Involving patients and the public in clinical trials design can be beneficial but requires resources, preparation, training, flexibility, and time. Issues to address include reporting deficits for risk of bias, study quality, and conflicts of interests. We need to address these tensions and improve dissemination strategies to increase PPI and health literacy.

One fifth of TB patients had unfavourable outcomes. Intervention strategies should target those at increased risk of unfavourable outcomes and all-cause mortality.

This study was made possible with research funding from University of Malaya (reference F0381/2005C) and University Kebangsaan Malaysia (reference FF-225-2005) Ethics committeeMedical ethics committee -University of Malaya Medical Centre (reference 454.3) and medical ethics committeeUniversiti Kebangsaan Malaysia (reference FF-225-2005)

ObjectiveTo compare the strengths and limitations of cardiovascular risk scores available for clinicians in assessing the global (absolute) risk of cardiovascular disease.DesignReview of cardiovascular risk scores.Data sourcesMedline (1966 to May 2009) using a mixture of MeSH terms and free text for the keywords ‘cardiovascular’, ‘risk prediction’ and ‘cohort studies’.Eligibility criteria for selecting studiesA study was eligible if it fulfilled the following criteria: (1) it was a cohort study of adults in the general population with no prior history of cardiovascular disease and not restricted by a disease condition; (2) the primary objective was the development of a cardiovascular risk score/equation that predicted an individual's absolute cardiovascular risk in 5–10 years; (3) the score could be used by a clinician to calculate the risk for an individual patient.Results21 risk scores from 18 papers were identified from 3536 papers. Cohort size ranged from 4372 participants (SHS) to 1591209 records (QRISK2). More than half of the cardiovascular risk scores (11) were from studies with recruitment starting after 1980. Definitions and methods for measuring risk predictors and outcomes varied widely between scores. Fourteen cardiovascular risk scores reported data on prior treatment, but this was mainly limited to antihypertensive treatment. Only two studies reported prior use of lipid-lowering agents. None reported on prior use of platelet inhibitors or data on treatment drop-ins.ConclusionsThe use of risk-factor-modifying drugs—for example, statins—and disease-modifying medication—for example, platelet inhibitors—was not accounted for. In addition, none of the risk scores addressed the effect of treatment drop-ins—that is, treatment started during the study period. Ideally, a risk score should be derived from a population free from treatment. The lack of accounting for treatment effect and the wide variation in study characteristics, predictors and outcomes causes difficulties in the use of cardiovascular risk scores for clinical treatment decision.

BackgroundPatient safety is vital in patient care. There is a lack of studies on medical errors in primary care settings. The aim of the study is to determine the extent of diagnostic inaccuracies and management errors in public funded primary care clinics.MethodsThis was a cross-sectional study conducted in twelve public funded primary care clinics in Malaysia. A total of 1753 medical records were randomly selected in 12 primary care clinics in 2007 and were reviewed by trained family physicians for diagnostic, management and documentation errors, potential errors causing serious harm and likelihood of preventability of such errors.ResultsThe majority of patient encounters (81%) were with medical assistants. Diagnostic errors were present in 3.6% (95% CI: 2.2, 5.0) of medical records and management errors in 53.2% (95% CI: 46.3, 60.2). For management errors, medication errors were present in 41.1% (95% CI: 35.8, 46.4) of records, investigation errors in 21.7% (95% CI: 16.5, 26.8) and decision making errors in 14.5% (95% CI: 10.8, 18.2). A total of 39.9% (95% CI: 33.1, 46.7) of these errors had the potential to cause serious harm. Problems of documentation including illegible handwriting were found in 98.0% (95% CI: 97.0, 99.1) of records. Nearly all errors (93.5%) detected were considered preventable.ConclusionsThe occurrence of medical errors was high in primary care clinics particularly with documentation and medication errors. Nearly all were preventable. Remedial intervention addressing completeness of documentation and prescriptions are likely to yield reduction of errors.

Background Health literacy (HL) skills are essential to enable self-management and shared decision-making in patients with type 2 diabetes mellitus (T2DM). Limited HL in these patients is associated with poorer outcomes. It is not clear what the burden of limited HL in patients with T2DM across countries and what factors influence it. Methods A systematic review was conducted according to the PRISMA guidelines. The study protocol was registered with PROSPERO (CRD42017056150). We searched MEDLINE, EMBASE, PsycINFO, CINAHL and ERIC for articles published up to January 2017. Articles that measured HL levels in adult patients with T2DM; that used validated HL tools; and that were reported in English were included. Two reviewers assessed studies for eligibility and quality, and extracted the data. Prevalence of limited HL is calculated from the number of patients with less than adequate HL over the total number of patients with T2DM in the study. Meta-analysis and meta-regression analysis were conducted using the Open Meta-analyst software. Results Twenty-nine studies involving 13,457 patients with T2DM from seven countries were included. In total, seven different HL measurement tools were used. The prevalence of limited HL ranged from 7.3% to 82%, lowest in Switzerland and the highest in Taiwan. Meta-regression analysis of all included studies showed the country of study (p<0.001), HL tool used (p = 0.002), and the country’s region (p<0.001) contributed to the variation findings. Thirteen studies in the USA measured functional HL. The pooled prevalence of inadequate functional HL among patients with T2DM in the USA was 28.9% (95% CI: 20.4–37.3), with high heterogeneity (I 2 = 97.9%, p <0.001). Studies were done in the community as opposed to a hospital or primary care (p = 0.005) and populations with education level lower than high school education (p = 0.009) reported a higher prevalence of limited HL. Conclusion The prevalence of limited HL in patients with T2DM varied widely between countries, HL tools used and the country’s region. Pooled prevalence showed nearly one in three patients with T2DM in the USA had limited functional HL. Interactions with healthcare providers and educational attainment were associated with reported of prevalence in the USA.

BackgroundTelemonitoring of home blood pressure (BP) is found to have a positive effect on BP control. Delivering a BP telemonitoring service in primary care offers primary care physicians an innovative approach toward management of their patients with hypertension. However, little is known about patients’ acceptance of such service in routine clinical care.ObjectiveThis study aimed to explore patients’ acceptance of a BP telemonitoring service delivered in primary care based on the technology acceptance model (TAM).MethodsA qualitative study design was used. Primary care patients with uncontrolled office BP who fulfilled the inclusion criteria were enrolled into a BP telemonitoring service offered between the period August 2012 and September 2012. This service was delivered at an urban primary care clinic in Kuala Lumpur, Malaysia. Twenty patients used the BP telemonitoring service. Of these, 17 patients consented to share their views and experiences through five in-depth interviews and two focus group discussions. An interview guide was developed based on the TAM. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used for analysis.ResultsPatients found the BP telemonitoring service easy to use but struggled with the perceived usefulness of doing so. They expressed confusion in making sense of the monitored home BP readings. They often thought about the implications of these readings to their hypertension management and overall health. Patients wanted more feedback from their doctors and suggested improvement to the BP telemonitoring functionalities to improve interactions. Patients cited being involved in research as the main reason for their intention to use the service. They felt that patients with limited experience with the internet and information technology, who worked out of town, or who had an outdoor hobby would not be able to benefit from such a service.ConclusionPatients found BP telemonitoring service in primary care easy to use but needed help to interpret the meanings of monitored BP readings. Implementations of BP telemonitoring service must tackle these issues to maximize the patients’ acceptance of a BP telemonitoring service.

BackgroundChronic Obstructive Pulmonary Disease (COPD) is a chronic disease with repeated exacerbations resulting in gradual debilitation. The quality of life has been shown to be poor in patients with COPD despite efforts to improve self-management. However, the evidence on the benefit of self-management in COPD is conflicting. Whether this could be due to other unmet needs of patients have not been investigated. Therefore, we aimed to explore unmet needs of patients from both patients and doctors managing COPD.MethodsWe conducted a qualitative study with doctors and patients in Malaysia. We used convenience sampling to recruit patients until data saturation. Eighteen patients and eighteen doctors consented and were interviewed using a semi-structured interview guide. The interviews were audio-recorded, transcribed verbatim and checked by the interviewers. Data were analysed using a thematic approach.ResultsThe themes were similar for both the patients and doctors. Three main themes emerged: knowledge and awareness of COPD, psychosocial and physical impact of COPD and the utility of self-management. Knowledge about COPD was generally poor. Patients were not familiar with the term chronic obstructive pulmonary disease or COPD. The word ‘asthma’ was used synonymously with COPD by both patients and doctors. Most patients experienced difficulties in their psychosocial and physical functions such as breathlessness, fear and helplessness. Most patients were not confident in self-managing their illness and prefer a more passive role with doctors directing their care.ConclusionsIn conclusion, our study showed that knowledge of COPD is generally poor. There was mislabelling of COPD as asthma by both patients and physicians. This could have resulted in the lack of understanding of treatment options, outcomes, and prognosis of COPD. The misconception that cough due to COPD was contagious, and breathlessness that resulted from COPD, had important physical and psychosocial impact, and could lead to social isolation. Most patients and physicians did not favour self-management approaches, suggesting innovations based on self-management may be of limited benefit.