Pervez Alina, Martins Russell Seth, Moiz Huzaifa, Syed Abbas Raza, Khan Muneeb, Rizvi Nashia Ali, Mustafa Mohsin Ali, Nasim Muhammad Taha, Rehman Alina Abdul, Khalid Shayan, Rehman Saif Ur, Nadeem Sarah, Haider Adil H, Akhtar Shabbir
Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, 74800, Pakistan.
Section of Otolaryngology, Head and Neck Surgery, Department of Surgery, Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan.
BMC Prim Care. 2025 Mar 5;26(1):64. doi: 10.1186/s12875-025-02756-7.
Diseases of the ear, nose, and throat (ENT) account for a significant portion of a primary care physician's practice in Pakistan, a South Asian lower-middle income country. This increasing burden demands comprehensive clinical practice guidelines and primary care clinical referral algorithms to be devised so that general physicians can adequately provide standardized primary health care and prevent needless specialist ENT referrals.
We selected eight guidelines regarding epistaxis, neck masses, hearing loss, Meniere's disease, dysphonia, allergic rhinitis, acute otitis externa, and rhinosinusitis from the American Academy of Otolaryngology-Head and Neck Surgery Foundation as the source guidelines and employed the GRADE-ADOLOPMENT approach to contextualize guidelines by adopting, adapting, or excluding recommendations from these guidelines. Clinical referral algorithms were created using recommendations from the created clinical practice guidelines, with additional recommendations being sought via a best evidence review process.
We successfully created local clinical practice guidelines for the eight ENT conditions using the GRADE-ADOLOPMENT process. While most recommendations were adopted in the local clinical practice guidelines, one recommendation for acute otitis externa, hearing loss, and epistaxis and two for allergic rhinitis were adopted with minor changes to provide supporting information. Six recommendations were excluded mostly due to the unavailability of services in Pakistan. Eight clinical referral algorithms were also created which incorporated 17 additional recommendations to fill gaps in clinical practice including four additional recommendations to the epistaxis algorithm, three for neck lumps/mass, rhinosinusitis, and allergic rhinitis, two for acute otitis externa, and one for Meniere's disease and dysphonia algorithms.
The newly created clinical practice guidelines will help in the provision of standardized, high-quality care at the primary care level. Concomitantly, the clinical referral pathways can assist the general physicians in the management of patients as well as guide appropriate timely referrals to ENT specialists.
在南亚低收入国家巴基斯坦，耳鼻喉科疾病在基层医疗医生的诊疗工作中占很大比例。这种日益加重的负担需要制定全面的临床实践指南和基层医疗临床转诊算法，以便全科医生能够充分提供标准化的初级卫生保健，并避免不必要的耳鼻喉专科转诊。
我们选择了美国耳鼻咽喉 - 头颈外科学会基金会关于鼻出血、颈部肿块、听力损失、梅尼埃病、声音障碍、过敏性鼻炎、急性外耳道炎和鼻窦炎的八项指南作为源指南，并采用GRADE - ADOLOPMENT方法，通过采纳、调整或排除这些指南中的建议来使指南本地化。临床转诊算法是根据制定的临床实践指南中的建议创建的，并通过最佳证据审查过程寻求额外的建议。
我们使用GRADE - ADOLOPMENT流程成功为这八种耳鼻喉疾病制定了本地临床实践指南。虽然大多数建议被纳入本地临床实践指南，但急性外耳道炎、听力损失和鼻出血的一项建议以及过敏性鼻炎的两项建议在稍作修改以提供支持信息后被采纳。六项建议大多因巴基斯坦无法提供相关服务而被排除。还创建了八项临床转诊算法，其中纳入了17项额外建议以填补临床实践中的空白，包括鼻出血算法的四项额外建议、颈部肿块/肿物、鼻窦炎和过敏性鼻炎的三项建议、急性外耳道炎的两项建议以及梅尼埃病和声音障碍算法的一项建议。
新制定的临床实践指南将有助于在基层医疗层面提供标准化、高质量的护理。同时，临床转诊途径可以帮助全科医生管理患者，并指导及时将患者转诊至耳鼻喉专科医生处。
