ABSHD Flashcards
1
Q
What is best evidence?
A
Findings of rigorously conducted research
2
Q
In evidence-based healthcare, what kind of evidence is obtained for drugs practices and interventions?
A
Effectiveness
Cost-effectiveness
3
Q
What are the common consequences of using healthcare that is not evidence-based?
A
Waste of resources
Creates inequities
Causes harm
4
Q
What is evidence-based practice?
A
Evidence based practice involves the integration of individual clinical expertise with the best available external clinical evidence from systematic research.
5
Q
Why are systematic reviews useful?
A
- By appraising and integrating findings, they offer both quality control and increased certainty.
- They offer authoritative, generalisable and up to date conclusions
- They save clinicians from having to locate and appraise studies for themselves
- They may reduce delay between research discoveries and implementation.
- They can help to prevent biased decisions being made
- They can be relatively easily converted into guidelines and recommendations.
6
Q
How can we assess the quality of evidence?
A
Using a critical appraisal tool or instrument. These suggest the things to look for and the questions to ask of in research articles.
7
Q
What are the two categories of critiques of the evidence based practice movement?
A
Practical criticisms- around the possibility of evidence based practice
Philosophical criticisms- around the desirability of evidence based practice
8
Q
Give some examples of practical critiques of evidence based practice.
A
-Impossible task to maintain and create systematic reviews across all specialities
-Challenging and expensing to disseminate and implement findings
RCT’s are not always feasible or even necessary/desirable eg. Due to ethical considerations
-Choice of outcomes is often very biomedical
-Requires good faith on the part of pharmaceutical companies
9
Q
Give some examples of philosophical critiques of evidence-based practice.
A
- Does not align with doctors’ modes of reasoning
- Population-level outcomes doesn’t mean that an intervention will work for a certain individual
- Evidence based practice has the potential to create unreflective rule followers
- Might be understood as a means of legitimising rationing
- Professional responsibility/autonomy
10
Q
What are the difficulties of getting evidence into practice?
A
- Evidence exists but doctors don’t all know about it
- Doctors know about the evidence but don’t use it
- Organisational systems cannot support innovation
- Commissioning decisions reflect different priorities
- Resources not available to implement change
11
Q
What does the Cochrane collaboration logo show?
A
It is a systematic review.
12
Q
Why are priorities set for healthcare?
A
Scarcity of resources which could be used in many ways, demand outstrips supply.
13
Q
What types of new health interventions are relatively expensive?
A
- New cancer therapies often expensive and generally expand the pool of candidates
- Often don’t cure but increase survival
- Preventer drugs
14
Q
What are the two forms of rationing?
A
Explicit rationing- based on defined rules of entitlement
Implicit rationing- care is limited, but neither the decisions nor the bases for those decisions are clearly expressed
15
Q
What are the problems associated with implicit rationing?
A
- leads to inequities and discrimination
- open to abuse
- decisions based on perceptions of ‘social deservingness’
- doctors appear increasingly unwilling to do it
16
Q
Define implicit rationing.
A
Implicit rationing is the allocation of resources through individual clinical decisions without the criteria for those decisions being explicit.
17
Q
Define explicit rationing.
A
Explicit health care rationing or priority setting is the use of institutional procedures for the systematic allocation of resources within the healthcare system
18
Q
What are the advantages of explicit rationing?
A
- Transparent, accountable
- Opportunity for debate
- More clearly evidence-based
- More opportunities for equity in decision-making
19
Q
What are the disadvantages of explicit rationing?
A
- Very complex
- Heterogeneity of patients and illnesses
- Patient and professional hostility
- Impact on clinical freedom
- Some evidence of patient distress
20
Q
What does NICE do?
A
Provides guidance on whether treatments (new or existing) can be recommended for use in the NHS in England. It uses evidence of clinical and cost effectiveness to inform a national judgement on the value of a treatment relative to alternative uses of resources.
21
Q
What role does NICE have with regards to expensive treatments?
A
If approved, local NHS organisations must fund them sometimes with adverse consequences for other priorities.
If not approved, patients are effectively denied access to them.
22
Q
Define opportunity cost.
A
Once you have used a resource in one way, you no longer have it to use in another way.
23
Q
What does utility mean in terms of healthcare economics?
A
The value an individual places on a health state.
24
Q
How can we promote equity in terms of rationing?
A
Use explicit rationing instead of implicit rationing.
25
How is opportunity cost measured?
Benefits foregone - cost is viewed as sacrifice rather than financial expenditure. What could you have paid for with the same amount of money you paid for this treatment?
26
What are the two types of efficiency and the differences between them?
Technical efficiency- you are interested in the most efficient way of meeting a need
Allocative efficiency- you are choosing between the many needs to be met
27
What does economic analysis compare?
The inputs (resources) and outputs (benefits and value attached to them) of alternative interventions. This allows better decisions to be made about which interventions represent best value for investment.
28
What are the different categories of costs?
```
Costs of:
Healthcare services
Patient's time
Care-giving
Employers, other employees and the rest of society
```
29
What are the different categories of the benefits of health interventions?
Impact on health status
Savings in other healthcare resources if the patients health state is improved
Improved productivity if patient or family members return to work earlier
30
What are the four types of economic evaluation?
1. Cost minimisation analysis
2. Cost effectiveness analysis
3. Cost benefit analysis
4. Cost utility analysis
31
Describe cost minimisation analysis.
Outcomes assumed to be equivalent
Focus is on costs (inputs)
Not often relevant as outcomes are rarely equivalent.
32
Describe cost effectiveness analysis.
Used to compare drugs or interventions which have a common health outcome
Compared in terms of cost per unit outcome
If costs are higher for one treatment, but benefits are too, need to calculate how much extra benefit is obtained for extra cost.
33
Which method of economic evaluation would answer this question:
Is extra benefit worth extra cost?
Cost effectiveness analysis
34
What is cost benefit analysis?
All inputs and outputs valued in monetary terms
Can allow comparison with interventions outside healthcare
There are methodological difficulties- putting monetary value on non-monetary benefits such as lives saved
35
What is cost utility analysis?
Focuses on quality of health outcomes produced or foregone
Most frequently used measure is quality adjusted life year (QALY).
Interventions can be compared in cost per QALY terms.
36
What does QALY mean?
Quality adjusted life year
They adjust life expectancy for quality of life.
1 year of perfect health = 1 QALY
Assumes that 1 year in perfect health = 10 years with a quality of life of 0.10 perfect health.
37
Why do we use QALY's instead of life years gained?
To use cost-effectiveness as a guide to decision-making in a wide ranged of settings.
Life years gained are only useful where survival is the main outcome.
QALY's allow us to measure survival and quality of life.
38
How is quality of life measured?
Measuring health on a generic quality of life instrument- EQ-5D
39
A man is diagnosed with cancer. He is told he has 4 years to live but his QoL will be 0.2 of perfect health. Interpret this in terms of QALYS
0.8 QALYs
| Therefore, there is no gain in QALYS associated with treatment.
40
What alternatives are there to QALYs?
Health Year Equivalents (HYEs)
Saved-young-life equivalents (SAVEs)
Disability Adjusted Life Years (DALYs)
41
What do NICE use to measure the cost-effectiveness of health interventions?
Costs per QALY
42
If a treatment is below £20K per QALY, would it normally be approved by NICE?
Yes
43
What are the problems with the way that NICE evaluate treatments?
- may be resented by patient groups
- may be resented by pharmaceutical companies
- CCGs prioritise NICE-approved interventions, sometimes with unintended consequences
- concerns about political interference
44
List some criticisms of QALYs.
- Controversy about the values they embody
- Do not distribute resources according to need, but according too the benefits gained per unit of cost
- May disadvantage common conditions
- Technical problems with their calculations
- Do not embrace all dimensions of benefit; values expressed by experimental subjects may not be representative
- QALYs do not assess impact on carers or family
- RCT evidence is not perfect. Statistical modelling can address some problems and areas of uncertainty
45
What are the determinants of health and disease?
A range of factors that have a powerful and cumulative effect on the health of populations, communities and individuals.
Physical environment
Social and economic environment
Individual genetics, characteristics and behaviours
46
What is the difference between health promotion and public health?
Public health tends to focus on protection and promotion on a population level.
Health promotion places more value on the methods used to achieve these using health education and healthy public policy.
47
What sociological critiques are there for health promotion?
1. Structural critiques
– Material conditions that give rise to ill health marginalized,
– Focus on individual responsibility rather than general social factors
2. Surveillance critiques
– Monitoring and regulating population
3. Consumption critiques
– Lifestyle choices not just seen as health ‘risks’ but also tied up
with identity construction so health promotion privileges the wealthy
48
What are the five approaches to health promotion in action?
1. Medical preventative - eg. Informing patient of health consequences
2. Behaviour change - eg. Persuasive campaigns to deter people from smoking or health care professionals encouraging patients to attend smoking cessation clinics
3. Education - eg. Informing general population the effects of smoking and how they can stop.
4. Empowerment - eg. Asking patients what they would like to stop smoking and personalising approach
5. Social change eg. Government enforced smoking ban in public places- makes it the norm to stop smoking
49
What is primary prevention?
Aims to prevent the onset (incidence) of disease or injury by reducing exposure to risk factors.
(The cause or risk factors for the disease has to be known)
50
Give some examples of primary prevention measures. (4)
1. Immunisation
2. Prevention of contact with environmental risk factors
3. Taking appropriate precautions with communicable disease
4. Reducing risk factors from health related behaviours
51
What is secondary prevention?
Aims to detect and treat a disease or its risk factors at an early stage to prevent progression/potential future complications and disabilities from the disease.
Eg. Screening for cervical cancer
52
What kind of prevention is monitoring and treating blood pressure an example for?
Secondary prevention
53
What is tertiary promotion?
Aims to minimise the effects of established disease.
54
For which types of prevention does the cause of the disease need to be known?
Primary prevention
55
A patient is given steroids to prevent asthma attacks. Which type of prevention is this an example of?
Tertiary prevention
56
What are the dilemmas associated with health promotion? (6)
1. Ethics of interfering in people's lives
2. Victim blaming
3. Fallacy of empowerment - does giving people the information give them the power if they do have social constraints preventing them from taking action?
4. Reinforcing of negative stereotypes
5. Unequal distribution of responsibility- most often left up to women
6. The prevention paradox- interventions at a population level may not have much effect on the individual
57
Explain the prevention paradox and how it shows the relevance of lay beliefs to health promotion interventions.
Interventions that make a difference at population level might not have much effect on the individual.
Why?
– If people don’t see themselves as a ‘candidate’ for a
disease they may not take on board the health promotion messages.
– Awareness of anomalies and randomness of a
disease (e.g. heart attacks) will also impact on views about candidacy
58
What are the difficulties of evaluating outcomes of health promotion? (4)
Demonstrating an attributable effect is difficult because:
1. Design of the intervention- may have many different components, how do you evaluate the effect of each in isolation?
2. Possible lag time to effect
3. Many potential intervening or concurrent confounding
factors
4. High cost of evaluation research - studies are likely
to be large scale and long term
59
What is the purpose of evaluating healthcare promotion interventions? (4)
1. Need for evidence-based interventions
2. Accountability
3. Ethical obligation
4. Programme management and development
60
What are the types of health promotion evaluation and what are the differences between them?
Process
Impact - immediate effects
Outcome - long-term consequences
61
What is health promotion?
– aims to acknowledge and address the wide and
complex determinants of health
– comprises different levels and strategies (with
different strengths & limitations)
– raises some important dilemmas.
62
What is screening?
A systematic attempt to detect an unrecognised condition by the application of tests, examinations, or other procedures, which can be applied rapidly (and cheaply) to distinguish between apparently well persons who probably have a disease (or its precursor) and those who probably do not
63
What is the difference between spontaneous presentation and opportunistic case finding?
Spontaneous presentation
Person presents with symptoms, self-defined as a patient and a diagnosis is made
Opportunistic case finding
Person presents with symptoms related to a disease and healthcare professional takes opportunity to check for other potential conditions
64
Is finding a condition earlier the primary objective of screening?
No
65
What is the purpose of screening?
To give a better outcome compared with finding something by spontaneous presentation or opportunistic case finding.
66
Is there a point in screening if treatment can wait until there are symptoms?
No
67
List the criteria for implementing a screening programme. (5)
1. Condition
2. Test
3. Intervention
4. Screening programme
5. Implementation
68
What important factors need to be considered about a condition you are screening for?
- incidence, prevalence, frequency, severity
- cost-effective primary interventions should have been implemented as far as possible
- psychological implications and history of people identified with disease should be understood
69
What errors are made by any type of screening test?
-FALSE POSITIVES
Put them through stress, anxiety and inconvenience
Cost
-FALSE NEGATIVES
Inappropriate reassurance
Delays presentation with symptoms
70
What is meant by the sensitivity of a screening test?
The proportion of people with the disease who are test positive out of the people who really have the disease.
Sensitivity = true positives/ true positives + false negatives
I've got the disease, will it show up as positive?
71
What is meant by specificity of a screening test?
Proportion of people who really do not have the disease who are identified correctly by the test as not having the disease.
Specificity = true negatives/ false positives + true negatives
I've not got the disease, will it show up as negative?
72
Is sensitivity and specificity of a screening programme independent of the population it is testing?
Yes if the same test is applied in the same way
73
What is a positive predictive value?
Probability someone who has tested positive actually has the disease
PPV = true positives/ true positives + false positives
The test is positive, do i have the disease?
74
If there is a high prevalence of a disease, will the PPV value be high or low?
High
75
What is a negative predictive value?
Proportion of people who are test negative who actually do not have the disease.
NPV = true negatives/false negatives + true negatives
The test is negative, do I definitely not have the disease?
76
What features of test validity need to be considered when implementing a screening programme?
Sensitivity
Specificity
Positive predictive value
Negative predictive value
77
List the advantages of screening for a disease.
To give a better outcome compared with finding
| something in the usual way (having symptoms and self- reporting to health services)
78
List the disadvantages of screening for disease.
False negative – the screening test indicates that they
do not have the disease when in fact they do.
• They will not be offered (invasive) diagnostic testing
when in fact they may have benefited from it. Their
disease, although present will not be diagnosed.
• They will be falsely reassured – may present late with
symptoms as a consequence.
False positive – the test indicates patients MAY have the
disease when in fact they do not
• They will be offered (invasive) diagnostic testing with all its
attendant anxieties and risks – for a condition they actually
do not have. They will be turned into “patients” when they
are not actually ill
• May also lead to lower uptake of screening in future and
greater risk of interval cancer
• If the PPV is low there will be a lot of people with false
positive results who undergo stress and unnecessary
procedures
79
Give some examples of screening programmes in the UK. (3)
NHS abdominal aneurysm programme
NHS breast screening programme
NHS cervical screening programme
NHS sickle cell and thalassaemia screening programme
80
What are the difficulties associated with evaluating the effectiveness of screening programmes? (3)
1. Lead time bias - screening patients appear to survive longer only because they were diagnosed earlier.
2. Length time bias - Diseases that are detectable through screening are more likely to have a favourable prognosis, and may indeed never have caused a problem
3. Selection bias - Those who have regular screening likely to also do other things that protect them from disease
81
Explain sociological critiques of health promotion and
| screening.
• Victim blaming / Individualising pathology
• Individuals and populations increasingly subject to
surveillance – prevention as social control?
• Moral obligation
• Feminist critiques
82
What are health-related behaviours?
Anything that may promote good health or lead to illness eg. Smoking, drinking, drug use...
83
What theories help us to understand people's health related behaviour?
1. Learning theories- learning from unconscious association
- classic conditioning
- operant conditioning
- social learning theory
2. Social cognition models - bringing attitudes and knowledge together
- health belief model
- theory of planned behaviour
3. Stages of change model - 5 stages people may pass through over time in decision making
84
Describe how classic conditioning can affect health behaviours.
Health behaviours (eg. smoking, drinking) can become unconsciously paired with environment (eg. Work break) or emotions (eg. Anxiety)
85
How can we change health behaviour using classic conditioning?
Pair behaviour with an unpleasant response
Eg. Alcohol + medication to induce nausea
Break unconscious response- avoid behaviours associated with negative health behaviours
86
What is operant conditioning?
People act on the environment and behaviour is shaped by the consequences.
Behaviour increases if it is rewarded or punishment is removed.
Behaviour decreases if it is punished or a reward is taken away.
87
Unhealthy behaviours are immediately rewarding and this influences an individuals choice to engage in them. Which learning theory is this reinforced by?
Operant conditioning
88
Money saved towards holiday by giving up smoking. Which learning theory is this an example of?
Operant conditioning
89
Describe social learning theory.
Behaviour is goal-directed. People are motivated to perform behaviours that are valued and that they can enact. We learn from observing others and if it models high status or 'like us'.
90
Celebrities in health promotion campaigns.
| Which learning theory is this an example of?
Social learning theory
91
Describe cognitive dissonance theory.
People feel discomfort when they hold inconsistent beliefs or actions/events that don't match beliefs
They reduce discomfort by changing beliefs or behaviour.
92
Having slogans such as 'smoking kills' on cigarette packets is an example of which type of social cognition model?
Health belief model ---> Cognitive dissonance theory
93
What is the health belief model?
Beliefs about health threat (susceptibility, perceived severity)
Beliefs about health-related behaviour (perceived benefits, perceived barriers)
Cues to actions (health promotion interventions)
94
What 3 factors influence planned behaviour?
- attitude towards behaviour
- subjective norm
- perceived control
95
Describe the stages of change model.
The way people think about health behaviours and willingness to change their behaviour are not static.
Different conditions may be important determinants of health behaviour at the same time.
It is important to consider which stage a patient is in when giving advice about changing their health behaviours.
96
What are stimulants?
Substances make you feel more alert and like you have more energy and confidence
Eg. Tobacco, cocaine, amphetamine, mephedrone
97
What are hallucinogens?
Substances described as mind altering as they can change or impact your perceptions, mood and senses.
Eg. LSD, magic mushrooms
98
What are depressants?
Substances that make you feel more relaxed.
| Eg. Heroin, alcohol, cannabis, tranquillisers
99
Describe the medical model as a treatment for substance misuse.
Abnormal condition that causes discomfort, dysfunction or distress to individual afflicted.
Focus on physical donation eg. Tolerance, physical withdrawal symptoms, vitamin deficiency, pancreatitis
100
Describe the disease model as treatment for substance misuse.
Addiction is an illness with loss of control the primary symptom.
Addiction is genetic and therefore predetermine.
Abstinence/avoidance is the only viable treatment.
101
Describe the behavioural model for treatment of substance misuse.
Addiction doesn't exist. Excessive use is merely a mislearnt coping mechanism.
Excessive use/misuse is a result of social, economic and familial learned experiences
Alternative coping mechanisms can be taught and past experiences addressed
102
What is cognitive behavioural therapy?
Use of tools - drinks/drug diaries/decision balance sheets
Alcohol and drugs can be used by individuals to cope with anxiety, low self esteem amongst other things.
Therefore, techniques are used to address these feelings which will in turn reduce substance use eg. Relaxation training, anger management, problem solving skills
