Efficacy of telerehabilitation for spine pain during the Coronavirus pandemic lockdown: a retrospective propensity score-matched analysis

PURPOSE

Despite increased usage of telemedicine to deliver treatment during the coronavirus disease 2019 (COVID-19) pandemic, the efficacy of telerehabilitation for spine pain is unknown. This study aimed to investigate the effect of telerehabilitation on pain and disability in patients with spine pain treated during the COVID-19 pandemic and compare the results to in-clinic rehabilitation.

MATERIALS & METHODS

In this propensity score-matched analysis, 428 patients with spine pain who underwent telerehabilitation during the 6 months of COVID-19 pandemic lockdown and 428 patients who underwent in-clinic multimodal rehabilitation treatment during the 6-month period prior to lockdown were compared. Propensity score matching was done based on gender, age, pre-treatment pain, and disability. Post-treatment numerical pain rating scale (NPRS), Oswestry or Neck disability index (ODI or NDI), and minimal clinical important difference (MCID) achieved for NPRS and ODI/NDI scores were compared between the 2 groups.

RESULTS

Post-treatment, the mean NPRS (mean difference - 1, p < 0.0001) and ODI/NDI (mean difference - 5.8, p < 0.0001) scores, were significantly lower in the telerehabilitation group when compared to control group. Similarly, the percentage of patients who achieved MCID of ≥ 2 for NPRS (mean difference - 6%, p = 0.0007) and MCID of ≥ 10 for ODI/NDI (mean difference - 7.5%, p = 0.005) scores were significantly higher in the telerehabilitation group.

CONCLUSIONS

Telerehabilitation achieved significant reduction in pain and disability among patients with spine pain, better than in-clinic rehabilitation. These encouraging results during the COVID-19 pandemic indicate the need to further explore and test the efficacy and wider application of telerehabilitation for treating spine pain.IMPLICATIONS FOR REHABILITATIONTelerehabilitation can help achieve significant reduction in pain and disability among patients with spine pain.These encouraging results indicate the need to further explore a wider application of telerehabilitation for treating patients with spine pain during non-pandemic times.

Comparison with Navigation of a Novel Three-Step Technique for Improving Accuracy of the Distal Femoral Resection during Conventional TKA: A Case-Control Study

Correct placement of the femoral component in the coronal plane during primary total knee arthroplasty (TKA) is related to long-term survival. The aim of this radiographic study was to determine the accuracy of a novel three-step technique for improving the accuracy of the distal femoral cut during conventional technique and compare it with computer navigation during TKA. A total of 458 TKAs were retrospectively analyzed (178 conventional TKAs with the novel technique and 280 navigated TKAs) for postoperative femoral component coronal alignment and compared between the two groups. Mean femoral component coronal alignment was not significantly different (p = 0.314) between the two groups. There was no significant difference in the mean femoral component coronal alignment between varus and valgus knees. The number of outliers (90 ± 3 degrees) for femoral component coronal alignment was not significantly different between the two groups when assessed separately for varus and valgus deformities. The mean value of femoral component alignment using the conventional technique in knees with varus deformity <10 degrees was 88.8 degrees, in knees with varus deformity 10 to 20 degrees was 89.4 degrees, and in those with varus deformity >20 degrees was 90.2 degrees. Femoral component alignment in knees with varus <10 degrees was significantly different from those >20 degrees (p = 0.006); there was no significant difference between knees with varus <10 degrees and those with 10 to 20 degrees varus (p = 0.251), nor between 10 and 20 degrees varus knees and those with varus >20 degrees (p = 0.116). Using the novel three-step technique during conventional TKA to perform the distal femoral cut can help achieve femoral component coronal alignment comparable to the navigation technique.

Strengthening the immunization supply chain through EVM assessment: Comparing India's two successive national assessments

Background

Effective immunization supply chain (iSC) is crucial for safe and timely transport of potent vaccines to the beneficiary. India's iSC, with a network of ~29,000 cold chain points (CCP), measures its quality standards using the World Health Organization-United Nations International Children's Emergency Fund (WHO-UNICEF) global tool on effective vaccine management (EVM). The two national EVM assessments (EVMA) were conducted in 2013 and 2018. This study helps to see the impact of policies and practices through EVMA in maintaining an efficient iSC for effective implementation of immunization program.

Materials and Methods

We conducted a desk analysis using EVMA reports to summarize and compare the findings of the two studies. Cut-off of 80% was considered ideal for each category/criteria score.

Results

Both EVMA 2013 and 2018 were conducted using Android-based global EVM tool, though across a wider sample of CCP. Maximum and minimum changes in scores were sub-national and lowest distribution (16% each) and national buffer stores (7%), respectively. Maximum and minimum improvements were seen in vaccine management (29%) and MIS and supportive functions (3%), respectively. The improvement was statistically significant for the overall scores (P = 0.02), primary (P = 0.01), subnational (P = 0.02), and lowest distribution stores (P = 0.03). Among the 36 recommendations of 2013 assessment, 78% and 22% were fully and partially implemented (or ongoing), respectively.

Conclusion

Implementation of EVM recommendations has significantly led to improvement and continues to provide a benchmark for iSC and its processes. Follow-up assessments every 3-5 years can further help to evaluate iSC and ascertain the impact of recommendations.

Prevalence of low back pain in India: A systematic review and meta-analysis

BACKGROUND: Although many studies have investigated the prevalence of low back pain (LBP) among Indian subjects, no meta-analysis has been conducted to determine the comprehensive epidemiological point, annual, lifetime prevalence of LBP among Indian subjects. OBJECTIVE: The purpose of this systematic review and meta-analysis was to investigate the point, annual, and lifetime prevalence of LBP in the Indian population. METHODS: We searched PubMed, Embase, Science Direct, and Cochrane Library databases for relevant studies that reported point, annual, or lifetime prevalence of LBP among Indian subjects,. Pooled point, annual and lifetime prevalence rates were calculated. Meta-analysis, subgroup analysis, sensitivity analysis and publication bias assessment were performed. RESULTS: Ninety-seven studies were included in this review. Fifty-four studies included in the review (55.5%) were found to be of higher methodological quality. The pooled point, annual, and lifetime prevalence of LBP in India was 48% (95% CI 40–56%); 51% (95% CI 45–58%), and 66% (95% CI 56–75%), respectively. The pooled prevalence rates were highest among females, the rural population, and among elementary workers. CONCLUSION: The point, annual, and lifetime prevalence rates of LBP in the Indian population is higher compared to global and other ethnic populations affecting a large proportion of the population, especially among women, rural population and in elementary workers. The findings of this study can be the basis for formulating policy regarding the prevention and treatment of LBP in a large part of the global population.

Post-COVID-19 pandemic public health: Issues and challenges in India

COVID-19 was an unexpected public health emergency. The key positive features of the Indian health system were demonstrated during the pandemic. Postpandemic is the time to introspect. Various issues and challenges facing the Indian Public Health System require due attention.

Shifting towards online training-Possible challenges from Educators/Trainers perspective in Indian setting

Worldwide metastasis of novel coronavirus COVID-19 has caused immense alterations among every walk of human existence and social interaction(1). Education and training sector being as vulnerable to these adjustments as any other domain(2). Owing to its extremely infectious nature, the COVID-19 pandemic enforced the closure of training institutes globally. All the traditional classroom training were restricted as an instant consequence, to achieve the norms of social distancing which can perhaps aid in obliterating the infection curve and lessen the resultant fatalities(3). Educational institutions in India predominantly bank on traditional methods of training, utilizing conventional setup of in-person training and lectures in a teaching space. While over the years, there is a marked shift towards blended learning, still most of the academic institutes are guided by the existing orthodox learning methodologies. An unexpected outbreak of the Covid-19 pandemic caused by Corona Virus (SARS-CoV-2) shuddered the entire world (4). This complete shutdown kind of circumstances has tested the education system globally and coerced the educators to shift to digital platforms and online modules almost instantaneously. Academic institutions were required to shift from their traditional pedagogical approach to online teaching-learning. The article recognises the possible barriers to swiftly shift from traditional methods of learning towards e-learning among adult professionals through analysing the limitations faced by the authors while converting and conducting traditional trainings into e-trainings at The National Cold Chain and Vaccine Management Resource Centre (NCCVMRC-NIHFW), New Delhi. This article also put some light on methodologies that could assist academic institutions in dealing with challenges associated with shifting towards e-learning.

Status and challenges for tuberculosis control in India - Stakeholders' perspective

BACKGROUND

Tuberculosis is one of the ten major causes of mortality worldwide. The trend of increasing TB cases and drug resistance in India is very disturbing. The objectives of the study were to study the perspectives and opinions of different stakeholders on the status, challenges and the ways to tackle the issues of TB in India.

METHODS

The online survey was done for the data collection from national and international experts. The data collection took place during October 2017. We received 46 responses.

RESULTS

The experts had varied answers as to the menace of TB in India, effect of TB on individuals, family and society, failure of government plans in India, TB awareness campaign and ways to create awareness. Everyone believed that urgent action needs to be taken against the disease like improving the healthcare infrastructure of the country (improving the quality and quantity of medical facilities and doctors) and creating awareness about the TB.

CONCLUSION

Government of India is making lot of efforts to bring down the problems associated with TB through. In spite of this, there is a long way to go to achieve significant reduction in high incidence and prevalence of TB in India. Factors like lack of awareness and resources, poor infrastructure, increasing drug resistant cases, poor notification and overall negligence are the major challenges. If we eradicate poverty and undernourishment, educate the masses and eliminate the stigma attached with TB, we can hope for a disease free future.

Gender differences in the risk factors for high and very high blood glucose levels: A study of Kerala

BACKGROUND AND AIMS

Worldwide, lifestyle is a significant risk factor for diabetes. Lifestyle changes can lead to differences in the extent of risk of diabetes among women and men. Kerala, a state with one of the best health indicators in India, has a high prevalence of diabetes. This study aimed at comparing the variations in the risk factors for HBG and VHBG among adult women and men in Kerala.

METHODS

Data from the fourth round of the National Family Health Survey (2015-16) used to examine the differences in the risk factors for HBG and VHBG in men and women aged 15-49 years. We used bivariate, multivariate and Population Attributable Risk (PAR) techniques for analysing the data.

RESULTS

Bivariate results have shown the pattern of HBG and VHBG prevalence in women and men was same among all the age groups; however, men show a higher HBG and VHBG than women in all the age groups. Prevalence of HBG and VHBG was higher in women with a primary education, who were poor and not working as compared to their male counterparts. PARs results show that the prevalence of VHBG was higher among obese men and women as compared to normal men and underweight women. Prevalence of HBG was higher among men as compared to women due to alcohol use and weekly consumption of non-vegetarian food.

CONCLUSIONS

The study suggests that there is an urgent need for targeted intervention programs to address the problem of HBG and VHBG in both men and women in Kerala to control blood glucose levels.

Experiences of Older Persons in Seeking Care at a Private Hospital in Urban India

Objective: The study aims to describe the experiences of older persons in seeking health care in a private hospital in urban India. Methods: Semi-structured interviews were conducted with 50 older persons admitted in or visiting a private hospital in Hyderabad city in India between the period November 2017 and April 2018. The data were analyzed using Content Analysis. Results: Dimensions related to payment mechanisms, quality of health care staff, and hospital quality were reported to be important for the older persons. Payment mechanisms were related to discounts, insurance support, and reducing out-of-pocket expenditure. Quality of care was related to optimizing hospital operational processes like discharge time, standard of treatment, and trustworthiness of the medical staff. Discussion: Payment mechanism can be made friendly for the older persons. Quality of hospital including its staff can be enhanced by developing geriatric-specific competencies which can help them to understand and treat complex health problems specific for the older population.

Comparison of Functional Outcomes of Computer-Assisted vs Conventional Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of High-Quality, Prospective Studies

BACKGROUND

Computer-assisted navigation system (CAS) in total knee arthroplasty (TKA) has been shown to improve mechanical alignment and prosthesis positioning as compared to conventional TKA. However, the evidence with regard to whether CAS-TKA has better patient function over conventional TKA is not clear. This systematic review and meta-analysis compares functional outcomes of CAS vs conventional TKA at longer follow-up periods.

METHODS

This study was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Embase, gray literature, and clinicaltrials.gov were searched up to April 30, 2018. All prospective original studies (only level 1 and 2) that compared functional outcomes of CAS-TKA vs conventional TKA, with minimum 2-year follow-up, were included. The research question and eligibility criteria were established a priori. Pertinent data were extracted and random-effects model was used.

RESULTS

A total of 18 studies with 3060 knees were included; of which 1538 underwent TKA with CAS and 1522 underwent conventional TKA. Studies were grouped based on the follow-up reported into: (1) ≥2 years to <5 years; (2) ≥5 years to <8 years; (3) >8 years. Pooled mean Western Ontario and McMaster Universities Osteoarthritis Index scores (P < .001) and Knee Society Score-function score (P = .03) were better in the CAS-TKA group in the 5- to 8-year follow-up. For the remaining follow-ups, there was no difference between the 2 groups.

CONCLUSION

The meta-analysis concluded that there is limited evidence that CAS-TKA improves functional outcomes at 5- to 8-year follow-up as measured by Western Ontario and McMaster Universities Osteoarthritis Index and Knee Society Score-function scores. More prospective studies with larger sample size and longer-term follow-up are required to support the trend toward better functional outcomes with CAS.

Status of Health Management Education in India: Past, Present, and Future

This article provides a perspective on the evolution of health management education in India, its current state and the way forward. Health management originated in India in response to the administrative needs of the healthcare system, which is now moving toward institutional care, away from its earlier form of home healthcare. As this field evolved over time, new roles emerged for health management professionals. Several articles have been published in the past describing the state and growth in the field of health management education. This article emphasizes the need to rationalize the sector and shape its future to suit the needs of over a billion people, who use the services of multiple organizations, directly or indirectly in a highly dynamic healthcare environment. We have identified the various challenges that affect the sector today; filling vacant positions, matching jobs with training, and changes in curricula required to achieve good matches. Solutions to address these challenges have also been considered, which in our view could be a way forward in this sector.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Effect of menstruation on girls and their schooling, and facilitators of menstrual hygiene management in schools: surveys in government schools in three states in India, 2015

Background

Lack of menstrual knowledge, poor access to sanitary products and a non-facilitating school environment can make it difficult for girls to attend school. In India, interventions have been developed to reduce the burden of menstruation for school girls by government and non-governmental organizations (NGOs). We sought to identify challenges related to menstruation, and facilitators of menstrual management in schools in three states in India.

Methods

Surveys were conducted among menstruating school girls in class 8-10 (above 12 years of age) of 43 government schools selected through stratified random sampling in three Indian states (Maharashtra, Chhattisgarh, Tamil Nadu) in 2015. For comparison, ten model schools supported by NGOs or UNICEF with a focussed menstrual hygiene education program were selected purposely in the same states to represent the better-case scenario. We examined awareness about menarche, items used for menstruation, and facilitators on girls’ experience of menstruation in regular schools and compared with model schools. Factors associated with school absence during menstruation were explored using multivariate analysis.

Findings

More girls (mean age 14.1 years) were informed about menstruation before menarche in model schools (56%, n = 492) than in regular schools (36%, n = 2072, P < 0.001). Girls reported menstruation affected school attendance (6% vs 11% in model vs regular schools respectively, P = 0.003) and concentration (40% vs 45%, P = 0.1) and was associated with pain (31% vs 38%, P = 0.004) and fear of stain or smell (11% vs 16%, P = 0.002). About 45% of girls reported using disposable pads in both model and regular schools, but only 55% and 29% of pad-users reported good disposal facilities, respectively (P < 0.001). In multivariate analysis, reported absenteeism during menstruation was significantly lower in Tamil Nadu (adjusted prevalence ratio (APR) 95% confidence interval (CI) = 0.24, 0.14-0.40) and Maharashtra (APR 0.56, CI = 0.40-0.77) compared to Chhattisgarh, and halved in model compared to regular schools (APR 0.50, CI = 0.34-0.73). Pain medication in school (APR 0.71, CI = 0.51-0.97) and use of disposable pads (APR 0.57, CI = 0.42-0.77) were associated with lower absenteeism and inadequate sanitary facilities with higher absenteeism during menstruation.

Conclusions

Menstrual hygiene education, accessible sanitary products, pain relief, and adequate sanitary facilities at school would improve the schooling-experience of adolescent girls in India.

Outcome of School-Based Intervention Program in Promoting Personal Hygiene in Primary School Children of Mumbai, India

Personal hygiene plays an important role in preventing communicable diseases especially in children. In developing countries like India, the burden of communicable diseases is high which makes an awareness program imperative in school children. The objective was to study the outcome of school-based intervention program in promoting personal hygiene among the primary school children of Mumbai and Thane. This is a comparative study carried out from July 2015 to March 2016 between intervention and nonintervention groups before and after intervention. Using random sampling, 119 schools in Mumbai and 24 schools in Thane were selected. Our results suggest that knowledge, attitude, and practices were significantly different in end-line than baseline in the intervention group and had better effects as reflected in scores compared with comparison group. The findings reveal that a health education program clubbed with entertainment and interaction can bring positive attitudinal shift which is otherwise difficult to change.

Study of Awareness, Enrollment, and Utilization of Rashtriya Swasthya Bima Yojana (National Health Insurance Scheme) in Maharashtra, India

INTRODUCTION

Government of India launched a social health protection program called Rashtriya Swasthya Bima Yojana (RSBY) in the year 2008 to provide financial protection from catastrophic health expenses to below poverty line households (HHs). The objectives of the current paper are to assess the current status of RSBY in Maharashtra at each step of awareness, enrollment, and utilization. In addition, urban and rural areas were compared, and social, political, economic, and cultural (SPEC) factors responsible for the better or poor proportions, especially for the awareness of the scheme, were identified.

METHODS

The study followed mixed methods approach. For quantitative data, a systematic multistage sampling design was adopted in both rural and urban areas covering 6000 HHs across 22 districts. For qualitative data, five districts were selected to conduct Stakeholder Analysis, Focused Group Discussions, and In-Depth Interviews with key informants to supplement the findings. The data were analyzed using innovative SPEC-by-steps tool developed by Health Inc.

RESULTS

It is seen that that the RSBY had a very limited success in Maharashtra. Out of 6000 HHs, only 29.7% were aware about the scheme and 21.6% were enrolled during the period of 2010-2012. Only 11.3% HHs reported that they were currently enrolled for RSBY. Although 1886 (33.1%) HHs reported at least one case of hospitalization in the last 1 year, only 16 (0.3%) HHs could actually utilize the benefits during hospitalization. It is seen that at each step, there is an increase in the exclusion of eligible HHs from the scheme. The participants felt that such schemes did not reach their intended beneficiaries due to various SPEC factors.

DISCUSSION AND CONCLUSION

The results of this study were quite similar to other studies done in the recent past. RSBY might still be continued in Maharashtra with modified focus along with good and improved strategy. Various other similar schemes in India can definitely learn few important lessons such as the need to improve awareness, issuing prompt enrollment cards with proper details, achieving universal enrollment, ongoing and prompt renewal, and ensuring proper utilization by proactively educating the vulnerable sections.

Knowledge, Practices, and Restrictions Related to Menstruation among Young Women from Low Socioeconomic Community in Mumbai, India

The main objective was to assess knowledge, practices, and restrictions faced by young women regarding their menstrual hygiene. The views of adult women having young daughters were also included and both views were compared. In addition, the factors influencing the menstrual hygiene practices were also studied. The study was carried out during 2008 in Mumbai, India. The mixed methods approach was followed for the data collection. Both qualitative and quantitative methods were used to collect the data. For quantitative survey, totally 192 respondents (96 adult and 96 younger women) were selected. While young women were asked about questions related to their menstruation, adult women were asked questions to find out how much they know about menstrual history of their daughters. The qualitative data helped to supplement the findings from the quantitative survey and to study the factors affecting menstrual practices in young women. The mean age at menarche reported was 13.4 years and 30–40% of young girls did not receive any information about menstruation before menarche. It is thus seen that very few young girls between the age group 15 and 24 years did receive any information before the onset of menstruation. Among those who received some information, it was not adequate enough. The source of information was also not authentic. Both young and adult women agreed on this. Due to the inadequate knowledge, there were certain unhygienic practices followed by the young girls resulting in poor menstrual hygiene. It also leads to many unnecessary restrictions on young girls and they faced many health problems and complaints, which were either ignored or managed inappropriately. The role of health sector was almost negligible from giving information to the management of health problems of these young girls. This paper reemphasizes the important, urgent, and neglected need of providing correct knowledge to the community including adolescent girls.

Usage of Complementary and Alternative Medicine among Severe Hemophilia A Patients in India

Documented evidence of the usage of complementary and alternative medicine among patients with rare disease such as hemophilia is limited. Therefore, we explored the types of complementary and alternative medicines used, the associated sociodemographic and clinical factors, and the cost and reasons for usage among severe hemophilia A patients in India. Our study demonstrates an increased usage of complementary and alternative medicine (42.3%) among hemophiliacs. Significant factors associated with usage of these therapies were economic status, comorbidity status, and education of head of households. Among users of complementary and alternative medicine, cost of these therapies was found to be higher (17.22%) compared with hemostatic drugs (5.63%) from the average cost of treatment (Rs 29 029). The findings of this study warrant multicenter research to explore different dimensions of complementary and alternative medicine and also incorporate it in comprehensive hemophilia care programs to address issues of treatment gap and quality of life of hemophiliacs.

Optimal bearing surfaces for total hip replacement in the young patient: a meta-analysis

Although there is general consensus about the efficacy of total hip replacement (THR) in young patients, the most appropriate bearings in young patients remain highly debated. The three most popular bearings in use include metal-on-polyethylene (MOP), metal-on-metal (MOM) and ceramic-on-ceramic (COC). We conducted a systematic review and meta-analysis of literature to summarise the best available evidence on relative success of the three most popular bearings used in THR in young active patients. Our findings support the use of MOM bearings in the management of the young arthritic hip. These findings, largely based upon observational studies, should be taken in the context of the limitations of such non-randomised study designs.

Role of hormonal genes and risk of prostate cancer: gene-gene interactions in a North Indian population

Prostate cancer represents a heterogeneous disease with varying degrees of aggressiveness, patterns of metastasis, and response to therapy. It arises from a complex etiology that involves both exogenous (diet, environment, etc.) and endogenous (hormonal and genetic) factors. The present study was performed to explore the role of various genotypes involved in steroid metabolism and synthesis in the causation of prostate cancer. Genetic polymorphism of the ER, CYP17, SRD5A2 (TA repeats), and PSA genes were analyzed in 157 cases of prostate cancer and 340 controls [170 healthy males and 170 patients of benign prostate hyperplasia (BPH)]. Mutant genotypes of ER and CYP17 showed 2- and 3- and 3.5-fold increased risk of prostate cancer, respectively, as compared to BPH and healthy controls. Interaction of mutant (homozygous and heterozygous) alleles of CYP17 with TA (0/0) led to a twofold increased risk of prostate cancer. Risk was more than twofold with the combination of mutant alleles of ER and CYP17. The PSA gene polymorphism did not show any increased risk of prostate cancer. This indicates the role of mutant allele of ER and CYP17 in the development and progression of prostate cancer and rules out any increased risk with PSA polymorphism in the north Indian population.

Developing clinical indicators for the secondary health system in India

QUALITY PROBLEM OR ISSUE

One of the prime goals of any health system is to deliver good and competent quality of healthcare. Through World Bank-assisted Maharashtra Health Systems Development Project, Government of Maharashtra in India developed and implemented clinical indicators to improve quality.

INITIAL ASSESSMENT

During this, clinical areas eligible for monitoring quality of care and roles of health staff working at various levels were identified.

CHOICE OF SOLUTION

Brainstorming discussion sessions were conducted to refine list of potential clinical indicators and to identify implementation problems.

IMPLEMENTATION

It was implemented in four stages. (a) Self-explanatory tool of record, standard operating procedures and training manual were prepared during tools preparation stage. (b) Pilot implementation was done to monitor the usefulness of indicators, document the experiences and standardize the system accordingly. (c) The final selection of indicators was done taking into consideration points like data reliability, indicator usefulness etc. For final implementation, 15 indicators for district and 6 indicators for rural hospitals were selected. (d) Transfer of skills was done through training of various hospital functionaries.

EVALUATION AND LESSONS LEARNED

Selection and prioritization of clinical indicators is the most crucial part. Active participation of local employees is essential for sustainability of the scheme. It is also important to ensure that data recorded/reported is both reliable and valid, to conduct monthly review of the scheme at various levels and to link it with the quality improvement programme.