Assessing the application of evidence-based clinical guidelines by medical service trips:

an integrative review of the literatureChristopher Dainton, Charlene Chu, Henry Lin, & Lawrence Loh

Prepared for APHA 2015November 2 2015, Chicago, USA

Introduction

• Many challenges to care on primary care medical service trips (MSTs) in Latin America• Local epidemiology, limited resources, low health literacy, unclear follow-up

• Clinical guideline use by clinicians engaged in primary care medical service trips in Latin America and the Caribbean is poorly understood

• Guidelines should account for the uniqueness of this mode of health provision

Aim

To identify, assess, summarize existing guidelines employed in the clinical management of patients served by MSTs operating in Latin America

Methods• An integrative review summarizes quantitative, qualitative, and

theoretical literature (Knafl & Whittlemore, 2005)

• Librarian assisted electronic database search of MEDLINE and Lilacs • Between 2000 and 2015• No language limitations

• Search terms included “medical brigades”, “Latin America” and “primary health care”

• Ancestral search and hand search also completed

Methods

• MMAT (Pluye et al, 2011) and AGREE II (AGREE Next Steps Consortium, 2009) used to score article and guideline quality

• Two independent reviewers completed the screening, data extraction, and quality appraisals • Disagreements resolved by group discussion and consensus

• Accessed university library and health network library to retrieve studies

Results

Results• 8 articles included in review• 5 qualitative and 3 quantitative

• Duration: 6 MSTs were between 1 and 2 weeks, 2 were shorter than 3 days

• Setting: All rural

• Staff: All except one involved physicians

Results• Aims of included studies:• prevalence of UTI observed on an MST,11 • process papers describing the conduct of dermatologic MSTs,12,13 • disease epidemiology seen by MST clinics,14 • MST travel reports,15,16 and • descriptions of the ethics and guiding principles for MSTs.17,18

• No studies described development or use of standard format guidelines.

Results: MMAT scores

Clear research question?

Data address research question?

Data sources relevant?

Relevant analysis process?

Considers context of data collection?

Considers researchers influence on participants?

Boyd Yes Yes No No No Can't tellBradke Yes Yes Yes Yes Yes YesFrelick Yes Yes No No Yes NoSuchdev Yes Yes Can't tell Can't tell Can't tell YesWilbur No Can't tell Can't tell No Yes Can't tell

Clear research question?

Data address research question?

Sampling is relevant?

Sample is representative of population studied?

Measurements are appropriate?

Acceptable response rate?

August et al Yes No No No Can't tell YesNiska and Sloand Yes Yes Yes Yes Yes Can't tellRamirez-Fort et al Yes Yes Yes Can't tell Yes Can't tell

• High variability in study quality, with no patterns identified across categories

Results: AGREE II scores• Only one article had a positive rating (>0.5) in overall

assessment• High variability in scores in individual domains

Scope and purpose

Stakeholder involvement

Rigour of development

Clarity of presentation Applicability

Editorial independence

Overall score

Suchdev 0.67 0.67 0.35 0.61 0.38 0.67 0.58Niska and Sloand 0.53 0.44 0.35 0.58 0.38 0.25 0.41August et al 0.39 0.17 0.08 0.39 0.17 0.67 0.33Frelick 0.06 0.03 0.02 0.06 0 0 0Wilbur 0.08 0.03 0.03 0.06 0.13 0.08 0Boyd 0.44 0.22 0.09 0.53 0.33 0.42 0.17Ramirez-Fort et al 0.47 0.31 0.05 0.08 0.46 0.67 0.25Bradke 0.03 0 0.01 0.06 0.15 0.25 0

Discussion• Limited descriptions of guideline development and use in the

literature

• Concerns: • reflexive application of North American guidelines, • prioritizing care provision over research, • reliance on veteran participants and subjective experiences

• Existence of WHO and MSF guidelines, but not specific to Latin America, and no evidence of their use

Discussion

Epidemiology Description of epidemiology in location of medical service is clearly Case definitions Unambiguous inclusion criteria or case definitions are provided for each Evidence Source of guidelines, evidence base and level of evidence are clearly

AccountabilityA mechanism is articulated for quality assurance, outcome assessment and follow up, feedback, degree of adherence to protocol, and

FeasibilitySpecific statements around the feasibility of implementation based on local context (e.g. nature of medical service, available resources)

Discussion

• Further research based on patient follow up required to create robust MST guidelines

• Symptom management on MSTs might parallel Western guidelines, but evidence is needed to support this hypothesis as the scale of MSTs grows

• Developing guidelines appropriate to local contexts might improve care, and give MSTs opportunities to liaise with domestic clinicians

Conclusion

• Minimal development or use or clinical guidelines on MSTs in Latin America

• Research should focus on tailored guidelines for communities served by MSTs

References

1. Maki J, Qualls M, White B, Kleefield S, Crone R. Health impact assessment and short-term medical missions: A methods study to evaluate quality of care. BMC Health Serv Res. 2008;8: 121.

2. Langowski MK, Iltis AS. Global health needs and the short-term medical volunteer: Ethical considerations. HEC forum. 2011;23(2):71-78.

3. Wall A. The context of ethical problems in medical volunteer work. HEC forum. 2011;23(2): 79-90.4. Hawkins J. Potential Pitfalls of Short-Term Medical Missions. J Christ Nurs. 2013;30(4): E1-E6.5. Green T, Green H, Scandlyn J, Kestler A. Perceptions of short term medical volunteer work: a qualitative study in

Guatemala. Global Health. 2009;5:4.6. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-553. 7. National Guideline Clearing House. Template of Guideline Attributes [Internet]. 2005 [Cited June 8, 2015]. Available

from: http://www.guideline.gov/about/template-of-attributes.aspx. 8. AGREE Next Steps Consortium. The AGREE II instrument (electronic version) [Internet]. 2009 [Cited February 7, 2015].

Available from http://www.agreetrust.org/wp-content/uploads/2013/06/AGREE_II_Users_Manual_and_23-item_Instrument_ENGLISH.pdf.

9. Pluye P, Robert E, Cargo M, et al. Proposal: A mixed methods appraisal tool for systematic mixed studies reviews [Internet]. 2011 [Cited June 8, 2015]. http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/84371689/MMAT%202011%20criteria%20and%20tutorial%202011-06-29updated2014.08.21.pdf.

10. August SL, Rosa MJ, Vermund SH. Evaluation of the prevalence of urinary tract infection in rural Panamanian women. PLoS One, 2012;7(10):e47752.

References

11. Ramirez-Fort MK, Lastra-Vicente R, Levitt JO, Sanchez JL, Reizner GT. Organizing a dermatology service mission. Int J Dermatol, 2013;52(3):342-349. 12. Boyd AS. Medical missions: A therapeutic primer. J Am Acad Dermatol. 2012;66(1):e5-e8. 13. Niska W, Sloand E. Ambulatory medical care in rural Haiti. J Health Care Poor Underserved. 2010;21(1):70-80.14. Wilbur K. Medical mission to Honduras. Can Pharma J. 2007;140(6):395-396.15. Frelick RW. Medical mission to Honduras. December 20, 1998–January 2, 1999. Del Med J. 1999;71:513–516.16. Bradke AJ. The ethics of medical brigades in Honduras: who are we helping? [Master's thesis]. Graduate Faculty of Arts and Sciences, University of Pittsburgh; 2009.17. Suchdev P, Ahrens K, Click E, Macklin L, Evangelista D, Graham, E. A model for sustainable short-term international medical trips. Ambul Pediatr. 2007;7(4):317-320.18. Woolf HS, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. Br Med J. 1999;318(7182):527-530.19. World health organization, Department of Child and Adolescent Health and Development. Epidemiology and management of common skin diseases in children in developing countries [Internet]. 2005 [Cited June 9, 2015]. Available from: http://apps.who.int/iris/bitstream/10665/69229/1/WHO_FCH_CAH_05.12_eng.pdf?ua=1&ua=1. 20. World Health Organization. Prevention and control of noncommunicable diseases: guidelines for primary healthcare in low resource settings. Geneva, Switzerland: World Health Organization; 2012.

AUTHOR CONTACT:

Dr. Christopher Dainton, MD, CCFP (EM)www.medicalservicetrip.com

christopher.dainton@gmail.com