Assessment of population coverage of hypertension screening in Thailand based on the effective coverage framework.

BACKGROUND: Hypertension (HT) is a major risk factor, and accessible and effective HT screening services are necessary. The effective coverage framework is an assessment tool that can be used to assess health service performance by considering target population who need and receive quality service. The aim of this study is to measure effective coverage of hypertension screening services at the provincial level in Thailand. METHODS: Over 40 million individual health service records in 2013 were acquired. Data on blood pressure measurement, risk assessment, HT diagnosis and follow up were analyzed. The effectiveness of the services was assessed based on a set of quality criteria for pre-HT, suspected HT, and confirmed HT cases. Effective coverage of HT services for all non-HT Thai population aged 15 or over was estimated for each province and for all Thailand. RESULTS: Population coverage of HT screening is 54.6%, varying significantly across provinces. Among those screened, 28.9% were considered pre-HT, and another 6.0% were suspected HT cases. The average provincial effective coverage was at 49.9%. Around four-fifths (82.6%) of the pre-HT group received HT and Cardiovascular diseases (CVD) risk assessment. Among the suspected HT cases, less than half (38.0%) got a follow-up blood pressure measurement within 60 days from the screening date. Around 9.2% of the suspected cases were diagnosed as having HT, and only one-third of them (36.5%) received treatment within 6 months. Within this group, 21.8% obtained CVD risk assessment, and half of them had their blood pressure under control (50.8%) with less than 1 % (0.7%) of them managed to get the CVD risk reduced. CONCLUSIONS: Our findings suggest that hypertension screening coverage, post-screening service quality, and effective coverage of HT screening in Thailand were still low and they vary greatly across provinces. It is imperative that service coverage and its effectiveness are assessed, and both need improvement. Despite some limitations, measurement of effective coverage could be done with existing data, and it can serve as a useful tool for performance measurement of public health services.

Self-efficacy in diabetic care and occurrence of adverse events in an ambulatory setting.

OBJECTIVE: To assess the relationship between patients' self-efficacy and the occurrence of adverse events in patients with insulin-using, type-2 diabetes mellitus in an ambulatory setting. DESIGN: A prospective cohort study. Patients' risks were estimated by relative risk (RR) and analyzed by Poisson regression using the generalized estimating equation (GEE). SETTING: Diabetic clinic at a university-affiliated, tertiary-care hospital in Bangkok, Thailand. PARTICIPANTS: One hundred and fifty-seven patients in the low self-efficacy group and 153 patients in the high self-efficacy group based on their pre-test scores, including self-efficacy in problem-solving and daily living. MAIN OUTCOME MEASURES: Adverse events defined as unplanned incidents related to medical management in diabetic care, leading to patient harm. Patient data were followed up every 3 months for 1 year. RESULTS: The incident rate of adverse events in the low self-efficacy group was 2.12 incidents per 100 person-months, in comparison with 0.44 incidents per 100 person-months in the high self-efficacy group, resulting in adjusted RR of 4.75 (95% confidence interval (CI): 2.19-10.28). The use of long-acting insulin was also found to increase the risk of adverse events by 3.11 times (95% CI: 1.35-7.18) without interaction with patients' self-efficacies. CONCLUSION: To increase patients' self-efficacy by strengthening patient and family involvement may help prevent harmful events and improve patient safety in an ambulatory setting among chronically ill patients with type-2 diabetes mellitus.

Cost-effectiveness and estimated net monetary benefits of a fluoride varnish application program during well-child visits by 9- to 30-month-old children in three areas of Thailand.

OBJECTIVES: To evaluate the cost-effectiveness and estimated net monetary benefits of a fluoride varnish application program during well-child visits in young children in three Thai provinces. Costs and benefits from both the provider and patients are presented. METHODS: Cost-effectiveness and estimated net monetary benefit analysis of one to five visits for fluoride varnish application using a retro-prospective cohort study design. Cost and outcomes were estimated using dental personnel survey data, hospital procurement data and guardian survey. The primary outcomes were decayed (treatment needed), missing due to caries and filled teeth (dmft). RESULTS: From the provider's perspective, one to three visits for fluoride varnish application decreased dmft and saved costs compared to no visits, one visit and two visit strategies (ICER = -468.36, -424.40 and -65.72, respectively). These strategies also showed an estimated net monetary benefit of 430.89, 216.44 and 7.23 THB, respectively. From the patient's perspective, the estimated net monetary benefits were positive for up to three visits (383.24, 212.45 and 45.82 THB, respectively); however, the incremental cost-effectiveness ratios were no different with these strategies (ICER = -416.56). The one and two visit strategies had a very high chance of showing cost saving in the probabilistic sensitivity analysis (97.1% and 95.5%, respectively). CONCLUSIONS: The one to three visits fluoride varnish application program during well-child visits appears to be cost-effective with estimated net benefit interventions for dental caries prevention. These findings suggest that children between 9 and 30 months old should attend at least three visits of the fluoride varnish application program during well-child visits.

Health-related quality of life of daily-life-affected benign essential blepharospasm: Multi-center observational study.

PURPOSE: To compare Thais' health-related quality of life (HRQOL) and severity grading, efficacy and safety in daily-life-affected benign essential blepharospasm (BEB) patients at baseline and after Botulinum toxin type A (BTX-A) treatment. DESIGN: Prospective-observational study. PARTICIPANTS: BEB patients with Jankovic rating scale (JRS) at least 3 in both severity and frequency graded from 14 institutes nationwide were included from August 2020 to June 2021. METHODS: Demographic data, HRQOL evaluated by the Thai version of EQ-5D-5L and NEI-VFQ-25 questionnaires, and severity grading score evaluated by Jankovic rating scale (JRS) at baseline, 1, and 3 months after the treatment were collected. The impact of the BTX-A injections and their complications were recorded. RESULTS: 184 daily-life-affected BEB patients were enrolled; 159 patients (86.4%) had complete data with a mean age of 61.40±10.09 years. About 88.05% were female, and 10.1% were newly diagnosed. Most of the patients had bilateral involvement (96.9%) and 12.6% had history of BEB-related accident. After BTX-A treatment, HRQOL improved significantly in 4 dimensions of EQ-5D-5L, except self-care. The EQ_VAS (mean±SD) was 64.54±19.27, 75.13±15.37, 73.8±15.85 (p<0.001) and EQ-5D-5L utility score was 0.748±0.23, 0.824±0.19 and 0.807±0.19 at baseline, 1, 3 months after treatment, respectively. From NEI-VFQ-25, HRQOL also improved in all dimensions, except eye pain. The JRS improved in all patients. Self-reported minor adverse events were 22.6%, which mostly resolved within the first month. CONCLUSION: Daily-life-affected BEB impacted HRQOL in most dimensions from both generic and visual-specific questionnaires. BTX-A treatment not only decreased disease severity, but also improved quality of life.

Cost analysis of a teaching hospital in Thailand: Impacts of the first wave of COVID-19.

COVID-19 has had adverse impacts on the health sector in Thailand and information on hospital costs is required for planning and budgeting. The aim of this study was to estimate costs that the pandemic imposed on a teaching hospital in the country, focusing on the first wave which took place in March-May 2020. A retrospective cost analysis was performed. Data on COVID-related activities, including when and where they were undertaken, were retrieved from existing sources and supplemented by in-depth interviews with the hospital's staff. The data collection period was January-October 2020, covering three distinct phases: before, during, and after the first wave of the pandemic. The total costs during the preparation phase in January-February, the pandemic phase in March-May, and the standby phase in June-October were 0.6, 3.9, and 1.2 million US dollars respectively. Costs related to treatment of COVID-19 patients were higher than those related to infection control in the first two phases but not in the standby phase, making up 82.09%, 75.23%, and 43.95% of the total costs in the three phases respectively. Costs were incurred in all areas of the hospital, including those that were set up to serve COVID patients, those serving non-COVID patients, and those serving both groups. Public donations were integral to the provision of services and made up 20.94% of the total cost during the pandemic phase. This study was the first to estimate hospital costs of COVID-19 in Thailand. It demonstrated high costs of a national outbreak and supported the establishment of a contingency fund for medical emergencies at the hospital level.

Association Between Hospital Accreditation and Outcomes: The Analysis of Inhospital Mortality From the National Claims Data of the Universal Coverage Scheme in Thailand.

BACKGROUND: In Thailand, hospital accreditation (HA) is widely recognized as one of the system tools to promote effective operation of universal health coverage. This nationwide study aims to examine the relationship between accredited statuses of the provincial hospitals and their mortality outcomes. METHOD: A 5-year retrospective analysis of the Universal Coverage Scheme's claim dataset was conducted, using 1 297 869 inpatient discharges from 76 provincial hospital networks under the Ministry of Public Health. Mortality outcomes of 3 major acute care conditions, including acute myocardial infarction, acute stroke, and sepsis, were selected. RESULTS: Using generalized estimating equations to adjust for area-based control variables, hospital networks with HA-accredited provincial hospitals showed significant associations with lower standardized mortality ratios of acute stroke and sepsis. CONCLUSION: Our findings added supportive evidence that HA, as an organizational and health system management tool, could help promote hospital quality and safety in a developing country, leading to better outcomes.

Does reviewing fasting plasma glucose results patterns before glycosylated hemoglobin testing in type-2 diabetic patients lead to better testing decision?

AIMS: Glycosylated hemoglobin (HbA1c) test for blood glucose control in type-2 diabetic patients is recommended at least once annually under the guidelines of the Thai National Health Security Office (NHSO) benefits coverage. With limited resources and capability for HbA1c testing in most primary-care providers, this study explored patterns of fasting plasma glucose (FPG) tests for proper timing of HbA1c test would increase value of the money spent. METHODS: A retrospective review of laboratory findings of 4906 type-2 diabetic outpatients in two university hospitals in Thailand was conducted. Percentages of discordant results between the indexed FPG and HbA1c tests were compared between the patient groups with different FPG patterns before HbA1c testing and the control group of randomly selected cases. RESULTS: Having HbA1c tested after two and three consecutively normal FPG tests (OO and OOO patterns) were found to have significantly less discordance than the control group (-9.6% and -15.7%). HbA1c testing after two abnormal and one normal consecutive FPG tests (XXO pattern) gained the discordant results by 24.8%. CONCLUSIONS: Some FPG patterns were more predictive of HbA1c findings than focusing on one-time FPG results. Reviewing and recognizing certain patterns of FPGs prior to taking HbA1c tests can lead to better HbA1c testing decision than randomly prescribing the tests.

Associations between structures and resources of primary care at the district level and health outcomes: a case study of diabetes mellitus care in Thailand.

BACKGROUND: The structural factors of primary care potentially influence its performance and quality. This study investigated the association between structural factors, including available primary care resources and health outcomes, by using diabetes-related ambulatory care sensitive conditions hospitalizations under the Universal Coverage Scheme in Thailand. METHODS: A 2-year panel study used secondary data compiled at the district level. Administrative claim data from 838 districts during the 2014-2015 fiscal years from the National Health Security Office were used to analyze overall diabetes mellitus (DM) hospitalizations and its three subgroups: hospitalizations for uncontrolled diabetes, short-term complications, and long-term complications. Primary care structural data were obtained from the Ministry of Public Health. Generalized estimating equations were used to estimate the influence of structural factors on the age-standardized DM hospitalization ratio. RESULTS: A higher overall DM and uncontrolled diabetes hospitalization ratio was related to an increasing concentration of outpatient utilization (using the Herfindahl-Hirschman Index) (overall DM; beta [standard error, SE]=0.003 [0.001], 95% CI 0.000, 0.006) and decreasing physician density and bed supply (overall DM; beta [SE]=-1.350 [0.674], 95% CI -2.671, -0.028), beta [SE]=-0.023 [0.011], 95% CI -0.045, -0.001, respectively). Hospitalizations for short-term complications increased with a decrease in health care facility density, whereas hospitalizations for long-term complications increased as that density increased. Rurality was strongly associated with higher hospitalization ratios for all DM hospitalizations except short-term complications. CONCLUSIONS: This study identified structural factors associated with health outcomes, many of which can be changed through reorganization at the district level.

Cost analysis of hematopoietic stem cell transplantation in adult patients with acute myeloid leukemia at King Chulalongkorn Memorial Hospital.

The purpose of the study was to analyze the first-year cost ofhematopoietic stem cell transplantation (HSCT) program for the treatment of adult patients with acute myeloid leukemia (AML) at King Chulalongkorn Memorial Hospital (KCMH). The present retrospective study was carried out on 67 AML patients treated with bone marrow transplantation (BMT) or peripheral blood stem cell transplantation (PBSCT) at KCMH during the period of 1994 to 2005. The actual total one-year cost from the provider perspective were determined by the reviewing medical records for medical care costs (MCCs) and by adjusting data from the reports of annual cost analysis of KCMH for routine services costs (RSCs). All costs were converted to 2006 values using the Thai consumer price indices. It was found that the full cost of allogeneic HSCT (allo-HSCT) and autologous HSCT (auto-HSCT) in the first year of the program was $22,592.85 and $24,171.25 per case respectively. Cost-effective appraisal, comparing with chemotherapy, need to be studied further.

Cost-benefit analysis of hepatitis a vaccination in Thailand.

We constructed a decision model to simulate costs and benefits for persons in the context of hepatitis A prevention. Three strategies were compared: i) no intervention; ii) vaccination against hepatitis A without screening; iii) vaccination against hepatitis A for those susceptible after screening for anti-HAV. We divided the population into 3 age groups : 3-11 years, 12-18 years and 19-40 years. Data regarding the cost of treatment and vaccination were obtained from the King Chulalongkorn Memorial Hospital. Relevant probabilities were obtained from published literature and expert opinion. At the present incidence of hepatitis A infection, in all age groups examined, the net benefits of a universal no-intervention strategy were higher than those of either vaccination (intervention) strategy. The cost of vaccination without screening in the 3-11-year and 12-18-year groups would equal the benefit if the incidence rates amounted to approximately 138 and 212 infected individuals per 100,000, respectively, that of vaccination with screening at incidence rates of about 200 and 260 infected persons per 100,000, respectively. In the 19-40-year group, the cost incurred by vaccination either with or without screening would equal the benefit at an incidence rate above 450 infected individual per 100,000. For the benefits to outweigh the estimated vaccination costs at present the vaccine is still too expensive. The cost of vaccination without screening in the 3-11-year group would equal the benefit if the cost of vaccine was about 586 baht/2 doses (293 baht/dose), and about 500 baht/2 doses (250 baht/dose) in the 12-18-year group. Likewise, because of the cost of vaccine, it would not be cost-beneficial in the 19-40-year group both with and without screening, and neither would it be in the 3-11-year and 12-18-year groups including screening. According to current standards, under the conditions of the present study the benefit of hepatitis A vaccination administered to the general population between the age of 3 and 40 years in Thailand does not justify the expenses incurred. Major changes in hepatitis A incidence, anti-HAV seroprevalence, vaccine cost or the treatment outcome would be required to potentially render either intervention strategy cost beneficial.

Situation analysis of occupational and environmental health laboratory accreditation in Thailand.

The objective of this study was to analyze the current situation of laboratory accreditation (LA) in Thailand, especially on occupational and environmental health. The study integrated both quantitative and qualitative approaches. The response rate of the quantitative questionnaires was 54.5% (226/415). The majority of the responders was environmental laboratories located outside hospital and did not have proficiency testing. The majority used ISO 9000, ISO/IEC 17025 or ISO/ EEC Guide 25, and hospital accreditation (HA) as their quality system. However, only 30 laboratories were currently accredited by one of these systems. Qualitative research revealed that international standard for laboratory accreditation for both testing laboratory and calibration laboratory was ISO/IEC Guide 25, which has been currently revised to be ISO/IEC 17025. The National Accreditation Council (NAC) has authorized 2 organizations as Accreditation Bodies (ABs) for LA: Thai Industrial Standards Institute, Ministry of Industry, and Bureau of Laboratory Quality Standards, Department of Medical Sciences, Ministry of Public Health. Regarding LA in HA, HA considered clinical laboratory as only 1 of 31 items for accreditation. Obtaining HA might satisfy the hospital director and his management team, and hence might actually be one of the obstacles for the hospital to further improve their laboratory quality system and apply for ISO/IEC 17025 which was more technically oriented. On the other hand, HA may be viewed as a good start or even a pre-requisite for laboratories in the hospitals to further improve their quality towards ISO/IEC 17025. Interviewing the director of NAC and some key men in some large laboratories revealed several major problems of Thailand's LA. Both Thai Industrial Standards Institute and Bureau of Laboratory Quality Standards did not yet obtain Mutual Recognition Agreement (MRA) with other international ABs. Several governmental bodies had their own standards and accreditation systems, and did not accept other bodies' standards and systems. This put a burden to private laboratories because they had to apply and get accredited from several governmental bodies, but still had to apply and get accredited from international ABs especially for those dealing with exports. There were only few calibration laboratories, not enough for supporting the calibration required for the equipment in testing laboratories' LA. Purchasing proficiency testing specimens from abroad was very expensive, and often got into troubles with the customs duty procedures. The authors recommend some strategies and activities to improve laboratory accreditation in Thailand. Improvement in occupational and environmental health laboratories would essentially be beneficial to laboratory accreditation of other areas such as clinical laboratory.

Comparison of health care professionals' and surveyors' opinions on problems and obstacles in implementing quality management system in Thailand: A national survey.

OBJECTIVE: To explore problems and obstacles of hospitals in Thailand implementing quality management systems according to the hospital accreditation (HA) standards. DESIGN: Questionnaire survey. SETTING: Thirty-nine hospitals in all 13 regions of Thailand. PARTICIPANTS: A total of 728 health care professionals and 41 surveyors of the national accreditation program. MAIN OUTCOME MEASURES: Health care professionals' and surveyors' opinions on problems and obstacles in 24 items representing Thailand HA standards. RESULTS: The response rates were 94.9 and 73.2% in health care professionals and surveyors, respectively. More than 90% of both groups thought that there had been problems in the items such as 'quality improvement (QI) activities' and 'integration and utilization of information'. The items considered by health care professionals as major obstacles included 'adequacy of staff' (34.6%) and 'integration and utilization of information' (26.6%), for example. For surveyors, 'integration and utilization of information' was ranked highest as presenting a major obstacle (43.9%), followed by 'discharge and referral process' (31.7%) and 'medical recording process' (29.3%). The rank orders for the 24 items as problems and major obstacles were similar in both groups (Spearman's rank correlation 0.436, P = 0.033 and 0.583, P = 0.003, respectively). Surveyors had a higher degree of concern and paid more attention to care-related items than health care professionals. CONCLUSIONS: Health care professionals have been facing many problems with multidisciplinary process-related issues of the accreditation standard, whereas surveyors might have had some difficulties in conveying the core QI concepts to them. The findings might be explained by the effects of health care reform on the underlying accreditation principles. One of the strategies to respond to the situation was presented.

Hospitalwide quality improvement in Thailand.

BACKGROUND: In 1999 King Chulalongkorn Memorial Hospital, a 1,500-bed teaching hospital in Thailand, started planning and implementing a hospitalwide quality improvement program, as required for accreditation. DEPLOYING THE NINE-STEP LADDER STRATEGY: The steps in the strategy were as follows: (1) ensure commitment and formulate mutual strategies; (2) develop teams, technical staff, and support; (3) pilot new improvement activities and expand existing quality programs; (4) improve core systems and functions; (5) expand to the whole organization; (6) perform self-assessment and internal survey, (7) complete the incomplete; (8) submit the request for accreditation; and (9) improve continuously for excellence. For example, for step 3, the hospital set up five pilot cross-functional quality lead teams: the infection control committee, emergency-care patient care team, medication system team, laboratory and x-ray services team, and operating room team. RESULTS: The hospital was accredited by the Institute of Hospital Quality Improvement and Accreditation, Thailand. Improvements were shown in inpatient mortality, patient satisfaction, and reporting of patient risk incidents and the number of serious incidents. LESSONS LEARNED: Critical success factors in implementing a hospitalwide QI program were as follows: (1) role of leadership, (2) need for "quality strategists," (3) physician involvement and participation in QI teams, (4) vertical and horizontal communication, (5) performance drivers, (6) simplicity in continuous quality improvement, and (7) the value of a learning culture.