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  1. Tan F, Liew SF, Chan G, Toh V, Wong SY
    J Eval Clin Pract, 2011 Feb;17(1):40-4.
    PMID: 20807297 DOI: 10.1111/j.1365-2753.2010.01367.x
    RATIONALE, AIMS AND OBJECTIVES: To evaluate the impact of clinical audit on diabetes care provided to type 2 diabetic patients attending our hospital general medical clinics.
    METHODS: Performances on diabetes-related process measures and intermediate outcome measures were evaluated through structured review of outpatient medical records. The results were fed back to the doctors and measures were implemented to improve care. The performance indicators were re-evaluated 2 years later to complete the audit cycle.
    RESULTS: Annual testing rates improved for HbA1c (68.4% vs. 87.4%; P < 0.001) and lipid profile (91.8% vs. 97%; P = 0.027). Enquiry on smoking improved from 45.9% to 82.3% (P < 0.001), eye screening rates from 68.9% to 78.8% (P = 0.020) and foot examinations from 22.4% to 64.1% (P < 0.001). Prescription rates for insulin increased from 17.3% to 31.8% (P = 0.001) and statin from 83.2% to 94.4% (P < 0.001). The use of aspirin (80.6% vs. 83.8%; P =0.402) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (92.3% vs. 88.9%; P = 0.239) remained high in both cycles. More patients achieved targets for HbA1c < 7% (38% vs. 26%; P = 0.006), blood pressure < 130/80 mmHg (43% vs. 32%; P = 0.071) and low-density lipoprotein cholesterol < 2.6 mmol/L (71% vs. 52%; P <0.001).
    CONCLUSION: Clinical audit is a useful tool in improving diabetes care.
    Study site: Outpatient clinic, Sarawak General Hospital, Kuching, Sarawak, Malaysia
  2. Biswas R, Umakanth S, Strumberg J, Martin CM, Hande M, Nagra JS
    J Eval Clin Pract, 2007 Aug;13(4):529-32.
    PMID: 17683292 DOI: 10.1111/j.1365-2753.2007.00837.x
    BACKGROUND AND RATIONALE: Evidence based medicine is the present backbone of rational and objective, modern medical problem solving and is a meeting ground for quantitative and qualitative researchers alike as it culminates into applying the fruits of clinical research to the individual patient. A systematic enquiry into the evolving paradigms in EBM is a need of the hour.
    AIMS AND METHODS: A qualitative enquiry examining the impact of different methodologies in EBM and their role in generating meaning interpretable at individual levels.
    RESULTS: Present day outcome based research deals less with patients as individuals than as populations. Evidence based medicine struggles to apply the fruits of population based research to individuals who are often not as predictable as linear quantitative research would like them to be. The present EBM literature neglects a lot of events it doesn't believe to be statistically significant and perhaps here is an area that needs to be improved on - it assumes that because associations are demonstrated between interventions and outcomes in RCTs/meta-analysis, these associations are linear and causal in the real world. While they may be demonstrated repeatedly in highly controlled environments, in the real 'uncontrolled' world of clinical practice with real people, their validity breaks down.
    CONCLUSIONS: One needs to make the EBM standard model patient-individual (a projection of collective patient event data) resemble the real human individual patient so that optimal EBM individual data that matches our query can be easily and quickly spotted from the dense jungle of information that has grown over the years. This hints at rethinking our entire research methodology and modifying it to suit the needs of the individual patient.
  3. Biswas R, Maniam J, Lee EW, Gopal P, Umakanth S, Dahiya S, et al.
    J Eval Clin Pract, 2008 Oct;14(5):750-60.
    PMID: 19018906 DOI: 10.1111/j.1365-2753.2008.00997.x
    The hypothesis in the conceptual model was that a user-driven innovation in presently available information and communication technology infrastructure would be able to meet patient and health professional users information needs and help them attain better health outcomes. An operational model was created to plan a trial on a sample diabetic population utilizing a randomized control trial design, assigning one randomly selected group of diabetics to receive electronic information intervention and analyse if it would improve their health outcomes in comparison with a matched diabetic population who would only receive regular medical intervention. Diabetes was chosen for this particular trial, as it is a major chronic illness in Malaysia as elsewhere in the world. It is in essence a position paper for how the study concept should be organized to stimulate wider discussion prior to beginning the study.
  4. Biswas R, Martin CM, Sturmberg J, Shanker R, Umakanth S, Shanker S, et al.
    J Eval Clin Pract, 2008 Oct;14(5):742-9.
    PMID: 19018905 DOI: 10.1111/j.1365-2753.2008.00998.x
    Evidence based on average patient data, which occupies most of our present day information databases, does not fulfil the needs of individual patient-centred health care. In spite of the unprecedented expansion in medical information we still do not have the types of information required to allow us to tailor optimal care for a given individual patient. As our current information is chiefly provided in disconnected silos, we need an information system that can seamlessly integrate different types of information to meet diverse user group needs. Groups of certain individual medical learners namely patients, medical students and health professionals share the patient's need to increasingly interact with and seek knowledge and solutions offered by others (individual medical learners) who have the lived experiences that they would benefit to access and learn from. A web-based user-driven learning solution may be a stepping-stone to address the present problem of information oversupply in medicine that mostly remains underutilized, as it doesn't meet the needs of the individual patient and health professional user. The key to its success would be to relax central control and make local trust and strategic health workers feel more engaged in the project such that it is truly user-driven.
  5. Romli MH, Mackenzie L, Lovarini M, Tan MP, Clemson L
    J Eval Clin Pract, 2017 Jun;23(3):662-669.
    PMID: 28105771 DOI: 10.1111/jep.12697
    RATIONALE, AIMS AND OBJECTIVES: Falls can be a devastating issue for older people living in the community, including those living in Malaysia. Health professionals and community members have a responsibility to ensure that older people have a safe home environment to reduce the risk of falls. Using a standardised screening tool is beneficial to intervene early with this group. The Home Falls and Accidents Screening Tool (HOME FAST) should be considered for this purpose; however, its use in Malaysia has not been studied. Therefore, the aim of this study was to evaluate the interrater and test-retest reliability of the HOME FAST with multiple professionals in the Malaysian context.

    METHODS: A cross-sectional design was used to evaluate interrater reliability where the HOME FAST was used simultaneously in the homes of older people by 2 raters and a prospective design was used to evaluate test-retest reliability with a separate group of older people at different times in their homes. Both studies took place in an urban area of Kuala Lumpur.

    RESULTS: Professionals from 9 professional backgrounds participated as raters in this study, and a group of 51 community older people were recruited for the interrater reliability study and another group of 30 for the test-retest reliability study. The overall agreement was moderate for interrater reliability and good for test-retest reliability. The HOME FAST was consistently rated by different professionals, and no bias was found among the multiple raters.

    CONCLUSION: The HOME FAST can be used with confidence by a variety of professionals across different settings. The HOME FAST can become a universal tool to screen for home hazards related to falls.

  6. Price A, Liew SM, Kirkpatrick J, Price J, Lopreto T, Nelken Y
    J Eval Clin Pract, 2017 Feb;23(1):178-184.
    PMID: 27917564 DOI: 10.1111/jep.12678
    What are the strengths, gaps, expectations, and barriers to research engagement in clinical trials as communicated through social media? Clinical trials test treatments to provide reliable information for safety and effectiveness. Trials are building blocks in which what is learned in earlier research can be used to improve treatments, compare alternatives, and improve quality of life. For 20 years, the percentages of clinical trials volunteers have decreased whereas the costs of running clinical trials have multiplied. Participants enroll in trials to access latest treatments, to help others, and to advance science, but there is growing unrest. The priorities of those running the trials differ from those of the participants, and the roles for public research involvement lack clarity. Changes to bridge these gaps in the research culture are proposed through the use of participatory action research (PAR) in which stakeholders collaborate to improve research methodology, galvanize citizen participation, multiply health knowledge, problem-solve barriers to access, and explore the value of research volunteers as collaborators. PAR enabled the inclusion of citizens as full collaborators. Social media data were gathered for 120 days until saturation was reached. De-identified data were organized into a Strengths Weaknesses, Opportunities and Threats framework and coded into themes for analysis. After the analysis, the authors prioritized potential solutions for improving research engagement. Strengths and opportunities remained constant through trial phases, disease burdens, and interventions. Threats included alienation, litigation, disparity, and shaming. Poor management and barriers to inclusion were identified as weaknesses. Opportunities included improving resource management and information quality. Barriers were minimized when relationships between staff and participants were inclusive, respectful, tolerant, and open to change. Participants' communications ranged from fulfillment through trial involvement to disparities and rights violations. PAR provides a safe space without power imbalances in which researchers and citizen worked as equals rather than as researchers and objects of research.
  7. Lee YK, Ng CJ, Low WY
    J Eval Clin Pract, 2017 Dec;23(6):1281-1288.
    PMID: 28585242 DOI: 10.1111/jep.12777
    RATIONALE, AIMS, AND OBJECTIVES: Patient concerns are often neglected in consultations, especially for chronic diseases where patients and providers fall into the routine of chronic disease management in consultations. One strategy to elicit patient concerns has been to ask patients to complete agenda lists before the consultation. This study aimed to explore the impact of a preconsultation agenda website in addressing patients' unmet needs during chronic disease consultations.
    METHODS: Patients entered their concerns into a website (Values In Shared Interactions Tool (VISIT)). Doctors accessed this information via the electronic medical records before consultations. Individual in-depth interviews were then conducted with patients and doctors on the website's impact on consultations. Interviews were transcribed verbatim and analysed thematically.
    RESULTS: The average age (years) was 65.7 for patients (n = 8) and 35.7 for doctors (n = 7). Patients in the study entered between 1 to 6 items in the website. From postconsultation interviews, we found that the website impacted the consultation in 5 ways: (1) It facilitated patients to communicate their full agenda to doctors; (2) it helped address unmet patient needs as it gave them opportunity to raise other issues besides their chronic condition; (3) it facilitated rapport between doctor and patient; (4) it facilitated doctors to organize their consultation around the concerns the patient had listed; and (5) it disrupted the doctor's usual consultation style if the list of concerns was lengthy.
    CONCLUSIONS: Integrating patient concerns into electronic health records helped to facilitate patient-centred consultations. Doctors found this information useful but felt uneasy if the agenda list was too long or too complex. Areas for future studies include training doctors to manage complex agendas and formal evaluation of the VISIT tool.
    Study site: Primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
  8. Ahmad N, Hassan Y, Tangiisuran B, Meng OL, Abd Aziz N, Ahmad FU, et al.
    J Eval Clin Pract, 2013 Oct;19(5):798-804.
    PMID: 22583820 DOI: 10.1111/j.1365-2753.2012.01852.x
    RATIONALE, AIMS AND OBJECTIVES: Existing literature suggests that doctors' poor adherence with guidelines is one of the major contributing factors to suboptimal control of hypertension. This study aims to evaluate doctors' adherence with Malaysian clinical practice guideline (CPG 2008) in a tertiary care hospital, and factors associated with guideline adherence and hypertension control.
    METHODS: This was a cross-sectional study conducted at Hospital Pulau Pinang, Penang, Malaysia. Prescriptions written by 26 enrolled doctors to 650 established hypertensive outpatients (25 prescriptions per enrolled doctor) were noted on visit 1 along with patients' demographic and clinical data. The noted prescriptions were classified either as compliant or non-compliant to CPG (2008). Five hundred twenty (80%) of the enrolled patients (20 patients per enrolled doctor) were followed for one more visit. Blood pressure (BP) noted on visit 2 was related to the prescription written on visit 1. SPSS 16 (SPSS Inc., Chicago, IL, USA) was used for data analysis.
    RESULTS: Three hundred forty-nine (67.1%) patients received guidelines compliant pharmacotherapy. In multivariate analysis, hypertension clinic had significant negative association with guidelines adherence. Two hundred sixty-five patients (51%) were at goal BP on visit 2. In multivariate analysis, angiotensin-converting enzyme inhibitors and guidelines adherence had significant positive, while renal disease, diabetes mellitus and diabetic clinic had significant negative association with hypertension control.
    CONCLUSIONS: An overall fair level of adherence with guidelines and better control of hypertension was observed. Guidelines compliant practices resulted in better control of hypertension. The gaps between what guidelines recommend and clinical practice were especially seen in the pharmacotherapy of uncomplicated hypertension and hypertension with diabetes mellitus and renal disease.
    KEYWORDS: Malaysia; adherence; guidelines; hypertension
    Study site: Cardiology, nephrology, diabetic and hypertension clinics, Hospital Pulau Pinang, Malaysia
  9. Mohammed SA, Yusof MM
    J Eval Clin Pract, 2013 Apr;19(2):379-87.
    PMID: 22502634 DOI: 10.1111/j.1365-2753.2012.01839.x
    Poor information quality (IQ) must be understood as a business problem rather than systems problem. In health care organization, what is required is an effective quality management that continuously manages and reviews the factors influencing IQ in health information systems (HIS) so as to achieve the desired outcomes. Hence, in order to understand the issues of information quality management (IQM) practices in health care organizations, a more holistic evaluation study should be undertaken to investigate the IQM practices in health care organizations. It is the aim of this paper to identify the significant evaluation criteria that influence the production of good IQ in HIS.
  10. Kassab YW, Hassan Y, Aziz NA, Akram H, Ismail O
    J Eval Clin Pract, 2013 Aug;19(4):658-63.
    PMID: 22845427 DOI: 10.1111/j.1365-2753.2012.01894.x
    RATIONALE: Despite the availability of various prevention guidelines on acute coronary syndrome (ACS), secondary prevention practice utilizing aspirin, beta-blockers, angiotensin converting enzyme inhibitors and statins still can be sub-optimal.
    AIMS AND OBJECTIVES: To review and document the utilization of pharmacotherapy for the secondary prevention of ACS in patients discharged from a Malaysian hospital.
    METHODS: A retrospective cross-sectional study was conducted at a tertiary hospital in Penang, Malaysia. Patients with a primary diagnosis of ACS were identified from medical records over a 4-month period. A range of clinical data was extracted from medical records, including medical history, clinical presentation and pharmacotherapy both on admission and at discharge. This audit focused on the use of four guideline-recommended therapies: aspirin ± clopidogrel, beta-blockers, statins and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blockers (ARBs).
    RESULTS: Data pertaining to a total of 380 ACS patients was extracted and reviewed, the mean age of the study population was 57.49 years and 73.9% of population was males. Patients with unstable angina accounted for 56.6% of the admissions whereas 23.4% and 20% of the patients were admitted for ST-elevation myocardial infarction and non-ST-segment elevation infarct respectively. 95.7% of the patients received antiplatelets comprising of at least aspirin, and 82% received aspirin plus clopidogrel. Furthermore, 80.3% of the patients received a beta-blocker at discharge, 95% a statin and 69.7% received either an ACEI or ARB. Compared with patients who presented with myocardial infarction (with or without ST-segment elevation), those presenting with unstable angina were less likely to receive the combination of aspirin plus clopidogrel or an ACEI/ARB at discharge. Patients over 65 years of age were also less likely to receive a beta-blocker at discharge, compared with younger patients.
    CONCLUSIONS: There is a good adherence to evidence-based guidelines for the secondary prevention of ACS in this local setting. However, there is some potential underutilization in the older population and patients presenting with unstable angina.
    KEYWORDS: acute coronary syndromes; evidence-based pharmacotherapy; secondary prevention; utilization
  11. Price A, Albarqouni L, Kirkpatrick J, Clarke M, Liew SM, Roberts N, et al.
    J Eval Clin Pract, 2018 02;24(1):240-253.
    PMID: 29076631 DOI: 10.1111/jep.12805
    BACKGROUND: Funders encourage lay-volunteer inclusion in research. There are controversy and resistance, given concerns of role confusion, exploratory methods, and limited evidence about what value lay-volunteers bring to research. This overview explores these areas.

    METHODS: Eleven databases were searched without date or language restrictions for systematic reviews of public and patient involvement (PPI) in clinical trials design. This systematic overview of PPI included 27 reviews from which areas of good and bad practice were identified. Strengths, weaknesses, opportunities, and threats of PPI were explored through use of meta-narrative analysis.

    RESULTS: Inclusion criteria were met by 27 reviews ranging in quality from high (n = 7), medium (n = 14) to low (n = 6) reviews. Reviews were assessed using CERQUAL NICE, CASP for qualitative research and CASP for systematic reviews. Four reviews report risk of bias. Public involvement roles were primarily in agenda setting, steering committees, ethical review, protocol development, and piloting. Research summaries, follow-up, and dissemination contained PPI, with lesser involvement in data collection, analysis, or manuscript authoring. Trialists report difficulty in finding, retaining, and reimbursing volunteers. Respectful inclusion, role recognition, mutual flexibility, advance planning, and sound methods were reported as facilitating public involvement in research. Public involvement was reported to have increased the quantity and quality of patient relevant priorities and outcomes, enrollment, funding, design, implementation, and dissemination. Challenges identified include lack of clarity within common language, roles, and research boundaries, while logistical needs include extra time, training, and funding. Researchers report struggling to report involvement and avoid tokenism.

    CONCLUSIONS: 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.

  12. Elnaem MH, Nik Mohamed MH, Zaman Huri H, Azarisman SM
    J Eval Clin Pract, 2018 06;24(3):521-527.
    PMID: 29508492 DOI: 10.1111/jep.12903
    RATIONALE: Previous research reported underutilization of statin therapy among patients with type 2 diabetes mellitus. Improving health care providers' awareness and understanding of the benefits and risks of statin treatment could be of assistance in optimizing the statin prescribing process.
    AIMS AND OBJECTIVES: This study aimed to assess health care providers' knowledge related to statin therapy and the impact of educational outreach intervention based on the perceived knowledge.
    METHODS: This was a cross-sectional study based on educational outreach intervention targeting physicians and pharmacists in 1 major tertiary hospital in the state of Pahang, Malaysia. Participants responded to a 12-item, validated questionnaire both prior to and after the outreach educational program. Two sessions were conducted separately for 2 cohorts of pharmacists and physicians. The knowledge scores prior to and after the educational intervention were calculated and compared using a paired-samples t-test.
    RESULTS: The response rate to both pre-and post-educational outreach questionnaires was 91% (40/44). Prior to the intervention, around 84% (n37) of the participants decided to initiate statin therapy for both pre-assessment clinical case scenarios; however, only 27% (n12) could state the clinical benefits of statin therapy. Forty-five percent (n20) could state the drug to drug interactions, and 52.3% (n23) could identify the statin therapy that can be given at any time day/evening. The educational outreach program increased participants' knowledge scores of 1.450 (95% CI, 0.918 to 1.982) point, P 
  13. Foong RTK, Sellappans R, Loo JSE
    J Eval Clin Pract, 2019 Jun 05.
    PMID: 31168913 DOI: 10.1111/jep.13180
    BACKGROUND: Potentially inappropriate medications (PIMs) in older adults are detrimental to both clinical outcomes and health care costs, with their prominence set to increase in tandem with a fast-growing ageing population. Beers Criteria is one of the most commonly used guidelines that lists specific PIMs. Community pharmacists would therefore benefit from knowledge of Beers Criteria in detecting PIMs in primary care. This study therefore investigates the awareness of Beers Criteria and knowledge of PIMs among community pharmacists in the Klang Valley, Malaysia.

    METHODS: The study was conducted using a self-administered questionnaire. Knowledge of PIMs was assessed using 10 clinical vignettes based on the 2015 Beers Criteria. Practice behaviour towards older customers was assessed using 10 items with a 5-point Likert scale. Descriptive and inferential statistics were used to analyse the data.

    RESULTS: A total of 277 community pharmacists participated in the study. Only 27.1% of the pharmacists were aware of Beers Criteria, and of these, only 37.3% were aware of the latest 2015 update. The respondents demonstrated moderate knowledge of PIMs with a mean total score of 5.46 ± 1.89 out of a maximum of 10. Pharmacists who were aware of Beers Criteria had significantly higher scores (6.31 vs 5.14, P 

  14. Daghash H, Lim Abdullah K, Ismail MD
    J Eval Clin Pract, 2019 Sep 05.
    PMID: 31489762 DOI: 10.1111/jep.13280
    BACKGROUND: Health care institutions need to construct management strategies for patients diagnosed with acute coronary syndrome (ACS) that focus on evidence-based treatments, adherence to treatment guidelines, and organized care. These help to reduce variations as well as the mortality and morbidity rates, which indicates the critical need for standardized care and adherence to evidence-based practices for patients hospitalized with ACS. The care pathways translate research and guidelines into clinical practice to close the gap between the guidelines and the clinical practices.

    OBJECTIVES: This review focuses on identifying the indicators used to evaluate ACS care pathways and their effect on the care process and clinical outcomes.

    METHODS: This review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The systematic research was conducted using five research databases. Two groups were created by dividing the studies according to their year of publication. The first group included those studies published from 1997 to 2007 ("Group 1"), while the second included those published from 2008 to 2018 ("Group 2"). Selected studies were screened using the Effective Public Health Practice Project (EPHPP) quality assessment tool.

    RESULTS: Seventeen studies were included in this review. One study was a randomized controlled trial, 14 were predesigns and postdesigns, and two were longitudinal observational designs. The Group 1 studies demonstrated that ACS care pathways had a positive effect on reducing the length of the hospital stay and the door-to-balloon times. Similar effects were observed for the Group 2 studies.

    CONCLUSION: Implementing ACS care pathway helps to organize care processes and decrease treatment delays as well as improve the patient outcomes without adverse consequences for patients or additional resources and costs. While the current level of evidence is inadequate to warrant a formal recommendation, there is a need for more studies with an emphasis on well-designed randomization to measure patient outcomes.

  15. Tong WT, Ng CJ, Lee YK, Lee PY
    J Eval Clin Pract, 2019 May 21.
    PMID: 31115132 DOI: 10.1111/jep.13161
    RATIONALE, AIMS, AND OBJECTIVES: Few studies focus on patients' views on factors influencing implementation of patient decision aids (PDAs). This study aims to explore patients' views on the factors influencing implementation of an "insulin choice" PDA in a primary care setting.
    METHODS: This study used a descriptive qualitative study design. Interviews were conducted using a semistructured interview guide developed based on the theoretical domains framework. Nine in-depth interviews and three focus group discussions were conducted with patients with type 2 diabetes who have been advised to start insulin or were currently using insulin and those who had been seeking diabetes treatment in the clinic for more than 1 year. Interviews were conducted after the participants were familiarized with the PDA. Data were analysed using a thematic approach.
    RESULTS: Five themes emerged from the data analysis: (a) trust in the physician (patients preferred physicians to other health care providers in delivering the insulin PDA to them as they trusted physicians more when it comes to making decisions such as starting insulin), (b) physician's attitude (patients were more likely to trust a physician who is friendly and sympathetic hence would be more willing to use the insulin PDA), (c) physician's communication style (patients were more willing to use the insulin PDA if the physicians would take time and guide them in the PDA use), (d) conducive environment (patients preferred to read the PDA at home), and (e) cost (patients would not be willing to pay to use the insulin PDA unless they needed it).
    CONCLUSIONS: Patients want physicians to play a major role in the implementation of the insulin PDA; physicians' communication style and commitment may influence implementation outcomes. Health care authorities need to create a conducive environment and provide patients with free access to PDA to promote effective implementation.
    Study site: Primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
  16. Ng CJ, Lee YK, Abdullah A, Abu Bakar AI, Tun Firzara AM, Tiew HW
    J Eval Clin Pract, 2019 Dec;25(6):1074-1079.
    PMID: 31099120 DOI: 10.1111/jep.13163
    It is common for primary care providers (PCPs) to manage complex multimorbidity. When caring for patients with multimorbidity, PCPs face challenges to tackle several issues within a short consultation in order to address patients' complex needs. Furthermore, some PCPs may lack access to a multidisciplinary team and need to manage multimorbidity within the confine of a PCP-patient partnership only. Instead of attempting to address multiple health issues within a single consultation, it would be more feasible and time effective for PCPs and patients to jointly prioritize the health issue to focus on. Using the Malaysian primary care setting as a case study, a dual-layer-shared decision-making approach is proposed whereby PCPs and patients make decisions on which disease(s) (layer 1) and treatment(s) (layer 2) to prioritize. This dual-layer model aims to address the challenges of short consultation time and limited healthcare resources by encouraging PCPs and patients to discuss, negotiate, and agree on the decision during the consultation to ensure patients' health needs are addressed.
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