In my role as Divisional General Manager for Digital Health Transformation & Innovation at Mediclinic, I am responsible for harnessing the power of digital technology and making sure that we utilise it to the benefit of our patients and business. There’s no doubt that technology has revolutionised the way we access and deliver healthcare over the last 10 years, and will continue to do so.

Take telemedicine as an example. Back in 2015 when I started in telehealth, telemedicine was not a well-received service. Patients were not trusting of virtual doctors and insurance companies would not pay for it. Fast forward to 2020 and the COVID-19 pandemic, and you can see how this perception changed almost overnight. For most patients, with restricted access to healthcare facilities, it was the only way they could consult with a doctor, and for doctors, it was the only they could treat their patients.

Related: Personalised, next-gen healthcare experiences are within grasp

At Mediclinic, we started with 2,000 teleconsultations per month at the beginning of the pandemic, and now, almost four years later, we are conducting 20,000 a month. We have witnessed organic growth in the service, even after the necessity was removed because patients had tried it and saw the value in it. They are also better educated about their health and more conscious of whether their condition can be managed virtually or not. Insurers have also seen how telemedicine can reduce costs and provide access and have included telemedicine in their packages.

A huge shift has already taken place in how healthcare can be delivered, but we don’t expect it to end there. We anticipate that telemedicine will become part of a more integrated model of healthcare for the management of chronic conditions such as diabetes and hypertension, and linked to healthcare systems which use data from wearable devices. Wearables are not new. Patients were given a device by their doctor to be worn for some time, but the doctors would not see the results from that device until the patient’s next visit. Today, due to the advances in this type of technology, the model has moved to one of continuous engagement, where readings from the wearable can be sent continuously to the doctor, and if he sees an area for concern, he can intervene immediately. Increased use of these devices, however, means more pressure on the doctor, but AI systems will have a role in being able to predict possible deteriorations and so, intervention can be done at an earlier stage, and not always by a doctor.

This model is very beneficial for both the patient and the healthcare system because once you start helping the patient before their condition becomes acute, they are less likely to be hospitalised, and it costs the insurers less, which will help the implementation of future funding models like Value-Based Care (VBC). This balance between the needs of the patient and the payer is greatly needed for population health programmes such as this. There are still challenges though on how you engage the patient into that system. Just as patients needed to make the mental shift to telemedicine, they needed to appreciate the benefits of this type of system. Success is dependent on proper communication, engagement, onboarding and training.

AI and machine learning is becoming increasingly prevalent in healthcare. At Mediclinic, we are already using it behind the scenes, in administrative areas such as coding to improve accuracy, and clinically in the reading of radiology images. AI can release pressure on caregivers and act as a co-pilot, helping deliver more efficient and reliable outputs. AI is not about the replacement of the doctor, it’s about collaboration, empowerment and enablement. A doctor with AI can manage a much greater number of patients more effectively than a doctor without AI, and I think it will increasingly become the norm over the next few years.

Related: Six predictions that will impact healthcare in 2024

From a patient’s perspective, digital technology can empower them in their healthcare, give them the tools to make informed decisions about their treatment and improve accessibility. At Mediclinic, we’re proud of how far we have come in the digital space for the benefit of our patients – from the swift introduction of telemedicine in 2020, the launch of an appointment management app, which also serves as the platform for teleconsultations, a secure patient portal that allows them immediate access to their test results and medical records, the establishment of multiple communication channels so they can reach us whenever and however they wish, and automated processes to increase the speed of eligibility checks and insurance approvals, meaning that the process of visiting the doctor is faster and more seamless than ever before. In the future, we plan to use digital health as a companion to the patients during their treatment journey.

When it comes to the use of technology to improve our healthcare processes and services, Mediclinic has so much in store over the next few months and years. Watch this space!

Ahmad Awada is the Divisional General Manager for Digital Health Transformation & Innovation at Mediclinic.

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At a time when healthcare costs have become a sustainability concern globally, value-based care has emerged as a path to address future healthcare challenges while maintaining a focus on improving patient outcomes. In the UAE, the Dubai Health Authority’s (DHA) Dubai Health Insurance Corporation (DHIC) announced last year the launch of a first-of-its-kind value-based healthcare model for the Emirate, jumpstarting a new era in healthcare services.

The new initiative, known as EJADAH, is an innovative approach aimed at not only enhancing the quality of healthcare but also prioritising preventive care.

“EJADAH will work towards ensuring that Dubai’s healthcare sector becomes more sustainable and patient-centric going forward, with incentivising improvements in value – rather than volume – through alternative payment models,” according to DHIC consultant, Dr. Mohamed Farghaly, Family Medicine Consultant, Diabetologist and Professor of Medicine at Dubai Medical Collage.

Value-based care seeks to improve patient outcomes and elevate the patient experience while managing the efficiency of care and reducing unneeded costs within the healthcare system. It represents a system where providers are rewarded based on positive patient outcomes, quality, and efficiency. By pinpointing areas where quality improvements can be made, healthcare systems then can focus their resources more effectively on care paths that benefit their patients most.

Adoption of the Current Procedural Terminology (CPT) code set for use in the healthcare system in Dubai enables greater transparency to identify overlooked opportunities, such as preventive care or underutilised healthcare practices. The CPT code set is a medical terminology maintained by the American Medical Association (AMA) and forms the backbone of healthcare data interoperability in the UAE today. CPT codes support new and novel care delivery models by accurately describing the services and treatments patients receive and classifying healthcare data to reduce administrative burden and improve patient and public health outcomes. Furthermore, data classified by the CPT code set enables stakeholders, who manage limited resources, to benchmark quality measurements for patient cohorts and share care service and resources more equitably.

Use of the standardised CPT code set aligns with the mission of healthcare systems to enhance the quality of patient care while optimising cost-efficiency. Here are some examples of how CPT content contributes to these alternative payment models:

• Link cost and quality measures: CPT codes allow for standardised reporting of healthcare services, so that care can be accurately documented. Healthcare systems and providers can evaluate the cost-effectiveness of their discrete services. Additionally, the standardisation allows for the tracking and comparing of quality measures, so that patient care can be aligned with best practices and benchmarks, thus enhancing the quality of care delivered.
• Digitally enabled care and emerging technologies: With the advent of telemedicine, wearable devices, and health monitoring apps, CPT content accurately represents the services provided in a digital care setting. This not only allows for the efficient delivery of care but also enables new avenues for preventive healthcare. For example, remote monitoring and telehealth visits can help patients manage chronic conditions and receive timely interventions, reducing the overall cost of care while improving patient outcomes.
• Coordination of patient care: With CPT codes providing a standardised language, healthcare professionals can seamlessly communicate and coordinate patient care across different modalities, providers and specialties, helping them provide patients holistic and well-coordinated care. In a value-based model, this collaborative approach that CPT content facilitates can lead to better patient outcomes and reduce duplicative services and unnecessary costs.

CPT content continues to empower healthcare systems to accurately describe medical procedures and services, elevate quality, improve productivity, manage costs, and thus expand patient access. The DHA's commitment to launching EJADAH represents a positive step for new value-based models “that will no doubt also pave the way and inspire other territories in the region to consider similar approaches,” according to Dr. Farghaly.

As healthcare delivery transforms in the GCC region, pioneering developments serve as an inspiration for a healthier future. Value-based care with the CPT code set at its foundation holds promise as an effective healthcare delivery system that remains patient-centric and contributes to sustainable healthcare services across the region and beyond.

About the Current Procedural Terminology (CPT) code set

The Current Procedural Terminology (CPT) code set curated by American Medical Association (AMA) is a comprehensive, standardised language that seeks to empower physicians and health systems to improve quality, increase access, and lower costs. Frequently updated and trusted for more than 50 years, the CPT code set enables innovative clinical practices and technologies that support the modern delivery of care. 

Chris Jagmin, M.D. is the Chairperson, CPT Editorial Panel

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Value-based healthcare (VBHC) has become one of the most up-to-date hot topics and widely used terms among C-suite leaders in modern healthcare. The initiatives have been escalating, ever since Porter and Teisberg introduced the concept of value-based competition in their seminal book titled ‘Redefining Healthcare’ (2006), in response to the increasing cost of healthcare in the US and the failure of reforms to improve health outcomes and contain costs.

When talking about healthcare, the focus is often on the cost of providing treatment. Porter and Teisberg introduce seven principles of value-based competition — with the value being the main objective, simply defined as “the quality of patient outcomes relative to the dollars expended”.

Value = health outcomes that matter to patients/cost of delivering healthcare

The principals emphasise that the focus should be on value for patients, not just to lower costs, and there must be unrestricted competition based on the results. The competition should also focus on medical conditions over the full cycle of care while ensuring that high-quality care is less costly, and the competition is on regional and national levels. At the same time, the value is driven by provider experience, scale, and learning at the medical condition level. It is crucial for value-based competition (VBC) that information on results and prices needed must be widely available. As a final recommendation to foster VBC, innovations that increase value must be strongly rewarded.   

In KSA, VBHC entails a change from conventional fee-for-service models to strategies that put patient satisfaction, efficiency, and results first. The Saudi government has expressed interest in implementing VBHC to improve the efficiency and quality of healthcare.

Each country is addressing VBHC concept implementation based on their context perspective, strategic priority, available resources, cultural needs, and combating challenges to ensure alignment and coordination at all levels of healthcare delivery and substantial collaboration efforts, with the patient and his/her well-being placed at the centre of the system. The World Economic Forum (WEF) has provided a comprehensive framework for a Value-based Health System. The measurement of outcomes and costs incurred to deliver those outcomes are systematically collected and measured”.

Related: Trends in international healthcare collaborations in Saudi Arabia and across the GCC

To support this model, WEF has identified four enablers:

1. An integrated informatics infrastructure to capture, share, and analyse health outcomes.
2. Analytic tools for benchmarking and research.
3. New forms of value-based payments that introduce incentives for continuous improvement in patient value.
4. New roles and organisational models that allow better access to appropriate care.

Having a vibrant society with fulfilling lives, where all can live healthy, be healthy, and care for their health is a strategic goal of the Kingdom of Saudi Arabia Vision 2030. The Vision is committed to the healthcare sector that promotes competition and transparency among providers” that inevitably will enhance the capability, efficiency, and productivity of care and treatment, and increase the options available to our citizens”.

Among others, Vision 2030 is determined to optimise and better utilise the capacity of our hospitals and healthcare centres. These clear vision statements represent strong foundations to achieve the Vision 2030 health sector goal of increasing the average life expectancy from 74 to 80 years. At the same time, they represent a strong mandate for all regulators in the Kingdom to work towards these goals by utilising contemporary concepts of funding healthcare services.

Therefore, value-based healthcare (VBHC) is an established strategic objective of the Kingdom of Saudi Arabia’s healthcare transformation agenda. As an integral part of this transformation, the Council of Health Insurance (CHI) envisions a regulatory role that supports this objective and direction. In this context, the CHI has begun a process of initiating a series of VBHC enabler initiatives.

Thus far, CHI has progressed significantly in standardising data and introducing Minimum Data Set (MDS); launching contemporary health information exchange platform (i.e. NPHIES), and introducing patient classification systems (AR-DRG and SBS). It has also raised the requirements and standards around Health Information Management (clinical coding, training, accreditation, and billing).

In my opinion, there are six key fundamental components to VBHC enabler initiatives in Saudi Arabia:

Patient-centred care: Emphasise actual patients’ needs and preferences in treatment decisions to improve overall satisfaction and outcomes.

Outcome measurement: Use metrics to evaluate the efficacy and calibre of care; this approach focuses on health outcomes rather than the quantity of services provided.

Payment reform: Transition from fee-for-service to value-based payment models, where healthcare providers are incentivised to achieve positive patient outcomes.

Data integration: Implement robust health information systems to facilitate data sharing among healthcare providers, enabling better coordination and continuity of care.

Performance transparency: Make healthcare performance data accessible to the public, fostering accountability, and encouraging competition among providers.

Care coordination: Enhance collaboration among healthcare providers to ensure seamless transitions of care and avoid unnecessary services.

How the insurance sector in KSA will benefit from value-based healthcare (VBHC)

The insurance sector in Saudi Arabia will overcome many everlasting challenges in the next coming years and thrive from the VBHC initiatives sought by the Saudi government strategy. These initiatives shall achieve several benefits to the insurance sector in Saudi Arabia. The value-based healthcare (VBHC) can bring:

Cost containment: VBHC focuses on improving outcomes and efficiency, which can lead to better management of healthcare costs. Insurance companies stand to benefit from reduced expenses associated with unnecessary tests or treatments, ultimately contributing to more sustainable and predictable costs.

Quality assurance: VBHC emphasises the delivery of high-quality care and improved patient outcomes. Insurers can leverage this to negotiate better partnerships with healthcare providers, ensuring that the care covered by insurance plans aligns with established quality standards.

Risk management: By promoting preventive care and proactive health management, VBHC can help insurers mitigate long-term health risks. This shift towards preventive measures can lead to a healthier population, reducing the frequency and severity of claims for insurance companies.

Data-driven decision making: VBHC relies on data analysis to measure outcomes and identify areas for improvement. Insurers can use this data to make informed decisions about coverage, network partnerships, and risk assessments, ultimately enhancing their ability to provide effective insurance products.

Enhanced patient engagement: VBHC encourages patient involvement in their care. Insurers can leverage this by promoting wellness programmes, incentivising healthy behaviours, and using technology to engage policyholders in their health management, potentially reducing the likelihood of expensive health issues.

Collaborative partnerships: VBHC fosters collaboration between insurers and healthcare providers. Building strong partnerships can lead to more integrated and coordinated care, ensuring that insurance plans align with best practices and deliver value to policyholders.

Improved customer satisfaction: As VBHC aims to enhance patient experience and outcomes, insurers adopting these principles may see increased customer satisfaction. Satisfied policyholders are more likely to remain loyal, contributing to the overall success and sustainability of insurance programmes.

Incentives alignment: VBHC encourages aligning incentives across the healthcare ecosystem. Insurers can work with providers to establish shared goals, fostering a collaborative environment that benefits both parties and, ultimately, the insured population.

In conclusion, the adoption of VBHC principles in Saudi Arabia can positively impact the insurance sector by promoting cost-effective, high-quality care, improving risk management, and enhancing the overall value proposition for policyholders.

Related: Establish collaborative partnerships in Saudi’s transformative journey

Accreditations, patient safety, and public health that support VBHC initiatives in KSA

The establishment of different Saudi national programmes as infrastructure to standardise and advance the quality of care and care delivery, patient safety, healthcare providers competency, and public health represented by the Centre Board for Accrediting Health Institutions (CBAHI), the Saudi Patient Safety Centre (SPSC), the Saudi Commission for Health Specialties (SCFHS) and the newly Public Health Authority (PHA - WEQAYA), shall support the Kingdom’s strategy towards HCVB goals alignments and fully carry its implementation and outcomes efficiently.   

Accreditation plays a crucial role in supporting the implementation of value-based healthcare by establishing standards and ensuring that healthcare providers meet certain quality benchmarks. In the context of VBHC, accreditation helps validate the commitment of healthcare organisations to deliver high-value care. A master healthcare provider can clearly observe how accreditation and VBHC are interconnected in many ways:

Quality standards: Accreditation bodies set and uphold quality standards for healthcare facilities. Meeting these standards is aligned with the goals of VBHC, which prioritise delivering quality care and achieving positive patient outcomes.

Patient-centred focus: Both accreditation and VBHC emphasise a patient-centred approach. Accreditation standards often include criteria related to patient satisfaction and involvement, aligning with the core principles of VBHC.

Outcome measurement: Accreditation processes typically involve assessing outcomes and performance indicators. This aligns with the VBHC principle of measuring and improving outcomes to ensure value in healthcare delivery.

Continuous improvement: Accreditation encourages continuous improvement in healthcare practices. VBHC also emphasises ongoing assessment and improvement, making accreditation a supportive mechanism for healthcare organisations striving to enhance value.

Incentives for quality: Accreditation can serve as a mechanism to incentivise healthcare providers to adhere to VBHC principles. Achieving and maintaining accreditation status may be linked to financial incentives or improved market reputation, reinforcing the adoption of value-based practices.

Data integration: Both accreditation and VBHC require effective data management and integration. Accreditation processes often involve data collection and analysis, supporting the data-driven approach inherent in VBHC for measuring outcomes and improving care delivery.

In summary, accreditation provides a structured framework for healthcare organisations to align with VBHC principles. It helps ensure that healthcare services are not only accredited but also contribute to improved patient outcomes and overall value in healthcare delivery.

Finally, we view the VBHC holds great potential to improve overall healthcare quality, delivery, patient safety, healthcare providers calibers, effectiveness, productivity, incentives, transparency, and efficiency in the country, and hopefully, the model will mature over the next few years to reach the summit in 2030.   

References available on request.

Dr. Nashat Nafouri is the Chair of Healthcare Interest Group, Executive Officer of Saudi Quality Council, and Executive Consultant of Quality Logic. He will be speaking at the Quality Management conference at Arab Health 2024.

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Many people believe that a bunion is a bump that ‘grows’ on the bone, and that during bunion correction, it can simply be shaved off. Unfortunately, in most cases this is incorrect. Mostly the visible bump occurs because of the metatarsal bone moving towards the centre line of the body, with the big toe moving in the opposite direction, i.e. away from the midline. The visible bump is caused by the partially uncovered joint becoming prominent under the skin. In most cases this cannot simply be shaved off, because doing so would damage the joint, leading to more serious problems.

Bunions are mostly not caused by genetics. Genetics can play a role, however, modern shoes are the primary cause. There is an interesting research study from Japan from the early 1980s — before the introduction of Western shoes in the 1960s — where most of the population wore platform sandals. The incidence of bunions in the population was approximately 3 per cent (the true genetic incidence). After the introduction of Western shoes with high heels and narrow toe boxes, the incidence of bunions increased to over 30 per cent in the same population. (Kato and Watanabe 1981).

Bunions develop when there is a muscle imbalance in the foot. The accompanying picture (Image 01) shows a tug-of-war between two groups of children. Each child represents a separate muscle, and the flag in the middle represents the big toe. Just as the flag moves in the direction of the stronger group of children, the big toe moves towards the stronger or tighter muscles. Long-term use of narrow shoes will lead to stretching and weakening of the muscles on one side of the big toe, so the toe moves.

Most bunions can be managed perfectly well with shoes that are wide enough (Aebischer and Duff 2020). It is important to understand that the front of the foot naturally widens with age, and shoe size should be measured and updated every three years. The two main solutions to a mismatch between the width of the foot and shoes are to either (1) wear wider shoes, or (2) have the shoes stretched in the area of tightness.

Silicone toe spacers and bunion splints to wear in bed at night do not work to change the shape in real-life practical use (Tehraninasr and Forogh 2008). As a serious exercise, I recommend putting on a pair of shoes while wearing a silicone toe spacer. You will see that the tip of the big toe is now pushed into a position of prominence, and the tip of the big toe (or the toenail) can now rub uncomfortably against the far end of the shoe.

If changing shoes is not your choice, then the only other way is to surgically reduce the width of the foot. However, there are some pitfalls to consider (Aebischer and Duff 2020). Cosmesis alone is not a sufficient indication for surgery. Bunion surgery should not be offered to children or teenagers. Surgery should not proceed in smokers, as the complications are higher.

There are more than 130 operations available for bunions, most of which do not work well and are of historical interest only. There is no one-size-fits-all operation for bunions. Each bunion has its own personality, and the correct operation must be chosen. If the wrong operation is chosen, the toe can be worse off than before.

Related: How technology is shaping the future of surgery

In order to offer a complete bunion service, these are the minimum set of surgeries that any bunion surgeon must be able to perform well:

• Rotational Lapidus fusion (this operation is mostly only performed by properly trained foot and ankle experts)
• PROMO osteotomy (a new operation that is playing an increasing role in modern bunion surgery – I personally introduced this to the UAE in 2021).
• Scarf osteotomy
• Chevron osteotomy (including the biplanar variation)
• Akin osteotomy
• 1st MTP joint fusion
• Proper lateral release of soft tissues

The goal of the operation is to place the 1st metatarsal head directly over the sesamoid bones, and in so doing restore the muscle balance evenly around the toe (please refer to the tug-of-war picture again). This is important to understand. Foot surgeons are “engineers of the foot”, and these goals are mechanical and measurable.

A final technical note is to touch on the recent increase in popularity of the “minimally invasive” surgery. The type of surgery chosen should be viewed as a “tool” used to correct the specific deformity of the patient. Minimal invasive may have a role, however, just like any other operative tool, there are also drawbacks. Some common problems with minimal invasive surgery include significant shortening of the 1st metatarsal (with a painful transfer of force of walking onto the 2^nd and 3^rd toes, and eventual hammer toes forming as a result), incomplete lateral release of the soft tissues, and unstable osteotomy with loosening of the surgical fixation (something to consider in areas where Vitamin D deficiency and/or osteoporosis is a problem).

It is my observation that people with bunions often have little interest in the status of the muscle balance of the toe, but are rather more interested in lifestyle goals, including (but not limited to):

• easy recovery (recovery time and restrictions depend on the operation, which in turn is dictated by the deformity)
• expectation that the foot must never hurt again (it is important to note that most foot pain occurs in normal feet, as a result of lifestyle factors – therefore a foot can still hurt even after surgery if lifestyle factors are not addressed)
• the ability to wear any shoe (in research publications, up to 40 per cent of patients still cannot wear tight shoes after surgery)
• to be better at running (running is sometimes a little worse after a successful surgery – the slight stiffness from scarring of the soft tissues during healing can interfere with running)
• and, to be happy with how it looks (which is very subjective – different people like different visual outcomes)

It is important to realise that the surgeon’s goals are mostly completely different from the patient’s goals when it comes to bunion surgery. Surgeons have control over angles and position, but not direct control over any lifestyle-related goals. There is much room for disappointment in the difference between the two different goals. This is why it is important to seriously consider trying non-operative treatment of bunions first, before considering surgery.

Related: Laser-assisted robotic knee surgery advances orthopaedic treatment

In summary, by going to an expert foot and ankle surgeon, you can be confident that the correct operation is being recommended and will be performed well from a technical standpoint. However, surgery is no magic panacea. Always consider the surgical choices very carefully. The foot is the mechanical shock absorber of the body. Changing the shape of the foot can have unintended mechanical consequences. Surgery for cosmetic reasons alone is not recommended.

References available on request.

Dr. Roger Haene is the Consultant Orthopaedic Surgeon at Burjeel Hospital Abu Dhabi. He will be speaking at the Orthopaedics conference in Arab Health 2024.

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The UAE legal system faces several significant challenges when dealing with medical malpractice claims, particularly when assessing appropriate compensation levels sought by plaintiffs. This article reviews and discusses the disparity ('the Compensation Differential') between the amount(s) of compensation sought by plaintiffs (‘the Claim Amounts’) when they pursue litigation through the local courts and the corresponding final amount(s) of compensation/damages awarded by the local courts (‘the Judgment Amounts’).

The remarkable extent of this compensation differential was highlighted in a study of a sample of 72 medical malpractice decisions in cases litigated in the local courts over the period 1 January 2012 to 31 December 2022 (‘the Study’) carried out by my colleagues in the Medical Malpractice Group at Galadari Advocates and Legal Consultants.

In my experience, the underlying causes contributing to the compensation differential significantly hinder or impede settlement discussions advancing towards consensus, agreement and settlement. This is regrettable and inefficient as — in many cases — particularly where liability is not reasonably defeasible - many defendants and their medical malpractice underwriters would readily agree to enter into amicable settlements at reasonable levels commensurate with the actual disability incurred thereby saving significant legal costs of litigation and minimising stress/management time involved in such cases for the plaintiffs and defendant hospitals and physicians alike.

The Study headlines reveal that there were no cases in the sample where the Claim Amount in full was awarded; in 12 per cent of cases, the plaintiff did not pursue a Claim Amount but instead asked the Court to assess damages. NB: There is no evidence to suggest that those plaintiffs asking the Court to assess damages fared better or worse than plaintiffs who sought a specified/stated Claim Amount. In 10 per cent of cases, the final Judgment Amount(s) were between 40 per cent to 50 per cent of the Claim Amount(s); and in 78 per cent of cases, the final judgment amount(s) were less than 15 per cent of the Claim Amount(s). Excessive Claim Amounts have always been a cause for concern in the sector but the study emphasises just how commonplace they are.

Related: Mental health neglect: A healthcare business concern

The question arises why do plaintiffs consistently claim excessive amounts and what can be done to address this? It is suggested that the 'Compensation Differential' may be explained by a combination of three factors: 

Unrealistic expectations of plaintiffs

The subjective experience of pain, suffering, worry and distress of a plaintiff drives them to assess pain and suffering from their own viewpoint — rather than what is recoverable under UAE law. Plaintiffs often see their pain and suffering, etc. as being worth millions of dirhams whereas the court usually awards nominal amounts. In several cases where I have advised plaintiffs I have given a reasoned and accurate assessment of what a court is likely to award and my plaintiff clients have instructed me to pursue exorbitant amounts – only to have the actual judgment amounts in line with my assessments being pronounced and being upheld on appeal.

Unrealistic advice by plaintiffs’ lawyers

Local Courts of First Instance charge Court filing fees as a percentage of the Claim Amount – with a maximum/capped filing fees of Dh40,000 for a Claim Amount of approximately Dh700,000 or so. It appears that plaintiffs are being advised that given that the maximum/capped fee has been reached there is no disadvantage to claiming exorbitant amounts and provides a substantial margin to be reduced in any negotiation.

Moreover, in a civil law system as found in the UAE, there is no system of binding judicial precedent which presents challenges for lawyers advising plaintiffs, as they must provide accurate advice on matters of evidence and financial compensation while managing – perhaps — unrealistic expectations. Despite these challenges, providing accurate advice on likely Judgment Amounts is possible with a reasonable degree of due diligence, experience and research.

Incomplete or insufficient evidence speaking to quantum produced in court

The burden of proof in medical malpractice cases lies with the plaintiff, who must discharge his/her burden to prove their case by adducing documentary evidence to establish medical error and to justify their claim amount.

Whilst obtaining a supportive Medical Liability Committee/Higher Committee of Medical Liability Report is now reasonably established as the mandatory method of proving liability, i.e, whether or not there was a medical error or serious/gross medical error, it is frequently the case that plaintiffs do not adduce complete or — in the majority of cases — any documentary evidence speaking to their financial losses/damages.

I have defended cases where plaintiffs have claimed several tens of millions of dirhams without producing a single item of evidence speaking to quantum — no receipts, invoices or sick leave certificates. Although First Instance Courts have a wide discretion to assess damages – documentary evidence is still greatly valued by the judiciary - and lack of documentary evidence is usually the main reason of why excessive Claim Amounts fail to deliver commensurate Judgment Amounts.

Related: Saudi Arabia’s agile auditing and compliance system secures investor confidence

How can the issue be addressed and is there a resolution available? Unfortunately, there is no obvious panacea that can solve the problem in every case. Having plaintiffs represented and advised by experienced and competent counsel — who are aware of what the UAE Courts regularly award — only addresses a part of the problem.

Lawyers still have to do what their clients instruct them to do. Voluntary mediation may provide answers in many cases provided that the third party mediator is knowledgeable on UAE medical malpractice particularly how quantum is assessed by the local Courts and is skilful in encouraging the parties to reach an acceptable compromise.

I suspect that the hospitals or their medical malpractice underwriters would have to pay for this service but I envisage that — provided all sides enter into the mediation in good faith — we may well see a considerable rise in the number of medical malpractice cases being dispensed with by consensus and amicable settlement.

Stephen Ballantine is the Senior Counsel and Head of Medical Negligence at Galadari Advocates & Legal Consultants. He will be speaking at the Surgery conference at Arab Health 2024.

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Antenatal expression of breast milk, also known as colostrum harvesting or hand expression, is a practice gaining recognition among expectant mothers. This process involves manually expressing small amounts of colostrum (the nutrient-rich first milk produced by the mammary glands) before childbirth. While breastfeeding traditionally commences after delivery, antenatal expression offers a proactive approach to breastfeeding that comes with numerous benefits for both mothers and newborns.

Colostrum is often referred to as "liquid gold" due to its concentrated nutritional content and immune-boosting properties. Antenatal expression allows mothers to collect and store this valuable substance before labour, ensuring a readily available supply for the newborn during the crucial first few days of life. Colostrum is rich in antibodies, providing the baby with essential protection against infections and diseases. It comes in a few drops only and some parents may be concerned that will be not enough for the first days of life, but because of its rich amount of immunoglobulin and developmental factors, it covers the nutrition requirement for the newborn baby.

Related: The evolution of maternal immunisation

Antenatal expression can be especially beneficial for mothers to ensure a smooth start to the breastfeeding journey. By establishing a colostrum reserve, mothers can address potential issues such as latch difficulties or delayed milk production, providing a smoother start to breastfeeding and reducing stress for both the mother and the newborn.

Harvesting of colostrum is recommended for every mother, and it is essential for mothers with high-risk pregnancies or medical conditions that may necessitate early separation from the baby. Expressing and storing colostrum ensures that the newborn receives the crucial benefits of breast milk even if immediate breastfeeding is not feasible. This practice supports the bond between mother and baby, fostering a sense of closeness despite any temporary physical separation.

Aside from the baby benefits, antenatal expression of colostrum can also:
- Stimulate milk production: Regularly expressing small amounts of colostrum signals the body to prepare for breastfeeding, promoting the production of mature milk after childbirth. This can be particularly advantageous for mothers who may have concerns about low milk supply.
- Building maternal confidence: Engaging in antenatal expression empowers mothers by providing them with a hands-on approach to breastfeeding before the baby arrives. This proactive involvement fosters a sense of confidence and competence, making the transition to breastfeeding less daunting.

Understanding one's ability to express colostrum can boost maternal self-assurance and contribute to a positive breastfeeding experience.

There are only a few cases where antenatal expression cannot be performed. We need to remember that breast stimulation can induce early labour, therefore is not recommended before 36 weeks and in all the conditions where a woman is at risk of delivering her baby prematurely. Some particular cases like placenta previa are also a contraindication for colostrum collection. The advice is always to consult with a doctor, midwife, or lactation consultant prior to starting harvesting.

Related: Genomics aids non-invasive prenatal diagnosis

Practical tips for antenatal expression

• See a doctor to check if you can harvest your colostrum.
• Once you reach 36 weeks start to collect. Remember that at the beginning you might see only a few drops, the quantity will increase little by little. In case you do not see any colostrum and you are not able to collect please remember that this is not an indication of not having milk later. Some women experience dry breast during pregnancy, but they will have plenty of milk once the baby arrives.
• Use hand expression technique – press, compress and release (see picture).
• Expressing into a sterile container and label it with date and time. Colostrum can be kept six days in the fridge and six months in freezer.
• On the day of delivery, don’t bring all the colostrum to the hospital but just one container — you might not need it at all and with the handling and variation of temperature it cannot be used for longer. In case more is needed, it can be always collected later.
• Use a cool bag to transport colostrum from home to hospital.
• In case you have any doubts or need further guidance, always consult with a healthcare professional or a lactation consultant for personalized advice and support.

Conclusion

Antenatal expression of breast milk is a proactive and empowering practice that offers a range of benefits for both mothers and newborns. From ensuring a readily available supply of colostrum to promoting maternal confidence, this approach contributes to a positive breastfeeding experience. As awareness grows, more expectant mothers may choose to incorporate antenatal expression into their prenatal preparations, unlocking the numerous advantages it brings to the early stages of motherhood.

Wendy Menghin is a Midwife Educator and Lactation Consultant, IBCLC/MHF. She will be speaking at the Obs&Gyn conference at Arab Health. 

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Globally it is estimated that approximately 7.5 per cent of people with type 2 diabetes require insulin therapy and data from the National Diabetes Audit in the UK indicates that approximately 10 per cent of people with type 2 diabetes are on insulin, despite increased use of GLP1 agonists and SGLT2 inhibitors in recent years, which means fewer people are treated with insulin than in the past. Often those people with type 2 diabetes on insulin, due to their underlying insulin resistance, require high doses of basal insulin, which can become increasingly ineffective as the dose response curve starts to flatten out once doses exceed about 30 units.

When basal insulin doses exceed about 60 units daily or post-prandial glucose levels are poorly controlled then bolus insulin is often added, either with particular meals where carbohydrate content is greatest and/or glucose peaks are most marked, or with all meals, but the same problem occurs when higher doses of bolus insulin are required. The availability of higher-concentration insulins, such as U200 insulin degludec (Tresiba) and lispro (Humalog), and U300 insulin glargine (Toujeo), mitigates the flattening of the dose response curve to some extent, by increasing the insulin dose at which the curves start to flatten out.

However, those people with type 2 diabetes who require very high doses of insulin often have poor glycaemic control which does not respond particularly well to escalating doses, and the high insulin doses are commonly associated with marked weight gain in people who are usually significantly obese to begin with. Furthermore, insulin doses, particularly at mealtime, may be insufficient, due to underestimation of the carbohydrate content of the meal, or missed completely, adversely impacting glycaemic control. Administration of insulin by smart pens or insulin pumps can help address some of these issues that perpetuate suboptimal glycaemic control.

Related: The future of diabetes care in a digital world

Smart insulin pens

Studies with smart insulin pens have highlighted the frequency of missed insulin doses – as well as providing a means to avoid these instances happening. One study with 75 participants, including 16 older people aged over 65 type 2 diabetes, found 24 per cent of bolus and 36 per cent of basal insulin doses were non-adherent, with those in the least-adherent tertile missing 50 per cent of bolus doses and having significantly worse glycaemic control, a mean HbA1c of 8.6 per cent vs 7.7 per cent in the most-adherent tertile.

We have found using the NovoPen 6 smart insulin pen to be particularly useful in older people with type 2 diabetes on insulin treatment who have cognitive issues, which means they cannot remember whether or not they have administered an insulin injection. Moreover, this can be helpful for carers who may not be present when a dose is due but can give it at a later time if the dose has been missed. The ability to review all insulin doses that have been given by uploading data from the smart pen can also make for a more meaningful clinic consultation and give greater security when adjusting an insulin regimen. In pregnant women with type 2 diabetes, the combination of a smart pen and continuous glucose monitoring, for example with the Freestyle Libre, allows them to better appreciate the efficacy of their bolus dosing and enhances their ability to get time in target range (3.5-7.8 mmol/L) to over 90 per cent.

Insulin pump therapy

Insulin pump therapy is well established as an option for intensive insulin therapy in type 1 diabetes with meta-analysis highlighting its potential to give superior glycaemic control over multiple daily injection regimens. Hybrid-closed loop therapy, combining insulin pump therapy and continuous glucose monitoring to automate basal insulin delivery, is increasingly the preferred option for people with type 1 diabetes, with the National Institute for Health and Care Excellence (NICE) publishing guidance recommending this for people with type 1 diabetes who have an HbA1c above 7.5 per cent on multiple daily injection regimens, as well as all women pregnant or planning pregnancy and all children.

In contrast, national consensus guidelines, such as those from NICE, generally do not recommend the use of insulin pump therapy in people with type 2 diabetes. However, when multiple daily injections with high doses of insulin are ineffective in helping achieve target HbA1c for a person with type 2 diabetes, insulin pump therapy may be the best option for trying to improve glycaemic control. The largest randomised controlled trial of insulin pump therapy in type 2 diabetes, the OpT2mise study, randomised 331 people with type 2 diabetes on multiple daily insulin analogue injections (MDI) and with an HbA1c of 8.0 per cent or above to six months of insulin pump therapy or continued MDI.

The mean HbA1c in both groups was 9.0 per cent at baseline but fell by 1.1 per cent in the pump arm compared to 0.4 per cent in the MDI arm; the mean insulin dose fell from 112 to 97 units daily in the pump arm but increased from 106 to 122 units in the MDI arm. There was a small increase in weight in both groups which did not differ significantly between groups. Fifty-five per cent of pump users achieved an HbA1c

Related: Nurses require specialised training for monogenic diabetes management

Our experience of insulin pump therapy in type 2 diabetes has been very similar to that reported in these trials. We have used it for people with poor glycaemic control on insulin doses over 200 units and achieved reductions in HbA1c of over 2 per cent with insulin requirements falling by more than 50 per cent, in most cases the reduction in the insulin requirement more than covering the cost of the pump. We have also used insulin pump therapy in people with type 2 diabetes for more specific indications: insulin allergy, pregnancy and gastroparesis.

The main benefit of insulin pump therapy in type 2 diabetes appears to relate to more reliable absorption and hence consistent dosing with delivering basal insulin continuously rather than as large once or twice daily doses. Prandial glucose management has been less problematic, and this is reflected by the relative lack of glycaemic variability in most people with type 2 diabetes even when on multiple daily injections. There are published data supporting the use of hybrid closed loop systems in type 2 diabetes with significant improvements in glycaemic control over the use of MDI alone, but there is no evidence that these systems offer any benefit over pump therapy alone.

References available on request.

Dr. Peter Hammond, MD FRCP, is a Consultant Endocrinologist at Harrogate and District NHS Foundation Trust in the UK.

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Ventral hernias of the abdomen are defined as a non-inguinal, non-hiatal defect in the fascia of the abdominal wall. Ventral hernias are complex because of different factors including:

• The presence of local infection
• Size of the defect (large)
• Obesity, and other comorbidities
• The unusual location away from the common midline hernias (multiple)
• Previous unsuccessful repair

A survey in 2016 showed that 65 per cent of experts agreed that loss of domain and hernia volumes greater than 30 per cent of abdominal contents are mandatory characteristics for defining large, complex abdominal wall defects.

Despite operative innovation, recurrence rates remain far from acceptable. For this reason, surgeons are now enhancing their focus on optimising patient-related factors.

Related: Innovation caps rising costs of surgical care

SURGICAL MANAGEMENT OF COMPLEX VENTRAL HERNIA

Preoperative consultation

Preoperative assessment of large ventral hernia defects is the cornerstone of success. Evaluation should begin with a thorough history and physical examination. Overlying skin changes such as ulceration, thinning, and cellulitis should also be noted, as should the presence of draining sinuses or exposed mesh.

Surgical history, as well as previous operative reports, should be reviewed. The urgent or emergent nature of presentation can affect morbidity and mortality, with mortality rates reported to be 0.3 per cent for elective repairs compared with 1.1 per cent for complicated cases.

Preoperative optimisation
 

1. Laparoscopic ventral hernia repair when compared against open techniques has consistently shown decreased overall complication rates, decreased hospital length of stay, and a quicker return to work.
2. Robotic ventral hernia repairs have also become popular secondary to increased freedom of motion during surgery.
3. Component separations can be performed in several different ways and are typically reserved for large defects in which a tension-free closure cannot be achieved.

Rives-Stoppa Repair: The Rives-Stoppa repair was first described in the 1980s and uses a retrorectus dissection plane. However, despite its excellent record, the limited lateral dissection used in this technique limits its applicability.

Posterior Component Separation with Transversus Abdominis Release (TAR): The transversus abdominis release has demonstrated utility in repairing complex and non-midline defects that the Rives-Stoppa repair fails to address.

Anterior Component Separation: The anterior component separation uses a dissection anterior to the rectus muscles. During the operation, a subcutaneous plane is formed by incising the external oblique fascia, just lateral to the lateral aspect of the rectus muscles.

References available on request.

Dr. Sulaiman Shantour is a Consultant Surgeon at Ain AlKhaleej Hospital. He will be speaking at the Surgery conference in Arab Health 2024.

The emergence of the JN.1 coronavirus variant, classified as a "variant of interest" by the World Health Organisation (WHO), has sparked concern due to its increased contagiousness and potential impact on public health. Descendant from the BA.2.86 variant, JN.1 is marked by over 30 mutations in the spike protein, prompting questions about its severity, spread and implications for healthcare providers.

First identified in the US in September, JN.1 has swiftly spread across borders, with cases reported in China, the US and Singapore. India, witnessing over 4,000 active COVID-19 cases, detected its first JN.1 variant case in Kerala on December 8. However, despite its higher transmissibility, current data indicates that JN.1 does not exhibit greater severity than other existing strains. The WHO emphasises that existing vaccines remain effective in preventing severe disease and death from JN.1 and other variants. However, ongoing monitoring is crucial to understanding its spread rate, treatment susceptibility, and potential impact on global public health.

Related: Rise of COVID-19 variants: After Eris, Fornax and Pirola emerge

As JN.1 cases surge globally, the UK's Office for National Statistics (UK ONS) has identified two new symptoms associated with COVID-19 infection: trouble sleeping and anxiety. Alongside traditional symptoms including runny noses, coughs, headaches, and weakness, individuals with JN.1 infection have reported these additional challenges. Recognisable symptoms such as fever, cough, shortness of breath, fatigue, muscle aches, loss of taste and smell, sore throat, congestion, runny nose, nausea, and diarrhoea, remain consistent with previous waves.

The COVID-19 pandemic has already been linked to increased stress, anxiety, and sleep disturbances globally. JN.1's potential to exacerbate these issues further highlights the importance of addressing mental health concerns during the ongoing crisis. Elevated stress levels can trigger insomnia, and the constant influx of pandemic-related information and lifestyle changes has contributed to disrupted sleep patterns. Adequate sleep is crucial for maintaining a healthy immune system, making it imperative to address COVID-related sleep issues for overall well-being.

Related: Decoding factors driving growth in the flu vaccine market

Described as "quite devious" by experts, Dr. Thomas Russo, a professor and chief of infectious diseases in New York, highlights a spike protein mutation in JN.1 that makes it more immune evasive than its predecessors. This potential increase in infectiousness highlights the need for stringent preventive measures. These include regular hand washing, wearing a mask in crowded places, keeping physical distance, staying informed about the latest developments, following vaccination recommendations and seeking medical advice if symptomatic.

In addition to these recommendations, general precautions such as disinfecting surfaces, practicing good respiratory hygiene, and prioritising outdoor activities are important in being prepared. As JN.1 continues to spread, a proactive and cautious approach is advised for healthcare providers to effectively manage and mitigate the potential impact of this new variant on public health. Ongoing research, collaboration, and a commitment to public health measures will be crucial in addressing the challenges posed by the JN.1 variant and ensuring the well-being of communities worldwide.

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