Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan

BACKGROUND

Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan.

METHODS

A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines.

RESULTS

Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made.

CONCLUSION

The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.

Exploring medical and nursing students' perceptions about a patient safety course: a qualitative study

BACKGROUND

Educating health professionals on patient safety can potentially reduce healthcare-associated harm. Patient safety courses have been incorporated into medical and nursing curricula in many high-income countries and their impact has been demonstrated in the literature through objective assessments. This study aimed to explore student perceptions about a patient safety course to assess its influence on aspiring health professionals at a personal level as well as to explore differences in areas of focus between medical and nursing students.

METHODS

A dedicated patient safety course was introduced for year III medical and year II and IV nursing students at the Aga Khan University (2021-2022). As part of a post-course assessment, 577 participating students (184 medical and 393 nursing) wrote reflections on the course, detailing its influence on them. These free-text responses were thematically analyzed using NVivo.

RESULTS

The findings revealed five major themes: acquired skills (clinical, interpersonal), understanding of medical errors (increased awareness, prevention and reduction, responding to errors), personal experiences with patient safety issues, impact of course (changed perceptions, professional integrity, need for similar sessions, importance of the topic) and course feedback (format, preparation for clinical years, suggestions). Students reported a lack of baseline awareness regarding the frequency and consequences of medical errors. After the course, medical students reported a perceptional shift in favor of systems thinking regarding error causality, and nursing students focused on human factors and error prevention. The interactive course format involving scenario-based learning was deemed beneficial in terms of increasing awareness, imparting relevant clinical and interpersonal skills, and changing perspectives on patient safety.

CONCLUSIONS

Student perspectives illustrate the benefits of an early introduction of dedicated courses in imparting patient safety education to aspiring health professionals. Students reported a lack of baseline awareness of essential patient safety concepts, highlighting gaps in the existing curricula. This study can help provide an impetus for incorporating patient safety as a core component in medical and nursing curricula nationally and across the region. Additionally, patient safety courses can be tailored to emphasize areas identified as gaps among each professional group, and interprofessional education can be employed for shared learning. The authors further recommend conducting longitudinal studies to assess the long-term impact of such courses.

A Journey of Innovation: 40 years of Pioneering Medical Education at the Aga Khan University Medical College in Karachi, Pakistan

This article presents an overview of Aga Khan University's (AKU) pioneering medical education initiatives over the past 40 years, exploring its impact on healthcare in the region and its commitment to advancing medical education and research in the developing world. Established in 1983 as the first private university in Pakistan, AKU has evolved into a global institution with a focus on improving healthcare standards and addressing healthcare needs in the developing world. The article also discusses the undergraduate and postgraduate medical education programs at AKU Medical College, Pakistan, highlighting their unique features and pioneering approaches to medical education. The institution's journey highlights its ability to adapt to the evolving healthcare landscape while maintaining a focus on quality and excellence, offering a model for other institutions striving to meet healthcare needs in low- and middle-income countries.

No healthcare coverage, big problem: lack of insurance for older population associated with worse emergency general surgery outcomes

Introduction

Older populations, being a unique subset of patients, have poor outcomes for emergency general surgery (EGS). In regions lacking specialized medical coverage for older patients, disparities in healthcare provision lead to poor clinical outcomes. We aimed to identify factors predicting index admission inpatient mortality from EGS among sexagenarians, septuagenarians, and octogenarians.

Methods

Data of patients aged >60 years with EGS conditions defined by the American Association for the Surgery of Trauma at primary index admission from 2010 to 2019 operated and non-operated at a large South Asian tertiary care hospital were analyzed. The primary outcome was primary index admission inpatient 30-day mortality. Parametric survival regression using Weibull distribution was performed. Factors such as patients' insurance status and surgical intervention were assessed using adjusted HR and 95% CI with a p-value of <0.05 considered statistically significant.

Results

We included 9551 primary index admissions of patients diagnosed with the nine most common primary EGS conditions. The mean patient age was 69.55±7.59 years. Overall mortality and complication rates were 3.94% and 42.29%, respectively. Primary index admission inpatient mortality was associated with complications including cardiac arrest and septic shock. Multivariable survival analysis showed that insurance status was not associated with mortality (HR 1.13; 95% CI 0.79, 1.61) after adjusting for other variables. The odds of developing complications among self-paid individuals were higher (adjusted OR 1.17; 95% CI 1.02, 1.35).

Conclusion

Lack of healthcare coverage for older adults can result in delayed presentation, leading to increased morbidity. Close attention should be paid to such patients for timely provision of treatment. There is a need to expand primary care access and proper management of comorbidities for overall patient well-being. Government initiatives for expanding insurance coverage for older population can further enhance their healthcare access, mitigating the risk of essential treatments being withheld due to financial limitations.

Level of evidence

III.

Adolopment of clinical practice guidelines and creation of referral pathways for psychiatric conditions in Pakistan

Psychiatric disorders are highly prevalent in Pakistan and burdens the scarce number of psychiatrists present in the country. The establishment of evidence-based clinical practice guidelines (EBCPGs) and primary-care referral pathways within the local context is imperative to make the process efficient. In this Health Policy, we aimed to develop EBCPGs and primary-care referral pathways that are specific to Pakistan's primary-care setting, with the aim of facilitating the management of psychiatric conditions. Ten EBCPGs were created through the GRADE-ADOLOPMENT process; two recommendations were adopted with minor changes, 43 were excluded, and all others were adopted without any changes. Ten primary-care referral pathways for managing ten psychiatric disorders were created and 23 recommendations were added which will help to bridge the gap in care provision. These psychiatric referral pathways and EBCPGs will bring Pakistan's healthcare system a step closer to achieving optimal health outcomes for patients.

Undergraduate Medical Education Curriculum Reforms in Pakistan: A Mixed Methods Study of Academic Leadership Perspectives

PURPOSE

Periodic revision of undergraduate medical education (UGME) curricula is an essential part of evidence-based educational practices. Pakistan's national UGME curriculum, last updated in 2005, was reviewed, and recommended updates were made in 2022. The authors explore academic medical school leaders' perspectives about the proposed reforms, gaps within the existing curriculum, and how to ensure the reform implementation is effective, collaborative, and feedback-driven.

METHOD

Using a mixed methods approach, data were collected from April-July 2022. Academic leadership (principals, who could designate vice principals or medical educators) at all medical schools across Pakistan (n = 117) were invited. Agreement with each of 20 proposed reforms was measured via a survey employing a Likert scale. A semi-structured interview guide expanded on the survey questions with probes.

RESULTS

Eighty-eight survey responses, from private (59; 67.0%) and public (29; 33.0%) institutions, were obtained (75.2% response rate). Participants recommended most of the proposed reforms. The 3 reforms that received the highest agreement were teaching professionalism as an integral part of the curriculum (83; 94.3%), mandating bedside procedural skills training (80; 90.9%), and including patient safety in the UGME curriculum (79; 89.8%). Including multidisciplinary tumor boards and surgical oncology had the lowest agreement (26; 29.5%). Fifteen interviews were conducted, which revealed 3 major themes: perceptions about changes to the curricular content; limitation of human and financial resources as barriers to reform implementation; and recommendations for effective implementation of an updated curriculum.

CONCLUSIONS

The findings reflect an overall positive attitude of academic medical school leadership toward the 20 proposed UGME curriculum reforms, which could aid with on-the-ground implementation. However, major limitations, such as a lack of trained faculty and financial resources, must be addressed. The authors propose future research on the resources required for implementing UGME reforms and the reforms' impact after national implementation.

A review of top cardiology and cardiovascular medicine journal guidelines regarding the use of generative artificial intelligence tools in scientific writing

BACKGROUND

Generative Artificial Intelligence (AI) tools have experienced rapid development over the last decade and are gaining increasing popularity as assistive models in academic writing. However, the ability of AI to generate reliable and accurate research articles is a topic of debate. Major scientific journals have issued policies regarding the contribution of AI tools in scientific writing.

METHODS

We conducted a review of the author and peer reviewer guidelines of the top 25 Cardiology and Cardiovascular Medicine journals as per the 2023 SCImago rankings. Data were obtained though reviewing journal websites and directly emailing the editorial office. Descriptive data regarding journal characteristics were coded on SPSS. Subgroup analyses of the journal guidelines were conducted based on the publishing company policies.

RESULTS

Our analysis revealed that all scientific journals in our study permitted the documented use of AI in scientific writing with certain limitations as per ICMJE recommendations. We found that AI tools cannot be included in the authorship or be used for image generation, and that all authors are required to assume full responsibility of their submitted and published work. The use of generative AI tools in the peer review process is strictly prohibited.

CONCLUSION

Guidelines regarding the use of generative AI in scientific writing are standardized, detailed, and unanimously followed by all journals in our study according to the recommendations set forth by international forums. It is imperative to ensure that these policies are carefully followed and updated to maintain scientific integrity.

Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

Development and Validation of a Novel Literature-Based Method to Identify Disparity-Sensitive Surgical Quality Metrics

BACKGROUND

Disparity in surgical care impedes the delivery of uniformly high-quality care. Metrics that quantify disparity in care can help identify areas for needed intervention. A literature-based Disparity-Sensitive Score (DSS) system for surgical care was adapted by the Metrics for Equitable Access and Care in Surgery (MEASUR) group. The alignment between the MEASUR DSS and Delphi ratings of an expert advisory panel (EAP) regarding the disparity sensitivity of surgical quality metrics was assessed.

STUDY DESIGN

Using DSS criteria MEASUR co-investigators scored 534 surgical metrics which were subsequently rated by the EAP. All scores were converted to a 9-point scale. Agreement between the new measurement technique (ie DSS) and an established subjective technique (ie importance and validity ratings) were assessed using the Bland-Altman method, adjusting for the linear relationship between the paired difference and the paired average. The limit of agreement (LOA) was set at 1.96 SD (95%).

RESULTS

The percentage of DSS scores inside the LOA was 96.8% (LOA, 0.02 points) for the importance rating and 94.6% (LOA, 1.5 points) for the validity rating. In comparison, 94.4% of the 2 subjective EAP ratings were inside the LOA (0.7 points).

CONCLUSIONS

Applying the MEASUR DSS criteria using available literature allowed for identification of disparity-sensitive surgical metrics. The results suggest that this literature-based method of selecting quality metrics may be comparable to more complex consensus-based Delphi methods. In fields with robust literature, literature-based composite scores may be used to select quality metrics rather than assembling consensus panels.

Which curve is better? A comparative analysis of trauma scoring systems in a South Asian country

Objectives

A diverse set of trauma scoring systems are used globally to predict outcomes and benchmark trauma systems. There is a significant potential benefit of using these scores in low and middle-income countries (LMICs); however, its standardized use based on type of injury is still limited. Our objective is to compare trauma scoring systems between neurotrauma and polytrauma patients to identify the better predictor of mortality in low-resource settings.

Methods

Data were extracted from a digital, multicenter trauma registry implemented in South Asia for a secondary analysis. Adult patients (≥18 years) presenting with a traumatic injury from December 2021 to December 2022 were included in this study. Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Revised Trauma Score (RTS), Mechanism/GCS/Age/Pressure score and GCS/Age/Pressure score were calculated for each patient to predict in-hospital mortality. We used receiver operating characteristic curves to derive sensitivity, specificity and area under the curve (AUC) for each score, including Glasgow Coma Scale (GCS).

Results

The mean age of 2007 patients included in this study was 41.2±17.8 years, with 49.1% patients presenting with neurotrauma. The overall in-hospital mortality rate was 17.2%. GCS and RTS proved to be the best predictors of in-hospital mortality for neurotrauma (AUC: 0.885 and 0.874, respectively), while TRISS and ISS were better predictors for polytrauma patients (AUC: 0.729 and 0.722, respectively).

Conclusion

Trauma scoring systems show differing predictability for in-hospital mortality depending on the type of trauma. Therefore, it is vital to take into account the region of body injury for provision of quality trauma care. Furthermore, context-specific and injury-specific use of these scores in LMICs can enable strengthening of their trauma systems.

Level of evidence

Level III.

Methodological analysis of a community-based training initiative using the EPIS framework: an ongoing initiative to empower 10 million bystanders in CPR and bleeding control

Background

Out-of-hospital cardiac arrest (OHCA) and life-threatening bleeding from trauma are leading causes of preventable mortality globally. Early intervention from bystanders can play a pivotal role in increasing the survival rate of victims. While great efforts for bystander training have yielded positive results in high-income countries, the same has not been replicated in low and middle-income countries (LMICs) due to resources constraints. This article describes a replicable implementation model of a nationwide program, aimed at empowering 10 million bystanders with basic knowledge and skills of hands-only cardiopulmonary resuscitation (CPR) and bleeding control in a resource-limited setting.

Methods

Using the EPIS (Exploration, Preparation, Implementation and Sustainment) framework, we describe the application of a national bystander training program, named 'Pakistan Life Savers Programme (PLSP)', in an LMIC. We discuss the opportunities and challenges faced during each phase of the program's implementation and identify feasible and sustainable actions to make them reproducible in similar low-resource settings.

Results

A high mortality rate owing to OHCA and traumatic life-threatening bleeding was identified as a national issue in Pakistan. After intensive discussions during the exploration phase, PLSP was chosen as a potential solution. The preparation phase oversaw the logistical administration of the program and highlighted avenues using minimal resources to attain maximum outreach. National implementation of bystander training started as a pilot in suburban schools and expanded to other institutions, with 127 833 bystanders trained to date. Sustainability of the program was targeted through its addition in a single national curriculum taught in schools and the development of a cohesive collaborative network with entities sharing similar goals.

Conclusion

This article provides a methodological framework of implementing a national intervention based on bystander response. Such programs can increase bystander willingness and confidence in performing CPR and bleeding control, decreasing preventable deaths in countries having a high mortality burden.

Level of evidence

Level VI.

Disparities in patient-resident physician communication and counseling: A multi-perspective exploratory qualitative study

Effective communication between physicians and patients plays an integral role in clinical care. Gaps in a physician's ability to ensure effective communication, especially with patients from diverse backgrounds, are known causes of medical errors. This study explores the potential biases and disparities in patient-resident communication, which may influence a patient's quality of care. This exploratory qualitative study was conducted at the largest academic medical center in Pakistan. Purposive sampling was used to approach participants from surgery, medicine, obstetrics and gynecology, pediatrics and family medicine. Faculty, fellows and residents working in these departments and medical students in their fourth and fifth years of undergraduate education with prior experience of at least one month in these specialties during their clinical rotations were included. Focus group discussions (FGDs) lasting 45-60 minutes were conducted with each cohort of healthcare professionals separately, using a semi-structured interview guide. Sixty participants (19 males and 41 females, mean age: 32.9, SD: 10.9) took part in the study. Thematic analysis revealed five major themes. Four themes focused on residents' biases and patient disparities hindering patient-resident communication: (1) patient-resident gender discordance (2) ethnicity and language barriers, (3) differing social class of the patient, and (4) challenging patient-resident interactions (patients resistant to treatment, exceedingly inquisitive and those with multiple attendants, etc.). The fifth theme identified the need for a communication skills curriculum in postgraduate medical education. Opposite gender and discordant socioeconomic/cultural backgrounds of patients pose a challenge to effective patient-physician communication. Self-identification and awareness of residents' biases when interacting with patients can ensure their active elimination and improve their communication skills. Integrating these components in a standardized curriculum within postgraduate programs can enable resident-physicians to provide the same level of care and communicate more efficiently with patients of all backgrounds.

Barriers to research productivity amongst postgraduate trainees: results from a survey of 333 medical and surgical residents

PURPOSE

We aimed to determine the perceptions of, barriers to, and predictors of research engagement amongst residents at a national level in Pakistan.

METHODS

This cross-sectional study used REDCap for online survey dissemination to residents from 12 institutes accredited by the national accreditation body (College of Physicians and Surgeons Pakistan) for core medical and surgical specialties. Logistic regression was used to estimate associations between likelihood of publications and participant characteristics.

RESULTS

The response rate was 79% (333/423), with 171 (51%) medical and 162 (49%) surgical residents. The mean ± standard deviation age was 28.8 ± 2.7 years; 137 (41%) were males and 195 (59%) females. More than half the residents, 202 (61%), had received research training, but 189 (57%) scored <33% on basic research knowledge. While most residents agreed on the positive impact of research on their careers (P = .012) and realized that they should be involved in it (P = .33), they also strongly believed that it was difficult to engage in research during training (P < .01). Only 60 (18%) trainees had published a paper in local and 37 (11%) in international journals, respectively. The most significant barriers to conducting research included time limitation due to clinical work, lack of financial support, and unavailability of data (P < .01).

CONCLUSION

Residents have a positive attitude towards research. However, research engagement among residents is low. Improving research mentorship and creating systems that enable protected time and institutional access to data are needed to increase research output of postgraduate trainees. Key messages What is already known on this topic Postgraduate trainees benefit academically from research conducted during residency training. However, in low- and middle-income countries like Pakistan, research output among residents has remained low over the years. The nation has consistently produced very little research. What this study adds The current study helped shed light on the reasons for low research productivity amongst medical and surgical residents in Pakistan. How this study might affect research, practice, or policy The potential predictors for low research involvement highlighted in this study necessitate modification of the existing national residency curriculum to increase research engagement and productivity among residents. Not only can the potential factors be improved, but the study also helps in bringing stakeholders' attention to increasing research opportunities in Pakistan.

GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management-a Pakistani context

Due to its high prevalence, we aimed to create postmenopausal osteoporosis clinical practice guideline via GRADE-ADOLOPMENT for Pakistan. We recommend a higher dose (2000-4000 IU) of vitamin D for osteoporotic patients who are old, have malabsorption, or are obese. The guideline will help standardize care provision and improve health care outcomes for osteoporosis.

PURPOSE

Postmenopausal osteoporosis affects one in every five postmenopausal women in Pakistan. An evidence-based clinical practice guideline (CPG) is needed to standardize care provision to optimize health outcomes. Hence, we aimed to develop CPG for the management of postmenopausal osteoporosis in Pakistan.

METHODS

The GRADE-ADOLOPMENT process was used to adopt (as is or with minor changes), exclude (omit), or adapt (modify based on local context) recommendations to the source guideline (SG)-clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update from American Association of Clinical Endocrinology (AACE).

RESULTS

The SG was "adoloped" to cater to the local context. The SG consisted of 51 recommendations. Forty-five recommendations were adopted as is. Due to unavailability of drugs, 4 recommendations were adopted with minor changes, and one was excluded, while one recommendation was adopted with the inclusion of use of a surrogate FRAX tool specific for Pakistan. One recommendation regarding vitamin D dosage was adapted to recommend a dose of 2000-4000 IU of vitamin D in patients with obesity, malabsorption, and old age.

CONCLUSION

The developed Pakistani postmenopausal osteoporosis guideline consists of 50 recommendations. The guideline created recommends a higher dose (2000-4000 IU) of vitamin D for patients who are old, have malabsorption, or are obese, which is an adaptation from the SG by the AACE. This higher dose is justified as lower doses prove to be suboptimal in these groups and should be complemented with baseline vitamin D and calcium levels.

GRADE-ADOLOPMENT of clinical practice guidelines and creation of clinical pathways for the primary care management of chronic respiratory conditions in Pakistan

INTRODUCTION

In Pakistan, chronic respiratory conditions contribute a large burden of morbidity and mortality. A major reason for this is the lack of availability of local evidence-based clinical practice guidelines (EBCPGs) in Pakistan, particularly at the primary care level. Thus, we developed EBCPGs and created clinical diagnosis and referral pathways for the primary care management of chronic respiratory conditions in Pakistan.

METHODS

The source guidelines were selected by two local expert pulmonologists after a thorough literature review on PubMed and Google Scholar from 2010 to December 2021. The source guidelines covered idiopathic pulmonary fibrosis, asthma, chronic obstructive pulmonary disorders, and bronchiectasis. The GRADE-ADOLOPMENT process consists of three key elements: adoption (using recommendations as is or with minor changes), adaptation (effective context-specific changes to recommendations) or additions (including new recommendations to fill a gap in the EBCPG). We employed the GRADE-ADOLOPMENT process to adopt, adapt, adopt with minor changes, or exclude recommendations from a source guideline. Additional recommendations were added to the clinical pathways based on a best-evidence review process.

RESULTS

46 recommendations were excluded mainly due to the unavailability of recommended management in Pakistan and scope beyond the practice of general physicians. Clinical diagnosis and referral pathways were designed for the four chronic respiratory conditions, explicitly delineating the role of primary care practitioners in the diagnosis, basic management, and timely referral of patients. Across the four conditions, 18 recommendations were added (seven for IPF, three for bronchiectasis, four for COPD, and four for asthma).

CONCLUSION

The widespread use of the newly created EBCPGs and clinical pathways in the primary healthcare system of Pakistan can help alleviate the morbidity and mortality related to chronic respiratory conditions disease in the country.

Leveraging the vantage point - exploring nurses' perception of residents' communication skills: a mixed-methods study

INTRODUCTION

Effective communication is key to a successful patient-doctor interaction and improved healthcare outcomes. However, communication skills training in residency is often subpar, leading to inadequate patient-physician communication. There is a dearth of studies exploring the observations of nurses - key members of healthcare teams with a special vantage point to observe the impact of residents' communication with patients. Thus, we aimed to gauge the perceptions of nurses regarding residents' communication skills expertise.

METHODS

This study employed a sequential mixed-methods design, and was conducted at an academic medical center in South Asia. Quantitative data was collected via a REDCap survey using a structured validated questionnaire. Ordinal logistic regression was applied. For qualitative data, In-depth interviews were conducted with nurses using a semi-structured interview guide.

RESULTS

A total of 193 survey responses were obtained from nurses hailing from various specialties including Family Medicine (n = 16), Surgery (n = 27), Internal Medicine (n = 22), Pediatrics (n = 27), and Obstetrics/Gynecology (n = 93). Nurses rated long working hours, infrastructural deficits, and human failings as the main barriers to effective patient-resident communication. Residents working in in-patient settings were more likely to have inadequate communication skills (P-value = 0.160). Qualitative data analysis of nine in-depth interviews revealed two major themes: existing status-quo of residents' communication skills (including deficient verbal and non-verbal communication, bias in patient counselling and challenging patients) and recommendations for improving patient-resident communication.

CONCLUSION

The findings from this study highlight significant gaps in patient-resident communication from the perception of nurses and identify the need for creating a holistic curriculum for residents to improve patient-physician interaction.

Adolopment of adult diabetes mellitus management guidelines for a Pakistani context: Methodology and challenges

Introduction

Pakistan has the highest national prevalence of type 2 diabetes mellitus (T2DM) in the world. Most high-quality T2DM clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local T2DM CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of adult DM in Pakistan.

Methods

We employed the GRADE-ADOLOPMENT approach utilizing the T2DM CPG of the American Diabetes Association (ADA) Standards of Medical Care in Diabetes - 2021 as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context.

Results

The source document contained 243 recommendations, 219 of which were adopted without change, 5 with minor changes, and 18 of which were excluded in the newly created Pakistani guidelines. One recommendation was adapted: the recommended age to begin screening all individuals for T2DM/pre-diabetes was lowered from 45 to 30 years, due to the higher prevalence of T2DM in younger Pakistanis. Exclusion of recommendations were primarily due to differences in the healthcare systems of Pakistan and the US, or the unavailability of certain drugs in Pakistan.

Conclusion

A CPG for the management of T2DM in Pakistan was created. Our newly developed guideline recommends earlier screening for T2DM in Pakistan, primarily due to the higher prevalence of T2DM amongst younger individuals in Pakistan. Moreover, the systematic methodology used is a significant improvement on pre-existing T2DM CPGs in Pakistan. Once these evidence based CGPs are officially published, their nationwide uptake should be top priority. Our findings also highlight the need for rigorous expanded research exploring the effectiveness of earlier screening for T2DM in Pakistan.

Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes

OBJECTIVE

The aim of this study was to critically evaluate whether admission at the beginning versus end of the academic year is associated with increased risk of major adverse outcomes.

SUMMARY BACKGROUND DATA

The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989. Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published before December 20, 2019, looking for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching versus nonteach-ing hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression.

RESULTS

A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Metaanalyses of mortality [odds ratio (95% confidence interval): 1.01 (0.98-1.05)] and major morbidity [1.01 (0.99-1.04)] demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions.

CONCLUSION

The preponderance of negative results over the past 30 years suggests that it might be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.

Disparity-Sensitive Measures in Surgical Care: A Delphi Panel Consensus

BACKGROUND

In the US, disparities in surgical care impede the delivery of uniformly high-quality care to all patients. There is a lack of disparity-sensitive measures related to surgical care. The American College of Surgeons Metrics for Equitable Access and Care in Surgery group, through research and expert consensus, aimed to identify disparity-sensitive measures in surgical care.

STUDY DESIGN

An environmental scan, systematic literature review, and subspecialty society surveys were conducted to identify potential disparity-sensitive surgical measures. A modified Delphi process was conducted where panelists rated measures on both importance and validity. In addition, a novel literature-based disparity-sensitive scoring process was used.

RESULTS

We identified 841 potential disparity-sensitive surgical measures. From these, our Delphi and literature-based approaches yielded a consensus list of 125 candidate disparity-sensitive measures. These measures were rated as both valid and important and were supported by the existing literature.

CONCLUSION

There are profound disparities in surgical care within the US healthcare system. A multidisciplinary Delphi panel identified 125 potential disparity-sensitive surgical measures that could be used to track health disparities, evaluate the impact of focused interventions, and reduce healthcare inequity.

Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey

BACKGROUND

In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes.

METHODS

Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.

RESULTS

Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions.

CONCLUSION

This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Developing a communication-skills training curriculum for resident-physicians to enhance patient outcomes at an academic medical centre: an ongoing mixed-methods study protocol

INTRODUCTION

Effective physician-patient communication is directly linked to enhanced patient safety, improved healthcare quality and health outcomes. Numerous studies have been done to implement and reinforce communication skills as core competencies to be acquired during residency training for providing culturally competent care. Pakistan has an ethnically diverse culture with people from varying diasporas. Hence there is a need to develop a curriculum that teaches cultural competency to residents. Thus, the aim of this study is (1) the identification of existing problems of communication skills among residents across various specialties, and (2) to strategise a communication skills curriculum by organising a conference of experts based on the Delphi method/estimate-talk-estimate method.

METHODS AND ANALYSIS

This study is divided into two phases. The first phase will employ a mixed-methods approach whereby the perceptions of attendings, residents, fellows, nurses, medical students and patients about resident-patient communication will be assessed via validated surveys, focused group discussions and in-depth interviews. Quantitative and qualitative data will be analysed using Stata and NVivo, respectively. The second phase is the development of a communication skills curriculum for residents based on results from phase one and a Delphi consensus involving medical education experts. Both phases will be conducted at a tertiary care hospital in Karachi, Pakistan.

ETHICS AND DISSEMINATION

This study has received ethical approval from the Ethical Review Committee at the Aga Khan University (2021-6041-17126). All participants will be mandated to provide informed consent and their confidentiality will be maintained by using de-identifiers and limiting access of the data to the research team only. The findings from this study will be presented in the form of original research papers.

Core outcome measures for research in traumatic injury survivors: The National Trauma Research Action Plan modified Delphi consensus study

BACKGROUND

Until recently, survival has been the main outcome measure for injury research. Given the impact of injury on quality of life, the National Academies of Science, Engineering, and Medicine has called for advancing the science of research evaluating the long-term outcomes of trauma survivors. This is necessary so that treatments and interventions can be assessed for their impact on a trauma patients' long-term functional and psychosocial outcomes. We sought to propose a set of core domains and measurement instruments that are best suited to evaluate long-term outcomes after traumatic injury with a goal for these measures to be adopted as a national standard.

METHODS

As part of the development of a National Trauma Research Action Plan, we conducted a two-stage, five-round modified online Delphi consensus process with a diverse panel of 50 key stakeholders including clinicians, researchers, and trauma survivors from more than 9 professional areas across the United States. Before voting, panelists reviewed the results of a scoping review on patient-reported outcomes after injury and standardized information on measurement instruments following the Consensus-based Standards for the Selection of Health Measurement Instruments guidelines.

RESULTS

The panel considered a preliminary list of 74 outcome domains (patient-reported outcomes) and ultimately reached the a priori consensus criteria for 29 core domains that encompass aspects of physical, mental, social, and cognitive health. Among these 29 core domains, the panel considered a preliminary list of 199 patient-reported outcome measures and reached the a priori consensus criteria for 14 measures across 13 core domains. Participation of panelists ranged from 65% to 98% across the five Delphi rounds.

CONCLUSION

We developed a core outcome measurement set that will facilitate the synthesis, comparison, and interpretation of long-term trauma outcomes research. These measures should be prioritized in all future studies in which researchers elect to evaluate long-term outcomes of traumatic injury survivors.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, Level IV.

Impact of wire sensor location on coronary physiological measurement

Background

The location of the wire sensor to measure FFR and dPR has not been systemically studied. Therefore, we hypothesize that the coronary physiological measurements will vary with the location of the sensor. This exploratory study is to assess whole cycle pressure distal/pressure aorta (Pd/Pa) ratio, FFR, and dPR at different sensor position within the vessel to evaluate the impact of pressure drop and measurements based on sensor position.

Methods

54 patients who had an indication for coronary angiography were screened and 30 consecutive patients were enrolled. The OptoWire 2 or 3 generation fiberoptic pressure wire was used to assess Pd/Pa, dPR, and FFR. Our primary goal is to test if those measurements vary with the FFR wire sensor placed at 10mm (proximal), 35–45mm (mid), and greater than or equal 60–70mm (distal) distal to the target lesion respectively. We used a multilevel linear regression approach.

Results

Of 30 patients enrolled, 23 (76.6%) were males, mean age was 64.7 years (± 11.0 yrs), and mean stenosis was 61.6% (±13.4%). Adjusting for age, gender, and severity of stenosis, results showed that for all three measures (Pd/Pa, DPR, and FFR) (Figure 1), pressure decreased in a linear fashion the further the sensor was from the target lesion (p values &lt;0.001). Further, pairwise comparisons of the measurements at adjacent locations similarly showed significant declines in pressure (p values &lt;0.001).

Conclusions

This is first study to demonstrate that the location of the pressure wire can impact the results of both resting and hyperemic pressures which can cause a false negative result. This is especially important where the values are near the cut-off.

Funding Acknowledgement

Type of funding sources: None.

Patient reported outcomes 6 to 12 months after interpersonal violence: A multicenter cohort study

PURPOSE

Violence continues to be a significant public health burden, but little is known about the long-term outcomes of these patients. Our goal was to determine the impact of violence-related trauma on long-term functional and psychosocial outcomes.

METHODS

We identified trauma patients with moderate to severe injuries (Injury Severity Score, ≥9) treated at one of three level 1 trauma centers. These patients were asked to complete a survey over the phone between 6 and 12 months after injury evaluating both functional and psychosocial outcomes (12-item Short Form Survey, Trauma Quality of Life, posttraumatic stress disorder [PTSD] screen, chronic pain, return to work). Patients were classified as having suffered a violent injury if the mechanism of injury was a stab, gunshot, or assault. Self-inflicted wounds were excluded. Adjusted logistic regression models were built to determine the association between a violent mechanism of injury and long-term outcomes.

RESULTS

A total of 1,050 moderate to severely injured patients were successfully followed, of whom 176 (16.8%) were victims of violence. For the victims of violence, mean age was 34.4 years (SD, 12.5 years), 85% were male, and 57.5% were Black; 30.7% reported newly needing help with at least one activity of daily living after the violence-related event. Fifty-nine (49.2%) of 120 patients who were working before their injury had not yet returned to work; 47.1% screened positive for PTSD, and 52.3% reported chronic pain. On multivariate analysis, a violent mechanism was significantly associated with PTSD (odds ratio, 2.57; 95% confidence interval, 1.59-4.17; p < 0.001) but not associated with chronic pain, return to work, or functional outcomes.

CONCLUSION

The physical and mental health burden after violence-related trauma is not insignificant. Further work is needed to identify intervention strategies and social support systems that may be beneficial to reduce this burden.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.