An Assessment of Awareness of Specialists in Adequate Diagnostics of Chronic Pancreatitis in Kazakhstan

Our national center of gastroenterology provides highly specialized care, including chronic pancreatitis. Another area of our activities is educational programs, including postgraduate and fellows’ courses. Thereby, we have noted significant gaps in the knowledge of the specialists that involved in the chronic pancreatitis management. The most critical downsides are related to insufficient attention to etiology and risk factors, using outdated classifica-tions, the lack of knowledge in arsenal of diagnostic techniques, polypharma-cy or application of low level of evidence treatment methods. Finally, we have made amendments in the National Clinical Protocol in Chronic Pancreatitis [1], updated the State Educational Standard for residents of the gastroenterological profile [2]. The aim of the study was the analysis of the basic knowledge among different specialists in the management of chronic pancreatitis (CP) around the country. This qualitative study consists of two parts, including focus group interviews followed by interviews with the specialists across the country, which was conducted during the period 2015-2018. In this paper, we present results of diagnostic approaches at the different levels of medical care. The general practitioners have noted the absence of modern methods of laboratory and visual diagnostics in their routine practice, therefore explain-ing duct a number of training activities, as well as develop new algorithms for medical care specialists.


Introduction
Chronic pancreatitis is an important socio-economic problem given its prevalence, morbidity increase, temporary disability and incapacitation. It is responsible for 5.1% to 9% of gastrointestinal disturbances [3], while in general clinical practice it makes up from 0.2% to 0.6% [4].
In the past 30 years, the global trend towards an increase of more than 2-fold of acute and chronic pancreatitis was observed [5]. While in the 80s the incidence of CP was 3.5 -4.0 per 100 thousand of population a year [6], in the last decade a steady increase in the incidence of pancreatitis was registered, affecting annually 8.2 to 10 people per 100 thousand of population [5].
The pertinence of pancreatitis timely diagnosis is reinforced by the fact that CP is the precancerous condition, specifically for pancreatic carcinoma development. Usually CP develops in adulthood (35 -50 years old). Mortality after the initial diagnosis on average makes up 11.9% [7].
Up to 20% of CP patients die from complications developing after pancreatitis exacerbation, some are the results of secondary digestive disorders and infectious complications. Literature data indicate that pancreatic cancer related to mortality increases alongside with the increase in the CP incidence [5] [7] [8].
Diagnostics of pancreatic diseases have always been considered as one of the most complex problems of gastroenterology. Since there are no pathognomonic symptoms for the given disease, the diagnosis should be based on the objective criteria of imaging methods (CT or MRI) [3]. The choice of the imaging technique should be based on its availability, appropriate skills of the medical staff and degree of the study invasiveness [9] [10]. Thus, being the most informative method in early CP diagnostics, endoscopic ultrasound imaging requires high qualification on the part of a specialist and a strictly standardized approach [5] [6] [7].
Rapid development of pancreatology is determined, among other things, by the desire for early CP diagnosis based on timely measures making it possible to reduce the rate of disease progression and improve the life quality of patients, in spite of being accompanied by the appearance of a large number of scientific publications devoted to the study of CP etiology, mechanisms of its pathogenesis, new diagnostic and therapeutic techniques [6]. Quite often a practitioner is unable to timely follow even the fundamental works on clinical pancreatology and pharmacotherapy, letting alone individual research papers.
For several decades, many authors have pointed out that "training of physicians in clinical pancreatology is dire" [3] the lack of routine methods for diagnosing CP, and the absence of a single method that allows early diagnosis or adequate therapy [4] [5] [6]. At the same time, according to the literature, we found only a few studies aimed at studying knowledge and opinions of the specialists about CP management. Thus, according to a cross-sectional study in Ireland, it was noted that the specialists were more responsive to acute attacks, as well as when it was necessary to escalate therapy or urgent indications [7]. In addition, the researchers pointed out the lack of time for a comprehensive examination, poor communication between the primary and inpatient medical care levels, and insufficient nutritional correction.
Given this, a qualitative study has been completed to assess awareness of the specialists about diagnostic and treatment approaches in real pancreatology practice.

Material and Methods
Study objective. To study the specialist's awareness about the proper diagnosis and treatment of chronic pancreatitis aimed to develop recommendations and relevant information for practitioners in Kazakhstan. In order to achieve objective, we have held 3 focus-group discussions in Almaty city. The focus group participants were general practitioners, inpatient therapists and surgeons, ultrasound specialists who gave informed consent to participate in study. Discussions were lasted for 50 -60 minutes and recorded on video and audio.
Twenty-one specialists took part in the study; one of them did not give a single answer. In total the results of 20 participants of the focus group were accepted for the analysis. Among them, 3 of the participants were from the private and 3 from the state outpatient clinics, 7 were inpatient physicians and gastroenterologists, 2 surgeons and 5 others ultrasound diagnostics specialists.  When the questionnaire results processing the frequencies of the response options were calculated, the likelihood ratio criterion was applied for the intergroup distribution. The differences were considered statistically significant at the p < 0.05 level. Statistical analysis was performed using the IBM SPSS package, version 19.
Systematic error reduction. The interview has been preliminarily tested among 8 fellow gastroenterologists in our department to specify the wording of the questions in order to minimize the number of leading or unclear questions.
Ethical approval and legal expertise of the study have been carried out by the Local Ethical Committee of the Research Institute of Cardiology and Internal Diseases and approval has been obtained for the implementation.

Results
The socio-demographic distribution of the responders in the second part of the study is summarized in Table 1, Table 2.
Epidemiology. 30% of focus group participants mentioned a wide spread of CP within the general population. A significant proportion of the interviewed doctors (32.1% and 57.4 outpatient and inpatient specialists respectively as well as 47.7% of surgeons, p = 0.004) noted that during the day several patients with this disease were on treatment in the ambulatory or in the hospital.  CP belongs to genetically determined pathologies; however, this fact is recognized by only half of the surveyed doctors (31.6% -55.6% p = 0.35).
All the interviewed doctors (98.1% -100%) among etiological factors noted alcohol to be the most common cause of CP development, p = 0.840. According to the literature reviewed, alcohol abuse significantly contributes to the risk level increase, regardless of the type of alcohol used for both sexes. [15]. However, smoking is not perceived by the doctors as an etiologic factor: only 21.1% of surgeons, 53.7% hospital doctors and 56.08% (p = 0.09) noted smoking as a pancreas damaging factor, Figures 1(a), Figures 1(b)

Diagnostics
Laboratory tests. The long-established fact is the low sensitivity of serum amylase and lipase (only 10%) with high specificity (90% -95%) of these pancreatic enzymes for the diagnosis of chronic pancreatitis [19].

Discussion
Unfortunately, it should be noted that the doctors do not know the key factors of the etiopathogenesis and progression of chronic pancreatitis. In the relation there are some difficulties in early diagnosis of this pathology in Kazakhstan, regardless of work experience or region of residence. Primary care physicians responsible for patient identification and follow-up are not well familiar with informative diagnostic methods. In addition, hospital doctors, when faced with patients, as a rule, during an exacerbation, ignores serious clinical manifestations, not insufficient utilize visualization methods. Despite the fact that the doctors often encounter complicated forms of CP, the fact of insufficient use (inaccessibility) of diagnostic techniques is not recognized by them. The specialists consider that the reasons of the widespread prevalence of complications are not related to healthcare but to a patient: late recourse for the medical assistance or lack of commitment.
Thus, inadequate specialists' awareness and a lack of access to informative diagnostic methods may result in a great number of complications in chronic pancreatitis.

Conclusion
This study aims to understand the causes of inadequate management for chronic pancreatitis. We have identified some key gaps and barriers in early diagnosis and subsequent follow-up, requiring development and implementation, further educational and organizational measures in practical health care.

Limitations
It is well known that even a high level of evidence for some recommendations does not guarantee their reproducibility in clinical practice. That is why necessary to develop and implement tools to standardize the decision-making process of clinicians and assess their impact on patients.

Fund
The grant was received from the public fund "Kazakh Scientific Society for the Study of the Intestine".