EBDM & Role of self medication

what types of decisions are made in clinal practise?

• diagnosis

• prognosis

• treatment decision

Diagnosis

The process of determining the nature of a disorder by considering the signs, symptoms, medical background and when necessary: the lab results, imaging ect…. of the patient.

• unlike therapeutic procedures, usually do not have a direct impact on the patient in terms of treatment.

Prognosis

An assessment of the future course of a disease and the likely outcome.

• based on the knowledge of how a disease progressed in other patients together with general health, age, sex of the patient

What are the 3 theories of DM?

• normative

• descriptive

• prescriptive

Normative DM

focusses on what should be done, according to social or professional norms (expectations of a qualified DR)

Descriptive DM

what are you actually doing?

Prescriptive DM

Focusses on what we can improve in what your are already doing.

what are 2 different kinds of diagnostic reasoning models?

• hypothetico-deductive model (elstein et al 1978)

• pattern matching (norman 2005)

Is the hypothetico-deductive model used more by experienced or inexperienced clinicians?

Inexperienced clinicians

Describe the hypothetico-deductive model

Seeking evidence to prove your hypothesis and disprove your null hypothesis.

Elstein said medicine is a constant cycle of:

• Cue acquisition: gaining information - patients signs and symptoms

• Hypothesis formation: what do you think is wrong?

• Cue interpretation: does evidence collected match the hypothesis?

• Hypothesis evaluation: and then start over again if necessary

How did Norman 2005 describe experienced clinicians diagnostic reasoning process?

• suggested that HDM was less common in experienced DRs

• used patten matching as they are more familiar with the diagnostic task

• use reflective practise, evidence, scientific & experimental knowledge to determine less common cases

• BUT will use the HDM when encountering less familiar diagnostic problems

According to prospect theory (Tversky & Kahneman, 1988) what are the two phases in choice/ decision process?

1) Framing & Editing - preliminary analysis of decision problem

2) Phase evaluation - the framed ‘prospects’ are evaluated and those with the highest value are selected

How can decisions be influenced?

• Framing - how the problem is framed to the individual

• Values - peoples values & beliefs associated with benefits/harms of the outcomes or different options

• Evaluation - someone’s ability to evaluate information used

what is evidence?

Any factor that can and should influence clinical DM

• results form research studies

what is the hierarchy of evidence?

Type of study design is ranked on perceived ability to provide evidence for clinical practise.

• quality is associated with the potential bias in the study - so higher quality = more predictive power

Bias vs Error

• BIAS = systematic distortion

• ERROR = non-systematic distortion or random

What are the 9 segments of the evidence pyramid?

• Systematic reviews & meta analysis

• RCT (ideally double blinded)

• Cohort studies

• Case control studies

• Case series

• Case reports

• Ideas, editorials, opinions

• Animal research

• In vitro research

Systematic reviews & meta analysis

Comprehensive structured review & summary of all available evidence of a specific research question.

• statistical technique combines results from multiple studies to produce an idea of the effect size (often conducted as part of a systematic review)

Cohort studies

Longitudinal observational studies = follows a large group of participants over a period of time to examine how certain factors (eg: exposure/intervention) effects their health outcomes.

Case control studies

Observational studies that allow you to look at risk factors associated with diseases or their outcomes (smaller than corhort).

• there is a case group (risk of interest) and a control group (don’t have outcome of interest - but otherwise similar to case group)

Case series vs Case report

• Case series = multiple case reports (observations) of a group of individuals who share specific characteristics

• Both can be used to generate hypothesis BUT case series can help monitor emerging medical trends and describe common conditions

What are the S5 levels of organisation?

• Systems - computerised decision models

• Summaries - evidence based textbooks

• Synopses - evidence based journels

• Synthesis- systematic reviews

• Studies - original journel articals

How is evidence used in diagnosis decisions?

• to identify most likely hypothesis

• evaluate likelihood of hypothesis being correct

• accuracy of diagnostic tests

How is evidence used in prognosis decisions?

• to evaluate what happens to similar patients with same condition - giving a more accurate idea of what persons disease/illness will look like in the future

How is evidence used in treatment decisions?

• evaluate the likelihood of different options having an effect - will they even work?

• evaluate the likelihood of adverse events happening to patient - do other options cause harm?

• Likely acceptability of treatment by patient.

What is self medication?

An element of selfcare.

• it is the ability to select and use medication to treat a self recognised illness or symptoms - without medical supervision

what is self care?

The holistic person centres approach to health and wellbeing of each person - taking into account:

• their circumstances

• needs and desires across a lifetime

• environment in which they live

What is the purpose of individuals being active agents in their own hc?

Provides additional options and choices for healthcare, promotes disease prevention/ control, self medication, caring for dependants, rehab and palliative care.

What 3 factors influence self medication?

• policy - gov/treasury

• services - commissioning, inequalities in provision, accessibility and quality, design and implementation

• people - inequalities and deprivation, health literacy, age, legality, stigma

POLICY - what is the NHS/DHCS medicines value programme?

Policy aimed at getting the best value for money out of NHS medicines bill.

Medicines should not be routinely provided for:

• Self limiting illness

• Illnesses lending themselves to selfcare (eg:cold) - medications can be bought OTC for relief of symptoms

• Limited clinical evidence of clinical effectiveness (eg: probiotics, or vits/mins)

POLICY - what were drivers for medication policy change?

• Meds = 2nd largest proportion of NHS spend: £19.2bn 2022-23 (21% on OTC)

• Prescribed medications cost = too high

• CCGs - NHS Eng guidance: only prescribe vits/ mins if medically deficient (£48,100,000), coughs/cold &nasal congestion (£1,300,000) = only red flag symptoms, mild cystitis (£300,000)= only red flag symptoms

What did the report: Economic Impact if OTC products in the UK show?

• the value of encouraging people to take more proactive approach to their health & wellbeing by widening the scope of how to self care

• Could save the NHS £1.7bn/ yr by eliminating 25mill unnecessary GP app and 5 mill A&E visits

SERVICES - what kinds of service related factors can influence self medication as part of self care?

• Commissioning

• Inadequate provision

• Accessibility - service availability and uptake - can people afford to pay for services? how can they be changed to avoid this?

• Inclusion

• Design & implementation - need to acknowledge people factors

• User experiences - need to be positive (keep reviewing/ learning from errors)

What might be an unintended outcome/ consequence of unequal service provision or access?

Patient cohorts who may feel/ be excluded lose out on self care and seek alternatives as a result.

PEOPLE - what factors might influence who self medicates?

• Inequalities/deprivation

• Health literacy - a lot of information, but how helpful is this to some people?

• Age - high risk groups (very young/ very old)

• Legality

• Stigma

What can people self medicate with?

• OTC items - P meds, GSL items

• Herbal medications

• Vits/ mins & food supplements

• Illicit drugs

How can patients access medications for self care?

• Prescribers - GP, pharmacist, nurse, paramedics …

• Community pharmacy - p meds, GSL

• Lockable shop - GSL

• Health food shops - not licenced as meds

• Internet - anything and everything

• Black market/ counterfeit - potentially contain v.harmful substances

• Friends and Family

What are the risks of OTC medication abuse?

ADDICTION - Codeine = main medication implicated, but also decongestants (pseudenaphrine/ phenylephrine) & sedatives (promethazine/ diphenhydramine)

What is the governing body responsible for a change in license of medications?

MHRA - medicines & healthcare products regulatory body

• can encourage greater self medication/ management by moving products from POM - P (or P - GSL)

• This can require placing limits to P license compared to POM - eg: age group, indication, dose or strength ect….