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The ultimate purpose of diabetes care is achieving the outcomes that patients regard as important throughout the life course. Despite advances in pharmaceuticals, nutraceuticals, psychoeducational programs, information technologies, and digital health, the levels of treatment target achievement in people with diabetes mellitus (DM) have remained suboptimal. This clinical care of people with DM is highly challenging, complex, costly, and confounded for patients, physicians, and healthcare systems. One key underlying problem is clinical inertia in general and therapeutic inertia (TI) in particular. TI refers to healthcare providers’ failure to modify therapy appropriately when treatment goals are not met. TI therefore relates to the prescribing decisions made by healthcare professionals, such as doctors, nurses, and pharmacists. The known causes of TI include factors at the level of the physician (50%), patient (30%), and health system (20%). Although TI is often multifactorial, the literature suggests that 28% of strategies are targeted at multiple levels of causes, 38% at the patient level, 26% at the healthcare professional level, and only 8% at the healthcare system level. The most effective interventions against TI are shorter intervals until revisit appointments and empowering nurses, diabetes educators, and pharmacists to review treatments and modify prescriptions.
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Objectives@#The aim of these Clinical Practice Guidelines is to provide evidence-based recommendations to assist healthcare providers in the screening, diagnosis and management of patients with postmenopausal osteoporosis (OP). @*Methods@#A list of key clinical questions on the assessment, diagnosis and treatment of OP was formulated. A literature search using the PubMed, Medline, Cochrane Databases of Systematic Reviews, and OVID electronic databases identified all relevant articles on OP based on the key clinical questions, from 2014 onwards, to update from the 2015 edition. The articles were graded using the SIGN50 format. For each statement, studies with the highest level of evidence were used to frame the recommendation. @*Results@#This article summarizes the diagnostic and treatment pathways for postmenopausal OP. Risk stratification of patients with OP encompasses clinical risk factors, bone mineral density measurements and FRAX risk estimates. Non-pharmacological measures including adequate calcium and vitamin D, regular exercise and falls prevention are recommended. Pharmacological measures depend on patients’ fracture risk status. Very high-risk individuals are recommended for treatment with an anabolic agent, if available, followed by an anti-resorptive agent. Alternatively, parenteral anti-resorptive agents can be used. High-risk individuals should be treated with anti-resorptive agents. In low-risk individuals, menopausal hormone replacement or selective estrogen receptor modulators can be used, if indicated. Patients should be assessed regularly to monitor treatment response and treatment adjusted, as appropriate. @*Conclusions@#The pathways for the management of postmenopausal OP in Malaysia have been updated. Incorporation of fracture risk stratification can guide appropriate treatment.
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@#Introduction: The Patient Assessment on Chronic Illness Care (PACIC) was developed to assess patients’ perspectives on the alignment of primary care to the chronic care model. The Malay PACIC has been validated; however, Malaysia is a multicultural society, and English is spoken by many Malaysians and expatriates. We sought to validate the English version of the PACIC among patients with diabetes mellitus in Malaysia, as Malaysians may interpret a questionnaire that was originally developed for Americans in a different way. Method: This study was conducted between November and December 2016 at two primary care clinics that offered integrated diabetes care at the time. These sites were selected to assess the discriminative validity of the PACIC. Site 1 is a Malaysian Ministry of Health-run primary care clinic while site 2 is a university-run hospital-based primary care clinic. Only site 1 annually monitors patient performance and encourages them to achieve their HbA1c targets using a standard checklist. Patients with diabetes mellitus who understood English were recruited. Participants were asked to fill out the PACIC at baseline and two weeks later. Results: A total of 200 out of the 212 invited agreed to participate (response rate=94.3%). Confirmatory factor analysis confirmed the 5-factor structure of the PACIC. The overall PACIC score and the score in two of the five domains were significantly higher at site 1 than at site 2. The overall Cronbach’s alpha was 0.924. At test-retest, intra-class correlation coefficient values ranged from 0.641 to 0.882. Conclusion: The English version of the PACIC was found to be a valid and reliable instrument to assess the quality of care among patients with diabetes mellitus in Malaysia.
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OBJECTIVES: To compare and assess the performance of 6 osteoporosis risk assessment tools for screening osteoporosis in Malaysian postmenopausal women. METHODS: Six osteoporosis risk assessments tools (the Simple Calculated Osteoporosis Risk Estimation [SCORE], the Osteoporosis Risk Assessment Instrument, the Age Bulk One or Never Estrogen, the body weight, the Malaysian Osteoporosis Screening Tool, and the Osteoporosis Self-Assessment Tool for Asians) were used to screen postmenopausal women who had not been previously diagnosed with osteoporosis/osteopenia. These women also underwent a dual-energy X-ray absorptiometry (DXA) scan to confirm the absence or presence of osteoporosis. RESULTS: A total of 164/224 participants were recruited (response rate, 73.2%), of which only 150/164 (91.5%) completed their DXA scan. Sixteen participants (10.7%) were found to have osteoporosis, whilst 65/150 (43.3%) were found to have osteopenia. Using precision-recall curves, the recall of the tools ranged from 0.50 to 1.00, whilst precision ranged from 0.04 to 0.14. The area under the curve (AUC) ranged from 0.027 to 0.161. The SCORE had the best balance between recall (1.00), precision (0.04–0.12), and AUC (0.072–0.161). CONCLUSIONS: We found that the SCORE had the best balance between recall, precision, and AUC among the 6 screening tools that were compared among Malaysian postmenopausal women.
Subject(s)
Female , Humans , Absorptiometry, Photon , Area Under Curve , Body Weight , Bone Diseases, Metabolic , Estrogens , Malaysia , Mass Screening , Osteoporosis , Risk Assessment , Self-AssessmentABSTRACT
Objective: To determine the validity and reliability of the Chinese parent proxy and child self-report health related quality of life measure for children with epilepsy (CHEQOL-25) in Malaysia. Methods: Face and content validity of the Chinese parent proxy and child self-report CHEQOL-25 was verified by an expert panel, and piloted in five children with epilepsy (CWE). The Chinese CHEQOL-25 was then administered to 40 parent proxies and their CWE (aged 8-18 years), from two tertiary hospitals, at baseline and 2 weeks later. Results: Forty parents and their CWE were recruited. Cronbach’s alpha for each subscale ranged from 0.56-0.83. At test-retest, the interclass correlation for all items ranged from 0.68-0.97. Items 8 and 25 were removed as their corrected item-total correlation values were <0.3. Epilepsy severity, the number of anti-epileptic drugs taken daily, number of close friends and number of time spent with friends were found to be associated with the parent proxy CHEQOL-25 score. Duration of epilepsy, child’s cognitive ability, number of close friends and number of time spent with friends were associated with child self-report CHEQOL-25. The parent proxy and the child selfreport showed high to fair agreement on the “interpersonal/social” [Intraclass correlation coefficient (ICC)=0.670, p<0.001] and “epilepsy secrecy” subscale (ICC=0.417, p=0.048). Conclusions: Our small study found that the Chinese CHEQOL-25 was a valid and reliable questionnaire to assess the quality of life of children with epilepsy from the parent prospective and child self-report when items 8 and 25 were removed.
Subject(s)
EpilepsyABSTRACT
<p><b>INTRODUCTION</b>The aim of this study was to determine the extent to which primary care doctors assessed patients newly diagnosed with hypertension for the risk factors of cardiovascular disease (CVD) during the patients' first clinic visit for hypertension. The study also aimed to examine the trend of assessment for CVD risk factors over a 15-year period.</p><p><b>METHODS</b>This retrospective study was conducted between January and May 2012. Data was extracted from the paper-based medical records of patients with hypertension using a 1:4 systematic random sampling method. Data collected included CVD risk factors and a history of target organ damage (TOD), which were identified during the patient's first visit to the primary care doctor for hypertension, as well as the results of the physical examinations and investigations performed during the same visit.</p><p><b>RESULTS</b>A total of 1,060 medical records were reviewed. We found that assessment of CVD risk factors during the first clinic visit for hypertension was poor (5.4%-40.8%). Assessments for a history of TOD were found in only 5.8%-11.8% of the records, and documented physical examinations and investigations for the assessment of TOD and secondary hypertension ranged from 0.1%-63.3%. Over time, there was a decreasing trend in the percentage of documented physical examinations performed, but an increasing trend in the percentage of investigations ordered.</p><p><b>CONCLUSION</b>There was poor assessment of the patients' CVD risk factors, secondary causes of hypertension and TOD at their first clinic visit for hypertension. The trends observed in the assessment suggest an over-reliance on investigations over clinical examinations.</p>