Introduction Though colorectal cancer is a disease of public health importance, there is little evidence about risk factors of colorectal cancer in South Asians. Objectives We aimed to determine the behavioral, familial and comorbid illness risk factors for colorectal cancer among Sri Lankan adults. Methods W e conducted this study among 325 participants (65 incident colorectal cancer cases, 130 hospital and 130 community controls) in five major health care institutions and communities in areas with high incidence in Sri Lanka. Behavioral, genetic and comorbid risk factors were assessed through an interviewer administered questionnaire. Risk factors were evaluated using bivariate and multivariate logistic regression. Results Adjusted logistic regression showed that frequent consumption of red meat (OR 3.06, 95% CI 1.26-7.43) and deep fried food (OR 2.54, 95% CI 1.22-5.39), hypertension 10 years (OR 3.3, 95% CI 1.3-8.6), colorectal cancer (OR 4.91, 95% CI 1.70-14.18) and other cancers (OR 3.0, 95% CI 1.14-7.81) among first degree relatives and age >50 years (OR 2.6, 95% CI 1.1 to 5.9) were significant risk factors compared to hospital controls. Frequent consumption of deep fried food (OR 4.2, 95% CI 1.7-10.1), being an ever smoker (OR 3.2, 95% CI 1.1-9.3), a current or former drinker (OR 5.4, 95% CI 1.1-27.8) and hypertension 10 (OR 5.1, 95% CI 1.7-15.6) were risk factors compared to community controls. Conclusion The behavioral, familial and comorbid illness risk factors identified should be considered in designing preventive strategies and identifying high-risk individuals for screening for colorectal cancer.
BackgroundDue to finite resources, the clinical decision to subject a patient to colonoscopy needs to be based on the evidence, regardless of its availability, affordability and safety. This study assessed the appropriateness of colonoscopies conducted in selected study settings in Sri Lanka. In the absence of local guidelines, audit was based on European Panel on Appropriateness of Gastrointestinal Endoscopy II (EPAGE II) criteria.MethodsThis cross-sectional study assessed consecutive patients who underwent colonoscopy between June to August 2015 at four main hospitals in Sri Lanka. Interviewer administered questionnaire and secondary data were collected by trained health staff. Indications were assessed according to EPAGE II criteria.ResultsOut of 325 patients, male female proportions were 57.2 and 42.8%. Mean (SD) age was 54.9 (12.1) years. Colonoscopies were appropriate in 61.2% (95% CI 55.8–66.3), uncertain in 28.6% (95% CI 23.9–33.7) and inappropriate in 10.2% (95% CI 7.3–13.9). Colonoscopy to evaluate abdominal pain has highest percentage of inappropriateness of 10.0%. However, 9.5% of these colonoscopies revealed Colo-Rectal Cancer (CRC), reflecting differences in the profile of local CRC patients. Colonoscopies with appropriate or uncertain indications are three times more likely to have a relevant finding than inappropriate indications (42.5% vs. 18.2%; OR 3.32, 95% CI 1.33–8.3; P = 0.008).ConclusionsMajority of colonoscopies are appropriate. However, it cannot be neglected that every one in ten patients undergo inappropriate colonoscopy. Proportion of inappropriateness was highest for the indication of chronic abdominal pain, of which, 9.5% of patients were diagnosed with CRC. This may reflect the different profile of local CRC patients in terms of symptom manifestation and other characteristics. In conclusion, the authors recommend formulation of national guidelines for colonoscopy indications based on current best evidence and local patient profile. Use of such prepared local guidelines will improve the efficient use of finite resources.
Clinical records in primary healthcare settings in low- and middle-income countries (LMIC) are often lacking or of too poor quality to accurately assess what happens during the patient consultation. We examined the most common methods for assessing healthcare workers’ clinical behaviour: direct observation, standardized patients and patient/healthcare worker exit interview. The comparative feasibility, acceptability, reliability, validity and practicalities of using these methods in this setting are unclear. We systematically review and synthesize the evidence to compare and contrast the advantages and disadvantages of each method. We include studies in LMICs where methods have been directly compared and systematic and narrative reviews of each method. We searched several electronic databases and focused on real-life (not educational) primary healthcare encounters. The most recent update to the search for direct comparison studies was November 2019. We updated the search for systematic and narrative reviews on the standardized patient method in March 2020 and expanded it to all methods. Search strategies combined indexed terms and keywords. We searched reference lists of eligible articles and sourced additional references from relevant review articles. Titles and abstracts were independently screened by two reviewers and discrepancies resolved through discussion. Data were iteratively coded according to pre-defined categories and synthesized. We included 12 direct comparison studies and eight systematic and narrative reviews. We found that no method was clearly superior to the others—each has pros and cons and may assess different aspects of quality of care provision by healthcare workers. All methods require careful preparation, though the exact domain of quality assessed and ethics and selection and training of personnel are nuanced and the methods were subject to different biases. The differential strengths suggest that individual methods should be used strategically based on the research question or in combination for comprehensive global assessments of quality.
Rationale, aims, and objectives: Clinical practice guidelines (CPG) play a major role in patient care in Sri Lanka. This study evaluates the methodological quality of the Sri Lankan CPGs developed in 2007.Methods: A total of 94 CPGs developed by several professional colleges in Sri Lanka in the year 2007 were evaluated by 2 independent reviewers using AGREE II instrument for their methodological quality. Item score being ≤3 points was defined as "poor quality". Each domain score was calculated according to AGREE II. A guideline was labelled as "strongly recommended" if 4 or more domains scored above 60%, "recommended for use with certain modification" if only 3 domain scores were above 60% or if 4 or more domain scores were between 30% and 60%, and "not recommended" if 4 or more domains scored less than 30%.Results: Most (22.3%) guidelines were developed by the College of Pathologists.Most of the guidelines (>55%) poorly reported on all the items, except for items 1, 2, and 22 of AGREE II. Median domain scores [range] and the proportion of the guidelines with domain score of <30% were as follows: domain on scope and purpose (33.3% [2.8%-83.3%]; 42.6%), stakeholder involvement (14.9% [0.0%-61.1%]; 81.9%), rigour of development (6.1% [0.0%-49%]; 98.9%), clarity and presentation (30.5% [8.3%-61.1%]; 46.8%), and applicability (8.3% [4.2%-14.6%]; 100%). All CPGs scored 50% for "editorial independence". Reviewers reported the overall quality was poor in 86 (91.5%). Based on the definitions used in the study, of 94 CPGs, 8 (8.5%) could be recommended to be used with modifications, while 86 (91.5%) could not be recommended for clinical practice.Conclusions: The methodological quality of the CPGs was poor irrespective of the source of development. Major efforts are essential to update the CPGs according to the principles of evidence based medicine. In the ever-evolving world of Medicine, evidence-based medicine integrating the clinical expertise, best research evidence, the patient's unique sociocultural factors, and the circumstances plays a major role in the patient care, in doing the "right thing" for the patient. 1 In this process of evidence-based clinical practice, the usage of clinical practice guidelines has thus become increasingly familiar during the last decade. As defined by the Institute of Medicine, USA, clinical guidelines are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances". 2 Irrespective of the source of origin, these clinical guidelines may generally provide a concise background of the particular disease or condition and its complications, clinical symptoms and signs, what diagnostic tests to be ordered, potential medical or surgical services and procedure options, complications related to the possible medical or surgical treatment, when, how, and to which level of care the patient has to be referred to, and other relevant details.
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