Flashcards in Pink Deck (88):
Define cost benefit
Costs and benefits expressed in monetary units
Define cost minimisation
Compares costs of alternative treatments of equal effectiveness
Define cost consequence
Costs expressed in monetary units and consequences in natural units e.g. deaths or time to relief of pain
Define cost effectiveness
Ratio of cost in monetary units and consequences in natural units e.g. death or time to pain relief –e.g. cost/minute of pain avoided
Define cost utility
Ratio of costs in monetary units and overall measure of health status (well being/utility) e.g. EQ-5D, SF-6D
Which model of health economics is preferred by nice and why?
Allows comparison between treatments for different disorders
Cost per Quality Adjusted Life Year (QALY), Incremental cost effectiveness/utility ratio
Cost in monetary units of buying one year of life in perfect health
What is health utility? And how do we measure it?
Measure of current overall health status
Can be measured in different ways
Within RCTs EuroQol-5D is brand leader: Self-completed questionnaire; preferred by NICE
What are the 5 dimensions of health utility?
Pain / discomfort
Anxiety / Depression
What are direct and indirect costs?
Direct (NHS perspective): Cost used to deliver intervention (drugs, doctors, AHPs, transport, buildings)
Indirect costs (societal perspective): Lost productivity
Indirect costs (personal social care perspective): patient costs, social care costs
What is the Incremental Cost Effectiveness Ratio?
Cost / utility (QALYs)
What is proportional equality?
Equals should be treated equally and unequals unequally in proportion to the morally relevant difference
What is proportionate universalism?
Tackling social gradient in health requires a combination of both universal (population-wide) and targeted interventions that reflect the level of disadvantage and hence, the level of need
What is health inequality?
Differences in health experience and health outcomes between different population groups –according to socioeconomic status, geographical area, age, disability, gender or ethnic group
What is health inequity?
Differences in opportunity for different population groups which result in unequal life chances, access to health services, nutritious food, adequate housing etc. These can lead to health inequalities
What ethical principles are relevant in resource allocation in healthcare?
Maximising overall benefit (utilitarianism)
Prudence (managing public resources responsibly)
Respect for autonomy: Facilitating choice within prescribed options, Public involvement in decision making processes
Fair process: Consistency of reasons, Transparency, Opportunity for appeal/review
What is self management?
Individual’s ability to manage symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition
Efficacious self-management: ability to monitor one’s condition and to effect cognitive, behavioural and emotional responses necessary to maintain a satisfactory quality of life. Dynamic and continuous
process of self-regulation is established
What is self care?
Preventative strategy i.e. tasks performed by healthy people at home
What is self management support?
Portfolio of techniques and tools that help patients choose healthy behaviours
Fundamental transformation of patient-caregiver relationship into a collaborative partnership
Why is self management important?
Global burden of disease is growing
Long-term conditions are increasing as leading causes of
mortality worldwide: E.g. cardiovascular disease and diabetes
People with LTCs likely to spend
What do people with long term conditions want from healthcare?
To be involved in decisions about their care
To be listened to
Access to information to help them make those decisions
Support to understand their condition and confidence to manage
Joined up, seamless services and proactive care
Do not want to be in hospital unless it is absolutely necessary and then only as part of a planned approach
They want to be treated as a whole person and for the NHS to act as one team
What type of self management approach works best?
Active support works best, focused on self-efficacy (confidence) and behaviour to improve outcomes
Approaches that focus on whether people are ready to change
Information and knowledge alone are not enough
Describe the bandura model of self efficacy
Person -> efficacy expectations -> behaviour -> outcome expectations -> outcomes
What do efficacy expectations predict?
Whether individual is likely to engage in an activity or behaviour
The degree to which they will overcome obstacles
Likelihood of success in achieving and maintaining behaviour change
What do outcome expectations predict?
Whether performing specified task will have required effect
How can you enhance a persons self efficacy?
Positive mastery experiences
Positive vicarious experiences
Positive verbal persuasion
Positive emotional readjustment
What are key psychological components to positive emotional readjustment?
Finding and maintaining hope: believing in themselves, sense of personal agency, optimistic about the future
Re-establishment of positive identity: new identity which incorporates illness, but retains a core, positive sense of self
Building a meaningful life: making sense of illness, finding a meaning in life, despite illness engaged in life
Taking responsibility and control: feeling in control of illness and in control of life
What are the 3 enablers to positive emotional emotional readjustment and effective self management?
Agenda setting: Identifying issues and problems, Preparing in advance, Agreeing a joint agenda
Goal setting: Small and achievable goals, Builds confidence and momentum
Goal follow-up: Proactive: instigated by the system, Soon (within 14 days), Encouragement/ reinforcement
What is a SMARTER goal?
What are potential barriers to effective self management?
Behavioural beliefs (pain requires rest)
Subjective beliefs (its inevitable at my age)
Control beliefs and Self-efficacy (I can’t do anything to improve it)
Depression, weight problems, difficulty exercising, fatigue, poor physician communication, low family support, pain, and financial problems
What is the LTC 6 questionnaire?
Asks about long term condition patients health over previous 12 months. Questions are:
Did you discuss what was most important for you in managing your own health?
Were you involved as much as you wanted to be in decisions about your care or treatment?
How would you describe the amount of information you received to help you manage your health?
Have you had enough support from your health (and social care) team to manage your health?
Do you think the care and support you receive is joined up and working for you?
How confident are you that you can manage your own health?
What are self management interventions or programmes?
Psycho-educational self-management behaviour-change interventions, Face-to-face or online
What areas can be improved by self management interventions?
Use of self-management behaviours
Beneficial medical outcomes
Improvements in haemoglobin levels
Systolic blood pressure
Fewer asthma attacks
Improved OA pain
Cognitive symptom management
Frequency of aerobic exercise
What is the Stanford model CDSMP? What are the 4 enchanting strategies?
Chronic disease self management programme
Theoretically grounded within Social Learning Theory, includes four efficacy enhancing strategies: Skills mastery, social modelling, social persuasion and reinterpretation of symptoms
Six, weekly sessions, each lasting approximately 2.5hours
Led by pairs of trained tutors, who may themselves live with a LTC,
or co-delivered by a trained lay-tutor and health professional
Delivery guided by tutor's manual to ensure consistency of delivery and content
Tutors trained and accredited to rigorous set of quality standards
focusing on adherence to the timing, sequence and coverage of activities as set out in the manual to ensure fidelity
What are advantages of self management programmes?
Reduce healthcare utilisation
Strong effectiveness evidence
Structured content and delivery by trained tutors
Improve patient outcomes in numerous domains
What is the WHO definition of mental retardation (learning disability)?
Condition of arrested or incomplete development of the mind, especially characterized by impairment of skills manifested during developmental period, which contribute to the overall level of intelligence i.e. cognitive, language, motor and social abilities
What problems do people with learning disabilities have?
Difficulties with understanding information, communicating and learning new skills (impaired intelligence)
Reduced ability to cope independently (impaired social functioning)
Present from childhood and having a lasting effect on development
Higher rates of certain physical problems
What psychometric assessment can be used to assess intellectual functioning?
Wechsler Adult Intelligence Scale(WAIS) IV
What factors could affect someone's functioning on a psychometric assessment of intelligence?
Motivation, mental illness, fatigue, drugs , alcohol
What levels of IQ are classified as learning difficulty?
Mild LD: 50-69
Moderate LD: 35-49
Severe LD: 20-34
Profound & Multiple Disability:
What is a normal IQ?
Normal IQ: 100 +/- 15
Borderline IQ: 70 - 84
What is the prevalence of mild learning disability in the population?
What is the most common inherited cause of learning disability?
Fragile X Syndrome
What is the most common genetic cause of learning disability?
What is the most common cause of learning disability worldwide?
Name some chromosomal abnormalities present at conception which cause learning disability
Trisomy 21 (Down’s syndrome)
Fragile X Syndrome
5p syndrome (Cri du Chat syndrome)
Sex chromosome disorders
Prader Willi syndrome
Which primary disorders can cause secondary neurological damage and lead to learning disability?
Defective protein metabolism – PKU
Endocrine disorders – congenital hypothyroidism
Neurocutaneous disorders – tuberous sclerosis
What antenatal factors can caused an acquired learning disability?
Neural tube defects
Autoimmune disorders e.g. Rhesus incompatibility
Infectious diseases e.g TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes), measles, HIV, syphilis
Drugs, alcohol & toxins
What perinatal factors can cause an acquired learning disability?
Trauma e.g. use of forceps
Premature/low birth weight babies particularly at risk
What postnatal factors can cause an acquired learning disability?
Accidental & non-accidental injury
Infections e.g. encephalitis, meningitis and infections causing dehydration and electrolyte imbalance
Metabolic disorders e.g. hypoglycemia
Environmental e.g. abuse, neglect
What is an IMCA?
Independent mental capacity advocate
Legal safeguard for people who lack capacity to make specific important decisions, particularly those who don't have family members or friends to represent them
What considerations should be made in a best interests decision?
Don't make any assumptions based on person's age, appearance, condition or behaviour
Consider all relevant circumstances relating to the decision
Consider if person is likely to regain capacity after treatment (can decision wait?)
Involve the person as fully as possible in the decision that is being made
Consider persons past and present wishes and feelings, beliefs and values which could influence their decision
Consult other people if appropriate, carers, relatives, friends, LPA
What is makaton?
Language programme, provide means of communication to individuals who can't communicate efficiently by speaking
What health inequalities do people with learning disability experience?
58 X Increased mortality under 50
3 X overall mortality
4 X rate of preventable deaths
What associated health issues do people with learning disabilities have?
Epilepsy: Increases with level of LD (Sudden unexpected death in epilepsy 5x higher)
Sensory Impairment: visual, hearing
Mental Illness: higher rates of most disorders (3% schizophrenia)
Dysphagia: 60% if cerebral palsy (deterioration in 30’s)
Other eating disorders: PICA, atypical anorexia, autistic food fads
GORD: H. Pylori
Constipation: Effect on behaviour and seizures
Dental Health Problems
Endocrine Dysfunction: e.g. Hypothyroidism
Infectious Diseases: e.g. Hep A and B
Respiratory: commonest cause of death
CHD: 50% of people with Down syndrome congenital problems
Over medication: 60% on psychotropics. Beware Side Effects
Specific Genetic Syndromes: e.g. Down syndrome
Behavioural Phenotypes: eg Prader Willi
Low screening rates (breast, cervical smears)
What types of mental health problems are more prevalent in people with learning disability?
Neuroses (Depression, Anxiety, OCD)
Drug and Alcohol misuse
Why do people with learning disability get inferior medical care?
Patient: Cognitive ability, Communication, Poor Health Literacy, Phobia / anxiety (Autism), Sensory Impairment, Late presentation
Carer: Health awareness (training issue for paid carers), Own cognitive abilities, Poor Health Literacy
Clinician: Educational needs (CPD issue), Diagnostic Overshadowing, Personal communication skills, Awareness of Legislation (MCA)
Service: Accessibility, Flexibility of appointments, Clinical Environment, User friendly information
What should be done to support people with learning disability in access to healthcare?
Who is involved in a community learning disability team?
Community nurses (GP/Hospital liaison)
What are features of a clinical audit?
Produce information to inform delivery of best care
Measures against a standard to see whether a service reaches this
Why do clinical audits?
Health and social care act
CQC: essential standards of quality and safety
Revalidation for medical staff
NHS standard contract
Response to a serious incident, risk issue or complaint
Describe the clinical audit cycle
Preparation and planning
Sustaining improvement including re audit
Who might be on a clinical audit team?
Project team members
Clinical audit department
What is the Hawthorne effect?
Alteration of behaviour by subjects of a study due to their awareness of being observed
What are the 4 common random sampling techniques?
Simple random sampling: each item has equal chance of being selected
Systematic sampling: fixed intervals between individuals on population list
Stratified sampling: dividing population into strata, sample taken from each strata
Cluster sampling: not possible to spread sample across population as a whole, divide population into clusters, number of clusters are selected
How can you ensure valid data collection?
Collect the right data
How can you ensure reliable data collection?
Collect data in the right way
What are different types of quantitative data?
Continuous: interval or ratio
Discrete: ordinal or nominal
When would you use a mean?
Reasonable number of observations
When would you use a mode?
Distribution with a double peak
When would you use a median?
What data can be plotted on a bar chart?
Discrete data - nominal or ordinal
What data can be plotted on a histogram?
Continuous data - interval or ratio
What data can be plotted on a line graph?
Continuous data - nominal or ordinal
What data can be plotted on a pie chart?
Discrete data - nominal or ordinal
What are the NHS values and what do they mean?
Working together for patients: patients come first, fully involve them, staff, families, carers, communities and professionals. Speak up when things go wrong
Compassion: central to care, respond with humanity and kindness to persons pain, distress, anxiety or need
Commitment to quality of care: striving for basics - safety, effectiveness and patient experience
Respect and dignity: value every person as individual, respect aspirations and commitments in life, understand priorities, needs, abilities and limits
Improving lives: improve health and wellbeing and people's experiences
Everyone counts: maximise resources for benefit of whole community, nobody excluded, discriminated against or left behind
Which bodies can commission health services?
Clinical commissioning groups
Which types of health services are commissioned nationally?
Armed forces health care
Immunisation, screening and young children
Which types of health services are commissioned locally?
Mental health services
Local public health services
What is NICE?
National institute for health and care excellence
Independent organisation for providing national guidance and advice on promoting high quality health, public health and social care
What is the aim of NICE? And how do they achieve this?
Improve outcomes for people using NHS and other public health and social care services
Produce evidence based guidance
Develop quality standards and performance metrics for commissioning
Provide range of information services for commissioners, practitioners and managers
What different types of guidelines are produced by NICE?
Clinical: systematically developed recommendations on how health care professionals should care for people with specific conditions
Public health: recommendations for populations and individuals on activities, policies and strategies that can prevent disease or improve health
Social care: recommendations on what works
Medicines practice: recommendations for good practice for those involved in governing, commissioning, prescribing and decision making
Technology appraisals: considers single medical device which provides equivalent or enhanced outcomes for equivalent or reduced cost
Interventional procedures guidance: safety, whether it works well enough for routine use, whether special arrangements are needed for patient consent
To what extent must NICE guidance be followed by commissioners and service providers?
Legally obliged to fund and resource medicines and treatments recommended by NICE
Reflected in NHS constitution
If NICE recommends treatment as an option, it must be available within 3 months of its publication
What percentage of technologies assessed through NICE technology appraisal are recommended?
What is NICEs citizens council and what does it do?
Panel of 30 members of the public that reflect demographic characteristics of UK
Provides NICE with public perspective on overarching moral and ethical issues which should be taken into account when producing guidance
Give 4 key societal values that the citizens council have said should be considered across health care, public health and social care
Quality of life
Right to health and welfare for all
Quality of service
What are the Wilson and jungner criteria for validity of screening programme?
Important health problem
Natural history well understood
Detectable early stage
Treatment at early stage beneficial
Suitable test for early stage
Intervals for repeats should be determined
Health service provision made for extra clinical workload
Risks should be less than the benefits
Costs should be balanced against benefits
What are objectives of a health needs assessment?
Change services for better: effectiveness
Target efficiency: resources to those in need
Gather intelligence on population health