Inappropriate laboratory test utilization in outpatient tertiary care: Implications for value-based healthcare.

OBJECTIVES: To assess the rate of inappropriate repetition of laboratory testing and estimate the cost of such testing for thyroid stimulating hormone (TSH), total cholesterol, vitamin D, and vitamin B12 tests. METHODS: A retrospective cohort study was carried out in the Family Medicine and Polyclinic Department at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. Clinical and laboratory data were collected between 2018-2021 for the 4 laboratory tests. The inappropriate repetition of tests was defined according to international guidelines and the costs were calculated using the hospital prices. RESULTS: A total of 109,929 laboratory tests carried out on 23,280 patients were included in this study. The percentage of inappropriate tests, as per the study criteria, was estimated to be 6.1% of all repeated tests. Additionally, the estimated total cost wasted amounted to 2,364,410 Saudi Riyals. Age exhibited a weak positive correlation with the total number of inappropriate tests (r=0.196, p=0.001). Furthermore, significant differences were observed in the medians of the total number of inappropriate tests among genders and nationalities (p<0.001). CONCLUSION: The study identified significantly high rates of inadequate repetitions of frequently requested laboratory tests. Urgent action is therefore crucial to overcoming such an issue.

Comparing Coronary Artery Calcium Scoring With Cardiac Risk Scores for Predicting Cardiovascular Events in Primary Care Patients in Saudi Arabia.

Background Cardiovascular diseases are the leading cause of death in Saudi Arabia, and cardiac risk-stratification scoring methods are critical in the primary healthcare setting to predict and potentially prevent the fatal outcomes of CVD. Therefore, this study aimed to examine the prognostic value of coronary artery calcium scoring (CACS) and other cardiac risk-stratification scores: arteriosclerotic cardiovascular disease (ASCVD) risk estimator, cardiovascular risk score (QRISK2), and triglyceride glucose index (TyG) in primary healthcare facilities in Riyadh, Saudi Arabia. Methods A retrospective cohort study was conducted at Family Medicine Clinics, and data on patient's demographics, medical records, and chronic illnesses obtained from the Integrated Clinical Information System (ICIS) database that were recorded between 2010 and 2019 were analyzed. We performed descriptive statistics, student's t-test, analysis of variance (ANOVA), Pearson correlation, Cohen's Kappa, and regression analyses. Results QRISK (p<0.001) and ASCVD (p<0.05) risk estimators positively correlated with the CACS score in predicting fatal and non-fatal cardiac outcomes while the TyG score had the lowest prediction ability among all the other risk estimators. CACS (OR = 1.003; 95% CI: 1.005 -1.002) (p<0.001), ASCVD (OR = 18.177; 95%CI: 214.578 - 1.540) (p=0.021), and QRISK2 (OR=154.796; 95%CI: 4137.356 - 5.792) (p=0.003) significantly predict stenosis unlike the TyG score's statistically insignificant prediction (p>0.05). Conclusion These findings show that ASCVD and QRISK2 are consistent with CACS and are effective risk indicators that could be used to predict cardiac-associated fatal and non-fatal cardiac events among primary care patients. This indicates that the integration of multiple risk scores, as necessary, can all contribute to more effective risk assessment and prevention of coronary artery diseases and related cardiovascular events.

Identification and Characterization of Preventable Adverse Drug Events in Family Medicine Clinics from Central Saudi Arabia.

Background: Medication errors can result in adverse drug events (ADEs) and cause considerable patient harm. Limited data are available from Saudi Arabia and the Middle East regarding the prevalence of preventable adverse drug events (pADEs) in primary care settings. Objectives: To estimate the period prevalence of pADEs and assess the medication error severity in primary care setting in Saudi Arabia. Methods: This retrospective study is a continuation of a previous study where 117 of 2000 adult patients managed at the Family Medicine clinics of King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, were identified to have had least one medication error in the past 15 months. The electronic health records of these 117 patients were analyzed for a 3-month post-medication error period to explore the presence of pADE. Medication errors were categorized according to the National Coordinating Council for Medication Error Reporting and Prevention index (NCC MERP) and the occurrence of pADE was assessed using the NCC MERP scheme. Results: Of the included 117 patients, 9 (7.7% [95% confidence interval (CI): 2.79-12.59]) experienced pADE (Category E), while 108 (92.3% [95% CI: 87.97-98.35]) did not (Category C). All patients who experienced pADE were using over-the-counter medications and were on polypharmacy. Outcomes 2a and 2b (asthma and ß-blocker) accounted for two and four cases, respectively, while Outcomes 6 (warfarin and international normalized ratio), 7 (lithium and lithium level), 16 (new oral anti-coagulant or warfarin and antiplatelet), and 17 (acetylsalicylic acid [aspirin] and antiplatelet) each accounted for one case. Conclusions: This study provides the period prevalence of patients with pADEs from Family Medicine clinics at a major tertiary hospital of Saudi Arabia, and highlights the need for a multicenter study of clinically important medication errors at the prescribing and monitoring stages for the development of quality improvement programs.

Association Between Lipid Profile Measurements and Mortality Outcomes Among Older Adults in a Primary Care Setting: A Retrospective Cohort Study.

Background Lipid profile components play a role in predicting the development of cardiovascular disease and hence mortality, but recent studies have shown mixed results in the older population. The aim of our study was to investigate the association between levels of lipid profile components with all-cause mortality and cardiovascular outcomes among older adults in a primary care setting in Riyadh, Saudi Arabia. Methods A retrospective cohort study was performed among 485 individuals aged 60 years and older who visited the family medicine clinics linked to a tertiary care hospital during the first six months of 2010. The electronic charts of the participants were reviewed up to April 2022 to gather relevant data. Each lipid profile component, including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs), was categorized into four quartiles. LDL was calculated using the Friedewald formula. Cardiovascular outcomes included ischemic heart disease (IHD), heart failure (HF), and stroke. Results The mean follow-up period was 12 years. The elderly participants with the lowest HDL-C quartile (<1.1 mmol/L) were at higher risk of all-cause mortality (adjusted hazard ratio of 2.023 (95% CI 1.21-3.38)) and IHD (adjusted hazard ratio 3.2 (95% CI 1.6-6.2)). High TC (≥5.7 mmol/L) was associated with an increased risk of HF (adjusted hazard ratio 2.1 (95% CI 1.1-4.0)). Conclusion In patients aged 60 years and older, low HDL-C (<1.1 mmol/L) was associated with a higher risk for all-cause mortality and IHD, and high TC was associated with an increased risk of having HF. No significant association was found for LDL-C, TC, and TGs with all-cause mortality.

Breast Cancer Diagnosis and Survival among Patients Diagnosed by a Structured Community Based Screening Program Compared to Opportunistic Diagnosis: A Case Control Study.

INTRODUCTION: Breast cancer is ranked as the most common type of cancer effecting women worldwide. Early detection is associated with improved morbidity and mortality, along with decreased recurrence rates, due to regular breast cancer screening recommendations advised for women over the age of 40. Women in the Kingdom of Saudi Arabia (KSA) typically present with advanced symptoms at later stages due to lower-than-average rates of breast cancer awareness and screening. METHODS: A case-control study was conducted utilizing data collected over 20 years in the primary care clinics linked to at a tertiary hospital to demonstrate the role of structured breast cancer screening programs within well-established primary care setting. Results were compared with outcomes of cancer cases diagnosed in the community through opportunistic diagnosis. RESULTS: A total 292 patients included in the study had an overall mean survival time of 160 months, with a statistically significant higher survival time noted amongst the primary care group of 49 patients (p<0.01) by approximately 85 months. Clinical stages and clinical response rates between the two patient groups were found to be statistically significant (p<0.01), where 35 (73.3%) primary care patients were stage IIA and below, compared to 41 (30%) oncology patients. Patients who were diagnosed with breast cancer in the primary care group with well-established breast cancer screening programs were noted to present with breast cancer at earlier stages, have better prognosis and lower mortality as opposed to the oncology patient group. CONCLUSION: Our study highlights the need of structured breast cancer screening programs within well supported primary health services in Saudi Arabia and the region. Such programs were associated with improved survival outcomes and more favorable clinical responses. There is an urgent need to enable primary care services with the appropriate resources to significantly impact patient morbidity and mortality.

The yield of fecal occult blood testing as a screening tool for colon cancer in a primary care setting.

Background/Aims: The most common cancer among men and the third most common among women in Saudi Arabia is colon cancer. This study aimed to evaluate the yield of the fecal occult blood test (FOBT) used as a screening tool for colon cancer. Settings and Design: Medical records of all patients above the age of 50 years who had visited the Family Medicine clinic at King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia and who had undergone the FOBT screening between January 2002 and March 2017 were retrospectively reviewed. Materials and Methods: We collected patients' demographic data, FOBT results, and colonoscopy pathology reports results. Statistical Analysis: Data were analyzed using the Statistical Package for Social Science Version 25 (IBM Corp., Armonk, NY, USA). Results: We included 2179 patients in this study. The mean age was 59.8 ± 8 years. As a result of the FOBT screening, 19.7% of the patients had a positive FOBT. Colon cancer accounted for 3.5% of all abnormal colonoscopy pathology reports. The Saudi age-standardized incidence rate (ASIR) in our study was 26.56 per 100,000 persons. Conclusion: FOBT is a feasible tool that can be used for colon cancer screening in primary care settings. The Saudi ASIR in our study was higher than the Saudi Cancer Registry, but it was still lower in comparison to other countries. We recommend the establishment of a national community-based colon cancer screening program.

Awareness of medical law among health care practitioners in Saudi Arabia.

OBJECTIVES: To determine the level of awareness of medical law among healthcare practitioners and to identify factors that influence that level of awareness in Saudi Arabia. METHODS: This cross-sectional study was carried out in Riyadh, Saudi Arabia in 2020-2021 via a survey including 750 healthcare practitioners, from different specialties including all regions in Saudi Arabia. Participants included consultants, senior registrars, interns, and residents. RESULTS: Majority of enrolled healthcare practitioners had poor awareness of medical law (approximately 97%). Only 1.5% had adequate awareness of medical law, and only 1.5% had moderate awareness. Factors associated with increased medical law awareness were the age group between 25 and 34, being from the central region, and having a clinical practice for less than 10 years p-value of <0.05. CONCLUSION: Awareness of medical law among healthcare practitioners is limited in Saudi Arabia. Professional medico-legal education should be part of required competencies for undergraduate and postgraduate levels of medical education. Health care practitioners must be educated with laws and regulations of practicing health professions in the country.

Clinical and epidemiological aspects of herpes zoster disease in a primary care setting in Riyadh, Saudi Arabia: A retrospective cohort study.

Context: Herpes zoster (HZ), or shingles, is one of the most common infectious diseases. HZ can be associated with other diseases, such as cancer and immunocompromised conditions. Thus, early recognition of the disease characteristics and clinical manifestations is critical to decrease the disease burden and to avoid further complications. Aim: To assess the epidemiology of HZ disease, its clinical manifestations, coexisting and post-existing conditions, complications, and management among patients in a primary care setting. Subjects and Methods: This was a retrospective, single-armed, cohort study. Data of all patients diagnosed with HZ, aged 18 years and older, who visited the Family Medicine Department at King Faisal Specialist Hospital and Research Center from January 2014 to August 2021 were reviewed from their medical records. All data analyses were performed using IBM Statistical Package for the Social Sciences (SPSS) statistical software, version 20.0. Results: A total of 330 cases were included over the study period. The male-to-female ratio was 1:2, with a higher occurrence of HZ (44.5%) in those aged ≥ 50 years. Only 4.5% of the patients were recipients of zoster vaccines. Thoracic dermatome was the most affected dermatome (38%). The most common coexisting disease was diabetes (21.5%). The most common post-existing disease was cardiovascular disease (3%), and the most common complication was postherpetic neuralgia (15.2%). Suboptimal dosage of acyclovir was the most commonly used treatment for HZ infections (69.7%). Conclusions: Zoster vaccination uptake was low. A national program for adult vaccination, including zoster vaccination, should be developed, and a guideline to direct primary health-care professionals in the management of HZ infections should be implemented.

Attitude of parents towards seasonal influenza vaccination for children in Saudi Arabia.

INTRODUCTION: The aim of this study is to assess attitudes, beliefs, and behavior towards seasonal influenza vaccination for children among parents in Saudi Arabia and to correlate parental demographic characteristics with hesitancy. METHODOLOGY: This is a cross-sectional study conducted in the Family Medicine clinics linked to a tertiary referral hospital in Riyadh. Inclusion criteria were: being a parent, having a child aged six months to 14 years whom is following at that hospital, and living in Saudi Arabia. The Parent Attitudes about Childhood Vaccines (PACV) survey was used for data collection. Demographic questions were added. RESULTS: The number of participants was 388. Out of these, 298 (76.8%) parents were not hesitant for their child to get vaccinated. Whereas 90 (23.2%) parents were hesitant. Parental gender and age were the only demographic factors found to have a statistically significant impact on their hesitant behavior. For the influenza season of 2018-2019, 148 (38.14%) children received the influenza vaccine. The most common reason for not receiving it was the belief that the vaccine is not necessary. While 25 (27.78%) of the 90 parents who were hesitant allowed their child to get vaccinated, 123 (41.28%) of the 298 parents who were not hesitant allowed their child to get vaccinated, creating a statistically significant difference (p = 0.0255). CONCLUSION: Despite the overall positive attitude and low hesitancy, the vaccine uptake was low. Improving access, education about the importance of the vaccine, advocacy from doctors, and correction of misconceptions about it will facilitate an increase in the uptake.

The yield of pap smears and its characteristics in a community based setting in Saudi Arabia.

OBJECTIVES: To assess the yield of Papanicolaou tests (pap smears), including the characteristics of abnormal pap smears. Methods: In this record-based cross-sectional study, we reviewed pap smears of patients seen at the Family Medicine clinics, King Faisal Specialist Hospital and Research Center from January 2002 to January 2017. All women between the ages of 21 and 65 were included. Study-specific case report form was developed to capture patient demographics, pap smear histopathology (Bethesda III System), human papilloma virus polymerase chain reaction (HPV PCR), and the parity status. Results: A total of 3346 patients were included; 2.2% had abnormal pap smear. Most frequent abnormalities were atypical squamous cells of undetermined significance (2%), followed by glandular cell abnormalities (0.8%). Human papilloma virus infection was detected in 6.5% and all other infections were identified in 9.2% of all screened Pap smears. Conclusion: Pap smears remain an effective tool for cervical cancer screening. Low yields of pap smears compared to other developed countries could be attributed to lower risk factors for cervical cancer in Saudi Arabia. Routine screening especially among high risk women is strongly recommended.

Yield of prostate cancer screening at a community based clinic in Saudi Arabia.

OBJECTIVES: To estimate the incidence and prevalence of prostate cancer in Saudi Arabia. METHODS: This is a retrospective cohort study including male patients aged 40 years and over. The prostate-specific antigen screening tests were carried out in a community-based clinic affiliated with King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia between September 2002 and December 2016. RESULTS: A total of 2,160 male patients were included in the study. Of these, 1,521 (70%) were Saudi nationals and 639 (30%) were non-Saudi nationals. A total of 108 (5%) patients underwent a prostate biopsy. The biopsy results confirmed that 31 (2%) Saudi patients and 6 (0.93%) non-Saudi patients had prostate adenocarcinoma. The age-standardized incidence rate of prostate cancer in the Saudi male population is 70 per 100,000 males. Nearly two-thirds (71%) of the Saudi patients' prostate cancer was found to be in the early stages. Conclusion: The prevalence of prostate cancer in the Saudi male population is higher than that reported by the Saudi Cancer Registry; however, it is low compared with prevalences in developed countries. The mortality rate is also very low. Prostate-specific antigen screening in Saudi Arabia should not be carried out routinely; instead, it should only be carried out on an individual basis.

The process of litigation for medical errors in Saudi Arabia and the United Kingdom.

Efficient process of litigation of medical errors is a key to ensure fair, speedy, and accessible justice system. The conditions of establishing medical negligence are similar in both legal systems. These conditions include the duty of care, breach of that duty of care, the damages, and establishing causation. A culture of litigation and compensation is growing in the United Kingdom and Kingdom of Saudi Arabia; however the cost of medical claims and awarded compensations are much more in the United Kingdom compared to Kingdom of Saudi Arabia. In Kingdom of Saudi Arabia, there is a need for more transparency in the documentation and publication of litigated medical errors. In addition, there is a need to introduce interventions to shorten the duration of litigation in both legal systems. Financial caps on awarded compensation and caps on expert and legal fees are potential strategies to control the cost of medical errors which seems to work well in the Saudi model.

The role of renin blockers in the prevention of diabetes.

OBJECTIVE: To evaluate the role of renin blockers angiotensin converting enzymes inhibitors (ACEI) or angiotensin receptor blockers (ARB) in the prevention of diabetes. METHODS: We did a meta-analysis using the Cochrane group methodology of all available randomized controlled trials (RCTs) that evaluated the role of renin blockers in which outcomes of new-onset diabetes was reported. This meta-analysis was conducted between April 2005-April 2006 at King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia. RESULTS: Thirteen trials including 91,388 individuals met the inclusion criteria. There was a statistically significant reduction in the incidence of new-onset diabetes in patients receiving renin blockers compared to other antihypertensive agents [relative risks=0.79; 95% confidence interval=0.75-0.84). There was a statistically significant reduction in the incidence of new-onset diabetes in patients receiving renin-blockers compared to diuretics, conventional antihypertensive therapy (diuretics or beta-blockers), and calcium channel blockers. CONCLUSION: Renin blockers reduce the incidence of new-onset diabetes and should be considered as first line therapy, when indicated, in patients at high risk for diabetes.

The role of vitamin E in the prevention of coronary events and stroke. Meta-analysis of randomized controlled trials.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the world. Vitamin E as an anti-oxidant vitamin, was suggested to have a role in the prevention of CVD. We did a meta-analysis, using the Cochrane Group Methodology, of all available randomized controlled trials (RCTs) to evaluate the role of vitamin E in the prevention of CVD. Nine studies met inclusion criteria, including 80,645 participants. Vitamin E supplementation was not associated with a reduction in total mortality or total CVD mortality, but it was associated with a small statistically significant reduction in non-fatal myocardial infarction in patients with pre-existing coronary artery disease. Prophylactic use of vitamin E in doses ranging between 50-800 IU was not associated with any increase in the incidence of serious side effects.

The role of vitamin E in the prevention of coronary events and stroke. Meta-analysis of randomized controlled trials.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the world. Vitamin E as an anti-oxidant vitamin, was suggested to have a role in the prevention of CVD. We did a meta-analysis, using the Cochrane Group Methodology, of all available randomized controlled trials (RCTs) to evaluate the role of vitamin E in the prevention of CVD. Nine studies met inclusion criteria, including 80,645 participants. Vitamin E supplementation was not associated with a reduction in total mortality or total CVD mortality, but it was associated with a small statistically significant reduction in non-fatal myocardial infarction in patients with pre-existing coronary artery disease. Prophylactic use of vitamin E in doses ranging between 50-800 IU was not associated with any increase in the incidence of serious side effects.