Cardiorespiratory Flashcards
Describe the term ‘patient pathway’
- Describes the best route from primary contact with services.
- Stages of investigation/treatment.
- Then definitive treatments.
- Lastly discharge from NHS with or without social services.
- Useful to guide clinicians and to inform patients on what is supposed to happen next.
Outline the different ways people may access services
- GP.
- Self referral - A&E, online (111).
- Emergency - ambulance.
- Education institution - welfare.
- Dental practitioner.
- Charity/community programs.
- Lay referral.
- Pharmacists.
List factors that influence access to care
Postcode lottery - depending on where you live, you can get access to different services.
Barriers to health seeking:
- Inverse care law - poor areas have less provision.
- Geographical distance - transport costs, time.
- Previous bad experience - staff, waiting times.
- Childcare - availability and costs.
- Psychological factors - refusal to believe, worried, lack of education.
- Context of event - special events happening.
- Perception/evaluation of symptoms as harmless.
Triggers to health seeking:
- Interference with work/physical activity.
- Interference with social relations.
- Assigning arbitrary time limit.
- Interpersonal crisis - deaths, divorces.
- Sanctioning.
Describe the approaches to overcome barriers to accessing care
- Quality improvement - identifying barriers, think about changes, implement change, audit.
- Community outreach program - increase provision in the community, rather than centralised provision which may be more difficult to access.
- Transport - volunteer drivers, discounted hospital buses.
Why have publicly available indicators been proposed and used?
Performance indicators on each healthcare system
- Schools and other public sectors use it - why not healthcare system?
- Public scandals increase pressure for outcomes to be published and used.
- Already collect outcome data through coded computerized clinical databases, so why not publish it publically?
- Mostly influences clinicians and managers not so much patients.
What are the strengths and limitations of publicly available indicators?
Benefits
- Act as a driver for change - incentive.
- Identify issues and improvements that need to be made.
- Standardised across trust - comparable measure of performance.
- Policies used in high performance trusts can be used in other trusts.
Disadvantages
- Socioeconomic status of various locations.
- Different trusts have different access to primary care - different primary intervention, some are better than others.
- Some areas have older populations, which may lead to more complications post-surgery.
- Not a direct measure of performance.
What factors may be important in interpreting publicly available indicators?
- Location - services available.
- Budget.
- Some variation is normal - even if all healthcare was uniform there will always be random variation in mortality rates across hospitals as each patient is unique.
- Needs to be adjusted for confounders - age in elderly population will have higher mortality rates.
How would you explain publicly available indicators to a patient?
- Indicators for each trust shows ‘performance’ but they need to be taken with a pinch of salt.
- Can be used to compare other trusts.
- Points out areas that need improvement.
- BUT, have to look at it from the context of hospital itself - budget, population, not a direct measure of performance.
- Available to the public.
Outline the ethnic and gender differences in health and healthcare in IHD
- South Asians have increased risk of strokes.
- Afro-Caribbean have higher risk of HTN and T2D (risk factors for ACS).
- Oestrogen have protective effect (females).
- Culture - foods.
- Socioeconomic class - less obesity in developing countries as most people cannot afford it.
- Social norms - in some areas, being fat shows wealth.
- Differences in health seeking behaviour - native cultures might make them less inclined to see a doctor.
- Inaccessible due to language barrier.
- Discrimination - inverse care law.
- Smoking prevalence and decreased exercise levels in Bangladeshi populations.
- Migration and globalisation have changed patterns (Western diets).
List the major risk factors contributing to incidence of CVD
Modifiable
- HTN
- Smoking - increases by 50%.
- Diabetes.
- Total cholesterol + HDL:LDL ratio. Hyperlipidaemia.
- Obesity/lack of exercise.
- Heavy alcohol consumption.
Non-modifiable
- Age.
- Male sex.
- FMHx.
- Ethnicity.
- Socioeconomic class.
Explain the difference between primary, secondary and tertiary prevention of CVD
Primary: before onset of disease, stopping it from developing in the first place:
- Smoking cessation.
- Eating healthy.
- Exercise.
- Weight loss.
- Reduced alcohol consumption.
Secondary: preventing disease progression or any adverse events once disease has developed:
- Smoking cessation.
- Hypertension management.
- Lipid lowering therapy.
- Aspirin.
Tertiary: reducing impact of already existing disease:
- Revascularization e.g. PCI, CABG
- Cardiac rehabilitation.
Define prevention paradox
- A preventative measure that brings large benefits to the community but offers little to each participating individual.
Outline the pros and cons of high risk prevention strategies vs. population prevention strategies
High risk strategy:
- Pros: appropriate intervention, cost-effective use of resources, favourable benefit : risk ratio.
- Cons: cost/difficulty of screening, limited potential for change in the population.
Population strategy:
- Pros: large potential for change, radical.
- Cons: small benefit to the individual, little motivation for patients, questionable benefit : risk ratio i.e. prevention paradox.
Outline a strategy to reduce CVD in the local community
Strategy - set of choices and principles to support achievement of long term goals.
NATIONAL CVD PREVENTION PROGRAMME
- Improving and increasing early detection and treatment of CVD.
- Rapid treatment of those with high risk conditions.
- Expanding access for genetic testing for familial hypercholesterolaemia.
- Commissioning a new National CVD prevention audit for primary care called CVDPrevent. It will support primary care in understanding how many patients with high-risk conditions are potentially under diagnosed, under treated or over treated.
- Improve response of public to somebody having a cardiac arrest out of hospital and build defibrillator networks.
Describe the results of the two important studies in establishing cardiac risk factors
Framingham Heart Study - data used to create risk predictors:
- Cohort chart = works out 10 year risk of stoke/MI.
- These predictors tend to under-estimate risk in low risk population & over-estimate in high risk.
- Also fail to take into account other risk factors e.g. ethnicity (e.g. higher risk in South-East Asian) & socioeconomic status.
- These only suggest risk in average patient, cannot predict what will happen. Used with clinical judgement to decide when prevention is indicated = this includes consideration for ethnicity etc.
- Also important to apply these to age, as this is the biggest risk factor & some patients, who are healthy at that age are still considered high risk & treated = medicalization normal ageing risk.
- QRISK measures more risk factors – uses UK GP data.
INTERHEART study:
- 5 main risk factors: abnormal lipids, diabetes, smoking, hypertension, lack of exercise.
- Created by looking at the population with risk factors and without risk factors.
- Good to show patient how their risk would alter if they quit smoking for example.
- Role: illustrates visuality to patient —> red = bad.
- Informs clinician on who to treat/emphasis which risk factors are important.
