Treatment intensification and therapeutic inertia of antihypertensive therapy among patients with type 2 diabetes and hypertension with uncontrolled blood pressure.

Treatment intensification is essential to ensure guideline targets are attained in diabetes patients. The failure to intensify treatment when the targets are not achieved is therapeutic inertia. This study aimed to determine the proportions and factors associated with treatment intensification and therapeutic inertia of antihypertensive therapy in type 2 diabetes patients with uncontrolled hypertension in Malaysia. A retrospective cohort analysis was conducted utilising registry data. Diabetes hypertensive patients with uncontrolled baseline systolic or diastolic blood pressure were included. Treatment intensification was the increase in the number of antihypertensive agents from the index treatment. Therapeutic inertia was the absence of treatment intensification when the second blood pressure reading was still uncontrolled. About 6956 patients were followed up over 2.5 ± 1.1 person-years. Treatment intensification was observed in 29.8% of patients, while 38.6% had therapeutic inertia. Chinese, Indian, and 'others' ethnic groups, retinopathy, more antihypertensive agents, and higher systolic blood pressure were associated with therapeutic inertia. Underweight, overweight patients and those with dyslipidaemia had lower risks for therapeutic inertia. The results indicate suboptimal quality of care in public health clinics in Malaysia. Further studies are needed to determine the underlying causes to formulate precise interventions to tackle the problem in Malaysia.

Machine learning based predictive model of Type 2 diabetes complications using Malaysian National Diabetes Registry: A study protocol.

Background: The prevalence of diabetes in Malaysia is increasing, and identifying patients with higher risk of complications is crucial for effective management. The use of machine learning (ML) to develop prediction models has been shown to outperform non-ML models. This study aims to develop predictive models for Type 2 Diabetes (T2D) complications in Malaysia using ML techniques. Design and methods: This 10-year retrospective cohort study uses clinical audit datasets from Malaysian National Diabetes Registry from 2011 to 2021. T2D patients who received treatment in public health clinics in the southern region of Malaysia with at least two data points in 10 years are included. Patients with diabetes complications at baseline are excluded to ensure temporality between predictors and the target variable. Appropriate methods are used to address issues related to data cleaning, missing data imputation, data splitting, feature selection, and class imbalance. The study uses 7 ML algorithms, including logistic regression, support vector machine, k-nearest neighbours, decision tree, random forest, extreme gradient boosting, and light gradient boosting machine, to develop predictive models for four target variables: nephropathy, retinopathy, ischaemic heart disease, and stroke. Hyperparameter tuning is performed for each algorithm. The model training is performed using a stratified k-fold cross-validation technique. The best model for each algorithm is evaluated on a hold-out dataset using multiple metrics. Expected impact of the study on public health: The prediction model may be a valuable tool for diabetes management and secondary prevention by enabling earlier interventions and optimal resource allocation, leading to better health outcomes.

Prevalence of diabetic kidney disease and the associated factors among patients with type 2 diabetes in a multi-ethnic Asian country.

The actual prevalence of diabetic kidney disease (DKD) in patients with type 2 diabetes (T2D) in Malaysia is unknown. We aimed to determine the prevalence of DKD and its associated risk factors among T2D patients in Malaysia. An analytical cross-sectional study was conducted using the year 2022 clinical audit dataset from the National Diabetes Registry. DKD was defined as albuminuria, a decreased glomerular filtration rate, or both. Among 80,360 patients, 62.2% were female, 68.4% were Malay, and the mean age was 61.4 years. A total of 56.7% (95% CI 56.4-57.1%) of patients were found to have DKD. Increasing age, male sex, Malay ethnicity, longer duration of diabetes, overweight, obesity, hypertension, diabetic retinopathy, diabetic foot ulcer, nontraumatic lower-extremity amputation, ischaemic heart disease, stroke, insulin, higher numbers of antihypertensive agents, antiplatelet agents, poorer HbA1c control, higher systolic blood pressure, non-achievement of triglyceride target, and non-attainment of HDL-cholesterol goal were independent risk factors associated with DKD. Clinicians, program managers, and health policymakers should target modifiable factors to manage DKD and prevent its progression to end-stage kidney disease in Malaysia.

Prevalence of metabolic syndrome and metabolic dysfunction-associated fatty liver disease in Malaysia 2023: study protocol for a community-based nationwide cross-sectional survey.

INTRODUCTION: Metabolic syndrome (MetS) is a cluster of cardio-metabolic dysfunctions characterised by increased fasting plasma glucose, waist circumference, blood pressure, triglycerides and reduction in high-density lipoprotein cholesterol. Meanwhile, metabolic dysfunction-associated fatty liver disease (MAFLD) is the new term for fatty liver associated with MetS. People with MetS or MAFLD have higher risks for adverse cardiovascular outcomes and mortalities. However, large-scale data on MetS and MAFLD prevalence in Malaysia is mainly unknown. This study aims to determine the prevalence of MetS and MAFLD among the general adult population in Malaysia. METHODS AND ANALYSIS: This is a community-based nationwide cross-sectional study in Malaysia. The data collection period is from July 2023 until September 2023, with a planned sample size of 1296 participants. We use a two-stage proportionate stratified random sampling method to ensure national representativeness. The definition of MetS follows the Harmonised Joint Interim Statement in 2009. A diagnosis of MAFLD is made if a participant has fatty liver, defined as having a Fatty Liver Index ≥60 and has type 2 diabetes, a body mass index ≥23 kg/m2, or ≥2 metabolic risk abnormalities. Complex sample analysis will be conducted, and the disease prevalence will be reported with 95% CIs, unweighted counts and estimated populations. ETHICS AND DISSEMINATION: The protocol has been approved by the Medical Research and Ethics Committee of the Ministry of Health Malaysia (NMRR ID-22-02845-GUT). The findings will be disseminated through a formal report, policy brief, scientific publications, conference presentations, social media, print media and stakeholder engagement activities.

Baseline treatments and metabolic control of 288,913 type 2 diabetes patients in a 10-year retrospective cohort in Malaysia.

Diabetes is one of the quickest-growing global health emergencies of the twenty-first century, and data-driven care can improve the quality of diabetes management. We aimed to describe the formation of a 10-year retrospective open cohort of type 2 diabetes patients in Malaysia. We also described the baseline treatment profiles and HbA1c, blood pressure, and lipid control to assess the quality of diabetes care. We used 10 years of cross-sectional audit datasets from the National Diabetes Registry and merged 288,913 patients with the same identifying information into a 10-year open cohort dataset. Treatment targets for HbA1c, blood pressure, LDL-cholesterol, HDL-cholesterol, and triglycerides were based on Malaysian clinical practice guidelines. IBM SPSS Statistics version 23.0 was used, and frequencies and percentages with 95% confidence intervals were reported. In total, 288,913 patients were included, with 62.3% women and 54.1% younger adults. The commonest diabetes treatment modality was oral hypoglycaemic agents (75.9%). Meanwhile, 19.3% of patients had ≥ 3 antihypertensive agents, and 71.2% were on lipid-lowering drugs. Metformin (86.1%), angiotensin-converting enzyme inhibitors (49.6%), and statins (69.2%) were the most prescribed antidiabetic, antihypertensive, and lipid-lowering medications, respectively. The mean HbA1c was 7.96 ± 2.11, and 31.2% had HbA1c > 8.5%. Only 35.8% and 35.2% attained blood pressure < 140/80 mmHg and LDL-cholesterol < 2.6 mmol/L, respectively. About 57.5% and 52.9% achieved their respective triglyceride and HDL-cholesterol goals. In conclusion, data integration is a feasible method in this diabetes registry. HbA1c, blood pressure, and lipids are not optimally controlled, and these findings can be capitalized as a guideline by clinicians, programme managers, and health policymakers to improve the quality of diabetes care and prevent long-term complications in Malaysia.

Long COVID active case detection initiative among COVID-19 patients in Port Dickson, Malaysia: a retrospective study on the positive outcomes, the proportion of patients with long COVID and its associated factors.

Background: Long COVID is new or ongoing symptoms at four weeks or more after the start of acute COVID-19. However, the prevalence and factors associated with long COVID are largely unknown in Malaysia. We aim to determine the proportion and factors associated with long COVID among COVID-19 patients in Port Dickson, Malaysia. The positive outcomes of our long COVID active detection initiative were also described. Methods: This was a retrospective analysis of long COVID data collected by the Port Dickson District Health Office between 1 September 2021 to 31 October 2021. Monitoring long COVID symptoms was our quality improvement initiative to safeguard residents' health in the district. The study population was patients previously diagnosed with COVID-19 who resided in Port Dickson. The inclusion criteria were adults aged 18 years and above and were in the fifth week (day 29 to 35) post-COVID-19 diagnosis during the data collection period. We called all consecutive eligible patients to inquire regarding long COVID symptoms. Long COVID was defined as new or ongoing symptoms lasting more than 28 days from the date of positive SARS-CoV-2 by polymerase chain reaction test. Binary multivariate logistic regression was conducted to determine factors associated with long COVID. Results: Among 452 patients, they were predominantly male (54.2%), Malays (68.8%) and aged 18-29 years (58.6%). A total of 27.4% (95% CI [23.4-31.8]) of patients experienced long COVID symptoms and were referred to government clinics. The most frequent long COVID symptoms experienced were fatigue (54.0%), cough (20.2%), muscle pain (18.5%), headache (17.7%) and sleep disturbance (16.1%). Females, patients with underlying cardiovascular disease, asthma and chronic obstructive airway disease, those who received symptomatic care, and patients with myalgia and headaches at COVID-19 diagnosis were more likely to have long COVID. Three patients with suspected severe mental health problems were referred to the district psychologist, and ten patients with no/incomplete vaccination were referred for vaccination. Conclusion: Long COVID is highly prevalent among COVID-19 patients in Port Dickson, Malaysia. Long-term surveillance and management of long COVID, especially among the high-risk groups, are needed as we transition to living with COVID-19.

Estimating excess mortalities due to the COVID-19 pandemic in Malaysia between January 2020 and September 2021.

Excess mortalities are a more accurate indicator of true COVID-19 disease burden. This study aims to investigate levels of excess all-cause mortality and their geographic, age and sex distributions between January 2020-September 2021. National mortality data between January 2016 and September 2021 from the Department of Statistics Malaysia was utilised. Baseline mortality was estimated using the Farrington algorithm and data between 1 January 2016 and 31 December 2019. The occurrence of excess all-cause mortality by geographic-, age- and sex-stratum was examined from 1 January 2020 to 30 September 2021. A sub-analysis was also conducted for road-traffic accidents, ethnicity and nationality. Malaysia had a 5.5-23.7% reduction in all-cause mortality across 2020. A reversal is observed in 2021, with an excess of 13.0-24.0%. Excess mortality density is highest between July and September 2021. All states and sexes reported excess trends consistent with the national trends. There were reductions in all all-cause mortalities in individuals under the age of 15 (0.4-8.1%) and road traffic accident-related mortalities (36.6-80.5%). These reductions were higher during the first Movement Control Order in 2020. Overall, there appears to be a reduction in all-cause mortality for Malaysia in 2020. This trend is reversed in 2021, with excess mortalities being observed. Surveillance of excess mortalities can allow expedient detection of aberrant events allowing timely health system and public health responses.

Five-year LDL-cholesterol trend and its predictors among type 2 diabetes patients in an upper-middle-income country: a retrospective open cohort study.

Background: Patients with diabetes have increased risks of cardiovascular diseases (CVD), and their LDL-cholesterol (LDL-C) has to be treated to target to prevent complications. We aim to determine the LDL-C trend and its predictors among patients with type 2 diabetes (T2D) in Malaysia. Methods: This was a retrospective open cohort study from 2013 to 2017 among T2D patients in public primary health care clinics in Negeri Sembilan state, Malaysia. Linear mixed-effects modelling was conducted to determine the LDL-C trend and its predictors. The LDL-C target for patients without CVD was <2.6 mmol/L, whereas <1.8 mmol/L was targeted for those with CVD. Results: Among 18,312 patients, there were more females (55.9%), adults ≥60 years (49.4%), Malays (64.7%), non-smokers (93.6%), and 45.3% had diabetes for <5 years. The overall LDL-C trend reduced by 6.8% from 2.96 to 2.76 mmol/L. In 2017, 16.8% (95% CI: 13.2-21.0) of patients without CVD and 45.8% (95% CI: 44.8-46.8) of patients with CVD achieved their respective LDL-C targets. The predictors for a higher LDL-C trend were younger adults, Malay and Indian ethnicities, females, dyslipidemia, and diabetes treatment with lifestyle modification and insulin. Longer diabetes duration, obesity, hypertension, retinopathy, statin therapy, achievement of HbA1c target and achievement of BP target were independent predictors for a lower LDL-C trend. Conclusions: The LDL-C trend has improved, but there are still gaps between actual results and clinical targets. Interventions should be planned and targeted at the high-risk populations to control their LDL-C.

Eighteen months into the COVID-19 pandemic: The prevalence of depression, anxiety, and stress symptoms in Southeast Asia and the associated demographic factors.

Mental health has become a growing concern in the wake of the COVID-19 pandemic. We sought to determine the prevalence of mental health symptoms 18 months after the pandemic's declaration. Our cross-sectional study conducted among 18- to 65-year-old adults (N = 33,454) in October 2021 using the Depression, Anxiety and Stress Scales (DASS-21) found a high prevalence of severe to extremely severe anxiety (49%), depression (47%) and stress (36%) symptoms in Malaysia, Indonesia, Thailand, and Singapore. Multiple logistic regression showed that female and non-binary genders were associated with increased odds of severe/extremely severe symptoms of anxiety (female: aOR 1.44 [95% CI 1.37-1.52]; non-binary aOR 1.46 [1.16-1.84]), depression (female: aOR 1.39 [1.32-1.47]; non-binary aOR 1.42 [1.13-1.79]), and stress (female: aOR 1.48 [CI 1.40-1.57]; non-binary aOR 1.42 [1.12-1.78]). In all three symptom domains, the odds of severe/extremely severe symptoms decreased across age groups. Middle- and high-income respondents had lower odds of reporting severe/extremely severe anxiety (middle-income: aOR 0.79 [0.75-0.84]; high-income aOR 0.77 [0.69-0.86]) and depression (middle-income: aOR 0.85 [0.80-0.90]; high-income aOR 0.84 [0.76-0.94]) symptoms compared to low-income respondents, while only middle-income respondents had lower odds of experiencing severe/extremely severe stress symptoms (aOR 0.89 [0.84-0.95]). Compared to residents of Malaysia, residents of Indonesia were more likely to experience severe/extremely severe anxiety symptoms (aOR 1.08 [1.03-1.15]) but less likely to experience depression (aOR 0.69 [0.65-0.73]) or stress symptoms (aOR 0.92 [0.87-0.97]). Respondents living in Singapore had increased odds of reporting severe/extremely severe depression symptoms (aOR 1.33 [1.16-1.52]), while respondents residing in Thailand were more likely to experience severe/extremely severe stress symptoms (aOR 1.46 [1.37-1.55]). This study provides insights into the impacts of the COVID-19 pandemic on the point prevalence of psychological distress in Southeast Asia one and a half years after the beginning of the pandemic.

Correction: Implementation of a COVID-19 surveillance programme for healthcare workers in a teaching hospital in an upper-middle-income country.

[This corrects the article DOI: 10.1371/journal.pone.0249394.].

Changes in body mass index, glycosylated hemoglobin A1C, blood pressure, and LDL-cholesterol among type 2 diabetes patients in Malaysia: A population-based longitudinal study.

BACKGROUND: This study aimed to describe changes in body mass index, glycosylated hemoglobin A1C, blood pressure, and low-density lipoprotein (LDL)-cholesterol among type 2 diabetes patients in Malaysia. METHODS: A five-year retrospective cohort study was conducted using data from the National Diabetes Registry. Type 2 diabetes patients aged ≥18 years and had ≥2 clinical audits between 2013 and 2017 were included in the analysis. The first audit information formed the baseline characteristics, and the last audit information was used for comparison. Individualized A1C, blood pressure, and LDL-cholesterol goals were adapted from Malaysian Clinical Practice Guidelines on Type 2 Diabetes Management 2020, American Diabetes Association 2020, and European Association for the Study of Diabetes 2019. RESULTS: Of the 18 341 patients, 55.8% were female and 64.9% Malay ethnicity. The baseline mean age was 59.3 ± 10.6 years. During an average of 2.5 person-years of follow-up, the mean body mass index dropped by 0.16 kg/m2 to 27.9 kg/m2 , A1C increased by 0.16% to 8.0%, systolic blood pressure increased by 1.4 mm Hg to 136.2 mm Hg, diastolic blood pressure decreased by 1.0 mm Hg to 77.3 mm Hg and LDL-cholesterol reduced by 0.12 mmol/L to 2.79 mmol/L, P < 0.001 for all. Out of eight categories of individualized goals, most patients achieved the A1C goal of ≤8.0%. The new LDL-cholesterol goal of <1.4 mmol/L was least likely to be achieved. CONCLUSIONS: The body mass index, A1C, blood pressure, and LDL-cholesterol performance remained suboptimal. Standards of care for these clinical parameters remain to be achieved by the majority of diabetes patients.

Implementation of a COVID-19 surveillance programme for healthcare workers in a teaching hospital in an upper-middle-income country.

INTRODUCTION: The reporting of Coronavirus Disease 19 (COVID-19) mortality among healthcare workers highlights their vulnerability in managing the COVID-19 pandemic. Some low- and middle-income countries have highlighted the challenges with COVID-19 testing, such as inadequate capacity, untrained laboratory personnel, and inadequate funding. This article describes the components and implementation of a healthcare worker surveillance programme in a designated COVID-19 teaching hospital in Malaysia. In addition, the distribution and characteristics of healthcare workers placed under surveillance are described. MATERIAL AND METHODS: A COVID-19 healthcare worker surveillance programme was implemented in University Malaya Medical Centre. The programme involved four teams: contact tracing, risk assessment, surveillance and outbreak investigation. Daily symptom surveillance was conducted over fourteen days for healthcare workers who were assessed to have low-, moderate- and high-risk of contracting COVID-19. A cross-sectional analysis was conducted for data collected over 24 weeks, from the 6th of March 2020 to the 20th of August 2020. RESULTS: A total of 1,174 healthcare workers were placed under surveillance. The majority were females (71.6%), aged between 25 and 34 years old (64.7%), were nursing staff (46.9%) and had no comorbidities (88.8%). A total of 70.9% were categorised as low-risk, 25.7% were moderate-risk, and 3.4% were at high risk of contracting COVID-19. One-third (35.2%) were symptomatic, with the sore throat (23.6%), cough (19.8%) and fever (5.0%) being the most commonly reported symptoms. A total of 17 healthcare workers tested positive for COVID-19, with a prevalence of 0.3% among all the healthcare workers. Risk category and presence of symptoms were associated with a positive COVID-19 test (p<0.001). Fever (p<0.001), cough (p = 0.003), shortness of breath (p = 0.015) and sore throat (p = 0.002) were associated with case positivity. CONCLUSION: COVID-19 symptom surveillance and risk-based assessment have merits to be included in a healthcare worker surveillance programme to safeguard the health of the workforce.

Predictors of glycosylated haemoglobin A1C trend among type 2 diabetes patients in a multi-ethnic country.

Good control of glycosylated haemoglobin A1C in diabetes patients prevents cardiovascular complications. We aim to describe the A1C trend and determine the predictors of the trend among type 2 diabetes patients in Malaysia. Longitudinal data in the National Diabetes Registry from 2013 to 2017 were analysed using linear mixed-effects modelling. Among 17,592 patients, 56.3% were females, 64.9% Malays, and the baseline mean age was 59.1 years. The U-shaped A1C trend changed marginally from 7.89% in 2013 to 8.07% in 2017. The A1C excess of 1.07% as reported in 2017 represented about 22% higher risk of diabetes-related death, myocardial infarction, and stroke, which are potentially preventable. The predictors for higher baseline A1C were non-Chinese ethnicity, younger age groups, longer diabetes duration, patients on insulin treatment, polypharmacy use, patients without hypertension, and patients who were not on antihypertensive agents. Younger age groups predicted a linear increase in the A1C trend, whereas patients on insulin treatment predicted a linear decrease in the A1C trend. Specifically, the younger adults and patients of Indian and Malay ethnicities had the poorest A1C trends. Targeted interventions should be directed at these high-risk groups to improve their A1C control.

Clinical inertia in type 2 diabetes management in a middle-income country: A retrospective cohort study.

BACKGROUND: Clinical inertia can lead to poor glycemic control among type 2 diabetes patients. However, there is paucity of information on clinical inertia in low- and middle-income countries including Malaysia. This study aimed to determine the time to treatment intensification among T2D patients with HbA1c of ≥7% (≥53 mmol/mol) in Malaysian public health clinics. The proportion of patients with treatment intensification and its associated factors were also determined. MATERIAL AND METHODS: This was a five-year retrospective open cohort study using secondary data from the National Diabetes Registry. The study setting was all public health clinics (n = 47) in the state of Negeri Sembilan, Malaysia. Time to treatment intensification was defined as the number of years from the index year until the addition of another oral antidiabetic drug or initiation of insulin. Life table survival analysis based on best-worst case scenarios was used to determine the time to treatment intensification. Discrete-time proportional hazards model was fitted for the factors associated with treatment intensification. RESULTS: The mean follow-up duration was 2.6 (SD 1.1) years. Of 7,646 patients, the median time to treatment intensification was 1.29 years (15.5 months), 1.58 years (19.0 months) and 2.32 years (27.8 months) under the best-, average- and worst-case scenarios respectively. The proportion of patients with treatment intensification was 45.4% (95% CI: 44.2-46.5), of which 34.6% occurred only after one year. Younger adults, overweight, obesity, use of antiplatelet medications and poorer HbA1c were positively associated with treatment intensification. Patients treated with more oral antidiabetics were less likely to have treatment intensification. CONCLUSION: Clinical inertia is present in the management of T2D patients in Malaysian public health clinics. We recommend further studies in lower- and middle-income countries to explore its causes so that targeted strategies can be developed to address this issue.