Identify the importance of a population perspective in medicine?
- What do you understand by ‘taking a population perspective’? A population perspective complements the focus on the individual. Sometimes the interests of the individual and population conflict - In what ways may an understanding of health in populations influence the practice of a doctor? Understand what causes disease, know what works in terms of treatment and improve health
Outline the patterns of demography in both the developed and developing world.
- Can you give a definition of ‘health’? Health can be defined negatively, as the absence of illness, functionally, as the ability to cope with everyday activities, or positively, as fitness and well-being. In any organism, health is a form of homeostasis. This is a state of balance, with inputs and outputs of energy and matter in equilibrium (allowing for growth). Health also implies good prospects for continued survival. In sentient creatures such as humans, health is a broader concept. The World Health Organization defines health as “a state of complete physical, mental and social well-being, and does not consist only of the absence of disease or infirmity.” Though this is a useful and accurate definition, some would consider it idealistic and non-realistic. Using the WHO definition classifies 70-95% of people as unhealthy. - What are incidence and prevalence? - Prevalence - The total number of individuals, who have an attribute or disease at a particular time or during a particular period, divided by the total population at risk. What are major causes of death/illness among children and adults… - in the UK – Circulatory disease, cancer and respiratory disease in adults. Infection and poisoning and cancer in children. - in the developing world – Cholera, malnutrition, malaria, diarrhea, problems with pregnancy and neonatal death, infection, AIDS. - What factors led to changes in life expectancy in the developed world over the last century? Creation of safe water and sewage disposal systems, the control of disease-bearing insects and rodents, immunization programs, and improved nutrition. - What is a population pyramid, can you sketch one for the UK and for a ‘typical’ developing country? A population pyramid is two back-to-back bar graphs, one showing the number of males and one showing females in a particular population in five-year age groups. Males are conventionally shown on the left and females on the right, and they may be measured by raw number or as a percentage of the total population. A great deal of information about the population broken down by age and sex can be read from a population pyramid, and this can shed light on the extent of its development. There are two basic shapes of population pyramid.
What is a triangular population distribution?
- Triangular population distribution- The triangular distribution may also be called a pyramid or exponential distribution. The wide base indicates a
large number of children but the rapid narrowing shows that many people die between each age band. Therefore the pyramid indicates a population in which there is a high birth rate, a high death rate and a short life expectancy. This is the typical pattern for a less economically developed country where there is little access
to or incentive to use birth control, poor hygiene (often due to a lack of clean water) and little access to health services.
Note that there tend to be more females than males in each age group. This
is because females tend to have a longer life expectancy.
What is a rectangular population distribution?
he narrow base of the rectangular population
distribution indicates relatively few children and young people, and the lack of change in size between consecutive age groups that very few people die until they reach old age. This pyramid, then, is typical of a more economically developed country, which has low birth and death rates and a long life expectancy, and in which contraception is widely used and there is
good public hygiene and health care. - The base of the pyramid may even be narrower than the middle. This indicates a falling birth rate.
- Stillbirth Rate - This is the number of infants stillborn with a gestational age of at least 24 weeks per 1000 total births.
- Neonatal Mortality – Number of deaths within the first 28 days per 1000 births.
- Perinatal Mortality – Number of deaths after the first 28 days but within the first year of life per 1000 births.
- Infant Mortality – Number of deaths within 1 year of life per 1000 births. Includes neonatal mortality - How do fertility and infant, maternal and adult mortality differ between the developed and developing world? Fertility is higher in the developing world. Mortality would be higher in the developing world for adults, children and maternal indicators
How is EBDM implented?
- Evidence based clinical guidelines
- Summaries of evidence provided for practitioners
- Access to reviews of research evidence
- Practitioners evaulation of research
How do doctors use information to carry out their work?
- Evidence from research
- Clinical experience
- Available resources
- Patient preferences.
What is meant by the term evidence?
Evidence is an observation, fact or organised body of information offered to support or justify inferences or beliefs in a demonstration of some proposition or matter at issue.
What role can evidence play in decision making?
- Evidence from research
- Clinical experience
- Available resources
- Patient preferences
Why is EBDM important?
- Way of dealing with uncertaintly in medical practice.
Medical knowledge is incomplete
- Quantity of medical facts ever expanding and impossible to fully master
- Medical knowledge is constantly shifting – knowledge revised in the light of new evidence e.g.
peptic ulcer disease
- Constant need for innovation and improvement
- Seen as a way of improving clinical care by ensuring that patients receive the most
appropriate treatment, proven by research
- Improving efficiency of health care services
- Reducing variations in practice between healthcare professionals
- Central to current healthcare policy
- Development of guidelines for best practice based on research evidence
- Inherent work within clinical governance framework
- Government initiatives such as NICE (National Institute for Clinical Excellence) and CHI
(Commission for Healthcare Improvement)
What aspects of medical practice are affected by uncertainty?
- Diagnosis and treatment
- HRT
- Mamograms
- Cancer treatment
Outline the range of interacting resources involved in healthcare, and the ways in which they are managed.
Clinical commissioning groups (CCGs):
Clinical commissioning groups replaced primary care trusts (PCTs) on April 1 2013.
CCGs are clinically led statutory NHS bodies responsible for the planning and commissioning
of healthcare services for their local area.
CCGs members include GPs and other clinicians such as nurses and consultants.
They are responsible for about 60% of the NHS budget and commission most secondary care
services such as:
o planned hospital care
o rehabilitative care
o urgent and emergency care (including out-of-hours) o most community health services
o mental health and learning disability services
NHS England:
NHS England is an independent body, at arm’s length to the government.
It’s main role is to improve health outcomes for people in England.
It:
o provides national leadership for improving outcomes and driving up the quality of care o oversees the operation of clinical commissioning groups (CCGs)
o allocates resources to CCGs
o commissions primary care and specialist services
Foundation Hospital:
A hospital trust free of direct governance from the department of health.
Has considerable freedom of budget.
Responsible for providing a service to a “reasonable level of demand”.
Acute and community NHS trusts:
Have considerable levels of freedom.
Contribute to plans for improvement and modernisation.
Have the power to set their own wages and make financial decisions over staff, equipment,
buildings etc, must be consistent with local priorities.
Include acute examples such as hospitals and ambulance services and community examples
such as care trusts (deliver integrated health and social care). National Institute for Clinical Effectiveness:
Provides guidance to the NHS based on clinical evidence and cost effectiveness.
Produces two types of guidance: technology appraisals (look at clinical cost effectiveness of a
new or existing treatment – Usually takes around 1 year) and clinical guidelines covering
everything from self care to care by primary care, hospitals and specialist services.
Also includes recommendations for the use of new expensive drugs.
How is the NHS financed?
What user charges are there in the NHS, have they always been present? Prescription charges, dental care, ophthalmic care and treatment after RTAs
Where does most of the finance for the NHS come from? General taxation (85%), national insurance contributions (10%), user charges (5%)
What other systems of financing healthcare are there in Europe and North America?
USA – Medicare and Medicaid – Available to very poorest only
Italy – Mostly state provided but €50 charge for operations etc
France - Not free at the point of delivery. Rather, every patient must pay for his treatment and
is later refunded to a certain extent. Some treatment is totally refunded, other less so. Every medical treatment has a recommended price. Those who adhere to this are called “conventionné”, those who do not “non-conventionné”. The latter can charge what they like but the former can include “private” establishments. However, rather like notaries, even those who follow the fixed prices can on occasion charge extra, if, for example, there are complications, but such extra charges must be “tactful and reasonable”. It’s obviously best to establish what they are likely to be in advance, if you can.
Summarise the expected professional standards for doctors and medical students, and the regulatory role of the GMC.
- What are the main functions of the GMC? – Controls the UK medical register. Sets standards in undergraduate education, clinical practice and behaviour. Responsible for audits of UK medical schools and for the continuing professional development of practicing doctors. Continuing revalidation of doctors.
- Who is responsible to the GMC? – All medical students and doctors.
- What sanctions can the GMC apply? – Warning, conditions of license, suspension and removal from register
Peform and interpret simple summary statistics.
- Variable: A quantity that varies. An attribute, phenomenon, or event that can have different values.
- Numerical variable: variables given a numerical value.
- Continuous: A variable with a numerical value, which has a potentially infinite
number of possible values along a continuum, within a specified range.
- Discrete: A variable with a numerical value, which cannot take on any intermediate values e.g number of children, number of deaths.
- Categorical: a variable, which refers to categories. It is given a ‘value label’, which is usually a number.
- Dichotomous or binary: A variable where only two categories are possible
- Ordered categorical: A variable where values are ranked according to an ordered
classification.
- Mean: the average of a set of observations, derived by adding their values and then dividing by the total number of observations.
- Median: A measure of central tendency, which is useful if the data is skewed. It is the value that halves the distribution. It is the middle value when the values in a set are arranged in order. If there is an even number of values the median is defined as the mean of the two middle values.
- Inter-quartile range: The inter-quartile range describes the spread of data around the median. It is the distance between the lower quartile value and the upper quartile value of a distribution.
What is standard deviation?
A measure of how widely dispersed are the individual observations in a distribution. The standard deviation is the square root of the variance. (A measure of how widely dispersed are the individual observations in a distribution. The variance is the square of the standard deviation).
What is a skewed distribution and how might it influence your choice in a summary measure?
A skewed distribution is An asymmetrical frequency distribution. (The complete summary of the frequencies of the values or categories of a measurement made on a group of persons. The distribution tells either how many or what proportion of the group was found to have each value (or each range of values) out of all the possible values that the quantitative measure can have).
