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Empanelment: A foundational component of primary health care

Bearden T, Ratcliffe HL, Sugarman JR, Bitton A, Anaman LA, Buckle G, et al.

Gates Open Res, 2019;3:1654.
PMID: 32529173 DOI: 10.12688/gatesopenres.13059.1

Empanelment is a foundational strategy for building or improving primary health care systems and a critical pathway for achieving effective universal health coverage. However, there is little international guidance for defining empanelment or understanding how to implement empanelment systems in low- and middle-income countries. To fill this gap, a multi-country collaborative within the Joint Learning Network for Universal Health Coverage developed this empanelment overview, proposing a people-centered definition of empanelment that reflects the responsibility to proactively deliver primary care services to all individuals in a target population. This document, building on existing literature on empanelment and representing input from 10 countries, establishes standard concepts of empanelment and describes why and how empanelment is used. Finally, it identifies key domains that may influence effective empanelment and that must be considered in deciding how empanelment can be implemented. This document is designed to be a useful resource for health policymakers, planners and decision-makers in ministries of health, as well as front line providers of primary care service delivery who are working to ensure quality people-centered primary care to everyone everywhere.
Reducing medical errors in primary care using a pPragmatic complex intervention

Khoo EM, Sararaks S, Lee WK, Liew SM, Cheong AT, Abdul Samad A, et al.

Asia Pac J Public Health, 2015 Sep;27(6):670-7.
PMID: 25563351 DOI: 10.1177/1010539514564007

This study aimed to develop an intervention to reduce medical errors and to determine if the intervention can reduce medical errors in public funded primary care clinics. A controlled interventional trial was conducted in 12 conveniently selected primary care clinics. Random samples of outpatient medical records were selected and reviewed by family physicians for documentation, diagnostic, and management errors at baseline and 3 months post intervention. The intervention package comprised educational training, structured process change, review methods, and patient education. A significant reduction was found in overall documentation error rates between intervention (Pre 98.3% [CI 97.1-99.6]; Post 76.1% [CI 68.1-84.1]) and control groups (Pre 97.4% [CI 95.1-99.8]; Post 89.5% [85.3-93.6]). Within the intervention group, overall management errors reduced from 54.0% (CI 49.9-58.0) to 36.6% (CI 30.2-43.1) and medication error from 43.2% (CI 39.2-47.1) to 25.2% (CI 19.9-30.5). This low-cost intervention was useful to reduce medical errors in resource-constrained settings.
Fulltext Medical errors in primary care clinics--a cross sectional study

Khoo EM, Lee WK, Sararaks S, Abdul Samad A, Liew SM, Cheong AT, et al.

BMC Fam Pract, 2012 Dec 26;13:127.
PMID: 23267547 DOI: 10.1186/1471-2296-13-127

BACKGROUND: Patient 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.
METHODS: This 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.
RESULTS: The 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.
CONCLUSIONS: The 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.
Fulltext Validity and reliability of the SF-36: the Malaysian context

Sararaks S, Azman AB, Low LL, Rugayah B, Aziah AM, Hooi LN, et al.

Med J Malaysia, 2005 Jun;60(2):163-79.
PMID: 16114157

Results of construct validity and reliability of the SF-36 are described, based on data from a multi-centre study on asthmatics and a population based survey. Questionnaire refinement was carried out between the two studies. Quality of data was good, with all items having less than 0.5% missing values. Floor and/or ceiling effects were observed for REE, REP, PF and SF. For scaling assumptions, correlations between each items and its hypothesized scale were all above 0.50, except for one item in PF. and for both items in SF. Item discriminant validity was an issue for items in VT, SF and MH scales. Cronbach's as for all scales exceeded the recommended 0.70 level, except for SF. Only one latent dimension was identified in principal component analysis, and only 52-53% of variance accounted for. As expected, PF shows high correlations with the physical component while MH was highly correlated with the mental component. Contrasting findings in the loadings of other scales were observed in the asthma data. Age, disease severity and presence of self-reported handicap/disability significantly affect PF, while MH demonstrates no obvious pattern with declining age. In essence, the Malay version of SF-36 could be used in Malaysia, with its generally acceptable internal consistency and validity. The caveat is in the call for additional domains of importance to Malaysians that is not covered by the instrument, and in the caution to be employed when using and construing the instrument.
Improving Health Care Coverage, Equity, And Financial Protection Through A Hybrid System: Malaysia's Experience

Rannan-Eliya RP, Anuranga C, Manual A, Sararaks S, Jailani AS, Hamid AJ, et al.

Health Aff (Millwood), 2016 May 01;35(5):838-46.
PMID: 27140990 DOI: 10.1377/hlthaff.2015.0863

Malaysia has made substantial progress in providing access to health care for its citizens and has been more successful than many other countries that are better known as models of universal health coverage. Malaysia's health care coverage and outcomes are now approaching levels achieved by member nations of the Organization for Economic Cooperation and Development. Malaysia's results are achieved through a mix of public services (funded by general revenues) and parallel private services (predominantly financed by out-of-pocket spending). We examined the distributional aspects of health financing and delivery and assessed financial protection in Malaysia's hybrid system. We found that this system has been effective for many decades in equalizing health care use and providing protection from financial risk, despite modest government spending. Our results also indicate that a high out-of-pocket share of total financing is not a consistent proxy for financial protection; greater attention is needed to the absolute level of out-of-pocket spending. Malaysia's hybrid health system presents continuing unresolved policy challenges, but the country's experience nonetheless provides lessons for other emerging economies that want to expand access to health care despite limited fiscal resources.
Fulltext Effective implementation of a structured psychoeducation programme among caregivers of patients with schizophrenia in the community

Paranthaman V, Satnam K, Lim JL, Amar-Singh HS, Sararaks S, Nafiza MN, et al.

Asian J Psychiatr, 2010 Dec;3(4):206-12.
PMID: 23050889 DOI: 10.1016/j.ajp.2010.07.002

Background: Psychoeducation has shown promising benefits in managing patients with schizophrenia. In Malaysia, the use of psychoeducation is rather limited and its impact indeterminate.
Aims: To assess the effectiveness of a structured psychoeducation programme for the community in improving caregiver knowledge, decreasing caregivers’ burden, reducing patients’ readmission and defaulter follow up rates.
Method: In a controlled interventional study, 109 caregivers were included, 54 and 55 in the intervention and control groups respectively. Caregivers were assessed at baseline, 3 and 6 months post-intervention for knowledge and burden. Patients were monitored for relapse and defaulting follow up in the clinic.
Results: Caregivers in the intervention group showed significant improvement in knowledge, reduction in burden in assistance in daily living (severity) and a reduced defaulter rate was seen in the patients’ follow up.
Conclusion: The findings shows that structured psychoeducation programme among caregivers has the potential to improve outcome of care for patients with schizophrenia.
Keywords: Schizophrenia; Psychoeducation; Community; Caregiver Questionnaire: Family Burden Interview Schedule–Short Form (FBIS/SF)