Block 12 Flashcards
(169 cards)
1
Q
name the 5 big CAMs
A
Chiropractic Osetopathy Acupuncture Herbal medicine Homeopathy
2
Q
Most used CAM
A
Chiropractic
3
Q
least used CAM
A
Homeopathy
4
Q
Which 2 CAMs have statutorys regulation of professionals
A
Chiropractic
Osteopathy
5
Q
Number of people using chiropracters a year
A
7.5 million
6
Q
Number of people using acuptuncture a year
A
3.1 million
7
Q
Number of people using homeopathy a year
A
1.3 million
8
Q
3 ways people can access CAMS?
A
Self-referral
GP referral
NHS professional referral
9
Q
Most common way of accessing CAMS
A
Self-referral (70%)
10
Q
What % of CAMs use if GP referal
A
17%
11
Q
Ways of financing CAMs
A
Self
NHS
Other
12
Q
What % of CAMs is financed on NHS
A
14%
13
Q
CAMS is mostly accessed through what and funded through what?
A
Self-referral
Self funding
14
Q
68% of CAMS is used for what kinds of problem:
A
MSK
15
Q
Effectiveness gap =
A
An area where there is a lack of efficacy for treatment
16
Q
What % of people believe there is an effectiveness gap for msk problems?
A
95%
17
Q
The key principles that underline CAM use for msk problems can be shown by what model?
A
Biopsychosocial model
18
Q
biological side of CAMs:
A
Manipulation Moblisation Massage Guided movement Acupuncture
19
Q
Psychological aspects of CAMs
A
Communication
Compassion
Changing beliefs/perceptions
Promote self-efficacy
20
Q
Social aspects of CAMs
A
Advice on adjustments
Promote back to work
21
Q
NICE guidelines for lower back pain:
A
- Don’t offer acupuncture
- Consider manual therapy (massage, manipulation)
22
Q
Why don’t NICE offer acuptuncture for LBP?
A
> 0.5 placebo effect with sham needling
23
Q
NICE guidelines for headache:
A
- Consider course of 10 sessions of acupuncture for chronic tension-type headache
24
Q
NICE guidelines for osteoarthritis =
A
- Do not offer acupuncture
- Manipulation and stretching core treatments
25
Why do we need research ethics?
Historical examples
Social and political trends towards increased autonomy
Legislation
Research ethics codes
26
Historical examples of why we need research ethics =
Nazi medical experiments
Tuskegee syphilis study
Alderhey
Wakefield
27
Name some legislations which are related to research ethics involving humans/human tissues
Human Rights Act
| Human tissues act
28
Name 2 research ethics codes of conduct
Numremberg Code
| Helsinki declaration
29
Nuremberg code comprises a set of principles concerning research with
Humans
30
Nuremberg code states that research with humans should be:
- Voluntary consent
- Avoid all unneccessary physical and mental suffering
- Be done by scientific qualified persons
31
Helsinki declaration requires what
Any form of human research to be subject to independent ethical review
32
Why is human research more tricky than some others?
Need for consent
Respect autonomy
Reduce harm
33
Which research subjects are important in research ethics?
Vulnerable - children, mentally ill, reduced capacity
34
6 key principles of research ethics =
1. Usefulness
2. Necessity
3. Risk
4. Consent
5. Confidentiality
6. Approval
35
Usefulness =
Is the study likely to find something new?
36
Necessity =
Does the study need to be done on humans/this particular group?
37
Risk in research should be
Minimised, outweighed by potential benefits
38
Consent =
Getting permission from a person before involving them in research project
39
Why is consent important?
- Respects patients autonomy
| - Less likely to cause harm
40
Consent must be
Informed
| Voluntary
41
How can we aid informed consent?
Giving patient information sheets
42
How to facilitate consent =
```
Patient info sheet
Clear, avoid jargon
Summary of key points
Time for patient to ask questions
TIme to think about/decide
```
43
Human tissues act =
Consent for stoarge and use of tissue for 'schedules purposes' required for tissue from living or deceased persons
44
Why is confidentiality important?
Autonomy
Aids good care
Reduces harm - stops info getting in hands of wrong people
- Trust
45
Guidlines for confidentiality in research =
- All info confidential
- Anonmyised/coded
- Stored securely
- Accessed on need to know
46
When is research ethics approval needed?
Humans
Human tissue
Personalised data
47
When is research ethics not normally needed?
Clinical audit
| Service evaluations
48
Why do we need ethics approval?
```
Ensure research adheres to ethical principles
Protects patients
Protects researchers
Minimises negligence claims
Keeps integrity of profession
Legal
Publication.funding
```
49
Who is approval needed from?
NHS - if used patient data or facilities
| Uni faculty/research ethics committee
50
What do RECs consider when looking at an application?
- Purpose and scientific/ethical important
- Potential risks
- Consent procedure
- Vulnerable groups involved
- Method of recruitment
- Use of patient info sheet
- Storage procedure/confidentiality
- Likelihood of achieving aims
51
Process of EBDM =
- Answerable question
- Search
- Critical appraisal
- Make a decision: evidence, resources, patient preference, clinical experience
52
PICO =
Patient, problem, population
Intervention
Control, comparator, comparison
Outcome
53
When you have a factor you cannot control, what type of question do you use?
PEO
54
PEO =
Patient
Exposure
Outcome
55
Study for diagnosis question =
Cross-sectional study
56
Study of aetiology question:
Cohort
| Case-control
57
Study for prognosis question:
Cohort study
58
Study for treatment question:
RCT
59
Study for evaluation question:
Qualitative research
60
Systematic reviews =
Type of literature review that uses systematic methods to collect secondary data, critically appraise and synthesise studies.
61
Benefits of SR over individual primary studies =
Include all avaliable evidence
Research that is unpublished/not in English language journals
- Increases total sample size
- Meta analysis
- Indicate variation among studies
- Permit subgroup and sensitivity analysis
62
Subgroup analysis =
Evaluation of treatment effects for a specific end point in subgroups of patients defined by baseline characteristics
63
Sensitivity analysis =
Asks whether results are sensitive to quality of the research (e.g. what happens if we only look at 10 strongest trials)
64
Error =
Difference between average values in study population and average values in true population
65
Bias =
Systematic introduction of error into a study that can distort the results in a non-random way
66
We should assess a research study for:
Bias
Limitations
Values
Applicability
67
3 discrete questions when assessing study results:
Are the results valid
What are they
Can I apply them to my patient?
68
Validity =
Do the results represent an unbiased estimate of the treatment effect or have they been distorted in a systematic fashion to lead to a false conclusion
69
How might results be presented in an RCT?
Report relative risk reductions, absolute risk reduction, odds ratio, NNT (numbers needed to treat), confidence intervals
70
Relative risk reductions =
relative decrease in the risk of an adverse event in the exposed group compared to an unexposed group.
71
NNT =
number of patients you need to treat to prevent one additional bad outcome
72
How might results be presented in a study looking at diagnosis?
Sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, confidence intervals
73
How might results be presented in a study looking at prognosis?
Report how likely the outcomes are over time and how precise the prognostic estimates are (relative risks or odds ratios), confidence intervals
74
How might results be presented in a study looking at aetiology?
• Harm/aetiology
| Report relative risk, odds ratio, NNH (numbers needed to harm), confidence interval
75
NNH =
indicated how many persons on average need to be exposed to a risk factor over a specific period to cause harm in an average of one person who would not otherwise have been harmed.
76
What makes a study generalisable/particularisable
Population similar to patient
Resources/service
Cost, risks
77
What provides the frame work to empower and protect people who may lack capacity to make decisions for themselves?
Mental capacity act (2005)
78
5 Statutory principles of the mental capacity act:
1. Presumption of capacity
2. Right to be supported to make own decision
3. Right to make eccentric or unwise decisions
4. Anything done on behalf of patient must be in best interest
5. Least restrictive interventions
79
How might you determine a patient's best interest?
Advance statement of wishes
Look at previous decisions
Talk to family
Least restrictive option possible
80
Criteria for mental capacity =
Understand
Retain
Use/weigh up
Communicate decision
81
Capacity is specific to what?
The time
| The task
82
What does 'ability to understand' mean
Patient must not be able to understand, not sufficient that they don't understand (this may just be communication)
83
Considerations for patients ability to use/weigh up
Importance is that they can, should not be based on how the information is weighed up
84
How is a doctor to make a decision when a patient is deemed to lack capacity?
Advanced decision/directive
Best interest
Least restrictive possible
85
2 types of advanced care planning
Advanced statement of wishes
| Advanced decision/declaration
86
Which type of advanced care planning is legally binding?
Advanced directive/decisions
87
Advanced directives are specific to (wishes of treatment/refusal of treatment)
Refusal of treatment
88
An AD is legally binding if:
Applicable to that circumstance
>18
Informed, specific
89
Refusal to life saving treatment must be
Written, signed, witnessed
90
Pros of ADs
Encourage openness and forward planning
Patient autonomy
Reduces anxiety about unwanted treatment
Legal right to refuse treatment
91
What can patient's not refuse?
Basic care
92
Cons of ADs
Difficulties varifying whether opinion has changed
Ascertaining circumstances are what patient forsaw
Can patients ever truely be informed?
Coercion
93
If a person lacking capacity is very happy why should an AD apply?
Dworkin - experiential vs critical interests.
| ADs preserve critical
94
Experiential interests =
First hand experiences
95
Critical interests =
Across time, values, the kind of life we want to live
96
Why might some say an AD shouldn't be resepected for someone who undergoes severe personality changes?
Personal identity argument - numerically different due to changes psychologies.
97
Why should practice be research informed?
- Personal experience is bias
- Medical knowledge is incomplete
- Research involves application of the scientific method
- Recommendations assessed for cost/clinical effectiveness
- Standardise care
98
Describe the research cycle:
Clinical problem - basic research - applied research - clinical care
99
Clinical problems can be:
Observational
Association
Prognosis
100
What can we use to decide whether a clinical problem is important for research?
Priority setting partnerships - identify problems by doctors/public
101
Ex of a priority setting partnership
James Lind Alliance
102
2 practice gaps identified:
1. From bench to bedside - going from basic research into cinical trials
2. Implementation gap - from trial to clinical practice/policy
103
What can help with the gap between basic and clinical research
MRC - medical research council
104
What may help in gap between research and practice?
NICE
105
Characteristics of what may make barrier to uptake of evidence?
Recommendation
Adopters
Organisational/structural
106
Recommendation characteristics which may be barrier to uptake =
Complex
Requires new skill
Doesn't fit with existing norms
107
Recommendation characteristics which may facilitate uptake:
Simple/easy to understand
| Fit with existing norms/values
108
Adopter characteristics which may be barrier to uptake:
Knowledge - lack of knowledge, too many guidelines
Attitudes - percieved patient resistance, doubt credibility, reliance on trusted sources
Skills and abilities
109
Organisational characteristics which may be barrier to uptake:
Limitations: time, resources
Culture: behaviourm norms
Social norms: team norms
110
What may help change social norms in an organisation?
Opinion makers/influential team leaders
111
What can help get evidence into practive:
Quality improvement
112
QI aims to:
facilitate the uptake and continued use of evidence-based policy.
113
QI should be:
```
Interactive
Involve all
Empower staff
Foster a culture of change
Provide knowledge
Remove barriers
```
114
QI initiatives targeting organisations:
```
Revision of professional roles
MDT
Skill mix
Setting of delivery
Financial incentives
```
115
QI initiatives targeting health care professionals:
```
Education
Outreach visits
Local opinion leaders
Reminders
Multi-factoral
```
116
Name 2 financial incentives for QI
CQUIN
| QOF
117
CQUIN =
Commissioning for quality and innovation
118
What does CQUIN do?
Links a proportion of providers incomes to QI initiatives/achievement of goals
119
Example of CQUIN initiatives:
Reduce impact of serious infection
Improve staff wellbeing
Reduce disease from risky behaviours
120
QOF =
Quality and outcomes framework
121
QOFs target
GP
122
Do QOFs work: yes
When removed, improvements stable
123
Drawback of QOFs
Small detrimental effects on aspects not incentivised
124
Most common policy to manage waiting lists =
Some form of maximum wait
125
Current maximum wait in England
18 weeks
126
Current maximum wait in Denmark
4 weeks
127
Implementation of maximum wait can differ:
1. Target and sanctions
2. Choice, competition, private sector
3. Prioritisation
128
Countries which implement target and sanctions
England
| Finland
129
Countries which implement choice and competition
Denmark
Netherlands
Portugal
130
Countries which implement prioritisation
Australia
New Zealand
Canada
131
England 2000-2005
Maximum wait time guarantee
| Penalty: higher chance of hospital managers losing job
132
What might penalties cause:
Fraud
Misprioritisation of patients
Counter intuitive
133
Mis-prioritisation of patients =
Once the target has passed, no incentive to treat patient proptly and probablity of being seen decreases
134
NHS constitiution (2010) patient entiltlements:
Right to access care within max waiting time (18 weeks)
135
DoH expects what % of patients to be treated in target
90%
136
Breach of targets in England can result in what
Up to 5% reduction in that specialties funding for month of breach
137
Management of waiting lists in Denmark =
4 week wait regardless of disease
If hospital cannot fulfil max. wait, can go to another private or public at the expense of region
DRG tariff - profitable to keep patients in country
138
New Zealand system:
Booking:
1. Booked, treated within 6 months
2. Certainty of treatment within 6 months
3. Active care, review - sent back to GP
139
In NZ, patients waiting time depends on
Need
| Ability to benefit from specialist
140
What helps Canada and NZ assess need?
Priortisation tools
141
Prioritisation tools can be
Expensive to develop
142
Prioritistation tools help
Rules be applied in a consistent way
143
Australia prioritisation of patients:
3 urgency groups;
(1) Less than 30 days deteriorate quickly, may become an emergency
(2) Less than 90 days some pain, not likely to become emergency
(3) Less than 365 days minimal or no pain, does not have the potential to become an emergency
144
Norway prioritisation f patients:
(!) Emergency
(2) Elective with individual maximum waiting time
(3) Elective without maximum waiting time
145
Unconditional wait guarantees are
Easy to operate
| Contradict proritisation
146
Conditional wait guarantees are
Difficult to operationalise
| Do not contradict prioritisation
147
Confounding =
when a relationship between exposure and outcome is distorted by their shared relationship with something else
148
A confounder may:
Increase apparent relationship
| Decrease apparent relationship
149
A variable is not a confounder if -
No association with exposure
No association with outcome
On the causal pathway between outcome and exposure
150
Which type of studies are most subject to confounding?
Observational studies: cohort, case-control
151
RR >1
Risk higher in exposed group
152
RR <1
Risk lower in exposured group
153
RR = 1
Risk the same in both groups
154
Risk differnece +ve
Risk higher in exposed
155
Risk difference -ve
Risk lower in exposed
156
4 ways to reduce confounding
Restriction
Matching
Stratification
Multiple variable regression
157
Restriction and matching are a feature of
Design
158
Stratification and multiple variable regression are a feature of
Analysis
159
Restriction =
Limiting sample group to eliminate confounding
160
Problems with restriction =
Less data collected/greater study needed for same amount
Wasteful
Difficult when you have many confounders
161
Matching is most commonly used in what type of study
Case-control
162
Matching is good for
Strong confounders (age, sex)
163
Problems with matching =
Still need to consider confounding in analysis
| Not on its own an answer to confounding
164
Stratification =
Analyse exposure-outcome relationship in sub-groups associated with confounder. Adjust for confounder
165
Adjustment gives a
Weighted average of the effect seen in each stratum
166
Limits of stratification -
Eventually run out of data to fill strata
167
in y=a+bx b is the
gradient/regression coefficient
168
in y=a+bx a is the
Y-intercept
169
Multiple regression coefficent, like stratification allows for
Adjustment
