalidation by the GMC
• Medical audit as a compulsory part of routine practice and annual job planning
• GP and consultant contracts - Increasing transparency in comparative performance in relation to activity, costs, and patie
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What is clinical governance
- framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
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What are the types of neglect
-physical neglect
- educational neglect
- emotional neglect
- medical neglect
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What are the signs of neglect
- malnutrition
- poor hygiene, matted hair
- unattended physical or medical probelmes
- absence, lateness
- inappropriate clothing
- frequent illness, infections or sores
- being left unsupervised for long periods of time
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what are 4 types of child abuse
- neglect
- psychological abuse
- sexual abuse
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Who are the people involved in reproductive ethic debates
- parents
- future or existing children
- third parties, including the state
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What was the main outcome of the human fertilisation and embryology act (1990)
- a woman shall not be provided with fertility treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father)
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What are some of the criticisms of the human fertilisation and embryology act (2008)
- fertile couples don't have to meet this criteria
- 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
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what was the main outcome of the human fertilisation and embryology act (2008)
• Continues to talk about a duty to take account the welfare of the child in providing fertility treatment (hence, a welfare criterion remains) but replaces reference to 'the need for a father' with 'the need for supportive parents', thus valuing role of
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What is the pro-life argument
- abortion ends life of foetus
- human foetuses have moral status of a person?
- is it wrong to end the life of a person/ a creature with the moral status of a person (depends on the circumstances)
- therefore, abortion is morally wrong
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What is procreative autonomy?
- to have control over one's reproductive capabilities
- the freedom to choose wether or not to have children
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What did the abortion act (1967, ammeded 1990) state?
• A person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith:
• Pregnancy has not exce
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What is the scientific basis for linking diet to cancer?
- evidence for individual dietary factors is difficult to find
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Where is oesophageal cancer prevalent
- middle, east china
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where is gastric cancer prevalent
- russia
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where is colon cancer prevalent
- western world e.g. US, UK
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Link between fat intake and colorectal cancer
- increasing fat = correlation
- low fat = low levels of cancer
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- what did migrant studies show (fat)
- lifetime cancer risk increased for migrants moving from Japan to Hawaii compared to those who stayed in Japan
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Why 5 a day?
- evidence showed av fruit/veg intake of less than 200g associated with increased risk of cancer, but possibly little benefit beyond 400g/a day
- average portion size is 80g
- little evidence that 5 a day impacts cancer
- EPID study - little evidence
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What are some health promotion messages?
- increase levels of physical exercise
- don't put on weight in adulthood
- aim for BMI between 18-25
- safe levels of alcohol
- increase fruit and vegetable intake to 400g/day
- limit intake of preserved and red meat
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What problems are associated with case-control studies?
- recall bias
- people with disease are more likely to remember correctly
- people without disease unlikely to make as much of an effort
- possible early impact of disease on diet - if cancer effects diet it is and to tell whether the diet impacted the
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Problems with cohort studies?
- measuring diet in a large group
- maintaining follow-up over long period
- cancer takes a long time to develop
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Problems for all observational studies
- bias
- confounding - patterns of behaviour associated with certain types of diet so these behaviours may be impacting
- hard to establish causal relationship
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Describe the beta carotene
- in foods with good risk relationship with cancer
- RCT using beta-carotene - showed increased cancer risk
- protective findings due to confounding variables such as non-smokers, exercise etc.
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Problems with measuring diet
-random error - individual consumptions vary from day to day
- homogeneity of exposure - need to carry out on a diverse population
- bias
- confounding
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measures of diet?
- food disappearance data
- household survey (what do you buy and who eats what)
individual survey - 24 hr recall, food frequency (bias), diet diary, biomarkers
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Food frequency
- questionnaires
- pros - captures usual diet as eaten, overstimates fruit and vegetables, poor measure of energy intake, less flexible
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Diet diaries
pros - records diet as eaten, better estimate of energy and absolute intake, more flexible
- cons - required effort to complete and expensive to code
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outline the main associations between diet and GI cancers
- an old estimate - 30% cancers cased by diet - evidence of this relationship is unknown
- modifiable exposure has significant impact on disease development
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What is associated with osesophageal cancer?
- alcohol and obesity increases
- decreases - non-starchy veg, fruits, vit C
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what is associated with stomach cancer?
- increased = salted preserved foods
- decreased = non-starchy vegetables, allium vegetables, fruit
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What is associated with pancreas cancer
- overweight and obesity (increased)
- foods containing folate (decreases)
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- aflatoxin contamination (increased)
- alcohol (decreased)
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- preserved + red meat alcohol, body weight (Increases), alcohol for women
- physical activity, dietary fibre, milk, calcium supplements (decreases risk)
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-alcohol, overweight (increases)
- overweight and obesity (decreases post-menopausal)
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- fruit (decreases)
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- high calcium (increases)
- lycopene (decreases)
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Clinical decision support systems?
(cdss) designed to aid clinical decision making
- patient-specific assessments or recommendations to aid clinical decision making
- act as an aid
- may be computerised, paper based, reminder systems, may be developed to aid with particular systems
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Reminder systems
- screening
- vaccinations
- testing
- medication use
- identification of risky behaviour
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Diagnostic systems
- model individual patient data against epidemiological data
- often match patients signs and symptoms to database
- can provide hypotheses or estimates of probability of different potential diagnosis e.g. Ottawa ankle rules
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Ottawa ankle rules evaluation:
- Bachmann et al, 2003 : meta-analysis of 27 studies evaluating Ottawa ankle rules in any age
- sensitivity almost 100%
- specificity 30-40%
- its use should reduce unnecessary radiographs by 30-40%
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- advice on drug dosage
- advice on drugs to prescribe
- highlighting potential drug interactions
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Computer systems to support drug dosage decisions
computer support vs no computer support gave statistically significant reductions in
- time to achieve therapeutic stabilisation
- risk of toxic drug level
- Length of hospital stay
Statsitccaly significant increase in...
- size of initial dose
- seru
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Why use a clinical decisions support system
- Garg et al (2005)
- systematic review of effects of computerised clinical decision support systems on practitioner behaviour/patient outcomes
-100 studies from 1971-2004, most from US and UK
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Reminder systems
- 21 trials
- using a CDSS beneficial in 16/21 trials (76%)
- increases rates of screening, vaccination, medication use and identification of at-risk behaviours
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Disease Management
- 40 trials
- 37 looks at practitioner performance
- of these 23 showed improvements in disease management
- 71% of trail looking at diabetes management showed improvements
- 38% of trials looking at cardiovascular disease reported improvement
- 27 l
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Drug dosing and prescribing
- 29 trials
- 24 trails into single drug dosing
- 15/24 trials showed improved practioner performance
- 5 trials into multiple drug prescribing (4/5 trials showed improved practioner performance)
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What did Kawamoto et al (2005) syetmatic review find
- to identify the features of CDSS that lead to improvements in clinical practice
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What improves clinical practice when using decision support
1. providing decision support as part of the clinical workflow
2. providing recommendations for management
3. providing decision support when and where decision making was happening
4. computer-based decision support
- of the 32 systems possessing all t
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What may help or hinder the use of CDSS?
- Varonen et al (2008) qualitative study of 39 Finnish physicians (mix of primary and secondary care)
- identified barriers - earlier negative experience of IT
- potential harm to DR or Dr-pateint relationship
- obscured responsibilities
- reminders inc
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Clinical decision aids
no single best choice as individuals vary in their preferences for different treatments
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Patient decision aids
- specific aims and support provided may vary, enable patients to
- understand probable outcomes of options, by providing information relevant to the decision
- consider the personal value they place on benefits versus harms, by helping clarify preferen
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Stacey et al (2014)
- 115 trials of individual decisions aids
- increased knowledge
- more accurate risk perceptions
- reduced decisional conflict
some effects on secondary outcomes, but some inconclusive and varies by setting
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Computerised decision support systems
- potentially useful to aid clinical decision making
- can improve practioner performance
- if fully integrated into process of clinical care, likely to be used effectively
- patient decision aids may improve patient knoowldge
- need better evaluations
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- Priorities - 'Developed world academic' analyses of cost-effectiveness may not reflect the developing world realities
- Setting - Countries where t

Card 3


Current problems/issues?


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Card 4


What are public health objectives of vaccination?


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What is required for a disease to eradicated using vaccination?


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