Integrating a Community-Based Health Information System with a Patient-Centered Medical Home to improve care of patients with hypertension: a longitudinal observational study protocol.

BACKGROUND: The primary healthcare system in Pakistan focuses on providing episodic, disease-based care. Health care for low-middle income communities is largely through a fee-for-service model that ignores preventive and health-promotive services. The growing burden of cardiovascular illnesses requires restructuring of the primary health care system allowing a community-to-clinic model of care to improve patient- and community-level health indicators. METHODS: We propose a model that integrates a Patient-Centered Medical Home (PCMH) with a Community-Based Health Information System (CBHIS) using hypertension (HTN) as an example. This protocol describes the integration and evaluation of the PCMH-CBHIS infrastructure through a population-based, observational, longitudinal study in a low-middle income, urban community in Pakistan. Participants are being enrolled in CBHIS and will be followed longitudinally over two years for HTN outcomes. A mixed-methods approach is adopted to evaluate the process of integrating PCMH with CBHIS. This involves building partnerships with the community through formal and informal meetings, focus group discussions, and a household health assessment survey (HAS). Community members identified with HTN are linked to PCMH for disease management. A customized electronic medical record system links community-level data with patient-level data to track changes in disease burden. The RE-AIM evaluation framework will be used to monitor community and individual-level metrics to guide implementation assessment, the potential for generalization, and the effectiveness of the PCMH in improving HTN-related health outcomes. Ethical clearance has been obtained from the Ethics Review Committee at Aga Khan University (2022-6723-20985). DISCUSSION: This study will evaluate the value of restructuring the primary care health system by ensuring systematic community engagement and measurement of health indicators at the patient- and community-level. While HTN is being used as a prototype to generate evidence for the effectiveness of this model, findings from this initiative will be leveraged towards strengthening the management of other acute and chronic conditions in primary care settings. If effective, the model can be used in Pakistan and other LMICs and resource-limited settings.

The role of family and culture in the disclosure of bad news: A multicentre cross-sectional study in Pakistan.

Objectives: Disclosure of bad news is distressing for patients and family members. Our aim was to assess patients' perceptions and preferences regarding bad news in the health setting. Methods: Cross-sectional, multi-centered study supported by an external grant in 15 Government and Private Hospitals across Pakistan. A sample size of 1673 patients and family members was used. Ethics permission/consent was taken from each participating hospital and participant. Responses were compared across provinces, gender, age, education and income. Results: >80% patients preferred their relatives to know the diagnosis first and they wanted the news to be disclosed to them by doctors. Significant association between education level, income and preference for wanting to know the diagnosis was found. Reasons for wanting to know the diagnosis included treatment, prognosis and prevention options whereas reasons for not wanting to know included fear of emotions and God's will. Conclusion: The majority of Pakistani patients want to be informed and want the family to know first. Preferences for disclosure vary across, age, education and income level. Innovation: First countrywide study on this topic. Identifies need for culturally sensitive guidelines that include the family's role in disclosure of bad news.

Evaluation of postgraduate family medicine trainee's knowledge and attitude following an online Educational Module in Palliative Care: A descriptive study.

Objectives: To identify improvement in knowledge and attitude of Family Medicine (FM) postgraduate trainees (PGT) towards Palliative care (PC) in order to provide effective care to the patients with advanced disease. Methods: A cross-sectional study was conducted over eight weeks from 1st July till 3rd September 2021 at Family Medicine Department, Aga Khan University Hospital (AKUH). PGT who willingly signed the written informed consent were enrolled in the study. Descriptive analysis, frequencies, proportions and thematic approach were used for data analysis. Data was analyzed using SPSS version 23. Results: FM-PGT were included in the study. Improvement in knowledge was observed in posttest scores along with positive change in their attitude and improved perception of level of confidence for managing PC patients. Overall assessment of PCM was positive. Conclusion: This PCM seems to be a useful tool for PC training in postgraduate medical education (PGME). This highlights some useful aspects for future applications in PC education and training.

Assessing knowledge, attitudes, and practices of emergency department staff towards patients with suicidal behaviors in Pakistan.

The study aimed to assess knowledge, attitudes and practices of Emergency Department staff towards patients with suicidal behaviors at a tertiary care hospital in Karachi Pakistan. An online survey found that majority of respondents were unaware of the law regarding suicide and self-harm (SH) in Pakistan. Majority had not received any specific training in management of suicidal patients. About 50 % of doctors and 16 % of nurses felt that SH patients are treated 'less seriously than patients with medical problems.' Institutional policy on management and pathway to care for suicidal patients should be disseminated and monitored for its implications in clinical practice.

Patterns of suicide and self-harm in Pakistan: a retrospective descriptive study protocol.

INTRODUCTION: Suicide is a major global public health problem. Low-income and middle-income countries contribute 78% of all suicidal deaths. Pakistan, a South Asian country, lacks official statistics on suicides at national level. Statistics on suicide are neither collected nationally nor published in the annual national morbidity and mortality surveys. Medicolegal reports on suicides and self-harm are extremely rich and important source of information but greatly underused in Pakistan. We aim to examine the patterns of suicides and self-harm retrospectively in patients who were registered with medicolegal centres (MLCs) in Karachi, during the period January 2017 to December 2021. METHODS AND ANALYSIS: Using retrospective descriptive design, the data will be collected from the medical records maintained at the main office of the Karachi police surgeon. Data from all nine MLCs of Karachi are collated and stored at the main office of Police surgeon. Information on suicide and self-harm cases will be extracted from records of all MLCs. The data will be collected using structured proforma and it will be analysed using descriptive and inferential analysis. ETHICS AND DISSEMINATION: The study was approved for exemption from Aga Khan University, Ethical Review Committee. The findings of the study will be disseminated by conducting seminars for healthcare professionals and stakeholders including psychiatrists, psychologists, counsellors, medicolegal officers, police surgeons, mental health nurses, general and public health physicians and policy makers. Findings will be published in local and international peer-reviewed scientific journals.

Needs assessment survey regarding effectiveness of chronic care in diabetes in a hospital setting.

OBJECTIVE: To assess the current knowledge level about diabetes and acceptance of nurse-led educational programmes among diabetic patients. Methods: The cross-sectional study was conducted at a community health centre in Karachi from August, 2018 to December, 2019 and comprised adult patients of either gender with diabetes. Data was collected using a predesigned questionnaire to record demographic information, participants' DM knowledge, self-management aspects and their opinions along with preferences for a DM educational support group. Data was analysed using STATA/SE 15.1. RESULTS: Of the 215 participants, 80(37%) were males and 135(63%) were females. The overall mean age was 55.8±14.5 yrs. Most participants had diabetes for ≥5 years 127(59%) and 141(66%) did not know their type of diabetes. Most participants were prescribed anti-diabetic medications 201(94%), and 45(2%) had forgotten to take their medication recently. Insulin was being used by 65(30%) participants, and, among them, 27(42%) reused syringes. Most patients struggled to make lifestyle modifications 133(62%), and 144 (67%) were willing to attend nurse-led diabetic education sessions. Conclusion: There was found to be a need of diabetes education support programme to address knowledge deficiencies, and a nurse-led programme was found to be acceptable to the majority of study subjects.

Development of Palliative Care Services at a Tertiary Care Teaching Hospital in Pakistan: Retrospective Analysis of Existing Palliative Care Program.

CONTEXT: Palliative care (PC) is an important aspect of providing holistic care to patients and their families who are dealing with a serious or life limiting illness. Medical community and public poorly understand the implications and benefits of these services. Unfortunately, because of this, PC remains a neglected area of healthcare in the most institutions of Pakistan. OBJECTIVES: We sought to review the current structure, barriers in context of growing need for PC, possible means to overcome these challenges and future perspectives at tertiary care hospital. METHODS: Retrospective longitudinal cross-sectional study was done using data from 2017 to 2019 in the section of PC at Aga Khan University Hospital (AKUH). RESULTS: PC program has been self-sustainable and serving 3747 patients in 2017-2019. The results show that palliative care services (PCS) are well integrated for oncology with all three models of PCS delivery. Most of the patients opted for comfort code during hospital stay and preferred end-of-life-care at home. We received less referral from outside the hospital and other specialties but received more self-referrals surprisingly. Home-based-palliative-care was also a key aspect of the program. PCS providing quality of care and nearly reaching target goal of quality indicators. CONCLUSION: The enormous burden of life-threatening illnesses is associated with physical and psychosocial sufferings, which explains the illustrious need for PC in developing countries such as Pakistan. PCS at AKUH initiated in 2017. Nevertheless, there are challenges to service expansion and progress, which are being addressed.

Needs assessment of general practitioners in Pakistan: A descriptive cross-sectional survey.

Background: With the growing and complex nature of medicine, it is imperative for physicians to update their knowledge and skills to reflect current standards of care. In Pakistan, 71% of primary care needs are met by general practitioners (GPs). GPs are not required to complete structured training and no regulatory mandates exist for continuing medical education. We conducted a needs assessment to evaluate the readiness for competency-based updating of knowledge and skills, and the use of technology by practicing GPs in Pakistan. Methods: A cross-sectional survey inviting registered GPs across Pakistan was administered online and in-person. Questions pertained to physician demographics, practice characteristics, confidence in knowledge and skills, and preferred modes of updating knowledge and barriers. Descriptive analyses were performed for GPs and patient-related characteristics and bivariate analyses to evaluate the relationship between parameters of interest. Results: Of the 459 GPs who responded, 35% were practicing for <5 years and 34% reported practicing for >10 years. Only 7% had a post-graduate qualification in family medicine. GPs reported needing practice in neonatal examination (52%), neurological exam (53%), depression screening (53%), growth charts (53%) and peak flow meter use (53%), interpretation of electrocardiograms (ECGs, 58%) and insulin dosing for diabetes (50%). High workload (44%) was the most common barrier to updating clinical knowledge. Sixty-two percent used the Internet on a regular basis. Conclusion: Most GPs have no structured training and encounter gaps in knowledge and skills in clinical practice. Flexible, hybrid, and competency-based continuing medical education programs can be used to update knowledge and skills.