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PHPM > Week 2 > Flashcards

Week 2 Flashcards

1
Q

Used as proxies for SES

A

Race
Education
Income

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2
Q

Percentage of wealth blacks have as much as whites

A

8%

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3
Q

Avg. Black income compared to whites

A

62%

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4
Q

Reasons why blacks have higher mortality rates than whites

A

Heart disease
Diabetes
Cancer
Homocide

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5
Q

People within different zip codes of a city can have as much as 20 yrs. in life expectancy differences

A

“Zip code is Destiny”

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6
Q

Divergent outcomes

A

We can see improvements for disease rates in whites but not in blacks. Probably has to do with access and quality of care.

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7
Q

Reason to be cuatious of rewarding hospitals based on quality ratings

A

States with the largest percentage of white residents have the highest Medicare quality rankings.

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8
Q

All cancer mortality relative risk

A

Black men in general have much higher rate of prostate cancer death than whites. Has to do with access to quality care and aggressiveness of disease

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9
Q

Unability to provide quality care

A

Primary care physicians visited chiefly by black patients were more likely to report they were unable to provide high-quality care to all their patients than those visited primarily by white patients.

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10
Q

Mortality after heart attack

A

Mortality after heart attacks is higher in hospitals with more admissions of black patients than in those with no admissions of blacks.

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11
Q

Myocardial infarctions

A

Blacks with myocardial infarctions experience longer door-to-balloon times than all other groups

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12
Q

Pneumococcal vaccination

A

Minorities are less likely to have ever received a pneumococcal vaccination than whites

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13
Q

Psychiatric hospitals

A

Black and Hispanic youths are more likely to be restrained upon admission to a psychiatric hospital than white youths.

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14
Q

Hospitalizations due to preventable conditions

A

Blacks are two to four times more likely than whites and Hispanics to be hospitalized for potentially preventable conditions.

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15
Q

Emergency Department

A

Blacks are more likely than whites or Hispanics to visit the emergency department for conditions that could have been treated by a primary care provider.

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16
Q

Two reasons for health inequities observed by race

A

1) SES differences (most important)

2) Other manifestations of racism

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17
Q

Mechanisms of segregation

A

1) Zoning
2) Public Housing
3) Restrictive Covenants
4) Contract Loans
5) Redlining
6) Blockbusting and Neighborhood Violence
7) Discriminatory Taxation and Rule Enforcement

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18
Q

Symbolic Racism

A

When people say I’m not racist, but why change the way things are?

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19
Q

White fragility

A

Desperate desire not to be called “racist.” Racism without Racists.

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20
Q

Black high school drop outs who will be incarcerated in their lifetimes

A

1 in 3

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21
Q

Mind-body medicine

A

You can address body and brain pathology by either preventing it or treating it through the patient’s mind

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22
Q

Stress response affects 2 mechanisms

A
  1. Intentional (behavior)

2) Reflexive Effect

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23
Q

Stressor

A

An environmental exposure, real or imagined, that can be appraised as threatening or benign depending on an organism’s perceived capacity to cope with it.

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24
Q

Stress response

A

The combined cognitive, emotional, behavioral, and physiologic changes associated with that exposure. These changes can be adaptive or maladaptive.

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25
Q

Distress

A

Is the unpleasant emotional impact of an adaptive or maladaptive stress response.

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26
Q

Relaxation response

A

The combined cognitive, emotional, behavioral and physiologic changes that mitigate or prevent the stress response.

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27
Q

Smoke detector effect of stress

A

We have been left we a system that produces false alarms, because it was advantageous to be hypervigilant.

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28
Q

Fill out stress diagram

A

[Diagram]

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29
Q

4 most important systems for chronic stress

A

1) Cardiovascular
2) Neurologic
3) Immunologic
4) Endocrine

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30
Q

Main components of Stress Physiology

A

1) Pre frontal cortex
2) Amygdala (limbic system)
3) Hippocampus (limbic system)

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31
Q

2 pathways of stress physiology

A

1) Lupus serulus (brain stem)

2) Pitituary-CRH-ADH hormones to produce epinephrine

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32
Q

Fight of Flight Response

A

Sympathy-Adrenomedulary System

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33
Q

Long-Term Stress Response

A

HPA Axis

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34
Q

May help organism adapt to stress, but can end up eventually harming the organism

A

Maladaptive stress responses

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35
Q

Homeostasis

A

Dynamic regulatory process in which physiologic microsystems throughout the organism are maintained in a balanced state; parameters are preset and do not accommodate wide variation

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36
Q

Allostasis

A

A dynamic regulatory process in which homeostasis is maintained by physiologic and behavioral adaptation to environmental challenges; parameters may vary widely according to the demands on the organism

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37
Q

Allostatic load

A

Consequences of allostatic regulatory wear and tear on brain and body leading to multisystem dysregulation and ill health; represents the cost of adaptation

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38
Q

Placebo Effect

A

iImprovement in a patient’s illness attributable to the symbolic
significance or meaning of an intervention

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39
Q

Nocebo Effect

A

Worsening of a patient’s illness attributable to the symbolic
significance or meaning of an intervention

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40
Q

Placebos in Controlled Trials

A

1) Specifically designed to eliminate non-
specific psychobiologic effects through blinding; the more inert the better
2) A placebo response is above and beyond
other non-specific changes that may affect all groups*
3) The rate of placebo responses in randomized groups cannot be predicted
4) No effort is made to mirror the clinical environment
5) Nocebo responses uncommon

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41
Q

Open-Hidden Design

A

One group of patients knows when they treatment is administered and the other does not.

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42
Q

Placebos in Clinical Practice

A

1) Since blinding is irrelevant, clinical
placebos may take any form
2) Placebo response may account for all, part or none of any observed outcome
3) Occurrence of a placebo response in an
individual patient is largely unpredictable
4) The probability and intensity of placebo responses can be manipulated
5) Nocebo responses variable

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43
Q

When a resource is scarce, we tunnel our attention to preserving the resource

A

Scarcity

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44
Q

It is not enough to give people enough. A little bit of extra [..]

A

Slack

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45
Q

US health data is organized by

A

Race

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46
Q

Types of racism

A
  • Interpersonal racism (discrimination)
  • Implicit bias
  • Institutional racism
  • Structural racism
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47
Q

Results in chronic diseases

A

Maladaptive Stress Responses

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48
Q

Behaviors with greatest effect on stress

A

1) Exercise

2) Social interaction

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49
Q

Training people to manage their emotions

A

Cognitive Behavioral Therapy

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50
Q

Affects degree to which organism reacts to stressor

A

Perception and appraisal

51
Q

Four Features of A Productive Clinical Encounter

A
  1. A patient in distress
  2. A clinician who is perceived as an expert in dealing with the
    patient’s distress
  3. An explanation of the patient’s condition and a treatment plan
    acceptable to both the patient and clinician
  4. Some sort of healing ritual conducted by the clinician that
    serves to instill positive expectations in the patient
52
Q

2 Pathways of clinical encounter to Health outcome

A
  1. Non-specific, psychobiologic changes resulting from the clinical encounter
  2. Specific physiologic changes directly resulting from a medical intervention
53
Q

Pure Placebos

A

Interventions lacking any known specific physiologic activity

54
Q

Impure Placebos

A

Interventions with a non-zero but extremely low probability of producing a specific physiologic effect, or that have known clinical value for some conditions but lack specific physiologic effects for the presumptive diagnosis

55
Q

Open Label Placebos

A

Pure or impure placebos given to patients with full disclosure

56
Q

When you take a topic area and think ethically about the problems that arise in that field and work out particular answers to them

A

Applied Ethics

57
Q

Ethical theories that guide actions, and guide the way you should be. More general advice

A

Normative Ethics

58
Q

John Stuart Mill (theory and primary focus)

A

Consequentialism: Primary focus is action. The Greatest Happiness Principle

59
Q

Immanuel Kant (theory and primary focus)

A

Deontology. Primary focus is action. Decision procedure and the Categorical Imperative.

60
Q

Aristotle

A

Primary focus is character. Decision procedure: What would a virtuous person do?

61
Q

Metaethics

A

Tris to investigate very nature of ethics.

62
Q

Greatest Happiness Principle

A

actions are right in proportion as they tend to promote happiness; wrong as they produce the reverse of happiness.

63
Q

Mill’s influence on bioethics

A

End of life decisions.

64
Q

Categorical Imperative

A

Act in such a way that you treat humanity, whether in your own person or in that of another, always at the same time as an end and never simply as a means.

65
Q

Autonomy

A

A person’s capacity to use reason to figure out the best thing to do. Basis for human dignity

66
Q

Kant’s Influence On Bioethics

A

1) Informed Consent
2) Positive and negative duties regarding autonomy
3) Deontological approaches to the ethics of killing

67
Q

Negative duty

A

Don’t interfere with patient’s freedom

68
Q

Positive duty

A

Provide active support to help your patient’s make good decisions

69
Q

Firm and stable disposition to feel and act in certain ways

A

Character (Aristotle)

70
Q

Aristotle’s Advice For Bioethics

A

Downplay strict rules for ethical decisions. Instead, develop skills to navigate the rich moral landscape. Learn from the wise among us. Be guided by the purpose of your profession

71
Q

Three elements of End of Life Decisions

A

1) Active vs. Passive
2) Prognosis
3) Patient Preferences

72
Q

Nancy Cruzan case

A

Supreme Court ruled that withdrawing and withholding LST is permissible. However, States have wide latitude in establishing procedural safeguards.

73
Q

Doctrine of Double Effect (DDE)

A

It is permissible, under certain conditions, to perform an action that has a bad effect, including the effect of shortening life.

74
Q

Conditions for the Doctrine of Double Effect

A

The action is not intrinsically wrong
▪ The action has both good and bad effects, but you intend only the good effect (though you may foresee the bad effect)
▪ The good effect of the action is more weighty than the bad effect
▪ There is no way to achieve the good effect except by an action that also produces the bad effect
▪ The good effect is not achieved via a causal chain that includes the bad effect

75
Q

Palliative sedation to unconsciousness may be considered when

A

(1) the patient is terminally ill and close to death,
(2) the patient is experiencing significant physical pain and discomfort that is refractory to other methods of pain control
(3) the patient and/or patient’s decision making representative have been informed and consent to the option

76
Q

Good prognosis

A

Return to an acceptable baseline of health. Or return to good quality of Function life.

77
Q

Substituted Judgment

A

Determine what the patient would have wanted were they able to understand relevant information and make a choice.

78
Q

Best interest standard

A

What would the average person want in this situation? (It’s a last resort).

79
Q

Elements of Informed Consent

A
  1. Decision making capacity
  2. Voluntariness of the action
  3. Disclosure of information, including diagnosis, prognosis, treatment
    options and the risks, benefits and burdens of each option
  4. Practitioner recommendation (if appropriate)
  5. Assessment of understanding (using the teach back method)
  6. Reflection and choice
  7. Legal authorization (oral or written, documented as appropriate)
80
Q

Shared Decision Making

A

An approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences

81
Q

Capacity

A

Medical determination

82
Q

Competence

A

Judicial determination

83
Q

Conditions for decisional capacity:

A

1) the ability to communicate choices;
2) the ability to understand relevant information;
3) the ability to rationally manipulate information; and
4) the ability to appreciate the situation and its consequences.

84
Q

Order of persons who make decision for patients who lack capacity

A

In order of priority:

  1. Power of attorney (unless revoked)
  2. Court appointed guardian
  3. Family member acting as surrogate.
  4. Others who know the patient
85
Q

Accuracy of Surrogates

A

68%

86
Q

Societal costs

A

Per capita health care expenditures

87
Q

Societal affordability

A

Health care expenditures as % of GDP.

88
Q

Consumer costs

A

Premiums and out-of-pocket health care expenditures

89
Q

Consumer affordability

A

Health care expenditures as a % of total income.

90
Q

Decade US started to diverge in healthcare spending from other countries

A

1980s

91
Q

Significant Contributors to Health Care Cost Growth in the U.S (8)

A
  1. We pay providers for doing more.
  2. We are growing older, sicker and more obese.
  3. We want new drugs, technologies, services and
    procedures.
  4. Litigious society- difficult to measure impact.
  5. Increasing levels of health insurance coverage.
  6. No transparency in price and quality information.
  7. Consolidation of providers and insurers.
    8.High administrative costs- due to complex, multi-payer
    system.
92
Q

US Spends more than other countries in these services:

A

Outpatient care, Governance and administration (among others)

93
Q

Specialties that who practice defensive medicine, and it impacts its costs (increases and decreases)

A

Increases:

1) Primary Care
2) Emergency Medicine
3) Cardiology

Decreases:
OB-GYN
Orthopedic Surgery

94
Q

Healthcare costs formula

A

price x volume

95
Q

How are prices determined (public vs private sector)

A

Public: complicated formula

Private: Separate negotiations between insurers and providers

96
Q

Drivers of price variation in Commercial Market

A

Quality of provider (clinical Quality/perceived quality)

Hospital characteristics

Medicare/aid/Uninsured share

Provider and Insurer market

97
Q

Four target areas of cost reduction

A
  1. Pharmaceuticals
  2. High Volume, High-Margin Procedures
  3. Imaging
  4. Administrative Waste
98
Q

Which costs are we trying to contain?

A
  1. Overall health care spending in the United State
  2. Public sector spending
  3. Out-of-pocket spending for consumers/patients
  4. Health care spending within a state (often Medicaid
99
Q

Supply-Side Approaches to Cost Containment

A

Change the way resources/providers are deployed in the health care system

100
Q

Demand-Side Approaches to Cost Containment

A

Change the way patients seek health care services

101
Q

A functioning market would require: (4)

A
  1. Large number of buyers
  2. Full information about quality of services
  3. Full information about prices of services
  4. Enough providers/suppliers to avoid monopoly power
102
Q

Economic Stabilization Program (ESP)

A

Nixon Program (1970s). Froze wages and prices

103
Q

Managed Care

A

1990s. Capitation, HMO.

104
Q

Delivery System and Payment Reform

A

(2010s). Shifting away from fee-for-service, toward value-based payments.

  • Creating new provider organizations to align with new payment models.
  • Emphasis on coordination, integration, team-based care

• Drive consumers to high-value health care through value-based
insurance design and cost-sharing arrangements

105
Q

Single Payer Financing through Taxation

A

Shift the U.S. system to one that is financed through taxation,
rather than a combination of employer, employee, government, and consumer payments

106
Q

Global Budget

A

Budget often set at the level of federal or state government, within which total health care spending must be contained

107
Q

Prescription Drug Volume Purchasing

A

Entities (e.g., states) can create multistate purchasing agreements

108
Q

All-Payer Rate Setting

A

Payment for a specific service is the same for ALL patients receiving that treatment, procedure, or service from the same provider. Rates may be set by provider or by regulatory authority at state or federal level

109
Q

Global Payments

A

A fixed prospective payment made to a provider entity (e.g., group of
providers, health care system, Accountable Care Organization) to cover cost of ALL care provided to a population of patients.

110
Q

Episode-Based Payment

A

A single prospective payment for all the care related to a specific illness, condition, or medical episode for a defined period of time

111
Q

Accountable Care Organization

A

A provider-led organization that is accountable to a payer

for the total costs and quality of a defined population for a defined period of time

112
Q

Patient-Centered Medical Home

A

Primary care model that emphasizes team-based care,

care coordination, population health management, chronic condition management, and coordinated referrals

113
Q

High-Cost, High-Need Patients

A

An array of care delivery approaches that target high-

cost, high-need patients to manage illnesses, and prevent more expensive utilization of services

114
Q

Principles for Addressing Patients Who are High Cost and High Need

A
  1. Identify patient subgroups with similar need
  2. Shift care delivery to home and community, out of institutions
  3. Address social, behavioral, and medical needs (need more capacity to do this)
  4. Help make coordination happen – patients, caregivers, and professionals
  5. Set goals collaboratively, with patients, caregivers, and providers and align care delivery with these goals
  6. Allocate resources based on the potential for improving quality of life of patients and caregivers
115
Q

Administrative Simplification

A

An array of strategies to streamline administrative functions in the health care system

116
Q

Service Coverage Changes

A

Removing specific benefits from coverage as a means to reduce cost

117
Q

Cost Effectiveness Determinations

A

Use cost effectiveness analysis to determine what is covered and what is not covered and/or what is available

118
Q

Price Transparency

A

Require publication of prices for health care services, procedures, or drugs

119
Q

Generics vs. Brand Name

A

Requiring purchase of generic prescription drugs rather than brand name

120
Q

Government Rate Setting

A

Government sets rates for procedures, services, drugs

121
Q

Require Shared-Decision Making for Preference -Sensitive Services

A

Require that providers document that patients were
engaged in shared-decision making prior to electing a specific procedure that is determined to be preference sensitive. (:Preference sensitive:: where legitimate treatment options exist that may have quality of life or length of life trade-offs)

122
Q

Reference Pricing

A

Amount of co-insurance for a patient depends both on the price of the drug/service as well as the price for an alternative approach/less costly service location

123
Q

Value-Based Insurance Design

A

Design of health insurance plan has tiers that reflect cost and quality of provider networks

PHPM (4 decks)

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