Management of diabetes patients with comorbidity in primary care: a mixed-method study in Odisha, India.

BACKGROUND: Diabetes patients with comorbidities need regular and comprehensive care for their disease management. Hence, it is essential to assess the primary care preparedness for managing diabetes patients and the perspectives of the diabetes patients on the care received at the primary care facilities. METHODS: All 21 Urban Primary Health Centres (UPHCs) in Bhubaneswar city of Odisha, India, were assessed using the modified Primary Care Evaluation Tool and WHO Package of Essential Non-communicable disease interventions questionnaire. Additionally, 21 diabetes patients with comorbidities were interviewed in-depth to explore their perception of the care received at the primary care facilities. RESULTS: All the UPHCs had provisions to meet the basic requirements for the management of diabetes and common comorbidities like hypertension. There were few provisions for chronic kidney illness, cardiovascular disease, mental health, and cancer. Diabetes patients felt that frequent change in primary care physicians at the primary care facilities affected their continuity of care. Easy accessibility, availability of free medicines, and provisions of basic laboratory tests at the facilities were felt to be necessary by the diabetes patients. CONCLUSION: Our study highlights the existing gaps in India's healthcare system preparedness and the needs of diabetes patients with comorbidity. The government of India's Health and Wellness (HWC) scheme aims to deliver comprehensive healthcare to the population and provide holistic care at the primary care level for NCD patients. It is imperative that there is an early implementation of the various components of the HWC scheme to provide optimal care to diabetes patients.

Clusters of medical specialties around patients with multimorbidity - employing fuzzy c-means clustering to explore multidisciplinary collaboration.

BACKGROUND: Hospital care organization, structured around medical specialties and focused on the separate treatment of individual organ systems, is challenged by the increasing prevalence of multimorbidity. To support the hospitals' realization of multidisciplinary care, we hypothesized that using machine learning on clinical data helps to identify groups of medical specialties who are simultaneously involved in hospital care for patients with multimorbidity. METHODS: We conducted a cross-sectional study of patients in a Dutch general hospital and used a fuzzy c-means clustering algorithm for the analysis. We explored the patients' membership degrees in each cluster to identify subgroups of medical specialties that provide care to the same patients with multimorbidity. We used retrospectively collected electronic health record data from 2017. We extracted data from 22,133 patients aged ≥18 years who had received outpatient clinical care for two or more chronic and/ or oncological diagnoses. RESULTS: We found six clusters of medical specialties and identified 22 subgroups. The clusters were labeled based on the specialties that most characterized them: 1. dermatology/ plastic surgery, 2. six specialties (gynecology/ rheumatology/ orthopedic surgery/ urology/ gastroenterology/ otorhinolaryngology), 3. pulmonology, 4. internal medicine/ cardiology/ geriatrics, 5. neurology/ physiatry (rehabilitation)/ anesthesiology, and 6. internal medicine. Most patients had a full or dominant membership to one of these clusters of medical specialties (11 subgroups), whereas fewer patients had a membership to two clusters. The prevalence of specific diagnosis groups, patient characteristics, and healthcare utilization differed between subgroups. CONCLUSION: Our study shows that clusters and subgroups of medical specialties simultaneously involved in hospital care for patients with multimorbidity can be identified with fuzzy c-means cluster analysis using clinical data. Clusters and subgroups differed regarding the involved medical specialties, diagnoses, patient characteristics, and healthcare utilization. With this strategy, hospitals and medical specialists can further analyze which subgroups are target populations that might benefit from improved multidisciplinary collaboration.

Managing diabetes mellitus with comorbidities in primary healthcare facilities in urban settings: a qualitative study among physicians in Odisha, India.

AIM: To explore the perceived barriers and facilitators in the management of the patients having diabetes with comorbidities by primary care physicians. METHODS: A qualitative In-Depth Interview study was conducted among the primary care physicians at seventeen urban primary health care centres at Bhubaneswar city of Odisha, India. The digitally recorded interviews were transcribed verbatim and translated into English. The data were analysed using thematic analysis. RESULTS: Barriers related to physicians, patients and health system were identified. Physicians felt lack of necessary knowledge and skills, communication skills and overburdening due to multiple responsibilities to be major barriers to quality care. Patients' attitude and beliefs along with socio-economic status played an important role in treatment adherence and in the management of their disease conditions. Poor infrastructure, irregular medicine supply, and shortage of skilled allied health professionals were also found to be barriers to optimal care delivery, as was the lack of electronic medical records and personal treatment records. CONCLUSION: Comprehensive guidelines with on the job training for capacity building of the physicians and creation of multidisciplinary teams at primary care level for a more holistic approach towards management of diabetes with comorbidities could be the way forward to optimal delivery of care.

Optimising personal continuity for older patients in general practice: a study protocol for a cluster randomised stepped wedge pragmatic trial.

BACKGROUND: Continuity of care, in particular personal continuity, is a core principle of general practice and is associated with many benefits such as a better patient-provider relationship and lower mortality. However, personal continuity is under pressure due to changes in society and healthcare. This affects older patients more than younger patients. As the number of older patients will double the coming decades, an intervention to optimise personal continuity for this group is highly warranted. METHODS: Following the UK Medical Research Council framework for complex Interventions, we will develop and evaluate an intervention to optimise personal continuity for older patients in general practice. In phase 0, we will perform a literature study to provide the theoretical basis for the intervention. In phase I we will define the components of the intervention by performing surveys and focus groups among patients, general practitioners, practice assistants and practice nurses, concluded by a Delphi study among members of our group. In phase II, we will test and finalise the intervention with input from a pilot study in two general practices. In phase III, we will perform a stepped wedge cluster randomised pragmatic trial. The primary outcome measure is continuity of care from the patients' perspective, measured by the Nijmegen Continuity Questionnaire. Secondary outcome measures are level of implementation, barriers and facilitators for implementation, acceptability and feasibility of the intervention. In phase IV, we will establish the conditions for large-scale implementation. DISCUSSION: This is the first study to investigate an intervention for improving personal continuity for older patients in general practice. If proven effective, our intervention will enable General practitioners to improve the quality of care for their increasing population of older patients. The pragmatic design of the study will enable evaluation in real-life conditions, facilitating future implementation. TRIAL REGISTRATION NUMBER: Netherlands Trial Register, trial NL8132 . Registered 2 November 2019.

α-Blockers for uncomplicated ureteric stones: a clinical practice guideline.

OBJECTIVE: To develop an evidence-based recommendation concerning the use of α-blockers for uncomplicated ureteric stones based on an up-to-date Cochrane review, as the role of medical expulsive therapy for uncomplicated ureteric stones remains controversial in the light of new contradictory trial evidence. METHODS: We applied the Rapid Recommendations approach to guideline development, which represents an innovative approach by an international collaborative network of clinicians, researchers, methodologists and patient representatives seeking to rapidly respond to new, potentially practice-changing evidence with recommendations developed according to standards for trustworthy guidelines. RESULTS: The panel suggests the use of α-blockers in addition to standard care over standard care alone in patients with uncomplicated ureteric stones (weak recommendation based on low-quality evidence). The panel judged that the net benefit of α-blockers was small and that there was considerable uncertainty about patients' values and preferences. This means that the panel expects that most patients would choose treatment with α-blockers but that a substantial proportion would not. This recommendation applies to both patients in whom the presence of ureteric stones is confirmed by imaging, as well as patients in whom the diagnosis is made based on clinical grounds only. CONCLUSION: The Rapid Recommendations panel suggests the use of α-blockers for patients with ureteric stones. Shared decision-making is emphasised in making the final choice between the treatment options.

A three-goal model for patients with multimorbidity: A qualitative approach.

BACKGROUND: To meet the challenge of multimorbidity in decision making, a switch from a disease-oriented to a goal-oriented approach could be beneficial for patients and clinicians. More insight about the concept and the implementation of this approach in clinical practice is needed. OBJECTIVE: This study aimed to develop conceptual descriptions of goal-oriented care by examining the perspectives of general practitioners (GPs) and clinical geriatricians (CGs), and how the concept relates to collaborative communication and shared decision making with elderly patients with multimorbidity. METHOD: Qualitative interviews with GPs and CGs were conducted and analyzed using thematic analysis. RESULTS: Clinicians distinguished disease- or symptom-specific goals, functional goals and a new type of goals, which we labelled as fundamental goals. "Fundamental goals" are goals specifying patient's priorities in life, related to their values and core relationships. These fundamental goals can be considered implicitly or explicitly in decision making or can be ignored. Reasons to explicate goals are the potential mismatch between medical standards and patient preferences and the need to know individual patient values in case of multimorbidity, including the management in acute situations. CONCLUSION: Based on the perspectives of clinicians, we expanded the concept of goal-oriented care by identifying a three-level goal hierarchy. This model could facilitate collaborative goal-setting for patients with multiple long-term conditions in clinical practice. Future research is needed to refine and validate this model and to provide specific guidance for medical training and practice.

The availability and effectiveness of tools supporting shared decision making in metastatic breast cancer care: a review.

BACKGROUND: Shared decision-making (SDM) in the management of metastatic breast cancer care is associated with positive patient outcomes. In daily clinical practice, however, SDM is not fully integrated yet. Initiatives to improve the implementation of SDM would be helpful. The aim of this review was to assess the availability and effectiveness of tools supporting SDM in metastatic breast cancer care. METHODS: Literature databases were systematically searched for articles published since 2006 focusing on the development or evaluation of tools to improve information-provision and to support decision-making in metastatic breast cancer care. Internet searches and experts identified additional tools. Data from included tools were extracted and the evaluation of tools was appraised using the GRADE grading system. RESULTS: The literature search yielded five instruments. In addition, two tools were identified via internet searches and consultation of experts. Four tools were specifically developed for supporting SDM in metastatic breast cancer, the other three tools focused on metastatic cancer in general. Tools were mainly applicable across the care process, and usable for decisions on supportive care with or without chemotherapy. All tools were designed for patients to be used before a consultation with the physician. Effects on patient outcomes were generally weakly positive although most tools were not studied in well-designed studies. CONCLUSIONS: Despite its recognized importance, only two tools were positively evaluated on effectiveness and are available to support patients with metastatic breast cancer in SDM. These tools show promising results in pilot studies and focus on different aspects of care. However, their effectiveness should be confirmed in well-designed studies before implementation in clinical practice. Innovation and development of SDM tools targeting clinicians as well as patients during a clinical encounter is recommended.

Review of guidance on recurrence risk management for general practitioners in breast cancer, colorectal cancer and melanoma guidelines.

Background: General practitioners (GPs) will face cancer recurrences more frequently due to the rising number of cancer survivors and greater involvement of GPs in the follow-up care. Currently, GPs are uncertain about managing recurrence risks and may need more guidance. Objective: To explore what guidance is available for GPs on managing recurrence risks for breast cancer, colorectal cancer and melanoma, and to examine whether recurrence risk management differs between these tumour types. Methods: Breast cancer, colorectal cancer and melanoma clinical practice guidelines were identified via searches on internet and the literature, and experts were approached to identify guidelines. Guidance on recurrence risk management that was (potentially) relevant for GPs was extracted and summarized into topics. Results: We included 24 breast cancer, 21 colorectal cancer and 15 melanoma guidelines. Identified topics on recurrence risk management were rather similar among the three tumour types. The main issue in the guidelines was recurrence detection through consecutive diagnostic testing. Guidelines agree on both routine and nonroutine tests, but, recommended frequencies for follow-up are inconsistent, except for mammography screening for breast cancer. Only six guidelines provided targeted guidance for GPs. Conclusion: This inventory shows that recurrence risk management has overlapping areas between tumour types, making it more feasible for GPs to provide this care. However, few guidance on recurrence risk management is specific for GPs. Recommendations on time intervals of consecutive diagnostic tests are inconsistent, making it difficult for GPs to manage recurrence risks and illustrating the need for more guidance targeted for GPs.

A framework for crafting clinical practice guidelines that are relevant to the care and management of people with multimorbidity.

Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensus-based recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.

Towards efficient use of research resources: a nationwide database of ongoing primary care research projects in the Netherlands.

UNLABELLED: PURPOSE. Although in the last decades primary care research has evolved with great success, there is a growing need to prioritize the topics given the limited resources available. Therefore, we constructed a nationwide database of ongoing primary care research projects in the Netherlands, and we assessed if the distribution of research topics matched with primary care practice. METHODS: We conducted a survey among the main primary care research centres in the Netherlands and gathered details of all ongoing primary care research projects. We classified the projects according to research topic, relation to professional guidelines and knowledge deficits, collaborative partners and funding source. Subsequently, we compared the frequency distribution of clinical topics of research projects to the prevalence of problems in primary care practice. RESULTS: We identified 296 ongoing primary care research projects from 11 research centres. Most projects were designed as randomized controlled trial (35%) or observational cohort (34%), and government funded mostly (60%). Thematically, most research projects addressed chronic diseases, mainly cardiovascular risk management (8%), depressive disorders (8%) and diabetes mellitus (7%). One-fifth of the projects was related to defined knowledge deficits in primary care guidelines. From a clinical primary care perspective, research projects on dermatological problems were significantly underrepresented (P = 0.01). CONCLUSIONS: This survey of ongoing projects demonstrates that primary care research has a firm basis in the Netherlands, with a strong focus on chronic disease. The fit with primary care practice can improve, and future research should address knowledge deficits in professional guidelines more.

Effects of a multicomponent communication training to involve older people in decisions to DEPRESCRIBE cardiometabolic medication in primary care (CO-DEPRESCRIBE): protocol for a cluster randomized controlled trial with embedded process and economic evaluation.

BACKGROUND: Deprescribing of medication for cardiovascular risk factors and diabetes has been incorporated in clinical guidelines but proves to be difficult to implement in primary care. Training of healthcare providers is needed to enhance deprescribing in eligible patients. This study will examine the effects of a blended training program aimed at initiating and conducting constructive deprescribing consultations with patients. METHODS: A cluster-randomized trial will be conducted in which local pharmacy-general practice teams in the Netherlands will be randomized to conducting clinical medication reviews with patients as usual (control) or after receiving the CO-DEPRESCRIBE training program (intervention). People of 75 years and older using specific cardiometabolic medication (diabetes drugs, antihypertensives, statins) and eligible for a medication review will be included. The CO-DEPRESCRIBE intervention is based on previous work and applies models for patient-centered communication and shared decision making. It consists of 5 training modules with supportive tools. The primary outcome is the percentage of patients with at least 1 cardiometabolic medication deintensified. Secondary outcomes include patient involvement in decision making, healthcare provider communication skills, health/medication-related outcomes, attitudes towards deprescribing, medication regimen complexity and health-related quality of life. Additional safety and cost parameters will be collected. It is estimated that 167 patients per study arm are needed in the final intention-to-treat analysis using a mixed effects model. Taking loss to follow-up into account, 40 teams are asked to recruit 10 patients each. A baseline and 6-months follow-up assessment, a process evaluation, and a cost-effectiveness analysis will be conducted. DISCUSSION: The hypothesis is that the training program will lead to more proactive and patient-centered deprescribing of cardiometabolic medication. By a comprehensive evaluation, an increase in knowledge needed for sustainable implementation of deprescribing in primary care is expected. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov (identifier: NCT05507177).

[Managing multimorbidity is more than counting the number of conditions]. / Zorg voor multimorbiditeit is meer dan het tellen van ziektes.

The prevalence of patients with multimorbidity, defined by two chronic conditions is rapidly increasing. Defining multimorbidity remains challenging, with varying criteria in research. A recent study by MacRae et al. examined the impact of the number and selection of conditions on estimated multimorbidity prevalence, revealing significant variations from 4.6% to 40.5%. To standardize the definition for research, MacRae et al. recommend using three measurement instruments (Ho always + usually, Barnett, or Fortin condition-lists) to consistently measure prevalence over time. Multimorbidity's complexity is not adequately captured by dichotomous definitions, as this depends on context and purpose. Chronic diseases profoundly affect daily life, leading to reduced physical function and adverse psychosocial outcomes. Patients often experience increased stress, anxiety, and depression, which can further exacerbate somatic conditions. To assess multimorbidity from a patient perspective, considering experienced health and quality of life indicators like ADL functioning, mobility, mood, memory, and social factors is crucial. Effectively managing multimorbidity requires a holistic, tailored approach, including identifying and prioritizing key health issues, promoting self-management, proactive care planning, and coordinating treatments. Understanding the potential for differential treatment effects and considering individual life expectancy is vital. Multimorbidity also places a significant burden on healthcare systems, leading to fragmented care, communication gaps, and increased costs. Identifying complex disease clusters with high mortality and resource utilization can guide integrated care efforts. In less complex cases, primary care physicians can collaborate to provide comprehensive care. Multimorbidity remains a priority in healthcare, necessitating appropriate measurement and tailored interventions for diverse populations.

A Delphi consensus checklist helped assess the need to develop rapid guideline recommendations.

BACKGROUND AND OBJECTIVES: We aimed to develop a checklist to aid guideline developers in determining which scientific or societal cause ("triggers") are relevant when considering to initiate a rapid recommendation procedure. METHODS: We conducted a two-round modified Delphi procedure with a panel of Dutch guideline experts, clinicians, and patient representatives. A previously conducted systematic literature review and semistructured interviews with four science journalists were used to generate a list of potential items. This item list was submitted to the panel for discussion, reduction and refinement into a checklist. RESULTS: Thirteen experts took part. Two questionnaires were completed in which participants scored an initial list of 64 items based on relevance. During two online meetings, the scores were discussed, irrelevant items were removed, and relevant items were reformulated into seven questions. The final "quickscan assessment of the need for a rapid recommendation" covers user perspective, scientific evidence, clinical relevance, clinical practice variation, applicability, quality of care and public health outcomes, and ethical/legal considerations. CONCLUSION: The quickscan aids guideline developers in systematically assessing whether a trigger expresses a valid need for developing a rapid recommendation. Future research could focus on the applicability and validity of the checklist within guideline development programs.

Feasibility of a wiki as a participatory tool for patients in clinical guideline development.

BACKGROUND: Patient participation is essential in developing high-quality guidelines but faces practical challenges. Evidence on timing, methods, evaluations, and outcomes of methodologies for patient participation in guideline development is lacking. OBJECTIVE: To assess the feasibility of a wiki as a participatory tool for patients in the development of a guideline on infertility determined by (1) use of the wiki (number of page views and visitors), (2) benefits of the wiki (ie, number, content, and eligibility of the recommendations to be integrated into the guideline), and (3) patients' facilitators of and barriers to adoption, and the potential challenges to be overcome in improving this wiki. METHODS: To obtain initial content for the wiki, we conducted in-depth interviews (n = 12) with infertile patients. Transcripts from the interviews were translated into 90 draft recommendations. These were presented on a wiki. Over 7 months, infertile patients were invited through advertisements or mailings to formulate new or modify existing recommendations. After modifying the recommendations, we asked patients to select their top 5 or top 3 recommendations for each of 5 sections on fertility care. Finally, the guideline development group assessed the eligibility of the final set of recommendations within the scope of the guideline. We used a multimethod evaluation strategy to assess the feasibility of the wiki as a participatory tool for patients in guideline development. RESULTS: The wiki attracted 298 unique visitors, yielding 289 recommendations. We assessed the 21 recommendations ranked as the top 5 or top 3 for their eligibility for being integrated into the clinical practice guideline. The evaluation identified some challenges needed to be met to improve the wiki tool, concerning its ease of use, website content and layout, and characteristics of the wiki tool. CONCLUSIONS: The wiki is a promising and feasible participatory tool for patients in guideline development. A modified version of this tool including new modalities (eg, automatically limiting the number and length of recommendations, using a fixed format for recommendations, including a motivation page, and adding a continuous prioritization system) should be developed and evaluated in a patient-centered design.

[Are guidelines still supportive in clinical practice?] / Zijn richtlijnen nog ondersteunend in de praktijk?

Clinical practice guidelines are fundamental to support knowledge and decision making of healthcare professionals in many disciplines. They can contribute to reducing undesirable practice variation, educating patients, and monitoring care. However, the burden increases if the number and size of guidelines continues to increase and as more side effects occur due to injudicious use, both in the professional and policy setting. Restricting the scope and finding the right balance between completeness and conciseness are major challenges for guideline developers and stakeholders. Ongoing innovation projects are working on improving accessibility, updating, and applicability in multimorbidity through optimal use of digital technologies. As long as healthcare professionals are in the lead in guideline development and involved in policy making, doctors can continue to rely on guidelines, if used correctly for the right care.

[Coordinating and tailoring hospital care for patients with multimorbidity: who will take the lead?] / Regie bij multimorbiditeit in het ziekenhuis.

OBJECTIVE: To gain insight in medical specialists' and nurse practitioners' opinions on multimorbidity and coordination and tailoring of hospital care. DESIGN: Exploratory mixed-method design. METHOD: From August 2018 until January 2019, 35 Dutch medical associations were asked to forward a digital survey with open- and close-ended questions to their members. We used qualitative and quantitative methods to analyze the data. The main themes were identified with inductive, thematic analysis. RESULTS: There were 554 respondents from 22 associations, 43% of the medical specialist respondents were internist (n=221). The qualitative analysis of the answers regarding what is required in hospital care for patients with multimorbidity resulted in eight themes at the patient's, professional's and hospital organization's level. To the open question about who should take the lead, respondents most often answered the geriatrician or internist, followed by the general practitioner, 'the care professional who is treating the main problem', a nurse practitioner/physician assistant and the 'attending physician of the primary team'. All geriatricians and almost all internists felt they possessed the competencies to take the lead in hospital care for patients with multimorbidity. CONCLUSION: Medical specialists' and nurse practitioners' diverse ideas about who should take the lead in hospital care for patients with multimorbidity were a noteworthy finding. It is important to start local conversations about how to divide roles and responsibilities regarding the coordination and tailoring of hospital care for patients with multimorbidity.

Development and internal validation of prediction models for future hospital care utilization by patients with multimorbidity using electronic health record data.

OBJECTIVE: To develop and internally validate prediction models for future hospital care utilization in patients with multiple chronic conditions. DESIGN: Retrospective cohort study. SETTING: A teaching hospital in the Netherlands (542 beds). PARTICIPANTS: All adult patients (n = 18.180) who received care at the outpatient clinic in 2017 for two chronic diagnoses or more (including oncological diagnoses) and who returned for hospital care or outpatient clinical care in 2018. Development and validation using a stratified random split-sample (n = 12.120 for development, n = 6.060 for internal validation). OUTCOMES: ≥2 emergency department visits in 2018, ≥1 hospitalization in 2018 and ≥12 outpatient visits in 2018. STATISTICAL ANALYSIS: Multivariable logistic regression with forward selection. RESULTS: Evaluation of the models' performance showed c-statistics of 0.70 (95% CI 0.69-0.72) for the hospitalization model, 0.72 (95% CI 0.70-0.74) for the ED visits model and 0.76 (95% 0.74-0.77) for the outpatient visits model. With regard to calibration, there was agreement between lower predicted and observed probability for all models, but the models overestimated the probability for patients with higher predicted probabilities. CONCLUSIONS: These models showed promising results for further development of prediction models for future healthcare utilization using data from local electronic health records. This could be the first step in developing automated alert systems in electronic health records for identifying patients with multimorbidity with higher risk for high healthcare utilization, who might benefit from a more integrated care approach.

Health care utilization and out-of-pocket expenditure of type 2 diabetic patients: A study in primary care in Bhubaneswar, India.

Background: Globally, noncommunicable diseases (NCD) demand a higher healthcare expenditure. Among NCDs, diabetes mellitus is often associated with multiple, co-existing chronic conditions. In low- and middle-income countries where most of the healthcare expenditure is borne out of pocket, diabetes management may pose a significant financial stress. Methods: A cross-sectional study was conducted in 17 urban primary healthcare facilities of Bhubaneswar to assess the healthcare utilization and out-of-pocket expenditure among type 2 diabetes patients attending these facilities. Healthcare utilization was determined by the number of visits to healthcare facilities in the last 6 months, and out-of-pocket expenditure was assessed by outpatient consultation fees, medicines, travels to health care facilities, and diagnostic tests. Total out-of-pocket expenditure was defined as the sum of these costs. Results: The median number of visits in 6 months for diabetes patients with any comorbidity was 4 and 5 for diabetes patients with more than 4 comorbidities. Among the comorbid conditions, depression, stroke, auditory impairment, and acid peptic disease were associated with higher healthcare utilization. The total out-of-pocket expense was 2.3 times higher among diabetes patients with any comorbid condition compared to patients with diabetes only. The total median expenditure was higher for diabetes patients having stroke, heart diseases, kidney diseases, and cancer compared with other comorbid conditions. The association of comorbidity in diabetes patients with health care utilization and out-of-pocket expenditure is statistically significant after adjustment for sociodemographic characteristics and diabetes duration. Conclusion: Considerable expenditure is incurred by diabetes patients attending primary healthcare facilities for the management of diabetes and other chronic conditions. This is a significant burden for diabetes patients below the poverty line and with limited or no insurance cover. There is a need to increase the coverage of insurance schemes to address the chronic conditions management expenditure of outpatients.

Do clinical practice guidelines consider evidence about diagnostic test consequences on patient-relevant outcomes? A critical document analysis.

RATIONALE, AIMS AND OBJECTIVES: Supporting evidence for diagnostic test recommendations in clinical practice guidelines (CPGs) should not only include diagnostic accuracy, but also downstream consequences of the test result on patient-relevant outcomes. The aim of this study is to assess the extent to which evidence-based CPGs about diagnostic tests cover all relevant test-treatment pathway components. METHODS: We performed a systematic document analysis and quality assessment of publicly accessible CPGs about three common diagnostic tests: C-reactive protein, colonoscopy and fractional exhaled nitric oxide. Evaluation of the impact of the full test-treatment pathway (diagnostic accuracy, burden of the test, natural course of target condition, treatment effectiveness, and link between test result and administration of treatment) on patient relevant outcomes was considered best practice for developing medical test recommendations. RESULTS: We retrieved 15 recommendations in 15 CPGs. The methodological quality of the CPGs varied from poor to excellent. Ten recommendations considered diagnostic accuracy. Four of these were funded on a systematic review and rating of the certainty in the evidence. None of the CPGs evaluated all steps of the test-treatment pathway. Burden of the test was considered in three CPGs, but without systematically reviewing the evidence. Natural course was considered in two CPGs, without a systematic review of the evidence. In three recommendations, treatment effectiveness was considered, supported with a systematic review and rating of the certainty in the evidence in one CPG. The link between test result and treatment administration was not considered in any CPG. CONCLUSIONS: The included CPGs hardly seem to consider evidence about test consequences on patient-relevant outcomes. This might be explained by reporting issues and challenging methodology. Future research is needed to investigate how to facilitate guideline developers in explicit reliable consideration of all steps of a test-treatment pathway when developing diagnostic test recommendations.