HaDSoc Flashcards
1
Q
What is meant by equity in healthcare?
A
That everyone with the same needs get the same care
2
Q
What is inequitable care?
A
That patients vary in the extent to which they receive high quality care and in their access to care
3
Q
What is an adverse event?
A
An injury that is caused by medical management that prolongs hospitalisation, causes disability or both.
4
Q
Give some examples of preventable adverse events
A
Wrong blood group transfusion Wrong type/dose of medication given Wrong site surgery Wrong person surgery Wrong procedure Incorrect administration Retained object Failure to rescue Some infections
5
Q
What are the 3 main types of error?
A
Mistake - error of knowledge or planning. Action goes to plan but the wrong action is taken.
Slips and lapses - error of action. Correct action doesn’t go as intended.
Violation - intentional deviation from rules.
6
Q
Why do errors occur?
A
Due to poorly designed systems that don’t take human factors into account
Culture and behaviour
Over-reliance of individual responsiblity.
7
Q
Briefly describe the concept of the swiss cheese model of accident causation
A
There are numerous defences, barriers and safeguards that can be breeched by hazards.
Active failures are those that occur closest to the patient. The likelihood of active failures occurring is increased by latent conditions which are predisposing
8
Q
How can human factors be used to increase safety in the NHS?
A
Reduce reliance on memory Make things visible Review and simplify processes Standardise common procedures and practices Routinely use checklists Decrease reliance on vigilance
9
Q
What are the 7 NHS quality improvement mechanisms?
A
Clinical audits Disclosure Regulation Data gathering and feedback Standard setting Commissioning Financial incentives
10
Q
What are the 5 domains used in NHS outcomes framework?
A
Preventing people from dying prematurely
Enhance quality of life of people living with long term conditions
Helping people recover from episodes of ill health/injury
Ensuring people have a positive experience of care
Treating and caring for people in a safe environment and protecting from avoidable hazards
11
Q
What are the benefits of the NHS outcomes framework?
A
Provides overview of NHS performance on a national level
Holds secretary of state and NHS commissioning board accountable for £95bn of public money
Catalyst for behaviour and culture changes and so increased quality of care
12
Q
What are NICE quality standards?
A
Set of statements to define what quality care looks like.
They’re markers of high quality and cost effective patient care
Derived from best available evidence
Produced collaboratively with NHS and social care with they’re partners and service users
13
Q
What are clinical commissioning groups?
A
Commission services for local populations and drive increased quality through contracting.
14
Q
What’s the purpose of Quality and Outcomes Framework?
A
Set national quality standards using primary care markers such as patient experience. General practices then score points according to how well they perform against these markers. The practice is then paid based on points achieved and results are published online.
15
Q
What is the Commissioning Outcomes Framework used for?
A
To hold Clinical Commissioning groups accountable for progress using quality linked markers
16
Q
What are quality accounts?
A
Information on performance, safety, effectiveness and experience published annually and publicly.
17
Q
What is the Care Quality Commission?
A
Group with which all trusts must be registered. CQC can publish conditions of registration, make surprise visits and impose fines, warnings, prosecutions, closures etc
18
Q
What is a clinical audit?
A
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against criteria and the implementation of change.
19
Q
What are the stages of a clinical audit?
A
Set standards Measure current practice Compare results with criteria Change practice Re-audit
20
Q
What is clinical governance?
A
A framework through which NHS organisations are accountable for continuously improving quality and for safeguarding high standards of care, by creating as environment in which excellence in clinical care will fluorish.
21
Q
What is the ‘best evidence’?
A
Evidence based on findings of rigorously conducted research
22
Q
Before evidence based practice, what were practices mostly influenced by?
A
Professional opinion
Historical practice and precedent
Clinical fashion
Organisational and social culture
23
Q
Before evidence based practice, what did clinicians often do that led to inequities?
A
Tolerated huge variations in practice
Persisted with interventions that were ineffective
Failed to take up interventions known to be effective
24
Q
Why are systematic reviews useful?
A
Appraise and integrate findings to provide quality control and increased certainty
Reduce delay between findings and implementation
Save clinicians from having to locate and appraise studies themselves
Offer authoritative, generalisable and up to date conclusions
Help prevent biased decision making
Relatively easy to convert into guidelines and recommendations
25
How can evidence in systematic reviews be appraised?
By using a critical appraisal tool such suggests things to look for and questions to ask of a research article
26
Where can systematic reviews be found?
Medical journals
Cochrane library
NHS centre for reviews and dissemination
NHR technology assessment programme
27
What are some practical criticisms of evidence based practice?
Impossible to create and maintain systematic reviews across all specialties
Difficult and expensive to disseminate and implement findings
RCTs not always plausible, necessary or desirable
Outcomes often biomedical which could limit which interventions are funded
Requires good faith in the part of the pharmaceutical companies
28
What are some philosophical criticisms of evidence based practice?
Could make professionals unreflective rule followers
Opposes most doctors' modes of reasoning
Population level outcomes may not translate to an individual
May be legitimisation of rationing
Affects professional responsibility and autonomy
29
What are some problems with the implementation of evidence based practice?
Evidence exists but doctors don't always know about it
Doctors know about evidence but don't always use it
Organisations can't support innovation
Commissioning groups may have different priorities
Insufficient resources to implement change
30
What are some common quantitative research designs?
```
Cohort studies
Case control studies
RCTs
Cross sectional surveys
Secondary analysis from other sources eg surveys, official statistics
```
31
What's the difference between validity and reliability?
Validity means it measures what it's supposed to measure. Reliability means it measures it consistently
32
What's a disadvantage of using open questions in a questionnaire?
May need extra instructions
May take more time
Need a plan in advance of how to analyse responses
33
What are the advantages of quantitative research methods?
Good at describing, measuring, finding relationships between things and at allowing comparisons
34
What are the disadvantages of quantitative research methods?
Can force people into inappropriate categories
May not allow people to express themselves how they want
May not access all important information
May not be effective at establishing causality
35
What is ethnography?
The study of human behaviour in it's natural context
36
What are the two types of observation done in qualitative research?
Participant observation - observer integrates into surroundings/group
Non-participant observation- observer watches interaction often by camera but doesn't interact with subject
37
What are some benefits of focus groups?
Good for establishing parameters, encouraging people to participate and for accessing a collective group understanding of an issue
38
What are some disadvantages of focus groups?
```
Not good for individual experiences
Deviant views may be inhibited
Difficult to arrange
Need good facilitator
Membership should be carefully considered
```
39
How is qualitative data analysed?
Through ongoing iterative process involving close inspection of data, trying to identify themes. Data is then assigned to these themes and data analysis should be constantly compared against the themes
40
What are some advantages of qualitative research?
Good for explaining relationships, accessing information not revealed by quantitative methods and for understanding perspectives
41
What are some disadvantages of qualitative research methods?
Bad for finding consistent relationships and generalisability
42
What are some come measures used to demonstrate health inequalities between countries?
Life Expectancy from birth
Disability Free Life expectancy
Under 3 Mortality rate
Maternal mortality ratio
43
How are inequalities measured?
Using socioeconomic status (both individual and geographical classifications)
Gender
Ethnicity
44
What are some examples of inequalities between ethnicities in britain?
Higher prevalence of cardiovascular disease in men of south asian origin
Lower prevalence of cancer in BME groups
Higher rates of infant mortality in women of pakistani and black caribbean origin
45
What are some examples of inequalities between different socioeconomic groups in britain?
People in higher status jobs have lower rates of infant and -natal mortality
People in more deprived areas have lower life expectancy and disability free life expectancy
46
What are some examples of inequalities between genders?
Men have higher rates of mortality, suicide and violent death
Women have higher life expectancy, reporting of mental illness and rates of disability
47
What are the four explanations for health inequalities, given in the black report?
Artefact - health inequalities are evident due to the way in which data is collected
Social selection - causation direction is from health to social position
Behavioural-cultural - Ill health is due to people's choices, knowledge and goals
Materialistic - Inequalities in health arise from differential access to material resources
48
What are some limitations of the behavioural cultural explanation?
Behaviours are outcomes of social processes, not just individual choice
Choices may be hard to exercise in adverse conditions
Choices may be rational for those whose lives are constrained by lack of resources
49
How does the materialistic explanation work?
States that differences in access can be due to low income, poor control of job, poor housing etc and so a person's exposure to hazards isn't a choice and that there may be an accumulation of factors over a person's lifetime
50
How did WIlkinson's theory of income distribution help to explain inequalities in healthcare?
Stated that it was relative income of a country, not average that was most important as countries with biggest differences in income and biggest differences in health so recommended redistribution of wealth.
51
In general, what are the differences in how lower socioeconomic groups access healthcare?
Tend to use more GP and emmergency services and less preventative (ie screening) and specialist services
52
How are the differences in how lower socioeconomic groups access healthcare explained?
Tend to manage health as a series of crises
Normalisation of ill health
Difficulty marshalling resources needed for engagement with health resources
Tend to use most porous services
May reflect lack of cultural alignment between health services and lower socioeconomic groups
Adjudications of eligibility by doctors may impact on referrals to specialist services etc
53
What evidence is there of sub-optimal quality of care in the NHS?
Survey results on patient and staff satisfaction
| Variations in medical care throughout the country means that some people aren't getting the best possible care
54
What factors are related to inequalities in health?
```
Social status
ethnicity
gender
age
disability
```
55
What are the differences between sex and gender?
Sex is the biological and genetic determinant and gender is the social and behavioural aspects and personal identity.
56
What does the Black artefact explanation state?
That inequalities are due to the way that data is collected but this has generally been discounted as measurement recordings are more likely to give an underestimate of inequalities.
57
What does the Black behavioural-cultural explanation state?
That ill health is due to choices, knowledge and goals. Based on the assumption that people from disadvantaged backgrounds are more likely to make damaging health decisions and people from advantaged backgrounds are more likely to make positive health decisions and engage in positive behaviours.
58
What does the materialistic Black explanation state?
That inequalities arise from differential access to resources. These could arise due to low income, poor housing, lack of control over work, unemployment, poor work conditions etc. Therefore there's a lack of choice in the exposure to hazards.
59
What did the wilkinson report conclude about inequalities in health?
That inequalities are related to income distribution so it's a person's relative income that is more important that the average wealth. Countries with more equal income have improved health overall. Therefore, social cohesion is important to health of the population.
60
Why may differences in access to healthcare and diversity of population by linked?
```
Association with economic status
Cultural expectations
Differing needs of differing groups
Language barriers
Stigmatisation and stereotyping
Alienation by culturally discordant services.
```
61
What are lay beliefs?
How people understand and make sense of health and illness. Constructed without specialised knowledge and tend to be socially embedded and complex.
62
What do sociological theory and lay perceptions refer to?
How much control you think you can exert over your health
How much control you can exert in everyday life
How this relates to your wider social and cultural perceptions of health
63
What are the 3 main types of perceptions of health?
Negative definition is that health is the absence of illness
Functional definition is that health is the ability to do things
Positive definition is that health is a state of well being and fitness and so it can be achieved
64
Why is it difficult for lay understandings to develop independent of professional concepts?
As the public are constantly surrounded by these medical concepts. However, these professional concepts and interpreted and then made sense of in light of the public's every day experience
65
What is health behaviour?
An activity undergone with the purpose of maintaining health and preventing illness
66
What is illness behaviour?
An activity of an ill person to define their illness and so seek a solution
67
What is sick role behaviour?
A formal response to symptoms, including seeking formal help and the action of a person as a patient
68
What might illness behaviour be influenced by?
```
Culture
Visibility of symptoms
Extent to which symptoms impact on life
Frequency and persistence of symptoms
Tolerance threshold
Information and understanding
Availability and resources
Lay referral
```
69
What is lay referral?
The chain of advice seeking contacts that a sick person makes with other lay people before or instead of consulting a professional.
This aids understanding of why people delay contacting a professional and how and why they eventually do consult a professional
70
Why is lay referral important?
This aids understanding of
why people delay contacting a professional
how and why they eventually do consult a professional
Your role as a doctor in their health
Use of health services and medication
Use of alternative medicines
71
What are the four main factors that influence when a lay person decides to contact a health professional?
Symptom experience
Symptom evaluation
Knowledge of condition ad treatments
Experience of and attitudes towards health professionals
72
What's the difference between early presenters and delayers?
Early presenters experience significant and rapid impact on functional ability so quickly contact a professional, whereas delayers often develop explanations for symptoms related to preceding events. Consultation is often prompted when previous explanation is inadequate for progression of symptoms
73
Why might people delay contacting health professionals?
Perceptions of typical candidate for an illness or typical severity or progression of condition
Don't recognise possibility of variation and mildness of symptoms
74
What are deniers and distancers?
Deniers deny having a condition and distancers deny having a proper condition. These tend not to comply properly with treatment
75
What are acceptors?
Accept diagnosis and advice fully. Take medication properly
76
What are pragmatists?
Take medication on exacerbations rather than to prevent exacerbations occurring.
77
What are the implications of lay beliefs about medication, for health professionals?
Medication behaviour is linked to people's beliefs, social circumstances and threat to identity
Irrational use of medication is deeply embedded in complex social identities that need to be managed
Meanings of symptoms may be different than the meaning to health professionals.
78
What are health determinants?
A range of factors that have a powerful and cumulative effect on the health of a population. They shape behavioural and environmental risk factors.
79
What are the main global causes of ill health?
Poverty
Poor housing
Poor healthcare systems
social exclusion
80
What's the difference between health education and health promotion?
Health education targets individual health behaviours whereas health promotion takes a much broader approach and includes social and political aspects
81
What is health promotion?
The process of enabling people to increase their control over and to improve their health. Health is a positive concept, emphasising social and personal resources, as well as physical capacities. Therefore, health promotion isn't just the responsibility of the health sector but extends into well-being.
82
What are the main principles of health promotion?
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Empowering
Participatory
Multi-sectoral
Holistic
Equitable
Multi-strategy
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83
What are the 5 main approaches to health promotion?
```
Medical/preventative
Behavioural
Educational
Empowerment
Social change
```
84
What are the differences between primary, secondary and tertiary prevention?
Primary prevention is prevention of the onset of a disease or injury by reducing the exposure to risk factors
Secondary prevention is trying to detect and treat an illness or risk at an early stage to prevent progression
Tertiary prevention is minimising the effects of an established disease
85
What are the main dilemmas raised by health promotion?
Ethics of interfering in people's lives - potential psychological impact of health promotion messages and the intervention of the state in the lives of individuals raises questions about rights and personal choices
Victim blaming - focussing on individual behavioural change ignores wider social determinants of health such as poor housing and lack of green spaces
Fallacy of empowerment - education doesn't equal empowerment and healthy lifestyles aren't simply down to ignorance but to adverse circumstances and socio-economic determinants
Reinforcement of negative stereotypes
Unequal distribution of responsibility to the head of the household
Prevention paradox that interventions that make a difference on a population level might not make a difference to the individual
86
What are structural critiques of health promotion?
Focuses on responsibility of the individual
| Marginalises material conditions that lead to ill health
87
What is a surveillance critique of health promotion?
Issues with monitoring and regulating the population
88
What is a consumption critique of health promotion?
Lifestyle choices aren't just seen as health risks but are tied up with identity construction
89
What is evaluation?
The rigorous and systematic collection of data to assess the effectiveness of a programme in achieving predetermined outcomes
90
Why does health promotion need to be evaluated?
To provide evidence based interventions
To provide accountability. Evidence gives legitimacy and political support to interventions
As an ethical obligation to ensure there's no direct or indirect harm done
For programme management and development
91
What are the 3 main types of evaluation done for health promotion?
Process evaluation - mostly qualitative. Assesses the process of programme implementation
Impact evaluation - assesses immediate effects of the intervention
Outcome evaluation - Measures long term consequences but this can be influenced by timing of the evaluation. i.e. some interventions take a long time to have an effect - delay
Some interventions rapidly wear off - Decay
92
Why is it difficult to demonstrate an attributable effect through evaluation of health promotion?
Intervention design
Possible effect lagtime
Intervening or counfounding factors
High cost of evaluation research
93
What is a chronic illness?
One that's long term and has a profound influence on the lives of sufferers. They are controlled but not cured and they often have associated co-morbidities.
Their prevalence increases in ageing populations
94
How can a sociological approach help to understand chronic illness?
Focuses on how chronic illness impacts on social interaction and role performance
Is concerned with experiences and meanings of chronic illness
Interested in how people manage and negotiate chronic illness in everyday life
95
What is an illness narrative?
Refers to storytelling practices that occur in illness
96
What are the 5 types of work done in chronic illness?
```
Illness work
Everyday life work
Identity work
Biographical work
Emotional work
```
97
What is meant by illness work of chronic illness?
Refers to symptom management and dealing with the physical manifestations of an illness. This is central to coping and should be done before work is done on social relationships
98
What is meant by everyday life work of chronic illness?
Coping and strategic management. Decisions about mobilisation of resources and how to balance putting demands on others whilst remaining independent.
99
What is normalisation through everyday life work?
Either trying to return to or maintain the pre-illness lifestyle or redesignating the new lifestyle and normal.
100
What is meant by coping?
Is the cognitive processes involved in dealing with illness
101
What is meant by strategy?
The actions and processes involved in managing a condition and its impact
102
What is meant by emotional work of chronic illenss?
Work people do to protect the emotional wellbeing of others. May be disruption of relationships and withdrawal from social terrain.
103
What is meant by biographical work of chronic illness?
A loss of self where former self image crumbles without the simultaneous development of an equally valued new image. Interaction between body and self identity.
104
What is meant by identity work of chronic illness?
Different conditions have different connotations and can affect how a person is seen by themselves and by others.
105
What problems can loss of self give rise to?
Scrutiny of reactions of others for signs of discreditation
Dependence on others which can put strain on relationships
As illness progresses, relationships are harder to maintain but increasing dependence requires more intimacy
Inability to do things leads to loss of social life
106
What is narrative reconstruction?
The process by which the shattered self is reconstructed in ways to explain the appearance of illness. Attempts to reconstitute and repair ruptures between the body, self and world by linking up and interpreting different aspects of biography to realign present and past and self with society. Also a desire to create a sense of coherence, stability and order in the aftermath of biographical disruption.
107
Why might optimum self management be difficult to achieve?
Low adherence rates
Low quality of life
Poor psychological wellbeing
108
What does the expert patient programme do?
Provides coping and patient management skills to aim to reduce hospital admissions. However, it places responsibility on patients who may be very ill.
109
What is stigma?
When a negatively defined condition, trait, attribute or behaviour is conferred as 'deviant'
110
What is meant by discreditable stigma?
When there are no visible characteristics but it can have negative connotations if patient is outed e.g. HIV
111
What is meant by discredited stigma?
If there are physically visible characteristics or well known stigma that sets patients apart
112
What is meant by enacted stigma?
A real experience of prejudice, discrimination and disadvantage as a consequence of the condition
113
What is meant by felt stigma?
The fear of enacted stigma. Includes a feeling of shame associated with having the condition and often involves selective concealment
114
What is the medical model of disability?
States that disability is a deviation from medical norms. Disadvantages experiences are a direct consequence of impairment and disability and medical interventions are required
115
What is a disadvantage of the medical model of disability?
Doesn't recognise social and psychological factors and uses stereotyping and stigmatising language
116
What is the social model of disability?
States that problems are a product of environment and a failure of that environment to adapt. Disability is a form of oppression and political social change is needed.
117
What is a criticism of the social model of disability?
The body is left out and there's a failure to recognise realities of the body and the extent to which they can be solved socially.
118
What's the difference between impairment, disability and handicap?
Impairment is an abnormality in the structure or function of the body.
Disability is the ability to perform activites
Handicap is the broader social and psychological consequences of living with an impairment or disability
119
What is the international classification of impairments, disabilities or handicaps?
Differentiates between impairments, disabilities and handicaps. It states that one of these states may or may not lead to another and that there's not necessarily a relationship between severity of impairment and the severity of the resulting disability or handicap.
120
What is a criticism of the ICIDH?
Implies that problems are intrinsic and inevitable and the use of 'handicap' is problematic. It has many characteristics of the medical model of disability.
121
What is the International classification of functions, disability and health?
Attempts to integrate the social and medical models of disability and recognises the significance of the wider environment. Incorporates the health condition and it's effects on body function and structure and participation. Also the relationship between the health condition and activities and the effects of environmental and personal factors on the ability to carry our activities.
122
Why is it useful to measure health?
To have an indication of the need for health care
To target resources to where they're needed most
To assess effectiveness of health interventions
To evaluate the quality of health resources
To use evaluations of effectiveness to get better value for money
To monitor patient's progress
123
What are the 3 types of health measures?
Morbidity
Mortality
Patient based outcomes
124
Evaluate mortality as a health measure
Easy to define but not always accurately recorded. Not a very good way of assessing outcomes and quality of care
125
Assess morbidity as a health measure
Collection of information is done routinely but not always reliably or accurately.
Doesn't tell us anything about patient experience and isn't always easy to use in evaluation
126
What's the purpose of patient based outcomes?
Aim to assess wellbeing from the patient's perspective, including HRQoL, health status and functional abilities
127
What are patient reported outcome measures?
Measures of health that come directly from patients. Compare scores before and after treatment or over longer periods of time
128
What are some advantages of patient based outcomes?
There's an increase in conditions that need managing rather than treating
Biomedical tests don't give a full picture
Improves patient-centred care
Help us pay attention to iatrogenic effects of care
129
What are some applications of patient based outcomes?
Clinically
As part of a clinical audit
To assess benefits in relation to cost
To compare interventions in a clinical trial
To measure the health status of populations
As a measure of service quality
130
Why should PROMs be introduced?
To improve the clinical management of patients to make informed, shared decisions
For comparison of providers and therefore to increase productivity through demand management and to improve quality through patient choice
131
What is done with the data from patient reported outcome measures?
Published by the health and social care information centre. This can then be broken down by provider in order to compare trusts. Data indicates quality of care and so is of interest to commissioners and patients
132
What are some challenges of PROMs?
Minimising time and cost of collection, analysis and presentation
Patient participation rates
The output to different audiences has to be appropriate
Possible misuse should be avoided
Expansion to other areas such as emergencies and mental health
133
What is meant by quality of life?
Represents the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient
134
What dimensions are covered by health related quality of life measures?
```
Physical function
Symptoms
Global judgements of health
Psychological well being
Social wellbeing
Personal constructs
Cognitive functioning
Satisfaction with care
```
135
What aspects are assessed in terms of physical function in HRQoLs?
```
Mobility
Dexterity
Range of movement
Physical activity
Activities of daily living
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136
What aspects are assessed in terms of psychological well being in HRQoLs?
```
Anxiety
Depression
Coping
Self esteem
adjustment
```
137
What aspects are assessed in terms of Social wellbeing in HRQoLs?
```
Intimate relations
Opportunities for social contact
Integration
Leisure activites
Sexual activity
Sexual satisfaction
```
138
What aspects are assessed in terms of cognitive functioning in HRQoLs?
```
Alertness
Concentration
Memory
Confusion
Ability to communicate
```
139
What aspects are assessed in terms of personal constructs in HRQoLs?
Spirituality
Stigma
Satisfaction with life
Bodily appearance
140
Evaluate the use of qualitative methods to measure HRQoLs
Gives access that other methods can't and is good for an initial look at the dimensions of HRQoLs so can inform the development of qualitative instruments
However, they require a lot of resources and aren't easily used for evaluation
141
What is meant by instrument reliability?
Is it accurate and internally consistent
142
What is meant my instrument validity?
Does it measure what it intends to
143
What's the aim of generic quantitative methods of measuring HRQoLs?
TO use with any population and generally cover perceptions of health. Include questions on social, emotional and physical functioning, pain, and self care
144
What are some advantages of generic instruments of measuring HRQoLs?
Can be used for a broad range of health problems
Can be used without a disease-specific instrument
Enable comparisons across treatment groups
Can detect unexpected effects of an intervention
Can be used to assess the health of populations
145
What are some disadvantages of generic instruments for measuring HRQoLs?
Can lose relevance
Can be less sensitive to changes as a result of an intervention
May be less acceptable to patients
146
What are 2 examples of a generic instrument for measuring HRQoLs?
Short form 36 item questionnaire - SF-36
| EuroQol - EQ - 5D
147
What can SF-36 generic instrument be used for?
```
Measure of general health
Population surveys
Patient management
Resource allocation
Audits
Clinically
```
148
What is the process of the SF-36 generic instruments?
Uses a 4 week recall period or 1 week if acute. Questionnaire contains 36 items that are grouped into 8 dimensions. Responses are then scored and added together within each dimension so that each dimension has a separate score.
149
What are the different dimensions used in an SF-36 generic instrument?
```
Physical functioning
Social functioning
General health
Mental health
Physical role functioning
Emotional role functioning
Vitality
Bodily pain
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150
What are the advantages of the SF-36?
```
Acceptable to people
Only takes 5-10 minutes
Good internal consistency
Responsive to change
Population data available
```
151
How is the EuroQoL 5-D carried out?
5 dimensions are used with 3 levels for each dimension (no problems - moderate problems - extreme problems) A single index is then given for health status with 1 = full health and 0 = death
152
What are some advantages of the EUROQoL 5D?
Reliable and valid.
| Good for economic evaluations
153
What's the aim of specific instruments for measuring HRQoL?
Evaluate a series of health admissions, specific to a disease, state or dimension
154
What is an example of a disease specific instrument?
Asthma quality of life questionnaire
155
What's an example of a site specific instrument?
Oxford hip score
156
What's an example of a dimension specific instrument?
Beck depression inventory
| McGill pain questionnaire
157
What are some advantages of specific instruments for measuring HRQoL?
Relevant content
Sensitive to change
Acceptable to patients
158
What are some disadvantages of specific instruments for measuring HRQoL?
Comparison is limited
| May not detect unexpected effects
159
What should be considered when selecting an instrument for measuring HRQoL?
Has reliability and validity been established
Has there been successful use in a previous study
Is it relevant to area of interest
Does it adequately reflect patient's concerns
Is it acceptable to patients
Is it sensitive to change
Is there ease of analysis and administration
160
What is screening?
A systematic attempt to identify an unrecognised condition by the application of tests, examinations and other procedures which can be applied rapidly and cheaply, to distinguish between apparently well persons who probably have the disease or its precursor, and those who probably don't have the disease
161
How may diseases be detected?
Spontaneous presentation
Opportunistic finding
Screening
162
What is diagnosis?
The definitive identification of a suspected disease or defect by application of tests, examinations and other procedures to definitively label someone as either having the disease or not
163
What is the primary purpose of screening?
To give a better outcome compared with if condition was found in the usual way
164
What are the criteria for implementing a screening programme, in relation to the disease?
Must be important health problem
Must have an early detectable stage
Need a good understanding of it's epidemiology and natural history
Cost effective primary prevention interventions must have been considered and, if possible, implemented
165
What are the criteria for implementing a screening programme, in relation to the test?
Simple and safe
Precise and valid
Acceptable to population
Must know distribution of test values in the population
Need an agreed cut off level
Need agreed policy on who to investigate further
166
What are the criteria for implementing a screening programme, in relation to the treatment?
Effective evidence based treatment must be available
Early treatment must be advantageous
Agreed policy on who to treat
Clinical management of the condition and patient outcomes must be optimised in health care providers before participation in the screening programme
167
What are the criteria for implementing a screening programme, in relation to the programme itself?
Proven effectiveness, preferably by RCT
Parameters must be scientifically justifiable to the public
Quality assurances made about the whole programme, not just the test
Facilities for counselling
Facilities for diagnosis and treatment
Benefits should outweigh physical and psychological harm
Other options should be considered
Opportunity costs should be considered
168
What are the advantages of screening?
Early detection of the disease might improve outcome
| True negatives provide reassurance
169
What are the disadvantages of screening?
False negatives provide false assurances
False positives expose patients to invasive procedures
False negatives not offered diagnostic testing that they might benefit from
Expensive interventions may divert money away from possible treatment
170
What are the negative effects of false positives?
Cause stress, anxiety and inconvenience
| Direct and opportunity costs
171
What are the negative effects of false negatives?
May delay presentation with symptoms
| Provides false reassurances
172
What is sensitivity?
The proportion of people with the disease who are test positive.
= TP/(TP+FN)
173
What is specificity?
The proportion of people without the disease who test negative
= TN/(TN+FP)
174
What is positive predictive value?
The probability that someone who has tested positive will actually have the disease
= TP/TP+FP
175
What is positive predictive value affected by?
Prevalence. Low prevalence will reduce positive predicitve value
176
How is prevalence calculated?
TP+FN/whole population
177
What is the negative predictive value?
The proportion of people ho test negative and don't actually have the disease
= TN/TN+FN
178
What factors make it difficult to evaluate the effectiveness of screening programmes?
Lead time bias
Length time bias
Selection bias
179
What is selection bias in screening?
Refers to how studies of screening are likely to be skewed by the healthy volunteer effect as people who partake in screening regularly are more likely to also engage in other positive health behaviours
180
How could selection bias in screening be eliminated?
By carrying out a randomised control trial
181
How is the doctor patient contract affected by screening?
Normally in clinical practice, people self present, asking for help and so define themselves as patients. In screening, apparently healthy people are targeted by offering the help with something that they may never have considered
182
What issues lead to complexity of screening?
Who is screened
What results are clinically significant and which will regress/resolve on their own
Psychological impact must be considered
183
What are some limitations of screening?
Can't protect people from a disease
Proportion of false negatives and false positives is problematic
Carries the potential for harm as well as benefit
Increasing emphasis put on promoting informed choices about screening but communicating the benefits, harms and risks of preventative interventions can be problematic
184
What screening programmes are currently run in the UK?
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Abdominal aortic aneurysm
Bowel cancer
Cervical cancer
Breast cancer
Diabetic retinopathy
Down Syndrome
Foetal abnormalities
Phenylketonuria
Sickle cell and thalassaemia
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185
What is involved in the cervical screening programme?
Women aged 25-49 are invited every 3 years, and women 50-64 every 5 years, for a speculum test. Women over 64 who have had 3 consecutive normal results are then taken off the call/recall system.
HPV testing is also done to determine whether a low grade abnormality should be referred for colposcopy
186
What are the main critiques of health promotion and screening?
Structural
Feminist
Surveillance
Social constructionist
187
What are the structural critiques of health promotion and screening?
Victim blaming - Individuals are encouraged to take responsibility for their own health but not everyone is equally able to do this
Individualising pathology - doesn't address the underlying causes
188
What is the surveillance critique of health promotion and screening?
That individuals and populations are increasingly subject to population. Concern that prevention is part of a wider apparatus of social control
189
What is the social constructionist critique of health promotion and screening?
Health and illness practices may be seen as moral and the right thing to do
190
What is the feminist critique of health promotion and screening?
Concern that screening is targeted more towards women than men
191
What are 3 factors that reflect the inevitability of rationing in healthcare systems?
Demography - rising population. Elderly more expensive than young people
Technology - new therapies more expensive, increase pool of suitable candidates and then to improve life expectancy rather than cure
Priorities - have to be made.
192
Why are factors need to considered in terms of priorities of healthcare rationing?
Resources are scarce and can be used in other ways
Needs to be clear and explicit who benefits from public spending
Need to be clear whether the spending is 'worth it'
Need to be clear about end goals
Focus on alleviating chronic conditions
Need to be clear about what to prioritise ie relief from chronic pain, improving access, particular groups, or quality of care
193
What are the 5 Ds of rationing in the NHS?
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Deterrent (prescription charges)
Delay (waiting list)
Deflection (from secondary care by GPs)
Dilution
Denial
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194
What is implicit rationing?
Where care is limited but the decisions behind these limitations and the bases for these decisions, are not clearly expressed
195
What are some disadvantages of implicit rationing?
Open to abuse
Can lead to inequities and discrimination
Based on perceptions of social deservingness
Doctors are unwilling to partake
196
What is explicit rationing?
Decisions and the reasoning behind these decisions are clear. Based on defined rules of entitlement
197
What processes are involved in explicit rationing?
Technical processes, such as assessment of efficiency and equity
Political processes, such as participation of lay people
198
Who is responsible for explicit rationing?
Clinical commissioning groups
199
What are some advantages of explicit rationing?
Transparent and accountable
Opportunity for debate
Use of evidence based practice
More opportunities for equity in decision making
200
What are some disadvantages of explicit rationing?
Very complex
Not good for the heterogeneity of patients and illnesses
Can lead to patient and professional hostility
A threat to clinical freedom
Evidence of patient distress
201
What are the different levels of rationing?
Allocation to NHS compared to other government priorities
Allocation to different sectors
Allocation to specific interventions within sectors
Allocation of interventions between different patients in the same sector
How much to invest in each patient once an intervention has been initiated
202
What are tariffs?
Payments by results. Set nationally and given to healthcare providers as reflection of treatment given and subsequent results
203
What are healthcare resource groups?
A measured average of the cost for an individual patient stay. Then linked to tariff paid to healthcare provider.
204
How are people allocated to healthcare resource groups?
When a hospital treats a patient, the diagnosis and treatment is recorded. This information then determines the HRG that the patient is allocated to, and therefore the tariff paid
205
How do tariffs act to improve efficiency?
If avoidable complications occur, a lower tariff is paid. If a never event occurs in the treatment of a patient, no tariff is paid for that event. Therefore, efficient trusts may make a profit but inefficient trusts can lose money so is an incentive to improve efficiency.
206
What are some problems with letting the public decide on resource allocation?
Public priorities may differ from those of doctors and policy makers
Tend to prioritise heroic interventions and certain groups
Resistance to the inevitability of rationing
Preference for treating patients with dependent
Willingness to discriminate against those who could be seen to be partially responsible for their illness
Public priorities may be contrary to the spirit of equity and equal access according to need
Public priorities may go against cost effectiveness data
Strong reaction to some NICE guidelines reflects the large gap between public expectation and the necessity of rationing.
207
What assumption is made in healthcare economics?
That resources are scarce and so tries to make the most out of these resources, maximising benefits subject to the constraints imposed by resource availability
208
What is economic evaluation?
The comparison of resource implications and benefits of alternative ways of delivering healthcare. Can be used to make decision making more transparent and fair and is underpinned by concepts of scarcity, utility, efficiency and opportunity costs
209
What is meant by scarcity?
How need outstrips resources available so prioritisation is inevitable
210
What is meant by efficiency?
Getting the most out of limited resources
211
What is meant by equity?
The extent to which distribution of resources is fair
212
What is meant by effectiveness?
The extent to which an intervention produces desired outcomes
213
What is meant by utility?
The value that an individual places on a certain state of health
214
What is an opportunity cost?
The value of the next best alternative use of a resource. Measured in benefits foregone.
Refers to how once a resource is used in one way, it can't be used in another
215
What is the aim of economics
That we do activities where the benefit outweighs the opportunity costs and that benefit is the greatest overall.
216
What are healthcare economics views based on?
Technical efficiency - the most efficient way of meeting a need
Allocative efficiency - deciding between many different needs to be met
217
What are some inputs used in economic evaluation?
Medical and non medical costs such as cost of healthcare services, patient's time, cost of care-giving
218
What are some outcomes used in economic evaulation?
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Health status
Savings in other resources
Improved productivity
Quality of life
Survival
Clinical criteria
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219
What are the main methods of comparing costs and benefits in healthcare economics?
Cost effectiveness analysis
Cost benefit analysis
Cost utility analysis
Cost minimisation analysis
220
What is cost minimisation analysis?
Looks at interventions where they're equally efficient and so outcomes are assumed to be equivalent. Then simply compares inputs in order to minimise costs. This is rarely relevant however
221
What is cost effectiveness analysis?
Looks at interventions that aren't equally effective but where outcomes can't be measured in monetary terms or in QALYs. Compares interventions etc with similar outcomes and measurement is done in cost per unit outcome.
222
What happens if both costs and benefits are higher for an intervention in cost effectiveness alaysis?
Calculate extra benefit per the extra cost
223
What is cost benefit analysis?
If interventions aren't equally effective and outcomes can be measured in monetary terms. However, there are difficulties with putting all inputs and outcomes in monetary terms
224
What is cost utility analysis?
Branch of cost-effectiveness analysis. Focuses on quality of health outcomes produced or foregone. Used if outcomes can be measured in QALYs
225
How can benefits that take a long time to have an effect be evaluated in healthcare economics?
Using discounting. Looks at present value of inputs and value of outcomes that will be accrued in the future
226
Why are QALYs used?
To enable use to compare cost effectiveness so that it can be used to aid decision making
227
Why are QALYs better than life years gained?
Life years only account for survival as the main outcome. QALYs can look at many different aspects
228
What costing system is used to assess cost-effectiveness with QALYs?
Incremental cost-effectiveness rate. Looks at change in costs in relation to change in health status to give a cost per QALY
229
With a borderline cost per QALY, what is taken into account before a decision is made on an intervention?
Degree of uncertainty
If change in HRQoL is captured within the QALY calculation
If there are some benefits that haven't been taken into account
230
What are some disadvantages of QALYs?
Don't distribute according to need but according to benefits gained per unit cost
Concerns about the values that they embody
Technical problems with calculations
May not embrace all dimensions of benefit
Problems with RCT evidence such as: atypical care, atypical patients, length of follow up, sample size, limited generalisability and differences in comparison therapies
231
What are some problems with NICE?
Resented by some patient groups, especially those with long term but non-life threatening conditions
Resented by pharmaceutical companies
PCTs have to prioritise NICE approved interventions which can skew their own priorities
Concerns about government interference
232
What were main developments that drove interest in patient evaluation of healthcare?
NHS plan patient prospectus publishes review of patients' views and outcomes. This led on to the Involving of the Public in Healthcare in 2001.
NHS Act in 2006 placed duty on NHS services to involve and consult patients and the public
NHS outcomes framework ensures positive experience of care
Local Healthwatch influences set-up and commissioning of services to provide information, advice, support and recommendations about local healthcare services
233
What did NHS Act state that the public and patients should become more involved in?
Planning of services
Decisions affecting the operation of these services
Development and consideration of changes in the way that these services are provided
234
What is the purpose of the parliamentary and health service ombudsman?
To independently investigate any complaints that haven't been acted on or haven't been dealt with properly to give an independent review of events
235
What are some causes of patient dissatisfaction?
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Poor communication
Competence
Poor hygiene standards
Waiting times
Culturally inappropriate care
Health outcomes
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236
What are some qualitative methods of obtaining patient evaluations of healthcare?
Interviews
Focus groups
Observation
237
What is the purpose of the patient advice and liason services?
To help resolve concerns in people using the NHS
To provide information on the NHS complaints system and how to get independent help if they want to make a complaint
To inform people how they can get more involved in their healthcare and the NHS
Improve the NHS by listening to concerns etc and taking them to people who design and manage services
Provide early warning system to NHS about problems and gaps in services
238
What are some advantages of quantitative surveys to access patient views on healthcare?
Relatively quick and easy
Less staff training needed
Anonymity is more easily guaranteed
Allows monitoring of performance
239
Evaluate the use of patient based outcomes in assessmen of performance of doctors
Ultimately, care is provided to patients so they should feel that it's adequate.
However, patients may not provide an objective view and their view is naturally going to be a selfish one in terms of improving their own health. Views may also not be applicable nationally
240
What is the functionalist approach to understanding the patient-professional relationship?
Interested in how a relationship characterised by asymmetry could work so well. States that many taboos have to be broken down in order for it to work. States that falling ill is a sociaocultural experience and that the sick role is a state of helplessness and patients don't have the tecnical competence to remedy their own situation. States that both the sick role and the doctor's role have associated rights and responsibilities
241
What are the rights and responsibilities of the sick role, according to the functionalist approach?
Legitimate freedom from social obligations and responsibilities
Demand of medical attention
Must want to get well and not abuse their exemption
Should seek out appropriate help and then cooperate with that help
242
What are the rights and responsibilities of the doctor, according to the functionalist approach?
Tend to sickness
Use skills for benefit of the patient
Be objective and non-discriminatory
Gain intimacy, autonomy, status and financial reward
243
What are some criticisms of the functionalist approach?
Sick role is not well thought out
Assumes patients are incompetent and passive
Doesn't explain why things go wrong
Assumes rationality and benificence of medicine
244
What is the conflict approach to understanding the patient-professional relationship?
Emphasis conflict. Replaces theories of trust and authority with those of supressed conflict and medical dominance. States that doctor holds bureaucratic power and monopoly on the definition of health and illness. Doctor's control not down to professional values or technical expertise.
Patients must be submissive
245
What is meant by medicalisation in relation to the conflict theory?
There's marginalisation of lay beliefs and colonisation of areas previously controlled by lay people, by medical profession
Pathologising of aspects of social life
Cultural iatrogenesis - people depend on medicine, lose self-reliance and become ill
246
What are some criticisms of the conflict theory?
Inaccurate portrayal of patients and professionals
patients may appear deferential in consultation but can exert control both in that situation and outside of it
Patients can also seek to medicalise certain issues
247
What is there interpretive/interactionist approach to understanding the patient-professional relationship?
Interested in the meanings that people ascribe to certain situations. Interested in patterns and the informal, unwritten rules that apply to most aspects of social life and may be more important than the formal rules.
248
What is the ceremonial order of the clinic, in relation to the interpretive/interactionist approach?
Every medical encounter is subject to certain expectations
Doctor and patient avoid matters that don't fit with the patient-doctor ideal
Each party orients themselves towards the idealised version of that encounter
249
What is the patient-centred model of understanding the patient-professional relationship?
Emphasis partnership and aspires to a less hierarchical patient-professional relationship through taking patient views more seriously. Underpins many recent policy initiatives
250
What are factors of the ideal consultation according to the patient centred model?
Explores the patients main reasons for coming and their main concerns
Seeks an integrated understanding of the patient's world
Enhances prevention and health promotion
Finds common ground on what the issue is and mutualy agrees management
Enhances the patient-professional relationship
251
What is meant by shared decision making in terms of the patient centred model?
Both parties are involved in the decision. Both share information with each other and express their treatment preferences, before agreeing on a final plan
252
What can the patient contribute, within the patient centred model?
Concerns and priorities in relation to their presenting problem
Personal perceptions of costs and benefits of alternative interventions
Complex judgements about the severity of their condition and their willingness to pay
Trade off issues of survival at the cost of quality of life
253
What is conversation analysis?
The sequencing and positioning of talk within interactions. Demonstrates how patient participation can be encouraged or forestalled through communication designs
254
What is a profession?
Any occupation that can make distinctive claims about its work practices and status
255
What is a professional?
Member of a profession that may or may not require formal registration. Members are committed to an organised professional community and sense of professional identity
256
What is professionalisation?
The social and historical process resulting in an occupation becoming a profession
257
What needs to happen for an occupation becoming a profession?
Assertion of an exclusive claim over a body of knowledge or expertise
Establishing control over a market with exclusion of competitors
Establishing of control over professional work practice
258
What is meant by self regulation?
Claims the professional work involves such an unusual degree of skill and knowledge that non-professions aren't equipped to regulate it.
Relies on individuals internalising and cooperating with the collective norms of the professional group and aligning their conduct with the profession's standards
259
What are some criticisms of self-regulation?
Claims of virtue are seen as self-serving and strategic
Favours interests of agents over principles
Control is mostly informal through 'quiet chats'
Bad apple enquiries show problematic behaviour isn't always detected and dealt with appropriately
Rules on professional propriety can be problematic
260
What is professional socialisation and what does it involve?
Is the process through which new entrants to a profession acquire their personal identities. Medical education is crucial for this and involves formal curriculum, ie facts that are examined, and informal curriculum involving values, attitudes and beliefs that are gained as part of education but aren't formally examined
261
What evidence is needed for revalidation?
```
Continuing professional development
Patient feedback
Feedback from colleagues
Significant events
Review of complaints and compliments
Quality improvement activity
```
262
What kind of problems can be referred to the GMC in terms of fitness to practice?
```
Misconduct
Poor performance
Physcial or mental health
Conviction or caution
Decisions by regulatory body in any country
```
263
What is involved in revalidation?
Royal colleges set content and standards. Doctors must take part in annual appraisals and maintain a portfolio of supporting information. Evidence of this and their fitness to practise is then shown to a responsible officer which can make recommendations based on outlines set out by GMC.
Doctor needs positive recommendation from responsible officer to be revalidated
264
How was self-regulation reformed?
Responsibility for standard setting, conduct and practice monitoring and management was moved from inside profession to the Professional Standards Authority for Health and Social Care
265
What are the aims of revalidation?
Provide positive affirmation to patients
Detect concerns at an early stage
Support doctors to keep up to date
Maintain and improve practise
Encourage patient feedback
Drive improvement of local clinical governance
Drive improvement of standards of patient care
266
Why do people use complementary therapies?
If they have persistent symptoms that aren't relieved by traditional treatment
Due to perceived or real adverse effects of conventional treatment
May prefer a holistic approach to their problem
May feel that they receive more time and attention
267
What are some common concerns about complementary therapies, from the patient's perspective?
```
Guilt
Safety and competence
Denial
Cost
Social factors
```
268
What are some common concerns about complementary therapies from the doctor's perspective?
Unqualified and unregulated practitioners
May risk a missed or delayed diagnosis
May waste money on ineffective treatment
Patient may refuse conventional treatment
Mechanism of some complementary therapies is so implausible that it cannot work
269
What complementary therapies have been recommended by NICE?
Alexander technique for parkinson's
GInger and acupressure for morning sickness
Massage and manual therapy for persistent lower back pain
270
What are some challenges in forming an evidence base for complementary therapies?
Resources- who will fund research
Trial of single intervention may not reflect reality
Difficult to double blind
Finding placebos and shams is difficult
Multifaceted intervention trial is very complex
Getting patients to agree to randomisation is difficult
271
What are some advantages of NICE evaluating complementary therapies?
High public interest
Should abide by same standards as conventional interventions
Half of GPs already provide access to complementary medicin
Adresses inequalities in access and opportunity
Stimulates more and higher research
272
What are some disadvantages of NICE evaluating complementary therapies?
Money in NHS is already limited
Poor evidence quality
NICE has other priorities
273
How does acupuncture work?
Involves stimulating special point in the body, along the flow of QI which is the vital force that controls the workings of the human body. Stimulating these points can help to alter the path of Qi. These points tend to correspond with physiological and anatomical features, such as peripheral nerve junctions
