Cost-effectiveness study of pediatric atopic dermatitis in Asia: atopiclair vs. regular emollient (AD-ATOP).

BACKGROUND: Atopic dermatitis (AD) is a highly prevalent, chronic relapsing condition in childhood with significant financial burden and impact on the quality of life of patients and caregivers. Proactive maintenance treatment with moisturizing agents is the mainstay AD therapy. OBJECTIVES: The aim of this study was to assess the cost-effectiveness of a non-steroidal barrier cream (Atopiclair), compared to regular emollient in pediatric patients with mild-to-moderate AD. METHODS: A Markov decision model was developed to evaluate the cost-effectiveness of Atopiclair versus regular emollient in 12 Asia-Pacific countries, grouped by income categories based on gross domestic product (GDP) per capita. Data was obtained from structured literature review, expert opinion, fee schedules, and findings from a 2012 survey of 12 Asia-Pacific countries. Analysis was performed a societal perspective. RESULTS: In the base case analysis, Atopiclair was cost-effective against regular emollient, with USD786, USD499, and USD289 in cost savings per year for high, middle, and low-income countries, respectively. Sensitivity analyses showed that Atopiclair remained cost-effective versus regular emollient. CONCLUSIONS: Modelling analysis showed that Atopiclair is a cost-effective treatment compared to regular emollient for mild-to-moderate pediatric AD in the countries included in the study.

Prevalence of faecal incontinence and its related factors among patients in a Malaysian academic setting.

BACKGROUND: Prevalence data is essential for planning of healthcare services. The prevalence of faecal incontinence (FI) varies worldwide, and in Malaysia is not known. We sought to estimate its prevalence among patients with various conditions in a Malaysian academic setting. METHOD: A questionnaire-based survey was conducted among a convenience sample of adult patients and relatives who visited the Obstetrics and Gynaecology and General Surgery Clinics of University of Malaya Medical Centre (UMMC) from June 2009 to February 2010. Data collected included patient demographics and pre-existing medical conditions known to be FI risk factors. Severity of FI was assessed using the Wexner Continence Scale (WCS). RESULTS: Among the 1000 subjects recruited into the study, 760 (76%) were female and the median age was 38 years with an inter-quartile range of 24 years. The prevalence of FI among the study subjects was found to be 8.3%. Among them, 63 subjects (75.9%) were determined to have mild FI as measured by the WCS. The proportions of patients with moderate and severe FI were 18.3% and 6.0%, respectively. FI was found to be significantly associated with older age, presence of diabetes mellitus and increased duration of defaecation. There was no statistically significant association between FI and sex, defaecation frequency, or history of surgery. CONCLUSION: FI in our setting is prevalent enough to warrant targeted healthcare interventions, including the need to improve general public awareness of the condition in order to counter social stigma and embarrassment that may be faced by patients.

Budget impact analysis of biosimilar natalizumab in the US.

OBJECTIVES: Biosimilars provide an opportunity for a more sustainable and cost-effective treatment for multiple sclerosis (MS). This study evaluated the potential financial impact of implementing a formulary change from reference to biosimilar natalizumab (NTZ) from the US commercial payer perspective. STUDY DESIGN: The budget impact of transitioning to biosimilar NTZ for the treatment of relapsing-remitting MS (RRMS) was estimated over a 3-year time horizon based on real-world dosing. Additional scenario analyses were conducted by varying the price differential of biosimilar NTZ. METHODS: The target population was estimated from a 1-million-member hypothetical commercial health plan. Model inputs were drug acquisition costs and treatment-related and patient coinsurance costs. Budget impact and cost savings per member per year were calculated by assuming a biosimilar uptake of 10% in year 1 to 20% in year 3. RESULTS: Over 3 years, 255 patients were estimated to be treated with high-efficacy disease-modifying therapies for RRMS. The inclusion of biosimilar NTZ onto a formulary would result in cumulative cost savings to payers of $452,611 over 3 years, with mean savings per treated member per year of $1179, $1769, and $2359 in years 1, 2, and 3, respectively. One-way sensitivity analyses indicated that budget impact results were most sensitive to drug acquisition costs of both reference and biosimilar NTZ. CONCLUSION: Adoption of biosimilar NTZ can yield considerable cost savings to US health plans that could result in increased treatment access for patients with RRMS.

Cost of Treatment for Myelofibrosis Patients in Ministry of Health Hospitals in Sarawak, Malaysia.

OBJECTIVE: Primary myelofibrosis is a rare type of myeloproliferative neoplasm with an annual incidence rate of 0.47 per 100,000. A retrospective, observational study was conducted to determine the disease evolution and costs of treatment for myelofibrosis (MF) patients managed in 4 Ministry of Health (MOH) hospitals in Sarawak, Malaysia. METHODS: The estimation of treatment cost was a planned analysis of the Real World Evidence (RWE) study which included retrospective chart review of adult MF patients treated in Sarawak General, Sibu, Bintulu and Miri Hospitals. The study was approved by Sarawak General Hospital HRRC and MREC. The current study was conducted to estimate the cost of out-patient visits, hospitalisation, transfusion and medication from the perspective of MOH. Out-patient visits and hospitalisation costs were calculated using current unit costs for full fee-paying charges of MOH hospitals. Transfusion costs were estimated for packed cell and platelet transfusions. Medication costs were calculated using drug prices from IQVIA database for MOH hospital sub-sector in 2021. Unit costs were standardised to index year of 2021. RESULT: Data from 63 patients was available for analysis. Mean annual health resource utilisation (HRU) was 6.13 clinic visits, 9.47 days of hospitalisation and 1.61 transfusions per patient per year. Mean HRU cost was RM23,320 (USD5,217) per patient per year, comprised of RM19,122 (USD4,278) in drug costs, RM3,030 (USD678) for hospitalisation, RM799 (USD178) for transfusions and RM368 (USD82) for outpatient cost. CONCLUSION: The present analysis suggests that medication and hospitalisation were the main drivers of costs for MF treatment in Sarawak MOH hospitals. This study provides the first RWE estimate of the cost of MF in Malaysia and may provide insight into unmet clinical needs and a guide for further health economic research into the treatment of MF.

Estimating an EQ-5D value set for Malaysia using time trade-off and visual analogue scale methods.

OBJECTIVES: To estimate a EQ-5D value set for Malaysia by using time trade-off (TTO) and visual analogue scale (VAS) valuation methods. METHODS: TTO and VAS valuations were obtained from face-to-face surveys of a convenience sample of patients, caregivers, and health professionals conducted at nine government hospitals in 2004 and 2005. Forty-five EQ-5D questionnaire health states were valued, divided into five sets of 15 health states. Analysis was conducted by using linear additive regression models applying N3 and D1 specifications. Model selection was based on criteria of coefficient properties, statistical significance, and goodness of fit. RESULTS: One hundred fifty-two respondents were interviewed, yielding 2174 TTO and 2265 VAS valuations. Respondents found TTO valuations to be more difficult than VAS valuations, and there were more inconsistencies in TTO valuations. All the independent variables in the models were statistically significant and consistent with expected signs and magnitude, except for the D1 specification modeled on TTO valuations. The N3 model provided the best fit for the VAS valuation data, with a mean absolute error of 0.032. CONCLUSION: This study provides a Malaysian EQ-5D questionnaire value set that can be used for cost-utility studies despite survey limitations.

Impact of routine PCV7 (Prevenar) vaccination of infants on the clinical and economic burden of pneumococcal disease in Malaysia.

BACKGROUND: Pneumococcal disease is the leading cause of vaccine-preventable death in children younger than 5 years of age worldwide. The World Health Organization recommends pneumococcal conjugate vaccine as a priority for inclusion into national childhood immunization programmes. Pneumococcal vaccine has yet to be included as part of the national vaccination programme in Malaysia although it has been available in the country since 2005. This study sought to estimate the disease burden of pneumococcal disease in Malaysia and to assess the cost effectiveness of routine infant vaccination with PCV7. METHODS: A decision model was adapted taking into consideration prevalence, disease burden, treatment costs and outcomes for pneumococcal disease severe enough to result in a hospital admission. Disease burden were estimated from the medical records of 6 hospitals. Where local data was unavailable, model inputs were obtained from international and regional studies and from focus group discussions. The model incorporated the effects of herd protection on the unvaccinated adult population. RESULTS: At current vaccine prices, PCV7 vaccination of 90% of a hypothetical 550,000 birth cohort would incur costs of RM 439.6 million (US$128 million). Over a 10 year time horizon, vaccination would reduce episodes of pneumococcal hospitalisation by 9,585 cases to 73,845 hospitalisations with cost savings of RM 37.5 million (US$10.9 million) to the health system with 11,422.5 life years saved at a cost effectiveness ratio of RM 35,196 (US$10,261) per life year gained. CONCLUSIONS: PCV7 vaccination of infants is expected to be cost-effective for Malaysia with an incremental cost per life year gained of RM 35,196 (US$10,261). This is well below the WHO's threshold for cost effectiveness of public health interventions in Malaysia of RM 71,761 (US$20,922).

Review article: Use of renal registry data for research, health-care planning and quality improvement: what can we learn from registry data in the Asia-Pacific region?

We review renal registry data from the Asia-Pacific region with an emphasis on their uses in health care and in dialysis care in particular. The review aims to demonstrate the information value of registry data. While renal registry provides a useful data resource for epidemiological research, there are severe methodological limitations in its application for analytical or therapeutic research. However, it is the use of renal registry data for public health and health-care management purposes that registry really comes into its own, and it is primarily for these that governments have invested in national patient and disease registries. We apply data from several renal registries in the Asia-Pacific region to illustrate its wide application for planning dialysis services, for evaluating dialysis practices and health outcomes, with a view to improving the quality of dialysis care. In the course of preparing the review, we have found that the quality and accessibility of renal registry data were highly variable across the region. Given the value of renal registry, every country in the Asia-Pacific region should establish one or should ensure that their current registries are better resourced and developed. Greater data sharing and collaboration among registries in the region could help advance the nephrology to serve our patients better.

The Cost and Quality of Life of Malaysian Type 2 Diabetes Mellitus Patients with Chronic Kidney Disease and Anemia.

BACKGROUND: Anemia is common among patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) and an independent risk factor for renal disease progression. Health economic evidence is important in Malaysia and yet cost and quality-of-life (QOL) data are scarce. OBJECTIVES: To investigate prevalence, factors associated with anemia, and cost and QOL among T2DM patients with CKD. Here, we present the estimated 1-year cost and QOL related to anemia in this group. METHODS: A cross-sectional, observational study was performed at 20 government clinics. Treatment cost was calculated on the basis of resource utilization ascertained through data extracted from medical records and patient recall. QOL was elicited using the short form 36 health survey version 2 questionnaire. Propensity score matching was performed and costs and QOL were analyzed by anemia status and CKD stage. RESULTS: Data for 816 patients were obtained. The propensity score matching enabled a comparison of 257 patients with and without anemia. Annual treatment costs were significantly higher for patients with anemia (Ringgit Malaysia [RM] 4219 [US $983] vs. RM2705 [US $630]; P = 0.01). QOL scores were lower for patients with anemia but not statistically significant (physical component summary score: 44.8 vs. 46.2; P = 0.052; mental component summary score: 51.3 vs. 51.7; P = 0.562). Costs were higher and QOL lower among CKD stage 5 patients. CONCLUSIONS: This study was the first to examine anemia in this group of patients. Costs were significantly higher among anemic patients compared with nonanemic patients; patients with higher CKD stage 5 fared less well than did those in lower stages. This information suggests the need to increase detection, prevention, and early treatment of anemia when managing T2DM patients, particularly those with CKD.

Quality of life among Patients with Acute Coronary Syndrome in Malaysia.

OBJECTIVES: This study's objectives were to estimate the quality of life (QOL) of Malaysian patients with acute coronary syndrome (ACS) during admission and at 12 months, to explore the factors associated with the QOL, and to compare utility scores derived from tariffs from local and foreign populations. METHODS: Data collected from patients with ACS between 2008 and 2009 for a study on cardiac rehabilitation at the Sarawak General Hospital were used for this study. QOL data were obtained using a validated version of the EuroQol five-dimensional questionnaire at baseline and at 12 months. Health utility scores were calculated using visual analogue scale scores and utility tariffs from Malaysia and the United Kingdom. RESULTS: Data from 104 subjects from the earlier study was used. The mean age was 56.1 years, with 88.5% being men. The mean hospitalization duration was 6.3 days. The mean utility score was 0.75 at baseline and 0.82 at 12 months. There was a statistically significant improvement in utility from baseline to 12 months based on the Malaysian tariff (P = 0.014) but not with the UK tariff (P = 0.086). The QOL of patients was associated with sex and diagnosis of ST-segment elevation myocardial infarction. CONCLUSIONS: Our results showed that there was a significant improvement in the QOL from baseline to 12 months. Only sex and diagnosis affected the QOL score at baseline because of limited variables available for testing. It also reconfirms the importance of applying the appropriate, country-specific utility tariffs in QOL studies. Despite limitations, the study is useful toward describing QOL among a group of Malaysian patients with ACS.

The Cost and Utility of Renal Transplantation in Malaysia.

UNLABELLED: Kidney transplantation is the optimal therapy for the majority of patients with end-stage renal disease. However, the cost and health outcomes of transplantation have not been assessed in a middle-income nation with a low volume of transplantation, such as Malaysia. AIM AND METHODS: This study used microcosting methods to determine the cost and health outcomes of living and deceased donor kidney transplantation in adult and pediatric recipients. The perspective used was from the Ministry of Health Malaysia. Cost-effectiveness measures were cost per life year (LY) and cost per quality-adjusted LYs. The time horizon was the lifetime of the transplant recipient from transplant to death. RESULTS: Records of 206 KT recipients (118 adults and 88 children) were obtained for microcosting. In adults, discounted cost per LY was US $8609(Malaysian Ringgit [RM]29 482) and US $13 209(RM45 234) for living-donor kidney transplant (LKT) and deceased donor kidney transplant (DKT), respectively, whereas in children, it was US $10 485(RM35 905) and US $14 985(RM51 317), respectively. Cost per quality-adjusted LY in adults was US $8826 (RM30 224) for LKT and US $13 592(RM46 546) for DKT. Total lifetime discounted costs of adult transplants were US $119 702 (RM409 921) for LKT, US $147 152 (RM503 922) for DKT. Total costs for pediatric transplants were US $154 841(RM530 252) and US $159 313(RM545 566) for the 2 categories respectively. CONCLUSIONS: Both LKT and DKT are economically favorable for Malaysian adult and pediatric patients with ESRD and result in improvement in quality of life.

Echovirus 7 associated encephalomyelitis.

BACKGROUND: Hand, foot, and mouth disease (HFMD) is endemic in Malaysia. In 1997, a large outbreak of enterovirus 71 (EV-71) associated HFMD resulted in 41 deaths due to severe left ventricular dysfunction and central nervous system infection with extensive damage to the medulla and pons. The clinical presentation in all these patients were rapid cardio-respiratory decompensation leading to cardiac arrest. Another large outbreak of HFMD with 55 fatal cases and a similar clinical picture was reported in Taiwan in 1998. In 2000, an outbreak of HFMD resulted in the deaths of three children who had rapid cardio-respiratory decompensation and one child who survived a central nervous system infection. OBJECTIVES: We set out to study the etiologic agent and mechanism involved in three children who presented to our hospital, two of whom died and one survived a central nervous system infection. STUDY DESIGN: The clinical course of the disease was described. Throat, rectal swab and cerebrospinal fluid samples were subjected to viral isolation and viral isolates were identified by immunofluorescence, micro-neutralisation using human rhabdomyosarcoma (RD) cells, and reverse transcritpase polymerase chain reaction. Magnetic resonance imaging was performed on two of the patients. RESULTS: Echovirus 7 was the sole pathogen isolated from three cases of acute encephalomyelitis, two of which were fatal due to severe left ventricular dysfunction resistant to inotropic support. The survivor had residual bulbar palsy, but is considered to have had a good neurological outcome. CONCLUSION: Echovirus 7 infection associated with encephalomyelitis could be fatal due to indirect involvement of the heart resulting in severe left ventricular dysfunction. In addition one of the children presented with hand, foot, and mouth disease, a syndrome that has not been previously associated with echovirus 7 infection.

Outcome of children with different accessibility to tertiary pediatric intensive care in a developing country--a prospective cohort study.

OBJECTIVE: Lack of direct access to tertiary pediatric intensive care services in rural hospitals may be associated with poorer outcome among critically ill children. Inter-hospital transport by non-specialized teams may also lead to increased morbidity and even mortality. We therefore studied the outcome of children with different accessibility to tertiary pediatric care in Malaysia. METHODS: We prospectively compared the Pediatric Risk of Mortality (PRISM II) adjusted standardized mortality ratio (SMR), unanticipated deaths and length of stay of 131 patients transported from rural hospitals (limited access) with 215 transferred from the casualty wards or other in-hospital wards (direct access) to a tertiary pediatric ICU. RESULTS: The transported patients were younger than the in-hospital patients (median age 1.0 versus 6.0 months, p=0.000) and were more likely to have respiratory diseases. Other baseline characteristics did not differ significantly. Differences in access to tertiary intensive care from community hospitals was associated with an extended median length of stay (4.0 versus 2.0 days, p=0.000) but did not affect SMR (0.92 versus 0.84, rate ratio 1.09, 95% CI 0.57-2.01; p=0.348) or percentage of unexpected deaths (4.8% versus 2.8%, p=0.485). The adjusted odds ratio for mortality (1.7, 95% CI 0.7-4.3) associated with transfer was not statistically significant (p=0.248). CONCLUSIONS: The outcome of critically ill children transferred from community hospitals did not differ from that of those who develop ICU needs in the wards of a tertiary center, despite being transported by non-specialized teams. Outcome was not affected by initial inaccessibility to intensive care if the children finally received care in a tertiary center.

Effect of surface treatment and cement maturation on the bond strength of resin-modified glass ionomers to dentin.

This study investigated the effect of surface treatment and cement maturation on the bond strength of resin-modified glass ionomer cements (RMGICs) to dentin. Forty-two freshly extracted premolars were embedded and horizontally sectioned at a level 2 mm from the central fossa to obtain a flat dentin surface. The premolars were randomly divided into three groups of 14 teeth and treated as follows: Group 1 (control)--no surface treatment, Group 2--conditioned with 20% polyacrylic acid for 10 seconds and Group 3--etched with 37% phosphoric acid for 15 seconds. RMGIC (Fuji II LC, GC) columns (3 mm diameter; 2 mm high) were applied to the dentin surface and shear bond testing was carried out after one week (n = 7) and one month (n = 7) storage in distilled water at 37 degrees C using an Instron Universal testing machine with a cross-head speed of 0.6 mm/minute. The failure mode was examined at 40x magnification and scored with imaging software. The results were analyzed using ANOVA/Scheffe's post-hoc test and Kruskal-Wallis/Mann-Whitney test at a significance level of 0.05. The effect of surface treatment on shear bond strength to dentin was time dependent. Mean strengths ranged from 3.16 to 5.81 MPa at one week and 5.00 to 14.95 MPa at one month. Although no significant difference in strengths was observed among the groups at one week, significant differences (Group 2 > Group 1 > Group 3) were detected at one month. At one month, conditioned and untreated specimens exhibited significantly less adhesive failure than etched specimens.

How public and private reforms dramatically improved access to dialysis therapy in Malaysia.

Between 1990 and 2005, dialysis treatment rates in Malaysia increased more than eightfold. Dialysis treatment reached a level comparable to rates in developed countries. This remarkable transformation was brought about in large part by the Malaysian government's large-scale purchase of dialysis services from the highly competitive private sector. This paper traces a series of public- and private-sector reforms that dramatically increased access to dialysis for patients with kidney failure from 13 per million people in the population in 1990 to 119 per million in 2005. Not all developing countries have had uniformly positive experiences with private-sector participation in health care. However, our data suggest that strong participation by the private sector in Malaysia has helped make for a stronger health care system as well as healthier patients. Yet the policy decisions that enabled the private sector to participate fully in providing dialysis have not been repeated with other medical services.

Cerebral salt wasting syndrome following atlantoaxial fracture dislocation in Down syndrome.

We describe cerebral salt wasting syndrome (CSWS) in a 5-year-old female child with Down syndrome who had acute myelopathy secondary to chronic atlantoaxial subluxation and fracture dislocation of the odontoid process. The patient developed hyponatraemia associated with excessive urine output and elevated urine sodium concentration following her injury. An administered volume-for-volume replacement of urine loss with 0.9% sodium chloride resulted in an excellent outcome. This patient illustrates the importance of ascertaining CSWS in children with spinal cord disorders, in addition to the syndrome of inappropriate antidiuretic hormone (SIADH) secretion and diabetes insipidus (DI) commonly encountered following a central nervous system (CNS) injury, as the specific treatment approaches is clearly associated with an excellent outcome.

Economic evaluation of centre haemodialysis and continuous ambulatory peritoneal dialysis in Ministry of Health hospitals, Malaysia.

BACKGROUND: This is a multi-centre study to determine cost efficiency and cost effectiveness of the Ministry of Health centre haemodialysis and continuous ambulatory peritoneal dialysis (CAPD) programme. METHODS: Forty-four haemodialysis and 11 CAPD centres were enrolled in this study in 2001. Sixty patients, 30 from each modality, were evaluated. Micro-costing was used to determine costs. RESULTS: The number of haemodialyses conducted ranged from 402 to 23,000 procedures per year, while for CAPD, output ranged from 70 to 2300 patient months/year. Cost ranged from RM79.61 to RM475.79 per haemodialysis treatment, with a mean cost of RM169 per HD (USD 1 = RM 3.80). The cost of CAPD treatment ranged from RM1400 to RM3200 per patient month, with a mean of RM2186. Both modalities incurred similar outpatient costs. The cost of erythropoeitin per year is RM4500 and RM2500 for haemodialysis and CAPD, respectively. The number of life years saved is 10.96 years for haemodialysis and 5.21 years for CAPD. Cost per life year saved is RM33 642 for haemodialysis and RM31 635 for CAPD. The cost for land, building, equipment, overheads, and staff were higher for haemodialysis, while consumables and hospitalization cost more for CAPD. Sensitivity analysis was performed for two discount rates (3 and 5%), varying erythropoietin doses and maximum and minimum overheads. Relative cost effectiveness of haemodialysis and CAPD was unchanged in all sensitivity scenarios, except for overhead costs, which influenced the cost effectiveness of HD. CONCLUSION: It is economically viable to promote the use of both CAPD and haemodialysis because the cost effectiveness of both are nearly equal.

Risk factors for hemorrhage in severe dengue infections.

The purpose of this study was to identify the early indicators of hemorrhage in severe dengue infections in 114 patients; 24 patients had severe hemorrhage and 92 had no hemorrhage. The platelet counts were not predictive of bleeding. The duration of shock (OR, 2.11; 95% CI, 1.13 to 3.92; P =.019) and low-normal hematocrit at the time of shock (OR, 0.72; 95% CI, 0.55 to 0.95; P =.020) were risk factors of severe hemorrhage.

Preventive transfusion in Dengue shock syndrome-is it necessary?

We compared 53 patients with Dengue shock syndrome (DSS) who received preventive transfusions with 53 who did not. Significant differences in the development of pulmonary edema and length of hospitalization (P<.05) and none in hemorrhage (P=.136) were observed. Preventive transfusions did not produce sustained improvements in the coagulation status in DSS.