Quality of primary care from the patient perspective in Saudi Arabia : a multi-level study.

Objectives: To assess primary care performance for measures of patients’ experience in Community-based Primary Care (CPC) and Employer-based Primary Care (EPC) systems in Saudi Arabia, to examine variations in performance across the two systems, and to explore factors at both the individual-level and the organizational-level that explain variations in primary care performance. Design and Methods: This is an observational and cross-sectional study, using comparative design and survey research methods. The newly revised and re-translated Arabic version of the Primary Care Assessment Survey (PCAS) was used to measure patients’ experience of primary care. PCAS operationalizes the IOM definition of primary care, which identified core domains of primary care as accessibility of care, continuity of care, comprehensiveness of care, coordination of care, interpersonal treatment, communication, and community orientation. A two-stage cluster, matched sampling was employed to select 16 primary care centers (eight CPC and eight EPC centers) in Riyadh, the capital and largest city (population \u3e 5.5 million) in Saudi Arabia. A systematic random sampling was employed to collect primary survey data from 612 adult patients visiting the selected primary care centers. Results: After adjusting for differences in the patient-mix and taking into account the multi-level structure of data by means of multi-level modeling, EPC performed statistically significantly better than CPC in interpersonal care (Mean EPC = 68.3, 95% CI [± 6.3] vs. Mean CPC = 59.5, 95% CI [± 5.9], p = 0.024, Effect Size (d) = 0.36) and communication (Mean EPC = 69.8, 95% CI [± 4.9] vs. Mean CPC = 64.4, 95% CI [± 5.5], p = 0.035, d =0.22), in addition to the total quality score (Total PCAS EPC = 60.4, 95% CI [± 2.9 ] vs. Total PCAS CPC = 56.1, 95% [± 3.3], p = 0.009, d =0.31). CPC performed statistically significantly better than EPC in community orientation (Mean CPC = 47.8, 95% [± 5.7] vs. Mean EPC = 35.5, 95% [± 6.2], p = 0.003, d =0.50) and accessibility of care (Mean CPC = 67.4, 95% [± 5.7] vs. Mean EPC = 63.5, 95% [± 4.5], p = 0.025, d=0.23). There were no significant differences between CPC and EPC in coordination of care (p= 0.098), comprehensiveness of care (p = 0.208), and visit-based continuity of care (p = 0.354). Patient-level (compositional) variables explained a significant proportion (R2 = 0.14) of the observed level-one (within-centers) variations in measures of patients’ experience. Those variables include gender, self-perceived health status, and patient-reported co-morbidity. Female patients, reporting poor health, and reporting chronic conditions are each statistically significantly associated with lower ratings of patients’ experience of care. Organizational-level (contextual) variables explained a significant proportion (R2 = 0.78) of the observed level-two (between-centers) variations in measures of patients’ experience. Those organizational variables include practice type and proportions of family physicians in a center. EPC centers and those centers with higher proportions of family physicians are each statistically significantly associated with better patients’ experience. Finally, aspects of care that were statistically significantly associated with better patients’ experience include knowing the name of the physician and being with the same physician for longer durations. Conclusion: Enhancing continuity and quality of patient-physician relationships may improve the overall patients’ experience of care. Healthcare systems in Saudi Arabia might embrace the Bio-Psycho-Social model to foster a culture of health and caring. Effective, community-oriented primary care systems have the potential to re-orient health systems’ from a sole focus on sickness and disease, to include additional approaches for prevention and wellness at the societal level. Positive indicators of health, at both the individual and community levels, are needed to better align existing healthcare systems with this goal, mission and vision to improve population health

To Admit or Not to Admit to the Emergency Department: The Disposition Question at a Tertiary Teaching and Referral Hospital

Background: Disposition decision-making in the emergency department (ED) is crucial to patient safety and quality of care. It can inform better care, lower chance of infections, appropriate follow-up care, and reduced healthcare costs. The aim of this study was to examine correlates of ED disposition among adult patients at a teaching and referral hospital based on patients’ demographic, socioeconomic, and clinical characteristics. Method: A cross-sectional study conducted at the ED of the King Abdulaziz Medical City hospital in Riyadh. A two-level validated questionnaire was used—a patient questionnaire and healthcare staff/facility survey. The survey employed a systematic random sampling technique to recruit subjects at a pre-specified interval as patients arrived at the registration desk. We analyzed 303 adult patients visiting the ED, who were triaged, consented to participate in the study, completed the survey, and admitted to a hospital bed or discharged home. We used descriptive and inferential statistics to summarize and determine the interdependence and relationships of variables. We used logistic multivariate regression analysis to establish relationships and the odds of admission to a hospital bed. Results: The mean age of the patients was 50.9 (SD = 21.4, Range 18 to 101). A total of 201 (66%) were discharged home while the rest were admitted to a hospital bed. Results of the unadjusted analysis suggest that older patients, males, patients with low level of education, and those with comorbidities and middle-income were more likely to be admitted to the hospital. The results of the multivariate analysis suggest that patients with comorbidities, urgent conditions, prior history of hospitalization, and higher triage levels were more likely to be admitted to a hospital bed. Conclusions: Having proper triage and timely stopgap review measures in the admission process can help new patients to locations that best support their needs and improve the quality and efficiency of the facility. The findings may be a sentinel indicator that informs overuse or inappropriate use of EDs for non-emergency care, which is a concern in the Saudi Arabian publicly funded health system

Psychometric Properties of the Moore Index of Nutrition Self-Care in Arabic: A Study among Saudi Adolescents at King Saud University, Riyadh, Saudi Arabia

Background and Objective. The Moore Index of Nutrition Self-Care (MIN-SC) questionnaire has been used widely in both English and Spanish languages. The purpose of this study is to convert MIN-SC into the Arabic language and to test the translated tool for validity and reliability among adolescents in Saudi Arabia. Method. The psychometric characteristics of MIN-SC were assessed using college freshman students at King Saud University in Riyadh, Saudi Arabia. The validity and reliability were examined using Cronbach’s alpha coefficient. The construct validity was examined through principal component analysis. Results. The MIN-SC instrument was shown to be internally consistent with reliable scoring (Cronbach’s alpha = 0.910). Exploratory factor analysis resulted in 42 items loading on three main components: estimative, production, and transitional, with a factor loading of eigenvalues >2. The final model explained 38% of the variance. Conclusion. The Arabic version of MIN-SC was shown to be a valid and reliable tool for assessing attitude toward nutrition among adolescent students

Discharge against Medical Advice (DAMA) from an Emergency Department of a Tertiary Care Hospital in Saudi Arabia

Background. The discharge against medical advice (DAMA) in the Emergency Department (ED) is an issue of great concern because it may result in adverse consequences at a later stage. The reported worldwide prevalence of DAMA ranges from 0.07 to 20% for emergency admissions. The outcomes of DAMA can have significantly damaging effects, causing possible relapses of disease, readmission, and increases in medical costs for the patient. Therefore, it is imperative to identify the predictors of DAMA in ED. Methods. It was a cross-sectional study. The medical records used were those of all the patients (n = 11513) admitted to the Emergency Department (ED) of King Abdullah Bin Abdulaziz University Hospital (KAAUH) in Riyadh, Saudi Arabia, between 2017 and 2018. A thorough analysis was performed using IBM SPSS Statistics version 22. Descriptive statistics were reported for quantitative and categorical variables and assessed by independent t-test/chi-square/ANOVA (analysis of variance), where appropriate. Unadjusted and adjusted odds ratios with their 95% CI (confidence interval) were reported by performing logistic regression. A p value of ≤0.05 was considered statistically significant throughout the study. Results. The prevalence of DAMA in our study was 1%. In a multivariable analysis, after adjusting for the other covariates, we observed a significant interaction between age and gender. It was observed that the odds of DAMA for ≤40-year-old males were 3.12 times higher than those of a ≤40-year-old female (p value < 0.1). To further investigate this interaction, men and women were modeled separately in multivariable models using the same covariates. We found that, for men, the effect of age (≤40 years) was significant (OR = 3.94, 95% CI 1.31–11.80, p=0.014), while, for women, the effect of age (≤40 years) was not as pronounced (OR = 1.27, 95% CI = 0.66–2.42, p=0.27). Conclusions. Our study concluded that DAMA was more likely among younger male patients (≤40 years of age). Most of the patients with DAMA were presented to the urgent care of the Emergency Department. We recommend that patients be given some financial support to bear the expenses of the hospital stay from the healthcare facility or from the state. Future studies should assess the socioeconomic status of the patients and estimate the cost that is incurred by the patients

The Epidemiology of Celiac Disease in the General Population and High-Risk Groups in Arab Countries: A Systematic Review

Background and Aims. Celiac disease (CD) is possibly the most common autoimmune disorder, which may lead to dietary problems in the Arab region. This paper is aimed at exploring the epidemiology of the celiac disease in Arab countries, including its prevalence, associated risk factors, and clinical patterns. Methods. An extensive search of the literature was conducted from electronic databases such as PubMed, Embase, and Google Scholar. In total, 134 research papers were retrieved. We extracted studies published from January 1996 to December 2019. Our search was limited to studies published in English. Findings. The review included 35 studies with 22,340 participants from 12 countries and demonstrated a wide variation in the prevalence of CD. The highest prevalence among the general population (3.2%) was reported in Saudi Arabia, and the lowest (0.1%) was reported in Tunisia. Women demonstrated a higher prevalence of celiac disease relative to men. The peak age at diagnosis fell between 1 and 3 years and 9-10 years. Most studies focused on type 1 diabetes. Children with type 1 diabetes have a higher prevalence of CD (range from 5.5% to 20%), while the prevalence of CD in Down’s syndrome patients was 1.1% and 10.7% in UAE and Saudi Arabia, respectively. Other autoimmune diseases associated with CD are thyroid disease and irritable bowel disease. The most widely recognized clinical presentation was an inability to flourish and poor weight gain, followed by short stature, abdominal pain, abdominal distension, bloating, and chronic diarrhea. Conclusion. The prevalence of the celiac disease in Arab countries varies with sex and age. However, we found that celiac disease presented similar clinical characteristics independent of the geographic region. Longitudinal population-based studies are needed to better identify the true burden and determinants of celiac disease

The Epidemiology of Migraine Headache in Arab Countries: A Systematic Review

Background. Recurring migraine disorders are a common medical problem, standing among the top causes of disability and sufferings. This study aimed to evaluate epidemiological evidence to report updated estimates on prevalence, risk factors, and associated comorbidities of migraine headache in the Arab countries. Design and Setting. A systematic review was conducted at the College of Public Health and Health Informatics, Riyadh, Saudi Arabia. Methods. A systematic search in electronic databases, such as PubMed and Embase, as well as manual searches with cross-referencing was performed from 1990 up to 2019. Overall, 23 included papers were rated independently by two reviewers. Studies were eligible for inclusion only if they investigated migraine headache epidemiology in any Arab country and were published in English. Results. Migraine prevalence among the general population ranged between 2.6% and 32%. The estimated prevalence of migraine headache among medical university students ranged between 12.2% and 27.9% and between 7.1% and 13.7% in schoolchildren (6 to 18 years). Females were found more likely to have migraine than males. The duration of migraine attacks became shorter with increasing age, while chronic (daily) migraine showed increasing prevalence with age. The most commonly reported comorbidities with migraine included anxiety, hypertension, irritable bowel syndrome, and depression. Most common headache-triggering factors included stress, fatigue, sleep disturbances, prolonged exposure to excessive sunlight or heat, and hunger. Conclusion. The prevalence and risk factors of migraine headache in Arab countries are comparable to reports from western countries. Longitudinal studies are still needed to investigate the prognosis and predictors of chronicity in the arab countries

Association between Chronic Pain and Diabetes/Prediabetes: A Population-Based Cross-Sectional Survey in Saudi Arabia

Background. Diabetes is a debilitating chronic health condition that is associated with certain pain syndromes. The present study sought to evaluate chronic pain and its association with diabetes mellitus at a population level. Methods. A population-based cross-sectional questionnaire survey study was conducted in Al-Kharj, Saudi Arabia, from January 2016 to June 2016. Participants from both private and governmental institutions were selected following a multistage sampling technique and using a cluster sampling method. Anthropometric measurements were taken, including body weight, height, body mass index (BMI) and waist circumference. A blood sample was also drawn from each respondent for fasting blood sugar, HbA1c, and fasting lipid profile. A P value of less than 0.05 indicated statistical significance. Results. A total of 1003 subjects were included for final analysis. Compared to prediabetic and nondiabetic individuals, diabetic subjects had a higher prevalence of lower limb pain (11.1%), back pain (8.9%), abdominal pain (6.7%), and neck pain (4.4%) (X2 = 27.792, P=0.015). In a multiple logistic regression model, after adjusting for age, gender, education level, cholesterol, and smoking status, diabetic/prediabetic patients had a significantly higher prevalence of chronic pain ((OR) = 1.931 (95% CI = 1.536–2.362), P=0.037). Increased age was also significantly associated with chronic pain ((OR) = 1.032 (95% CI = 1.010–1.054, P=0.004). Conclusion. Results of this study found a significant association between diabetes and prediabetes and chronic pain symptoms. Prospective studies are needed to explore temporality of such association