Assessing the application of evidence-based
clinical guidelines by medical service trips:
an integrative review of the literature
Christopher Dainton, Charlene Chu, Henry Lin, & Lawrence Loh
Prepared for APHA 2015
November 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
• High variability in study quality, with no patterns identified
across categories
Clear research
question?
August et al
Yes
Niska and Sloand Yes
Ramirez-Fort et al Yes
Boyd
Bradke
Frelick
Suchdev
Wilbur
Clear research
question?
Yes
Yes
Yes
Yes
No
Data address
research
question?
No
Yes
Yes
Data address
research
question?
Yes
Yes
Yes
Yes
Can't tell
Sampling is
relevant?
No
Yes
Yes
Sample is
representative of
population
studied?
No
Yes
Can't tell
Data sources
relevant?
No
Yes
No
Can't tell
Can't tell
Considers
Considers context researchers
Relevant analysis of data
influence on
process?
collection?
participants?
No
No
Can't tell
Yes
Yes
Yes
No
Yes
No
Can't tell
Can't tell
Yes
No
Yes
Can't tell
Measurements
are appropriate?
Can't tell
Yes
Yes
Acceptable
response rate?
Yes
Can't tell
Can't tell
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
Suchdev
Niska and Sloand
August et al
Frelick
Wilbur
Boyd
Ramirez-Fort et al
Bradke
Stakeholder
involvement
0.67
0.53
0.39
0.06
0.08
0.44
0.47
0.03
Rigour of
development
0.67
0.44
0.17
0.03
0.03
0.22
0.31
0
Clarity of
presentation
0.35
0.35
0.08
0.02
0.03
0.09
0.05
0.01
Editorial
independence
Applicability
0.61
0.58
0.39
0.06
0.06
0.53
0.08
0.06
0.38
0.38
0.17
0
0.13
0.33
0.46
0.15
0.67
0.25
0.67
0
0.08
0.42
0.67
0.25
Overall
score
0.58
0.41
0.33
0
0
0.17
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
A mechanism is articulated for quality assurance, outcome assessment
Accountability
and follow up, feedback, degree of adherence to protocol, and
Specific statements around the feasibility of implementation based on
Feasibility
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/wpcontent/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%20
and%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 shortterm 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
[email protected]