Block 13 Flashcards
(99 cards)
1
Q
Evidence based decision is based on…
A
Clinical expertise
Research
Patient preference
Available resources
2
Q
What is decision analysis?
A
Decision analysis is a systematic, explicit, quantitative way of make decisions in health care that can lead to both enhanced communication about clinical controversies and better decisions
3
Q
Normative decision making
A
What we should do
4
Q
Decriptive decision making
A
What we are doing
5
Q
Prescriptive decision making
A
How we can improve
6
Q
Decision analysis is based on
A
Based on a normative theory of decision making: subjective expected utility theory (SEUT)
7
Q
Normative =
A
Based on social norms, shared interpretations/understanding
8
Q
Subjective =
A
Subject to interpretation
9
Q
Expected =
A
Future events
10
Q
Utility =
A
desirability or value attaches to a decision outcome
11
Q
Evidence in decision trees come from
A
- Probabilities
2. Utility or cost associated
12
Q
Info in decision tree should come from
A
Good quality research/best available evidence
13
Q
5 stages of decision analysis:
A
- Structure into decision tree
- Assign probability
- Assign utility
- Calculate value
- Sensitivity analysis
14
Q
Square node =
A
Decision node, choice between actions
15
Q
Circle node =
A
Chance node/uncertainty or potential outcome
16
Q
Each branch is decision tree must =
A
100%
1
17
Q
Ways to assess utility
A
Utility measures
QALYs
VAS
18
Q
Name a utility measure
A
EQ-5D
19
Q
EQ-5D
A
People with a particular health state fill in questionnaire
20
Q
5 domains of EQ-5D:
A
- Mobility
- Independence
- ADLS
- Pain, discomfot
- Worried/sad/happy
21
Q
VAS =
A
Visual analogue scale
22
Q
QALY =
A
Quality adjusted life year
23
Q
Health states can be measured against what?
A
QALYs
24
Q
Value of each branch =
A
utility x probability
25
In a decision tree sensitivity analysis, a decision can be:
1. Preference sensitive
| 2. Probability sensitive
26
Benefits of DA
- Makes all assumptions in a decision explicit
- Allows examination of the process of making a decision
- Integrates research evidence into the decision process
- Gain insight during process
- Can be used for: individual, population level, cost-effectiveness analysis
27
Limitations of probability estimates in DA
- Required data dets of estimate probability may not exist
| - Subjective probability estimates are subject to bias
28
Limitations of utility measures in DA
- Individuals may be asked to rate a state of health they haven’t experienced
- Different techniques = different numbers
- Subject to presentation framing effects (e.g. survival/death)
- Reductionist – e.g. ‘affected’ vs ‘unaffected’ reduces a complex issue into 2 options.
29
Colin Murray Parkes states the
4 stages of grief
30
4 stages of grief (Colin Murray Parkes)
1. Numbness
2. Yearning/pining and anger
3. Disorganised and despair
4. Reorganisation
31
Who decribed some of the symptomology of acute grief?
Lindemann
32
Lindemann acute grief:
* Somatic/bodily distress
* Preoccupation with the image of the deceased
* Guilt re: the deceased or circumstances of death
* Hostile reactions
* Inability to function as one has before the loss
* Development of traits of the deceased in their own behaviour
33
Grief symptomology can be split into what domains?
Emotional
Somatic
Cognitive
Depression-like
34
Emotional symptoms of grief:
```
Sadness
Anger
Guilt
Anxiety
Loneliness
Helplessness
Shock
Yearning
Numbness
```
35
Somatic symptoms of grief:
```
Sensations from stomach, chest, throat
Sensitivity to noise
Breathlessness
Weakness
Lack of energy
```
36
Cognitive symptoms of grief:
Disbelief
Preoccupation
Sense of presence
Hallucination
37
Who described the tasks of mourning?
Worden
38
What did worden believe grief was?
An active process
39
Tasks of mourning:
* Accept the reality of loss
* Work through the pain of grief
* Adjust to an environment in which the deceased is missing
* Emotionally relocate the deceased and move on with life
40
Pathological grief is grief which is
Extended (>6 months)
41
What can happen in complicated grief?
Mummification
| denial
42
Mummification -
Preserving aspects of the deceased's life pathologically
43
Impact of close death:
Loss of presence (function, emotional, role in life)
May change persons role
Forced to confront own mortality
Traumatic undermining of world view
44
What effects grief severity?
1. Closeness of relationships, meaningfulness of relationship, nature of relationship.
2. Expectedness and manner of death
3. Age and developmental stage of griever
4. Individual resilience: neuroticism, introversion, childhood trauma, parenting, attachment and dependency
5. Religious belief
6. Social support
45
Which attachment style might lead to complex grief?
Dependent
46
Impact of religious belief of bereavement:
* Belief in afterlife: continuing existence of the loved one and possibility of meeting up again, continued attachment (prayer means of continuing connection).
* Defence against fear of personal death/extinction
* Religious funeral rituals aid and progress the grief response
* Religious funeral rituals that recruit social support
47
Palliative care =
The active, hollistic care of patients with advances, life-limiting, progressive illness
48
Palliative care aims to =
Improve QOL: pain, other symptoms, psychologial, social, spiritual support
49
2 types of palliative care services:
1. General
| 2. Specialist
50
General palliative care is done by
```
All health professionals:
Primary health team
Nursing home
Secondary care
Social services
```
51
What is included in general palliative care?
1. Holistic needs assessment
2. Provision of basic symptom control
3. Referral if needed
52
Supportive care =
Happens before diagnosis, after diagnosis, during treatment, palliative care, bereavement
53
Terminal care =
Treatment, care and support for people nearing end of life
54
When is specialist palliative care provided?
• Patients and carers with unresolved symptoms and complex psychosocial issues with complex end-of-life and bereavement issues
55
What does complex mean in the context of palliative care?
Cannot be dealt with by general professionals
56
Who provides specialist care?
Specialist nurses
Specialist consultants
Hospice
Chaplain etc.
57
Where does the funding for palliative care come from
NHS
| Voluntary and charity sector
58
What does the NHS provide for PC?
- Doctors, nurses
- Some in patient beds
- Community clinical nurse specialist
59
Macmillian funding =
Part NHS
| Part charity
60
What does the voluntary sector provide for PC?
Hospice
most inpatient beds
Marie curie nurses, macmillian nurses
61
District nurse =
Based in community
Generalist
Hands on
62
Practice nurse =
Based in practice
Generalist
Hands on
63
Marie curie nurse =
Community
Specialist
Hands on
64
Macmillian nurse
Community or hospital
Specialist
Advice, support, resource
65
Most people would prefer to die where
At home
66
Challenges for the future of PC:
- How do we maintain sense of humanity and compassion
- Attitude to death as not being a medical failure
- Inequality between cancer and other probelms for referal
- Recruitment and training
67
Highest cause of world-wide mortality:
Cardiovascular disease
68
What % of all CVD deaths are in low and middle income countries
75%
69
What % of deaths is attributable to CVD
30%
70
CVD rates change in one country depending on
Social gradient/socioeconomic status
71
Ethnicity with highest levels of CVD
Bangladeshi men
| Pakistani men
72
Ethnicity with lower levels of CVD
Carribean
| West africa
73
What might higher rates of CVD in Bangladeshi men be linked to?
Higher rates of smoking
74
What experience is important for CVD
Experiences in early life
75
Non-modifiable RF for CVD
```
Age
Male
FHx
ACE mutation
Social deprivation
```
76
Modifiable RF for CVD
```
Hyperlipidemia
Hyperchlesterolemia
Hypertension
Smoking
Diabetes
Lack of exercise
Coagulation factors
Homocyteinaemia
Obesity Gout
Drugs
```
77
Most important/RF which are targets in CVD
Hypercholesterolemia
Smoking
Hypertension
78
Risk =
Probability of an event occuring in a given time period
79
Risk ratio =
The ratio of the probability of an outcome in an exposed group to the probability of an outcome in an unexposed group.
80
Risk ratio is the same as
Relative risk
81
ABCD method of calculating risk what is RR
a/(a+b) / c/(c+d)
82
Odds ratio
Odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure.
83
ABCD method, what is OR?
ad / bc
84
Risk difference is the same as
Attributable risk
85
Risk difference equation
Risk in exposed - risk in unexposed
86
Why is size not everything in risk?
Small risk from a common exposure may have a big impact
87
What is a better measure of the impact of an exposure on a population?
Risk difference
88
What is used in epidemiology to measure and assess the public health impact of exposures in populations.
Population attributable risk
89
Population attibutable risk =
The fraction of all cases of a particular disease/adverse condition in a population that is attributable to a specific exposure.
90
PAR depends on
Prevalence of exposure
| RR/relationship between risk and exposure
91
PAR is higher with
Higher prevalence of exposure
| Higher RR
92
What is the prevention paradox
A preventative measure that brings large benefits to the community offers little to each participating individual.
93
Most CVD occur in people at what risk?
Low/moderate
94
2 strategies to reducing risk:
High risk strategy
| Population strategy
95
Which strategy is needed to have a large effect?
Population strategy
96
Benefits of high risk strategy
- Appropriate to individual
- Motivated subject
- Motivated clinician
- Cost-effective resource use
97
Cons of high risk strategy
- Screening difficult
- Palliative and temporary
- Limited potential
- Labelling
98
Pros of population strategy
large potential
99
Cons of population strategy
- Population paradox – small individual benefit
- Poor motivation
- Benefit:Risk (LOW)
