MEDS581 Midterm
What is the cost of providing care for one pressure ulcer?
$3,500 - $60,000
Cost of the five most common HAIs annually
$9.8 billion
Inhalation anthrax
(1) Exposed person may develop dry cough, mild chest pain, fever, fatigue; meningitis (2) Not transmitted from person to person (3) Tx = COMBO of ATB's (4) Fatality rate = 95-100%
I-PASS conclusions
- 23% reduction in the rate of all medical errors - 30% reduction in preventable adverse events - 6/9 sites had overall reduction in medical errors - quality of written and oral handoffs improved - reduction occurred without an increase in the time required to complete handoffs or a decrease in contact time with patients
Surgical Site infection facts
- 500,000 patients per year - 15-20% of nosocomial infections - caused usually by staph and strep
What was the inclusion criteria for the MODIFY trials?
- > age of 18 - Met C. diff definition - receiving standard of care abx
Medicaid
- A federal and state assistance program that pays for health care services for people who cannot afford them. - Medicaid is not a single national program but a collection of 50 state administered programs providing health insurance to low-income state residents with differing eligibility rules, benefits and payment schedules
What were the four groups in the MODIFY trials?
- Bezlotoxumab - Actoxumab - Bezlotoxumab + actoxumab - Normal saline placebo
National Health Insurance (NHI) programs
- Canada, France - Government-owned or quasi government - Financed by general revenue financing through the fiscal tax system and ability to pay criteria which leads to wealthier, younger, and healthier individuals paying disproportionately to finance the care of poorer, older, and sicker individuals - Not employment-based
Insurers as regulators
- Contract with physicians/hospitals to encourage quality, cost control, and market share - Set standards - Audit providers and institutions
Define Competency Domain 3: Interprofessional Communication
- Developing basic communication skills is a common area for health professions education, but health professions students often have little knowledge about or experience with interprofessional communication - Communicating a readiness to work together assists in collaboration: being available in place, time, and knowledge, as well as being receptive through displaying interest, engaging in active listening, conveying openness, and being willing to discuss indicate readiness - Teamwork and team-based competency for better patient-centered care requires mastery of numerous new communication technologies
Federal Public Health Responsibilities
- Ensure all levels of government have the capabilities to provide essential public health services - Act when health threats may span more than one state, a region, or the entire nation - Act where the solutions may be beyond the jurisdiction of individual states - Act to assist the states when they lack the expertise or resources to effectively respond in a public health emergency (e.g., a disaster, bioterrorism, or an emerging disease) - Facilitate the formulation of public health goals (in collaboration with state and local governments and other relevant stakeholders)
Flaws in the current payment models
- FFS incentivizes providers to promote unnecessary services - capitation has the disincentive to provide necessary treatment leading to poorer outcomes
Examples of public health surveillance programs
- GeoSentinel - Global Influenza Surveillance Network - Global Laboratory Network for Poliomyelitis Eradication - Global Outbreak Alert and Response Network
Public Health Challenges in insular areas
- Geography - Culture - Economy - Education - Morbidity and mortality
Multi-payer healthcare system or All-payer system
- Germany, Japan, France - Universal health insurance via "sickness funds" that is used to pay physicians and hospitals at a uniform rate, thus eliminating administrative costs - Financed through employee and employer contributions - In Germany, government general revenues cover premiums for children on the premise that the next generation is the fiscal responsibility of the entire country and not just the parents
CDC Classification of Bioagents
- Group agents together based on threat to the US - "potential to pose a severe threat to public health and safety" - A, B, and C
Significance of Alma Ata Declaration with regards to primary care
- Hope was to achieve health for all by 2000. - Core principles of universal access to care, equity, community participation, intersectoral collaboration, and appropriate use of resources - Countries with PHC inspired by Alma-Ata had strong evidence of better population health outcomes and reduced inequalities at lower cost (Chile, Cuba, Ethiopia, Nepal, Rwanda, Sri Lanka)
Seven elements of the I-PASS handoff bundle
- I-PASS mnemonic - 2-hour workshop to teach communication skills - 1-hour role-playing session for practicing skills from the workshop - A computer module to allow for independent learning - A faculty development program - Direct-observation tools used by faculty to provide feedback to residents - A process-change and culture-change campaign, which included a logo, posters, and other materials to ensure program adoption and sustainability
Transforming health care
- Improving value requires improving outcomes without a corresponding increase in cost - Reducing costs without corresponding compromise in outcomes - Restructuring of health care delivery and creation of new benchmarks of outcomes relevant to patients.
managed care plans
- In return for paying lower premiums, you have a limited choice of doctors/hospitals/drugs that are covered by the insurance company - Members of MCPs have to abide by rules designed to lower costs of medical care
CDC Category C characteristics
- Includes emerging pathogens - Easily available - Are easily spread and produced but not readily transmitted person-to-person - Significant potential for morbidity/mortality and public health impact
Strategies to incentivize primary care
- Increase salaries - Loan forgiveness - Favor admission to students more likely to go into medical care - reform residency programs to encourage more outpatient training and improve care delivered by residents
What are some challenges to applying the IP competency domains in real life?
- Institutional (lack of support from administrative leaders) - Lack of collaborators (some schools do not have the variety of fields needed - Practical issues (scheduling) - Faculty Development/Assessment -Lack of Regulatory Expectations
Effects of I-PASS study
- Integrated into EMR of UCSF - Altered mnemonic at Hopkins - Part of grading at USC
Hospital Acquired Infections
- Major concern in hospitals - High cost - Leads to a lot of mortality
Teamwork with CAUTIs
- Physicians only order the placement of catheters when medically indicated and document the necessity of the catheter each day - RNs learn and implement appropriate sterile technique - They collaborate on when it is appropriate to remove catheter
Population health issues in the United States
- Poor population-level health outcomes relative to other advanced countries - Rising health care costs - Increasing prevalence of chronic disease - Persisting health care disparities and access issues -Aging population
General characteristics of anthrax diagnostics
- Present in high concentrations in clinical specimens so can usually be seen on microscope - Microscope findings will shop gram positive non-motile rodes - Agar will show non hemolytic adherent colnies - Specific confirmatory tests such as DFA or PCR
What was the primary endpoint in the MODIFY trials?
- Proportion of participants with recurrent C. diff infection during 12 weeks of follow up
Governmental Public Health
- Retain the primary responsibility for health under the US constitution - State and Local Health Departments - Tribal Health Departments
Components of a Well-Functioning Public Heath System
- Strong partnerships where partners recognize they are part of the public health system - Effective channels of communication - System-wide health objectives - Resource sharing mechanisms - Leadership by governmental public health agency - Feedback loops among state, local, tribal, territorial, and federal partners
Define Competency Domain 2: Roles/Responsibilities
- To be an interprofessional requires an understanding of how professional roles and responsibilities complement each other in patient-centered and community-oriented care. - Being able to clearly describe one's own professional role and responsibilities to team members of other professions and understand others' roles and responsibilities in relation to one's own role as a core competency domain for collaborative practice - Each profession's roles and responsibilities vary within legal boundaries; actual roles and responsibilities change depending on the specific care situation
Canada's health care system
- Universal health insurance programs administered through territories and provinces - block grants provided by federal government - physicians are contracted, not salaried - Federal government cost controls
Quadruple Aim in healthcare
- access - quality - cost of care - physician satisfaction
SSI prevention
- antimicrobial prophylaxis - hand hygiene - surgical attire - preoperative skin cleansing with chlorhexidine-alcohol - preoperative hair removal (associated with increased risk of SSI)
CAUTI facts
- bacteriuria in patients with indwelling bladder catheters occurs at a rate of approximately 3 to 10% per day of catheterization - most common HAI - Biggest risk factor: duration of catheterization - Diagnosis made by finding bacteriuria who has signs/symptoms consistent with UTI or systemic infection - risk of spreading abx resistant bacteria
Pathogenesis of CAUTIs
- catheter disrupts innate immunity - catheter can act as a highway for bacteria - bacteria can move extraluminally or intraluminally - bacteria can be endogenous (meatal, rectal, or vaginal colonization) or exogenous (contaminated hands of personnel or equipment)
Most costly HAIs
- central line associated bloodstream infections - ventilated associated pneumonia - surgical site infections - C. diff - Catheter-associated UTIs
Bioweapons programs characteristics
- cheaper than other weapons programs - longer lasting effects - exceptionally good at disrupting society - difficult to detect
What was the exclusion criteria for the MODIFY trials?
- chronic diarrheal illness - Surgery for CDI planned within 24 hours - Treatment with IVIG in previous 6 months
What does the US Public Health Service Commissioned Corps do and who are they?
- clinical and public health professionals - provide primary care in underserved areas - staff domestic and international public health emergencies - work in research, admin and public health capacities in federal agencies
Social determinants of health in the U.S.
- college grads live longer than those who didn't finish high school - 10-14 year life expectancy difference between richest and poorest Americans - Clear gradient in health by educational level - non-Hispanic whites were more likely to be in very good or excellent health than other groups nationally and in almost every state.
Indian Health Service (IHS)
- created through treaties between government and tribes - special considerations: safe water and sewage; injury mortality rate 2-4x higher than other Americans
Primary Care Value
- decreased referrals to specialists who cost more - lower total utilization of health resources - better health outcomes in the long term
VAP facts
- develops 48-72 hours after endotracheal intubation - usually caused by aspiration of endogenous of HI oropharyngeal flora - highest mortality - long hospital stays and significant costs
Examples of weaponization
- drying agents into aerosolizable materials - increasing the lethality of the organisms - Making organisms resistant to vaccine or antibiotics - Genetic manipulation of organisms
VAP preventative strategies
- elevate head of bed to 30-45 degrees - decontaminate oropharynx regularly with chlorhexidine - give "sedation vacation" and assess readiness to extubate daily - consider use of peptic ulcer disease prophylaxis (PPIs)
Public Health assurance services
- enforce laws - link to/provide care - assure competent workforce - evaluate
Management as part of infection control committee
- established a multidisciplinary ICC - identifies appropriate resources for a program to monitor infections and apply the most appropriate methods for preventing infection - ensuring education and training of all staff through support of program on the prevention of infection in disinfection and sterilization techniques - delegating technical aspects of hospital hygiene to appropriate staff
Triple Aim concept of managing health
- focus on individuals and families - redesign of primary care and structures - population health management - cost control platform - system integration and execution
2 main concerns of high healthcare expenditures
- great strain on taxes paid by workers and employees - larger share of tax dollars for health care is crowding out expenditures on other important needs; such as education and infrastructure
Attributes of primary care
- health promotion - disease preventioin - health maintenance - counseling, patient education, diagnosis and treatment in various healthcare settings - physician often collaborating with other professionals, utilizing consultation or referral as appropriate - provides patient advocacy in the health care system to accomplish cost-effective care by coordination of healthcare services
What is unique about healthcare for veterans?
- healthcare infrastructure - inter-generational healthcare needs
Characteristics of Category A bioagents
- high lethality - easily disseminated - possible person-to-person spread - significant potential for mass panic/chaos - require special action for public preparedness - require coordination between healthcare workers and government officials - suited for airborne transmission
What is continuity of care associated with?
- higher patient satisfaction, fewer hospitalizations, reduced costs, lower overall mortality - Important to providers and patients - Requires an adequate number of providers and an organized system of delivery
Public health policy development services
- inform, educate, empower - mobilize community partnerships - develop policies
Unique considerations for correctional facilities
- injuries, infectious diseases and substance abuse - mental illness - aging in prisons
Barriers to effective communication
- intimidating hierarchy - a profession's culture - incomplete or incorrect handoffs - time constraints - interpersonal conflict - team members are unclear or unaware of roles
Weaknesses of US healthcare system
- limited access for underserved populations - high cost - fragmentation of care - insufficient primary care workforce - highly bureaucratic costs - misaligned incentives
Supply/demand mismatch with primary care
- lots of demand because of aging population, increased population, ACA insurance expansion - supply needs focus only on physicians - rural areas especially hard hit - shortage is growing
CDC Category B characteristics
- moderately easy to be disseminated - moderate morbidity, low mortality - require specific enhancement of diagnostic capability - require enhanced surveillance methods - could be engineered for mass dissemination - Significant potential for morbidity/mortality but less mortality than A
Public health assessment services
- monitor health - diagnose and investigate
Information needed to provide informed consent
- nature and purpose of the research - what will go on in the study - which parts of the study are experimental - how long the study is expected to take - possible risks or discomforts - possible benefits - options that may exist besides being in the study - where one can get helped if harmed from being in the study - contact information for questions - one's choice to take part in the study - one's ability to leave the study at any time for any reason
Endocarditis treatment
- often requires prolonged abx therapy - surgery often necessary to remove vegetation - teams involved include infectious disease and cardiothroracic surgery in addition to hospitalist team
Basis for informed consent
- participants must be given the opportunity to choose what happens to them, process should be explained at a 4th grade level
Poor communication results in
- patient safety incidents - poor quality care - patient complaints - poor employee morale - employee turnover
Challenges to primary care
- patients go to ER if they can't obtain a timely appointment - shortage of providers - growing demand for PCPs - reimbursement system that doesn't value primary care - absence of a gov. entity that is responsible for defining and overseeing implementation of a coordinated national primary care strategy
Role of Public Health
- prevent epidemics and the spread of disease - protects against environmental hazards - prevents injuries - promotes and encourages healthy behaviors - responds to disasters and assists communities in recovery - assures the quality and accessibility of health services
Consequences of an intimidating hierarchy
- prevents people from speaking up - often found in institutional hierarchy - physician vs. nurse for example - concern about offending those in power
Atsana declaration
- prioritizes disease prevention and HP and aims to meet all people's health needs across the life course through comprehensive preventative, promotive, curative, rehabilitative services, and palliative care
Reasons for mismatch of supply and demand with regard to primary care
- providers moving out of primary care - medical graduates are choosing not to pursue primary care
Bundled Payments
- providers receive a lump sum payment for each episode of care they provide to the patients
What was found in the Institute of Medicine Report from 1999?
- roughly 98,000 patients die each year due to medical error - recommended various strategies to combat this - did not place blame at the individual level but rather at the system level
Issues using NPs and PAs to provide primary care
- scope of practice laws - similar preferences for specialty fields
Responsibilities of management at healthcare organizations
- setting and monitoring organizational strategy, responsible for monitoring performance
Current attempts to expand access to healthcare in the United States
- subsidized private insurance - medicaid eligibility expansion - funding of community health centers
Examples of vulnerable research subjects
- testing new treatments - racial/ethnic minorities - the very sick - college students - prisoners - children - institutionalized persons - pregnant women, fetuses, and neonates - persons with diminished decision-making capacity - economically or educationally disadvantaged persons
Examples of Research
- testing new treatments - review and analysis of existing data - testing new educational materials - interviews - focus groups - surveys - observations
What factors are used to measure effective transfer of information?
- the receptiveness of the receiver to hear the info - clear, concise, and accurate delivery of information - the understanding that the message given is received as intended
Pure communication in healthcare
- the ultimate goal - has several components: timely, the message and response are given with sensitivity and without negative emotion, contest is expressed clearly and accurately, it is given with pure purpose, messages are received in the same spirit
Public health considerations for veterans
- war-related injuries - chemical exposure - homelessness - PTSD - prisoners of war
How federal public health can address the unique challenges of insular areas
- work with Insular Area public health leadership to better tailor our assistance to meet their needs - work within and between agencies to better coordinate public health support - place more federal personnel in the region - Explore and pilot more initiatives that are better suited to small, limited resource jurisdictions
Values of healthcare org managers
-"systems" aspect of their work - loyal to organization and invested in its success - comfortable working in a chain of command - value interpersonal skill and organizational political skill -evidence based management
Define Competency Domain 4: Teams and Teamwork
-Interprofessionalism means being a good team player - Teamwork behaviors involve cooperating in patient-centered delivery of care; coordinating one's care with other health professionals so that gaps, redundancies, and errors are avoided; and collaborating with others through shared problem-solving and shared decision making, especially in circumstances of uncertainty - Shared accountability, shared problem solving, and shared decision are characteristics of collaborative teamwork and working effectively in teams
Prevention of CLABSI
-Strict handwashing -Use procedural checklist - Insertion kit -Maximal sterile barrier -Follow antiseptic instruction precisely -Cover connectors - Empower nurses to halt insertion if asepsis is breached - Remove catheter if not needed
purpose of surveillance
-assess public health status -define public health priorities -plan public health programs -evaluate interventions and programs - early warning system to alert of a disease
2001 Anthrax attacks
-envelopes sent out that were said to contain anthrax -there were 2 waves of attacks - 22 victims, 5 deaths - 35 postal facilities and commercial mailrooms were contaminated
research approval process
-must adhere to federal regulation -experiment MUST be approved by local Institutional Review Boards (IRBs)
IHI Triple Aim
-population health -experience of care -per capita cost
How long is phase 3 of a clinical trial?
1 to 4 years
Incubation period for cutaneous anthrax
1-12 days
Lessons from NHI for U.S. health care
1. Achieving the goal of universal health coverage requires political will and legislation to make the coverage compulsory 2. Financing broader insurance coverage requires increasing subsidies based on ability-to-pay criteria 3. Health care systems with universal coverage rely on economic evaluation of health technology as a criterion for making coverage decisions 4. Containing health care costs has been achieved with greater reliance than in the U.S. through price regulation and systemwide budget targets
What 6 organizations make up the Interprofessional Education Collaborative Expert Panel?
1. American Association of Colleges of Nursing 2. Association of American Medical Colleges 3. American Association of Colleges of Osteopathic Medicine 4. American Association of Colleges of Pharmacy 5. American Dental Education Association 6. Association of Schools of Public Health
Name the 6 risk factors for C. difficile
1. Antibiotic use 2. Age 3. Gastric Acid Suppression (proton pump inhibitor use) 4. Gastrointestinal surgery/manipulation 5. Long length of stay in healthcare settings 6. A serious underlying illness
What are the three things that C. diff does to the body?
1. Colonocyte death 2. Loss of intestinal barrier function 3. Neutrophilic colitis
Clinical manifestations of anthrax
1. Cutaneous - most common, least life threatning. 2. GI - rare in humans (common in animals), high mortality. 3. Pulmonary - rare under natural circumstances but seen in occupational settings and 4. injection
What are the five steps of drug research?
1. Discovery and Development 2. Preclinical Research 3. Clinical Research 4. FDA Review 5. FDA Post-Market Safety Monitoring
Bacillus anthracis
1. Gram positive, spore forming rod with characteristic boxcar shape. 2. Causes disease in animals and humans 3. Especially infectious due to endospore formation and virulent due to intrinsic toxins
What are the 3 reasons why the acceptance of team-based healthcare has been slow?
1. In training, clinicians are given the idea that they are individually responsible for what happens 2. Each member of the healthcare system is educated in isolation 3. Interprofessional training is uncommon
What 5 conditions can C. diff cause?
1. Pseudomembranous colitis (PMC) 2. Toxic megacolon 3. Perforations of the colon 4. Sepsis 5. Death (rarely)
What are the five steps to treat C. diff?
1. Stop inciting antibiotic 2. Place in isolation precautions 3. Oral vancomycin or fidaxomicin 4. IV vancomycin 5. Recurrent refractory C. difficile is treated with fecal transplant
IPEC Panel Goals
1. Teamwork is essential to providing the best patient care possible 2. In order to do so, certain competencies must be developed by each individual 3. Each professional school teaches competencies needed for their specific discipline 4. Goal is to create interprofessional collaborative competencies that are taught to burgeoning professionals
Ten Great Public Health Achievements of the 20th century
1. Vaccination. 2. Motor-vehicle safety. 3. Safer workplaces. 4. Control of infectious diseases. 5. Decline in deaths from coronary heart disease and stroke. 6. Safer and healthier foods. 7. Healthier mothers and babies. 8. Family planning. 9. Fluoridation of drinking water. 10. Recognition of tobacco use as a health hazard.
Public Health Achievements 2001-2010
1. Vaccine - Preventable Diseases 2. Prevention and Control of Infectious diseases 3. Tobacco Control 4. Maternal and infant health 5. motor vehicle safety 6. CVD prevention 7. Occupational safety 8. Cancer prevention 9. Childhood lead poisoning prevention 10. Public Health preparedness and response
What are the four domains of interprofessional collaborative practice?
1. Values/ethics 2.Roles/responsibilities 3. Communication 4. Teamwork
What are four things that can prevent the spread of C. diff?
1. Wash hands 2. Patient given own bathroom 3. Clean C. diff rooms with sporicidal agents 4. Use disposable equipment in C. diff patients' rooms
What are the 6 signs that C. diff presents with?
1. Watery diarrhea 2. Lower abdominal pain and cramping 3. Low-grade fever 4. Nausea 5. Anorexia 6. Leukocytosis (high WBC)
Triple Aim of Healthcare
1. access 2. quality 3. cost of care
What are two examples of skills that a nurse caring for a cancer patient will have?
1. placing IVs 2. Listening to patient
Bacillus anthracis virulence factors
1. plasmid-encoded toxins: - 3 Toxin combined: protective antigen, edema factor, and lethal factor. - Results in massive edema - (Combined these can activate signal machinery inside the cell (such as activation of adenylate cyclase) which results in massive edema (accumulation of fluid) and eventually cell death.) 2. Unique capsule : - Made of poly-D-glutamic acid, rather than polysaccharide.(acid-protein capsule is unusual) - Difficult to phagocytosis as the human body also produces and possesses D-glutamic acid - As such it is difficult to produce AB for this bacterial capsule
Fiscal responsibilities of local boards of health
1. recommend health dept. budget approval 2. approve health dept. budget 3. identify sources of funding 4. receive fees 5. approve grant applications
How do you equip a workforce with new skills and "new ways of relating to patients and each other"?
1. retraining of the current health professions workforce 2. interprofessional learning approaches for preparing future health care practitioners
Responsibilities of a local board of health
1. review public health regulations 2. recommend public health policies 3. recommend community public health priorities 4. recommend health department priorities 5. propose public health regulations 6. collaborate with health department for strategic plan 7. collaborate with health department to establish priorities 8. ensure that a community health assessment is completed 9. revise public health regulations 10. establish community public health priorities
What were the main takeaways from the IOM report of 1972?
1. there were serious questions about how to use the existing health workforce optimally and cost-effectively to meet health care needs 2. educational institutions had a responsibility to produce a healthcare workforce that was responsive to health care needs and practice to their full scope of expertise 3. The existing educational system as not preparing health professionals for teamwork
How many patients are affected by HAIs each year in the US?
1.7 million
How much of the GDP is spent on healthcare?
18%
When was C. diff discovered?
1978
Traditional clinical services account for ___ of a population's health
20%
How many people take part in stage 1 of a clinical trial?
20-100 healthy volunteers or people with disease/condition
Medicare Part B premiums went up from ______ to ______.
2020; 2021
How many took part in MODIFY?
2265 adults receiving standard of care oral abx
Life expectancy increase 1900-1996
25 years
How many people take part in stage 3 of a clinical trial?
300 to 3000 volunteers with the disease/condition
How many competencies of interprofessional care are there?
38
How many stages does a clinical trial have?
4
How many cases of C. diff occurred in 2011?
453,000 (83,00 were first recurrences and 29,300 deaths)
What percentage of U.S. health insurance is employment-related?
61%
What percentage of the U.S. population under 65 has health insurance through a private or government program?
80%
What percentage of the US population is covered by Medicaid?
>20%
Alternative Payment Model (APM)
A Model through which physicians and other healthcare providers accept a measure of financial risk and are reimbursed based upon prudent resource use and quality of patients outcomes rather than on ha piecemeal fee-for-service basis. Examples of APMs include bundled payments for care and accountable care organizations.
Institutional Review Board (IRB)
A committee at each institution where research is conducted to review every experiment for ethics and methodology.
Spores contain what?
A complete copy of the bacterial chromosome
Medicare
A federal program of health insurance for persons 65 years of age and older and certain disabled groups
What was issued by the Interprofessional Education Collaborative Expert Panel (IPEC)?
A joint statement regarding the core competencies for interprofessional collaborative practice
human subject
A living individual about whom an investigator obtains (1) data through intervention or interaction with the individual, or (2) identifiable private information.
HMO (Health Maintenance Organization)
A managed care organization that provides comprehensive medical services for a predetermined annual fee per enrollee. - usually no deductibles - patient chooses a PCP that coordinates care including referral to specialists
infection control committee
A medical committee that is responsible for reviewing policies and procedures for minimizing infections in the hospital.
Patient-Centered Medical Home (PCMH)
A model of primary care that provides comprehensive and timely care to patients, while emphasizing teamwork and patient involvement.
Out-of-pocket maximum
A predetermined amount after which the insurance company will pay 100% of the cost of medical services.
What was key in the detection of an anthrax outbreak?
A single patient due to a functional routine surveillance system
Independent Practice Association (IPA)
A type of HMO in which contracted services are provided by providers who maintain their own offices.
Population health model definition
A web of causation in which multiple different influences interact to produce good or poor health, commonly discussed in the context of "determinants of health"
Developing effective teams and redesigned systems is critical to __________________________________________.
Achieving care that is patient-centered, safer, timelier, and more effective, efficient, and equitable (IOM, 2001).
Terrorism
Acts of violence designed to promote a specific ideology or agenda by creating panic among an enemy population
Who should take Zinplava?
Adults with a recurrence of C. diff within 6 months who are also taking SOC abx
Deductible
Amount you must pay before you begin receiving any benefits from your insurance company
Certificate of Need (CON)
An act to ensure that the state approved any capital expenditures associated with hospital and medical facility construction and expansion. - purpose is to contain cost, prevent unnecessary duplication, ensure high quality health services - extensive review process
Affordable Care Act
An expansion of medicaid, most of employers must provide health insurance, have insurance or face surtax, prevents rejection based on pre-existing condition. Also referred to as "Obamacare", signed into law in 2010.
Research
An investigation designed to develop or contribute to generalizable knowledge; collecting and breaking down data in the hopes of answering a question
Accountable Care Organization (ACO)
An organization of healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrolled in the traditional fee-for-service program
anthrax in animals
Animals ingest spores, spores are introduced to a favorable environment and rapidly cause illness and death in animal
How does C. diff develop?
Antibiotics alter the normal enteric flora, either permitting overgrowth of these relatively resistant organisms or making the patient more susceptible to exogenous acquisition of C. diff
What is the General Competency Statement for Competency Domain 4: Teams and Teamwork?
Apply relationship-building values and the principles of team dynamics to perform effectively in different tea roles to plan and deliver patient-centered care that is safe, timely, efficient, affective, and equitable
Artistic interest
Artistic occupations frequently involve working with forms, designs, and patterns. They often require self-expression, and the work can be done without following a clear set of rules.
What is the purpose of phase 4 of a clinical trial?
Assess safety and efficacy
What are C. diff monoclonal antibodies?
Bezlotoxumab and Actoxumab
CDC category B agents
Brucella, Q fever, Ricin
Symptoms of Injection Anthrax
Build up of blisters where the drug was injected, skin sore with black center, and build up of puss under skin
BioSense
CDC web-based program to improve detection, monitoring, and situational awareness of healthcare organizations
What organization maintains a small arsenal of BW agents?
CIA
IRB member roles
Chair, vice chair, member, consultant
What is the general competency statement for domain 3: Interprofessional Communication
Communicate with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to the maintenance of health and the treatment of disease
Federally Qualified Health Center (FQHC)
Community-based primary care center staffed by a multidisciplinary team of health care and related support personnel, with fees adjusted based on ability to pay.
Reimbursement is increasingly tied to what?
Compliance with federal standards
Conventional interest
Conventional occupations frequently involve following set procedures and routines. These occupations can include working with data and details more than with ideas. Usually, there is a clear line of authority to follow.
Pricing failures
Costs are typically higher in the U.S. (hospitals, drugs, salaries for HAs and MDs/DOs. - Biggest driver for overall costs have been lack of information and transparency
Hospitals as regulators
Credential healthcare staff, credentialing necessary for malpractice insurance eligibility, regularly review medical staff for quality, professional conduct, and practice standards
Rajneeshees
Cult that used bioterrorism at a salad bar to tried to sway a local election. (Oregon)
Who is the major federal actor in healthcare regulation?
DHHS
Bundled Payment for Care Initiative (BPCI)
Developed by the CMS Center for Medicare & Medicaid Innovation (CMMI) that was created by the ACA; the BPCI recognizes that separate Medicare fee-for-service payments for individual services provided during a beneficiary's single illness result in fragmented care with minimal coordination across providers and settings, rewarding service quantity rather than quality. The BPCI is testing whether, as prior research has shown, payments for bundled "episodes of care" can align incentives for hospitals, post-acute care providers, physicians, and other healthcare personnel to collaborate across many settings to achieve improved patient outcomes at lower cost.
What is the role of healthcare professionals in the healthcare system?
Diagnose, treat, care
Dialogue vs discussion
Discussions: primary objective of the sender is to clearly present their point of view and convince others of its validity Dialogue is a conversation that flows. Dialogue depends on shared interaction that build shared meaning through the exploration of ideas and opinions. Goal is to come up with the best decision. Body of knowledge influences the decision, not someone's opinion. Dialogue is the outcome of pure communication
Describe the clinical research stage of drug research
Drugs are tested on people to make sure they are safe and effective
describe the preclinical research stage of drug research
Drugs undergo laboratory and animal testing to answer basic questions about safety
secondary prevention
Efforts to limit the effects of an injury or illness that you cannot completely prevent.
primary prevention
Efforts to prevent an injury or illness from ever occurring.
Private health insurance is mainly ________________
Employer-based
Enterprising interest
Enterprising occupations frequently involve starting up and carrying out projects. These occupations can involve leading people and making many decisions. Sometimes they require risk taking and often deal with business.
What are interprofessional learning activities still primarily aimed at?
Exposure to students from other professions
Who was involved in the 2001 anthrax attacks?
FBI, CIA, CDC, national defense laboratories, physicians, government officialas
Who regulates pharmaceuticals and devices?
FDA
Describe the FDA post-market safety monitoring stage of drug research
FDA monitors all drug and device safety once products are available for use by the public
Describe the FDA review stage of drug research
FDA review teams thoroughly examine all of the submitted data related to the drug and make a decision to approve or not to approve it
T/F insurers can raise your rates because of a pre-existing condition
False
T/F market forces have controlled the cost of healthcare in the US
False
T/F there is cost control on healthcare
False
How is Medicare funded?
Federal general revenues and a payroll tax
What defines when an activity is research involving human subjects?
Federal regulations
Cost drivers in healthcare
Fee-for-service payment model, failure of care delivery, failure of care coordination, overtreatment/ overscreening, administrative complexity and fraud, pricing failures
What is the role of facilitating organizations in the healthcare system?
Finance, coordinate, regulate
Definition of primary care
First contact in a given episode of illness that leads to a decision regarding a course of action to resolve the health problem.
What makes the U.S. healthcare system is distinctive?
Formal insurance coverage is not universal in the U.S. with the elderly and the poor relying on government and the remained being mainly dependent on their employers
Cost conundrum
Gawande (2015): "The bigger the hospital, the more it can adopt systems and deliver better-organized, higher quality, less-wasteful care. But the bigger the hospital the more power it has to raise prices
SSI-Antibiotic Prophylaxis
Giving abx (usually cefazolin) before surgery to reduce burden of microorganisms at surgery site
What does the U.S. health system rely on?
Governmental action, market forces, and voluntary charitable initiatives
Population health model vs. public health model: Whitehall study
Gradient response vs. dose-response
What kind of bacteria forms spores?
Gram +
Microbiology of VAPS
Gram negative bacilli: e.coli, klebsilla, enterobacter, pseudomonas Gram positive cocci: Staph aureas, MRSA, streptococcus
What kind of bacteria can form a spore as a survival mechanism?
Gram positive
What kind of bacteria is C. diff?
Gram-positive, spore-forming bacillus (rod)
Why do surgical site infections make up the biggest percentage of total annual HAI costs?
High volume of surgeries
Where do the bulk of expenses of healthcare spending come from?
Hospital care, doctor visits, and prescription drugs
What is as important as what care is delivered?
How care is delivered
What does the field of population health assess?
How patterns of health determinants affect outcomes and develops policies and interventions that link these areas
I-PASS mnemonic
I: Illness Severity P: patient summary A: action items S: situation awareness and contingency planning S: synthesis by receiver
All research involving human subjects must be approved by an _____________ or _________________ before any activity is performed
IRB; determined to be exempt
treatment of anthrax
IV antibiotic + antitoxin
Define Competency Domain 1: Values and Ethics
Idea is to focus on the underpinning values of relationships
Examples of long-lasting protective interventions
Immunizations, brief intervention, cessation treatment, colonoscopy
Who is at most risk of C. diff?
Immunocompromised patients
What was the outcome of To Err is Human?
Increased interest in the quality and effectiveness of team-based healthcare
Who tracks and keeps surveillance data about C. diff?
Infection control and epidemiology
What is Competency Domain 3?
Interprofessional Communication
"Endocarditis Team" Study
Intervention was the formulation of an Endocarditis team at this hospital in France Team: cardiac surgeons, cardiologists, echocardiographers, infectious disease specialists
Investigative interest
Investigative occupations frequently involve working with ideas, and require an extensive amount of thinking. These occupations can involve searching for facts and solving problems mentally.
What does Toxin A do?
It destroys tight cell junctions leading to increased permeability of the intestinal wall and thus diarrhea
What happens when a spore encounters favorable environmental conditions?
It sheds the outer layer and allows for replication of the organisms
What does Toxin B do?
It targets actin and destroys cellular cytoskeletons; produces surface layer proteins which allows organisms to bind to intestinal epithelium and cause local damage
symptoms of cutaneous anthrax
Itchy bumps, small groups of blisters, and swelling in area infected, painless skin sore (ulcer) with a black center (eschar) usually on face, neck, arms, or hands
JCAHO
Joint Commission on Accreditation of Healthcare Organizations
Biggest problem with healthcare in the US
Lack of coordination
Administrative complexity and fraud
Lack of standardized system of electronic billing for all payers, lack of standardized enrollment system for public insurance, lack of standardized EHR system
Where is tertiary care typically provided?
Large regional medical centeres
Definition of a local board of health
Legally designated body whose role is to protect and promote the health of its community - Most of them provide oversight to the public health agency and foster activities such as community health assessment, assurance, and policy development
States provide what to regulate healthcare?
Licensure and oversight of medical facilities and providers, certificate of need process, regulation of insurance coverage
What is the field of public health concerned with?
Limiting health disparities and a large part of public health is the fight for health care equity, quality, and accessibility
What four behaviors facilitate dialogue?
Listening, responding instead of reacting, ask questions and clarify, recap understanding
Typical education for managers in healthcare settings
MPH, MHA, MBA, sometimes a fellowship, no licensing
Continuity of care
Maintaining a relationship with the same provider over time
What is the largest health insurance program in the U.S.?
Medicaid
50% of children and 1 in 3 adults in California is covered by ___________
Medical
Top reason for bankruptcy in the U.S.
Medical bills
What are the consequences of poor communication in healthcare?
Medical errors, patient complaints, poor employee morale
Medical model vs. population health model with regard to tobacco use
Medical model focuses on the individual patient using tobacco and smoking cessation counseling and treatment options requiring nicotine replacement. Population health model entails understanding the influences of tobacco production, advertising, distribution and patterns of use in different groups; interventions would include smoke free laws, tobacco taxes, regulation of marketing and advertisement
MACRA
Medicare Access and CHIP Reauthorization Act
Types of ACOs
Medicare, Medicaid, Commercial, Employer-driven
MIPS
Merit-based Incentive Payment System
What is the difference between mortgage rates and healthcare premiums?
Mortgage rates are fixed while premiums keep increasing
NCQA
National Committee for Quality Assurance
Do we repeat test for a cure for C. diff?
No, labs will remain positive and can't distinguish between active and carrier infections.
Who makes up the personnel of the current healthcare system?
Nurses, physicians, NPs and PAs, pharmacists, dentists, ancillary personnel
Who is traditionally left to care for pressure ulcers?
Nursing staff - physicians have usually signed off on nursing-initiated orders
What is the role of consumers in the healthcare system?
Obtain healthcare
Part of the solution to shortage of primary care
PAs and NPs - lower salary, less time training, easier to switch specialties mid-career
Examples of healthcare delivery system reform
Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACO)
Satisfaction in healthcare
Patient, provider and payer
value based payment models
Payment made to providers based on measures including quality, efficiency, cost, and positive patient experience - goals are in direct alignment with the Triple Aim
Risk of ACOs
People who are in the ACO model have to provide medicare with a prospective budget. If they exceed budget, they aren't penalized. Any savings are paid to the providers. Some providers can play both sides. They say they won't exceed budget, and they get higher return for high risk.
What are the delivery settings for primary care?
Physician office/clinic, self-care, alternative medicine
Exclusive Provider Organization (EPO)
Plan in which participants must use providers in the network of coverage or no payment will be made. - More flexible HMO because PCP doesn't need to refer to specialist; specialist still has to be in network
How do we prevent pressure ulcers?
Pressure relief (turn every 2 hours), eliminate shearing (lift sheets), optimal nutrition, moisture management (incontinence care)
Widespread patient error in U.S. hospitals is associated with what three things?
Preventable morbidity and mortality as well as major quality issues
What are the nine types of healthcare services?
Preventative care, primary care, specialized care, chronic care, long-term care, sub-acute care, acute care, rehabilitative care, end-of-life care
What is the focus of health promotion and preventative services?
Prevention of disease and maintenance of good health
What type of prevention has the biggest impact?
Primary
What are the delivery settings for chronic care?
Primary care settings, specialist provider clinics, home health, long-term care facilities, self-care, alternative medicine
Bismarck Model
Primary model for US citizens >65
Who was historically the major regulator of healthcare delivery before government and insurance industries?
Professional societies
Medicare Part A (aka Hospital Insurance or HI)
Provides hospital insurance automatically @ age 65 (if FICA qualified) @ no fee but may have deductible & co-pay. - Financed mainly by payroll tax
What are the delivery settings for preventative care?
Public health programs, community programs, and personal lifestyles
Insular Areas or Territories
Puerto Rico, Guam, US Virgin Islands, American Samoa, Commonwealth of the Northern Mariana Islands, Republic of the Marshall Islands, Federated States of Micronesia, Republic of Palau
What is the main driver of value-based care
Quality of care
O-NET Interests
Realistic, investigative, artistic, social, enterprising, conventional
What is the second competency domain?
Roles and Responsibilities
Examples of clinical interventions
Rx for high blood pressure, high cholesterol
IRB members
Scientists and non scientists; affiliates and non-affiliates with different backgrounds and experience, knowledge of their community and knowledge of research protections
Injection manifestation of anthrax
Scotland 2009-2010 among 47 heroin users; Novel strain of B. anthracis traced back to infected goats in Turkey
State Health Department responsibilities
Screening for diseases and conditions (e.g., newborn screening, HIV/AIDS, TB, diabetes) Treatment for diseases (e.g., TB, STDs, HIV/AIDS, diabetes) Technical Assistance and Training (e.g., emergency responders, hospitals, data management, policy development, local health departments) State Laboratory Services (e.g., bioterrorism agents test, food-borne illness testing, influenza typing, environmental toxins, newborn screening) Epidemiology and Surveillance (e.g., data collection and epidemiology on behavioral risk factors, communicable/infectious diseases, vital statistics, chronic diseases)
How many people take part in stage 4 of a clinical trial?
Several thousand volunteers who have the disease/condition
Results of ET study
Significant reductions in time to surgery, duration of abx, and length of in-hospital stay
Each year, the Medicare premiums, deductibles, and coinsurance rates are adjusted according to the _____________________.
Social Security Act
Social interest
Social occupations frequently involve working with, communicating with, and teaching people. These occupations often involve helping or providing service to others.
Single largest determinant of health
Socioeconomic factors
Factors that affect health from largest impact to smallest impact
Socioeconomic factors, changing the context to make individuals' default decisions healthy, ,long-lasting protective interventions, clinical interventions, counseling and education
What are the delivery settings for specialized care?
Specialist clinics
Coinsurance
Specified percentage of the cost of treatment the insured is required to pay for all covered medical expenses after the deductible has been met
Health Savings Account (HSA)
Tax-sheltered savings account similar to an IRA but created primarily to pay for medical expenses.
What is competency domain 4?
Teams and Teamwork
What type of prevention do we invest the most money in?
Tertiary
What is a real-world application of the IP competency domains?
The Health Mentors Program
What US system has a socialized medicine model?
The VA
weaponization
The creation of a weapon from a biologic agent generally found in nature and that causes disease; the agent is cultivated, synthesized, and/or mutated to maximize the target population's exposure to the germ.
What is often the first contact with the health system?
The emergency department (after hours, lack of appointments)
Medicare Part B
The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies. - monthly premium - deductible - 20% coinsurance - voluntary - financed by general revenues and beneficiary premiums
What is interprofessionalism?
The process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population...It involves continuous interaction and knowledge sharing between professionals, organized.to solve or explore a variety of education and care issues all while seeking to optimize the patient's participation...Interprofessionality requires a paradigm shift, since interprofessional practice has unique characteristics in terms of values, codes of conduct, and ways of working. These characteristics must be elucidated
National Health Service
The publicly funded health care system in the U.K, Denmark, Norway, Finland. Spain, New Zealand - Financed predominantly through general revenue taxation determined by ability to pay -Government organizes the delivery of services
Healthcare delivery systems are expected to provide __________________.
The right care to the right patient at the right time
Difference between gram-positive and gram-negative bacteria
Thickness of peptidoglycan layer (positive = thicker)
What are common competencies?
Those expected of all health practitioners
What are collaborative competencies?
Those that each profession needs to work together with others
What are the types and names of the toxins produced by C. diff?
Toxin A (enterotoxin), Toxin B (cytotoxin)
Which toxin is essential for C. diff virulence?
Toxin B
Which toxin is essential for C. difficile virulence?
Toxin B
How do we diagnose C. diff?
Toxin detection in feces
tertiary prevention examples
Treatment of chronic conditions with medication
What were the primary outcomes of the MODIFY trial?
Treatments with bezlotoxumab + actoxumab and treatment with bezlotoxumab alone were significantly more effective than actoxumab on its own or the placebo at preventing recurrent c. diff
T/F C. diff is a part of normal intestinal flora in a small number of healthy people and hospitalized patients
True
What are the two HMICs where healthcare is not a right?
U.S. and South Africa
Project BioShield
U.S. legislation provided funding for American drug companies to develop a vaccine against anthrax
Merit-based Incentive Payment System (MIPS)
Under the MACRA, combines three previous quality reporting programs into one reporting system, scoring eligible professionals (EPs) on quality , resources use, clinical practice improvement activities, and meaningful use of certified EHR technology. The composite MIPS performance score determines whether EPs will receive an annual upward, downward , or no payment adjustment.
I-PASS Study
Undertaken due to concern for medical errors in cases of poor communication
What are complementary competencies?
Unique competencies that enhance the delivery of healthcare
Role of Nursing on ICC
Use of aseptic technique, sterile technique, and reporting to attending any evidence of infection in patients
What is the General Competency Statement for Domain 2: Roles/Responsibilities?
Use the knowledge of one's own role and those of other professions to appropriately assess and address the healthcare needs of the patients and populations served
examples of primary prevention
Vaccines, healthy diet, exercise, well baby care and prenatal care
What is the first competency domain?
Values and Ethics
How does C diff spread?
Via the fecal-oral route by ingestion of spores (stethoscopes, roommates, unwashed hands)
Primary care and global health
WHO recognizes the central role of primary health care for achieving health and well-being for all, at all ages. - Stronger primary health care is essential to achieving health-related SDGs and universal health coverage
Institute of Medicine public health definiton
What society does collectively to assure the conditions for people to be healthy
What is the General Competency Statement for Domain 1: Values and Ethics?
Work with individuals of other professions to maintain a climate of mutual respect and shared values
CDC Category C agents
Yellow Fever, Influenza, Rabies, MDR TB
What is the name of the drug that came out of the MODIFY trials?
Zinplava by Merck (Bezlotoxumab)
monoclonal antibodies
a collection of identical antibodies that interact with a single antigen site
What do public health officials assure?
a competent public health and personal healthcare workforce
Tribal Health Department
a corporation or organization operated under the jurisdiction of a federally recognized tribe, or association of federally recognized tribes, and is funded by the tribe(s) and/or contract service(s) from the Indian Health Service (IHS).
Point of Service Plan (POS)
a network of selected contracted, participating providers; also called an HMO-PPO hybrid or open-ended HMO - Doctors are paid of a capitation basis - PCP required for coordination of care - Less restrictions to seek specialist care out of network - Patients have strong financial incentives to use POS plan doctors
Patients with C. difficile carriage are ____________________
a reservoir for environmental contamination
Copayment
a small fixed fee paid by the patient at the time of an office visit
Definition of health
a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity
fee-for-service
a system under which doctors and hospitals receive a payment for each service they provide - worked well for acute problems but not for chronic conditions
The IOM report from 1972 cited the obligation of whom to conduct interdisciplinary education and patient care?
academic health centers
Equation for quality in healthcare
access x outcomes x satisfaction (patient, provider, and payer)
Pros of PCMHs
accessibility, quality and safety, patient-centered care, coordinated care, whole patient orientation
the ACA has made health care __________ but not ____________
accessible; affordable
tertiary prevention
actions taken to contain damage once a disease or disability has progressed beyond its early stages
What does primary care address?
acute, chronic, and preventative/wellness issues
strengths of US healthcare system
advanced diagnostic and therapeutic technology; timely availability of specialists and procedures
Tertiary care is characterized by __________________
advanced technology and high volume of procedures
What is a competency?
an ability or skill; a skill needed to perform in a particular role, knowledge in a particular domain, or a value that can be expressed in action, or a combination of these three
Biological Weapons Convention (1972)
an agreement that prohibits the development, production, and possession of biological weapons but makes no provision for inspections
Fee-for-service (FFS)
an insurance payment system where providers are paid for each service, also called indemnity plan. The patient can make an appointment with any medical provider who then sends the claim to the insurance company. If the deductible has been met for the year, then the FFS pays the bill. - Higher premiums
What do public health professionals do?
analyze the effect on health of genetics, personal choice, and the environment in order to develop programs that protect the health of your family and community
Category A agents
anthrax, botulism, plague, smallpox, tularemia, viral hemorrhagic fevers
People in conflict tend to communicate _________________
as little as possible
What is the purpose of phase 1 of a clinical trial?
assess drug safety and find dosage
Public Health core functions
assurance, assessment, policy development
Access in healthcare
availability, timeliness, and capacity
Diagnosing gastrointestinal anthrax
blood cultures, swab of oropharynx
Examples of hospital acquired conditions (HAC)
blood incompatibility, foreign body retained after surgery, Stage III and IV pressure ulcer, infections, deep vein thrombosis
CAUTI
catheter associated urinary tract infection
CLABSI
central line associated blood stream infection
To Err is Human
challenged the healthcare system to focus on medical errors and patient safety
Diagnosing inhalational anthrax
chest x-ray, biopsy of tissue, fluid for gram stain
outcomes in healthcare
clinical, operational, throughput
Prevention and control is a _______________
collaborative effort
Biggest cause of sentinel events
communication issues
What do public health officials mobilize?
community partnerships to identify and solve health problems
What is the purpose of phase 3 of a clinical trial?
compare new treatment with current treatment to see which is better
The goals of the healthcare delivery system (access, quality, and cost) are often ____________
competing goals
Examples of counseling and education
condoms, eat healthy, be physically active
Healthcare is evolving into a ____________________________________
conglomeration of various different specialties (physician, pharmacist, MSW, RN, etc.)
Good communication requires a _______________
conscious effort
Special considerations for people with intellectual/developmental disabilities
consent capacity, treatment challenges, caregiver perspectives
Tertiary care is ____________
consultative subspecialty care
Four pillars of effective primary care
continuity of care, comprehensiveness, coordination of care, first contact care
Routine passive surveillance
data is passed along according to a set of rules and reported to state, city, and national health departments as needed. Diseases that have public health implications are required to be reported
Employment-related health insurance coverage in the U.S. is ________________
decreasing
What is a spore?
dehydrated, multi-shelled structure that allows bacteria to exist in suspended animation. Contains a copy of the chromosome, minimal concentration of essential proteins and ribosomes, and a high concentration of calcium
Health care has traditionally been ________________________________
delivered and reimbursed in acute episodes
Current responsibility of professional societies
determining acceptable professional practice standards, contributing to regulatory policy
Clostridium difficile
diarrheal disease that follows antibiotic use; usually nosocomial
closed loop communication
direct statements used to avoid a misunderstanding; message is confirmed by repeating it back to the speaker
What are the 3 important factors for weaponized spores?
dispersibility, floatability, and inhalability
Chargemaster
document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility's patient accounting system, and charges are automatically posted to the patient's bill (UB-04).
spores are resistant to
drying, heating, freezing, chemicals
Microbiology of CAUTIs
e. coli, enterococcus, candida, klebsiella - mostly gram-negative organisms
Important tools for providing protection during research activities
education, certification, and accreditation
What do public health officials evaluate
effectiveness, accessibility, and quality of personal and population-based health services
The bulk of increasing health care costs are passed on to _____________
employees
Interests of healthcare administrators
enterprising, conventional, social
Disciplines of public health
environmental health, epidemiology, health services administration/management, international/global health, maternal child health, nutrition, public health laboratory practice, public health policy, public health practice
What do stage 1, 2, 3, and 4 pressure ulcers affect, respectively?
epidermis, dermis, subcutaneous tissue, muscle/bone
Justice
equal treatment and fairness for all people; benefits and risks of research must be distributed fairly; results must be disseminated and shared with society, even if results are unexpected
What is the purpose of phase 2 of a clinical trial?
establish efficacy and side effects
Secondary endpoint of the ET study
evaluate the effect of the ET on 6 month and 1 year mortality, rate of surgery, time to surgery, duration of abx, length of in-hospital stay, occurrence of cardiac or neurological sequelae
overtreatment
excessive use of diagnostic tests
What are two examples of knowledge that a nurse caring for a cancer patient will have?
experience with chemo drugs, knowing what to look for
The traditional solo practitioner model is ________
fading
What are primary care specialties?
family medicine, general internal medicine, pediatrics, OBGYN
What can a primary care physician specialize in?
family medicine, internal medicine, or pediatrics
Primary weapon of terrorists
fear
Symptoms of gastrointestinal anthrax
fever, headache, myalgia, abdominal pain, bloody vomiting, septicemia
Primary concern of people in management roles at healthcare organizations
fiscal health of the organization
Examples of changing the context to make individuals' default decisions healthy
fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax
Health Professional Shortage Area (HPSA)
geographic area, population group, or medical facility with shortages of healthcare professionals that may not allow a full complement of healthcare services Examples: rural health clinics that receive federal grants to serve underserved populations; Indian Health Service facilities - Doesn't take into account services provided by NPs and PAs
HAIs are a ________________
global issue
Diagnosing cutaneous anthrax
gram stain, PCR, culture of vesicular fluid or eschar, culture of blood, biopsy
Preferred Provider Organization (PPO)
group of healthcare providers that provide services to a specific group, often at a reduced rate - Doctors are paid on an FFS system with negotiated fees for services offered - Greater choice of physicians for patients - No prior authorization necessary for seeking care from specialists
Contemporary applications of public health
handgun control, west nile virus, pandemics, childhood obesity, terrorism, public health preparedness
Consumer-Directed Health Plan (CDHP)
health care plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs - Plan with a very high front-end deductible, typically with an HSA over which the consumer has direct control with savings in pretax dollars within the limits allowed by the federal government
What do public health officials diagnose and investigate?
health problems and health hazards in the community
examples of secondary prevention
health screenings (diabetes, high blood pressure, self examinations)
What do public health officials monitor?
health status to identify community health problems
ACO model of insurance
here is a bundle of money that has to be worked out between hospitals and physicians to keep the patient healthy
What are the delivery settings for end-of-life care?
hospice services
What are the delivery settings for acute care?
hospitals
Common conditions at primary care level
hypertension, acute URIs, depression/anxiety, back pain, routine health maintenance, arthritis, diabetes
Primary endpoint of the Endocarditis team study
impact of the ET on the rate of all-cause in-hospital mortality
Tribal Health Organizations
include Tribal Health Departments, Indian Health Service Units, Area Indian Health Boards and Urban Indian Health Centers (a much broader group, and relates to a variety of entities that might provide health services in a tribal setting).
Traditional definition of value in healthcare
increasing the quality of care with a concurrent decrease in price value = quality/cost
Focus of volume-based care
individual patient episodes, ordering and performing as many interventions as possible to maximize reimbursement
endocarditis
infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve, or a blood vessel - often manifest as a vegetation: mass of platelets, fibrin, microorganisms, scant inflammatory cells - high mortality - subject of IDSA guidelines
Anthrax spore must be ______ to be effective
inhaled
CLABSI facts
intravascular device associated with as many as 200,000 bloodstream infections each year in US. Mortality rates of 12-25% - Derive largely from the cutaneous microflora of the insertion site, with pathogens migrating extraluminally to the catheter tip
Whitehall Study
investigated social determinants of health, specifically the cardiovascular disease prevalence and mortality rates among British male civil servants between the ages of 20 and 64. Showed that lower rank workers had a higher risk of mortality
Interests of pharmacists
investigative, conventional, social
Interests of surgeons
investigative, realistic, social
Interests of internists
investigative, social, realistic
Medicare—Part D Prescription Drug Coverage
is a voluntary program for paying for your prescription drugs. If you earn more, you pay more.
What do public health officials enforce?
laws and regulations that protect health and ensure safety
What are pressure ulcers?
localized areas of tissue damage or necrosis that develop because of pressure over a bony prominence
What are the delivery settings for long-term care?
long-term care facilities, home health
Tertiary care sites usually serve as _________________________
major education sites for students in a variety of health professions
Current trends in the healthcare system
medical tourism and concierge medicine
How do we identify bacteria?
microscopic appearance and gram staining
What do public health officials research?
new insights and innovative solutions to health problems
Each bacillus anthracis toxin factor on its own is ___________
nontoxic (need combos like PA + EF or PA + LF
failure of care coordination
occurs when patients experience care that is fragmented and disjointed; can include unnecessary hospital readmissions, avoidable complications, declines in functional status - a commonly cited failure is 30-day hospital readmission - more costly
There has been a paradigm shift away from the idea that _______________________________
outcomes are the result of individual efforts
Focus of value-based care
outcomes, keeping patients healthy and reducing unnecessary interventions
6 discrete types of waste in healthcare spending
overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, fraud and abuse
Beneficence
participants should not be harmed, research should maximize possible benefits and minimize possible harms, the nature and range of risks and benefits must be considered
Anthrax spores are ____________
particularly resilient
What was the strategy being tested in the MODIFY trials?
passive immunization against toxins secreted by C. diff
What do public health officials inform, educate, and empower?
people about health issues
What do public health officials link?
people to needed personal health services and assure the provision of healthcare when otherwise unavailable
What are the components of the current healthcare system? (5)
personnel, healthcare institutions, US Public Health Service Commissioned Corps, Drug and device manufacturers, Education and research
Multisectoral action on health
policy design, policy implementation and other actions related to health and other sectors carried out collaboratively or alone, which address social, economic, and environmental determinants of health associated commercial factors or improve health and well-being
McKeown Hypothesis
population growth and increased life expectancy not due to medical advancements but rather improvements in the overall standard of living and social infrastructure
Factors that create effective communication
positive body language, a belief that your opinion holds value and that the receiver of the information is open to hearing what you have to say, being able to share ideas without fear of consequences, retaliation, or judgement, being comfortable with exploring ideas and asking questions
Examples of socioeconomic factors
poverty, education, housing, inequality
2/3rds of healthcare spending in the US is attributable to ___________________.
preventable diseases
Half of ED visits could be prevented with _________________
primary care
Healthcare systems with a foundation of robust _________________ deliver more value that those without.
primary care
first contact care
primary care should be delivered at first contact to the system
Coordination of care
primary care takes responsibility for managing patient's health needs through the full spectrum of settings where health care is delivered
Three categories of HPSAs
primary care, dental, mental health
There has been a shift in medicine away from ______ to __________.
primary care; specialization
Commercial bundles
private health insurance companies have introduced bundle payments; bundles are not just limited to procedures
What are growing trends to meet prisoners' healthcare needs?
privatization and telemedicine
What are settings for primary care?
provider offices, clinics, schools, colleges, prisons, worksites, home, mobile vans
Role of physician on ICC
provides direct patient care using practices that minimize infection, follow appropriate hand hygiene, advise patients, visitors and staff on techniques to prevent the transmission of infection, complies with recommendations of various infection-oriented committees
Population health falls under the umbrella of ____________________.
public health
active surveillance
public health surveillance in which the health agency solicits reports.
Health insurance can be __________ through taxation or ______________ by employers or individuals
publicly funded; privately paid
What color do gram positive bacteria stain?
purple
Realistic interests
realistic occupations frequently involve work activities that include practical, hands-on problems and solutions. They often deal with plants, animals, and real-world materials like wood, tools, and machinery. Many of the occupations require working outside, and do not involve a lot of paperwork or working closely with others.
What color do gram negative bacteria stain?
red
First contact creates value by _______________________
reducing healthcare costs for the system
What are the delivery settings for rehabilitative care?
rehabilitation departments, home health, outpatient rehabilitation centers
Concierge Medicine
relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer
Comprehensiveness of care
requires that primary care be capable of addressing a wide scope of issues
Describe the discovery and development stage of drug research
research for a new drug begins in the laboratory
What is an example of a value that a nurse caring for a cancer patient will have?
respect for the patient's feelings and preferences
How long is phase 1 of a clinical trial?
several months
How long is phase 2 of a clinical trial?
several months to 2 years
Interests of social workers
social, investigative
Interests of registered nurses
social, investigative, conventional
Interests of nurse practicioners
social, investigative, realistic
What are the delivery settings for sub-acute care?
special sub-acute clinics, home health, outpatient surgical center
Most healthcare regulation comes from _______
states
Spores are formed in response to _____________
stress/unfavorable environmental factors
Secondary care is typically ___________________________
subspecialty care focused on a particular organ system or disease process; available in most communities; includes common inpatient and outpatient services
Belmont Report (1979)
summarizes the basic ethical principles and guidelines for the protection of human subjects of research. (Respect for persons, beneficence and justice)
SSI
surgical site infection
medical model
the concept that diseases, in this case psychological disorders, have physical causes that can be diagnosed, treated, and, in most cases, cured, often through treatment in a hospital.
Bioterrorism
the deliberate spread of pathogenic organisms into a community to cause widespread illness, disability, death, fear, and panic
Who is a major funder for basic medical research?
the government
Population Health
the health outcomes of a group of individuals, including the distribution of such outcomes within the group
APHA Public Health Definition
the promotion and protection of the health of the people and the communities where they live, learn, work, and play.
Public Health Definition
the science, practice, and art of protecting and improving the health of populations
What does pure communication depend on?
the sender and the receiver; emotional maturity
Public Health Surveillance
the systematic collection, analysis, interpretation, and dissemination of health data to gain knowledge of the pattern of disease occurrence in order to control and prevent disease in the community.
What kind of policies and. plans do public health officials develop?
those that support individual and community health efforts
T/F the cost of premiums for HI goes up 2-3x faster than inflation
true
What kind of trial was MODIFY?
two double-blind, randomized, placebo-controlled phase 3 trials
Catastrophic Coverage
type of insurance designed to cover catastrophes such as tornados, major accidents, or health emergencies - usually low premium and high deductible
How many people take part in stage 2 of a clinical trial?
up to several hundred people with the disease/condition
volume based care (then) to __ based care (now)
value
Multidisciplinary teams for PHC
varies by setting but may include generalist medical practitioners, PAs, nurses, specialist nurses, community health workers, pharmacists, social workers, dietitians, mental health counselors, physiotherapists, patient educators, managers, support staff
VAP
ventilator associated pneumonia
Shortage of primary care is expected to __________
worsen
Why is healthcare unique?
you get a bill much later after services and the total is usually unknown until the bill comes
State and Local Health Department Governance Classification System
•Local/Decentralized—Local health departments are units led by local governments, which make most fiscal decisions. •Mixed—Some local health departments are led by state government, and some are led by local government. No one arrangement predominates in the state. •State/Centralized—All local health departments are units of state government, which makes most fiscal decisions. •Shared—All local health departments are governed by both state and local authorities.
Medicare Part C (Medicare Advantage)
•Replaces and covers expenses found in Part A and B •Medicare private fee-for-service plans (PFFS) •Medicare managed care plans (HMOs and PPOs) •Medicare specialty plans