Assessing catastrophic health expenditure and impoverishment in adult asthma care: a cross-sectional study of patients attending six public health clinics in Klang District, Malaysia.

BACKGROUND: In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia. METHODS: This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis. RESULTS: We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors. CONCLUSION: The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship.

Facilitators and barriers for tuberculosis preventive treatment among patients with latent tuberculosis infection: a qualitative study.

BACKGROUND: Various factors influence tuberculosis preventive treatment (TPT) decisions thus it is important to understand the health beliefs and concerns of patients before starting TPT to ensure treatment compliance. This study aims to explore facilitators and barriers for TPT among patients diagnosed with Latent Tuberculosis infection (LTBI) attending six primary healthcare clinics in Selangor, Malaysia. METHOD: In-depth interviews were conducted face-to-face or via telephone among patients with a clinical diagnosis of LTBI using a semi-structured topic guide developed based on the common-sense model of self-regulation and literature review. Audio recordings of interviews were transcribed verbatim and analysed thematically. RESULTS: We conducted 26 In-depth interviews; Good knowledge of active tuberculosis (TB) and its associated complications, including the perceived seriousness and transmissibility of active TB, facilitates treatment. LTBI is viewed as a concern when immune status is compromised, thus fostering TPT. However, optimal health is a barrier for TPT. Owing to the lack of knowledge, patients rely on healthcare practitioners (HCPs) to determine their treatment paths. HCPs possessing comprehensive knowledge play a role in facilitating TPT whereas barriers to TPT encompass misinterpretation of tuberculin skin test (TST), inadequate explanation of TST, and apprehensions about potential medication side effects. CONCLUSIONS: Knowledge of LTBI can influence TPT uptake and patients often entrust their HCPs for treatment decisions. Improving knowledge of LTBI both among patients and HCPs can lead to more effective doctor-patient consultation and consequently boost the acceptance of TPT. Quality assurance should be enhanced to ensure the effective usage of TST as a screening tool.

Facilitators and barriers to latent tuberculosis infection treatment among primary healthcare workers in Malaysia: a qualitative study.

BACKGROUND: Healthcare workers (HCWs) have an increased risk of active and latent tuberculosis infection (LTBI) compared to the general population. Despite existing guidelines on the prevention and management of LTBI, little is known about why HCWs who tested positive for LTBI refuse treatment. This qualitative study sought to explore the facilitators and barriers to LBTI treatment uptake among primary HCWs in Malaysia. METHODS: This qualitative study used a phenomenological research design and was conducted from July 2019 to January 2021. A semi-structured topic guide was developed based on literature and the Common-Sense Model of Self-Regulation. We conducted one focus group discussion and 15 in-depth interviews with primary care HCWs. Interviewees were 7 physicians and 11 allied HCWs who tested positive for LTBI by Tuberculin Skin Test or Interferon Gamma Release Assay. Audio recordings were transcribed verbatim and thematic analysis was used to analyse the data. RESULTS: We found four factors that serve as barriers to HCWs' LTBI treatment uptake. Uncertainties about the need for LTBI treatment, alongside several other factors including the attitude of the treating physician towards treatment, time constraints during clinical consultations, and concerns about the treatment itself. On the other hand, facilitators for LTBI treatment uptake can be grouped into two themes: diagnostic modalities and improving knowledge of LTBI treatment. CONCLUSIONS: Improving HCWs' knowledge and informative clinical consultation on LTBI and its treatment benefit, aided with a definitive diagnostic test can facilitate treatment uptake. Additionally, there is a need to improve infection control measures at the workplace to protect HCWs. Utilizing behavioural insights can help modify risk perception among HCWs and promote treatment uptake.

A self-management app to improve asthma control in adults with limited health literacy: a mixed-method feasibility study.

BACKGROUND: Digital technology tailored for those with limited health literacy has the potential to reduce health inequalities. Although mobile apps can support self-management in chronic diseases, there is little evidence that this approach applies to people with limited health literacy. We aimed to determine the acceptability of a self-management app in adults living with asthma and have limited health literacy and the feasibility of delivering the intervention and assessing outcomes. METHODS: We recruited eligible adults from the Klang Asthma Cohort registry in primary care for a 3-month mixed-method study plus a 2-month extended observation. We collected baseline data on socio-demography, health literacy and asthma control level. The outcomes of the intervention were assessed at 1- and 3-month: i) adoption (app download and usage), ii) adherence (app usage), iii) retention (app usage in the observation period), iv) health outcomes (e.g., severe asthma attacks) and v) process outcomes (e.g., ownership and use of action plans). At 1-month, participants were purposively sampled for in-depth interviews, which were audio-recorded, transcribed verbatim, and analysed deductively. RESULTS: We recruited 48 participants; 35 participants (23 Female; median age = 43 years; median HLS score = 28) completed the 3 months study. Of these, 14 participants (10 Female; median age = 48 years; median HLS score = 28) provided interviews. Thirty-seven (77%) participants adopted the app (downloaded and used it in the first month of the study). The main factor reported as influencing adoption was the ease of using the app. A total of 950 app usage were captured during the 3-month feasibility study. App usage increased gradually, peaking at month 2 (355 total log-ins) accounting for 78% of users. In month 5, 51.4% of the participants used the app at least once. The main factors influencing continued use included adherence features (e.g., prompts and reminders), familiarity with app function and support from family members. CONCLUSIONS: An asthma self-management app intervention was acceptable for adults with limited health literacy and it was feasible to collect the desired outcomes at different time points during the study. A future trial is warranted to estimate the clinical and cost-effectiveness of the intervention and to explore implementation strategies.

Psychological well-being, quality of life and patient satisfaction among adults with chronic spontaneous urticaria in a multi-ethnic Asian population.

Patients with chronic spontaneous urticaria (CSU) have an increased risk of psychological distress. This cross-sectional study aimed to determine factors associated with psychological burden, quality of life (QoL) and patient satisfaction among adults living with CSU. Participants completed the self-administered Urticaria Activity Score-7 (UAS-7), Depression Anxiety Stress Scale (DASS 21), Dermatology Life Quality Index (DLQI), and Short Assessment Patient Satisfaction (SAPS) questionnaires. Multivariate logistic regression was used to determine the independent predictors of depression, anxiety, stress, QoL and patient satisfaction. From a total of 115 subjects with a median age of 42.6 years, range (19-89 years). 60.9% subjects reported moderate-to-severe CSU, 26.1% reported symptoms of depression, 54.8% had anxiety, 40.0% had stress, and 36.5% reported severely impaired QoL. The median UAS-7 score was 20 (IQR 11-27) while the median score of DLQI was 8 (IQR 4-13). The median score of SAPS was 20 (IQR 17-21). Low-income and severe disease were the significant predictors for depression while severe disease was predictive of impaired QoL and depression. Subjects who were diagnosed at older ages and those who required medical leave due to flares of CSU were less likely to be satisfied with their care. (192 words).

Sociocultural influences on asthma self-management in a multicultural society: A qualitative study amongst Malaysian adults.

BACKGROUND: Supported self-management improves asthma outcomes, but implementation requires adaptation to the local context. Barriers reported in Western cultures may not resonate in other cultural contexts. We explored the views, experiences and beliefs that influenced self-management among adults with asthma in multicultural Malaysia. METHODS: Adults with asthma were purposively recruited from an urban primary healthcare clinic for in-depth interviews. Audio-recordings were transcribed verbatim and analysed thematically. RESULTS: We interviewed 24 adults. Four themes emerged: (1) Participants believed in the 'hot and cold' concept of illness either as an inherent hot/cold body constitution or the ambient temperature. Hence, participants tried to 'neutralize' body constitution or to 'warm up' the cold temperature that was believed to trigger acute attacks. (2) Participants managed asthma based on past experiences and personal health beliefs as they lacked formal information about asthma and its treatment. (3) Poor communication and variable advice from healthcare practitioners on how to manage their asthma contributed to poor self-management skills. (4) Embarrassment about using inhalers in public and advice from family and friends resulted in a focus on nonpharmacological approaches to asthma self-management practice. CONCLUSIONS: Asthma self-management practices were learnt experientially and were strongly influenced by sociocultural beliefs and advice from family and friends. Effective self-management needs to be tailored to cultural norms, personalized to the individuals' preferences and clinical needs, adapted to their level of health literacy and underpinned by patient-practitioner partnerships. PATIENT AND PUBLIC CONTRIBUTIONS: Patients contributed to data. Members of the public were involved in the discussion of the results.

Development of a Sexually Transmitted Disease Client-friendly Unit at a Primary Care Clinic in Malaysia: Lessons Learnt.

Management of sexually transmitted diseases and human immunodeficiency virus is challenging due to the social stigma attached. We describe the development of a client-friendly sexually transmitted disease service in a primary care clinic in Malaysia with a special focus on key populations. Challenges and key lessons learnt from its development and implementation are discussed.

Variation of polypharmacy in older primary care attenders occurs at prescriber level.

BACKGROUND: Polypharmacy is particularly important in older persons as they are more likely to experience adverse events compared to the rest of the population. Despite the relevance, there is a lack of studies on the possible association of patient, prescriber and practice characteristics with polypharmacy. Thus, the aim of this study was to determine the rate of polypharmacy among older persons attending public and private primary care clinics, and its association with patient, prescriber and practice characteristics. METHODS: We used data from The National Medical Care Survey (NMCS), a national cross-sectional survey of patients' visits to primary care clinics in Malaysia. A weighted total of 22,832 encounters of patients aged ≥65 years were analysed. Polypharmacy was defined as concomitant use of five medications and above. Multilevel logistic regression was performed to examine the association of polypharmacy with patient, prescriber and practice characteristics. RESULTS: A total of 20.3% of the older primary care attenders experienced polypharmacy (26.7%% in public and 11.0% in private practice). The adjusted odds ratio (OR) of polypharmacy were 6.37 times greater in public practices. Polypharmacy was associated with patients of female gender (OR 1.49), primary education level (OR 1.61) and multimorbidity (OR 14.21). The variation in rate of polypharmacy was mainly found at prescriber level. CONCLUSION: Polypharmacy is common among older persons visiting primary care practices. Given the possible adverse outcomes, interventions to reduce the burden of polypharmacy are best to be directed at individual prescribers.

Development and validation of the Evidence Based Medicine Questionnaire (EBMQ) to assess doctors' knowledge, practice and barriers regarding the implementation of evidence-based medicine in primary care.

BACKGROUND: Evidence-Based Medicine (EBM) integrates best available evidence from literature and patients' values, which then informs clinical decision making. However, there is a lack of validated instruments to assess the knowledge, practice and barriers of primary care physicians in the implementation of EBM. This study aimed to develop and validate an Evidence-Based Medicine Questionnaire (EBMQ) in Malaysia. METHODS: The EBMQ was developed based on a qualitative study, literature review and an expert panel. Face and content validity was verified by the expert panel and piloted among 10 participants. Primary care physicians with or without EBM training who could understand English were recruited from December 2015 to January 2016. The EBMQ was administered at baseline and two weeks later. A higher score indicates better knowledge, better practice of EBM and less barriers towards the implementation of EBM. We hypothesized that the EBMQ would have three domains: knowledge, practice and barriers. RESULTS: The final version of the EBMQ consists of 80 items: 62 items were measured on a nominal scale, 22 items were measured on a 5 point Likert-scale. Flesch reading ease was 61.2. A total of 343 participants were approached; of whom 320 agreed to participate (response rate = 93.2%). Factor analysis revealed that the EBMQ had eight domains after 13 items were removed: "EBM websites", "evidence-based journals", "types of studies", "terms related to EBM", "practice", "access", "patient preferences" and "support". Cronbach alpha for the overall EBMQ was 0.909, whilst the Cronbach alpha for the individual domain ranged from 0.657-0.940. The EBMQ was able to discriminate between doctors with and without EBM training for 24 out of 42 items. At test-retest, kappa values ranged from 0.155 to 0.620. CONCLUSIONS: The EBMQ was found to be a valid and reliable instrument to assess the knowledge, practice and barriers towards the implementation of EBM among primary care physicians in Malaysia.

Mismatch between health-care professionals' and patients' views on a diabetes patient decision aid: a qualitative study.

BACKGROUND: Malaysia is an Asian country with population of diverse culture and health perceptions. Patient decision aid (PDA) is a new tool in Malaysia. Patients' and health-care professionals' (HCPs) expectation of a PDA is unknown. AIM: We aimed to explore patients' and health-care professionals'(HCPs) views on the information needed in a patient decision aid (PDA) on insulin initiation developed for patients with type 2 diabetes mellitus (T2DM). DESIGN: We used a qualitative design and thematic approach. SETTING: Three main primary health-care settings in Malaysia: public university-based primary care clinics, public health-care clinics and private general practices. METHOD: We conducted focus groups and one-to-one interviews with a purposive sample of health professionals and patients with type 2 diabetes. RESULTS: We interviewed 18 patients and 13 HCPs. Patients viewed the content of the PDA as simple and clear. However, HCPs felt the PDA might be difficult for patients with low literacy to understand. HCPs thought the PDA was too lengthy. Nevertheless, patients would prefer more information. HCPs tended to focus on benefits of insulin, while patients wanted to know the impact of insulin on their quality of life and practical issues regarding insulin and its side-effects. Patients preferred numbers to weigh the risks and benefits of treatment options. HCPs' views that presenting numbers in a PDA would be too complex for patients to understand. CONCLUSION: It is important to consider including issues related to psycho-social impact of treatment to patients when developing a patient decision aid.

Health profiles of foreigners attending primary care clinics in Malaysia.

BACKGROUND: The world population has become more globalised with increasing number of people residing in another country for work or other reasons. Little is known about the health profiles of foreign population in Malaysia. The aim of this study was to provide a detailed description of the health problems presented by foreigners attending primary care clinics in Malaysia. METHODS: Data were derived from the 2012 National Medical Care Survey (NMCS), a cross sectional survey of primary care encounters from public and private primary care clinics sampled from five regions in Malaysia. Patients with foreign nationality were identified and analysed for demographic profiles, reasons for encounter (RFEs), diagnosis, and provision of care. RESULTS: Foreigners accounted for 7.7 % (10,830) of all patient encounters from NMCS. Most encounters were from private clinics (90.2 %). Median age was 28 years (IQR: 24.0, 34.8) and 69.9 % were male. Most visits to the primary care clinics were for symptom-based complaints (69.5 %), followed by procedures (23.0 %) and follow-up visit (7.4 %). The commonest diagnosis in public clinics was antenatal care (21.8 %), followed by high risk pregnancies (7.5 %) and upper respiratory tract infection (URTI) (6.8 %). Private clinics had more cases for general medical examination (13.5 %), URTI (13.1 %) and fever (3.9 %). Medications were prescribed to 76.5 % of these encounters. CONCLUSIONS: More foreigners were seeking primary medical care from private clinics and the encounters were for general medical examinations and acute minor ailments. Those who sought care from public clinics were for obstetric problems and chronic diseases. Medications were prescribed to two-thirds of the encounters while other interventions: laboratory investigations, medical procedures and follow-up appointment had lower rates in private clinics. Foreigners are generally of young working group and are expected to have mandatory medical checks. The preponderance of obstetrics seen in public clinics suggests a need for improved access to maternal care and pregnancy related care. This has implication on policy and health care provision and access for foreigners and future studies are needed to look into strategies to solve these problems.

An individually-tailored multifactorial intervention program for older fallers in a middle-income developing country: Malaysian Falls Assessment and Intervention Trial (MyFAIT).

BACKGROUND: In line with a rapidly ageing global population, the rise in the frequency of falls will lead to increased healthcare and social care costs. This study will be one of the few randomized controlled trials evaluating a multifaceted falls intervention in a low-middle income, culturally-diverse older Asian community. The primary objective of our paper is to evaluate whether individually tailored multifactorial interventions will successfully reduce the number of falls among older adults. METHODS: Three hundred community-dwelling older Malaysian adults with a history of (i) two or more falls, or (ii) one injurious fall in the past 12 months will be recruited. Baseline assessment will include cardiovascular, frailty, fracture risk, psychological factors, gait and balance, activities of daily living and visual assessments. Fallers will be randomized into 2 groups: to receive tailored multifactorial interventions (intervention group); or given lifestyle advice with continued conventional care (control group). Multifactorial interventions will target 6 specific risk factors. All participants will be re-assessed after 12 months. The primary outcome measure will be fall recurrence, measured with monthly falls diaries. Secondary outcomes include falls risk factors; and psychological measures including fear of falling, and quality of life. DISCUSSION: Previous studies evaluating multifactorial interventions in falls have reported variable outcomes. Given likely cultural, personal, lifestyle and health service differences in Asian countries, it is vital that individually-tailored multifaceted interventions are evaluated in an Asian population to determine applicability of these interventions in our setting. If successful, these approaches have the potential for widespread application in geriatric healthcare services, will reduce the projected escalation of falls and fall-related injuries, and improve the quality of life of our older community. TRIAL REGISTRATION: ISRCTN11674947.

Unintentional injury and its prevention in infant: knowledge and self-reported practices of main caregivers.

BACKGROUND: Unintentional injuries are the major cause of morbidity and mortality in infants. Prevention of unintentional injuries has been shown to be effective with education. Understanding the level of knowledge and practices of caregivers in infant safety would be useful to identify gaps for improvement. METHODS: A cross-sectional study was conducted in an urban government health clinic in Malaysia among main caregivers of infants aged 11 to 15 months. Face-to-face interviews were conducted using a semi-structured self-designed questionnaire. Responses to the items were categorised by the percentage of correct answers: poor (<50%), moderate (50% - 70%) and good (>70%). RESULTS: A total of 403 caregivers participated in the study. Of the 21 items in the questionnaire on knowledge, 19 had good-to-moderate responses and two had poor responses. The two items on knowledge with poor responses were on the use of infant walkers (26.8%) and allowing infants on motorcycles as pillion riders (27.3%). Self-reported practice of infant safety was poor. None of the participants followed all 19 safety practices measured. Eight (42.1%) items on self-reported practices had poor responses. The worst three of these were on the use of baby cots (16.4%), avoiding the use of infant walkers (23.8%) and putting infants to sleep in the supine position (25.6%). Better knowledge was associated with self-reported safety practices in infants (p < 0.05). However, knowledge did not correspond to correct practice, particularly on the use of baby cots, infant walkers and sarong cradles. CONCLUSION: Main caregivers' knowledge on infant safety was good but self-reported practice was poor. Further research in the future is required to identify interventions that target these potentially harmful practices.

Unmet needs of patients with chronic obstructive pulmonary disease (COPD): a qualitative study on patients and doctors.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a chronic disease with repeated exacerbations resulting in gradual debilitation. The quality of life has been shown to be poor in patients with COPD despite efforts to improve self-management. However, the evidence on the benefit of self-management in COPD is conflicting. Whether this could be due to other unmet needs of patients have not been investigated. Therefore, we aimed to explore unmet needs of patients from both patients and doctors managing COPD. METHODS: We conducted a qualitative study with doctors and patients in Malaysia. We used convenience sampling to recruit patients until data saturation. Eighteen patients and eighteen doctors consented and were interviewed using a semi-structured interview guide. The interviews were audio-recorded, transcribed verbatim and checked by the interviewers. Data were analysed using a thematic approach. RESULTS: The themes were similar for both the patients and doctors. Three main themes emerged: knowledge and awareness of COPD, psychosocial and physical impact of COPD and the utility of self-management. Knowledge about COPD was generally poor. Patients were not familiar with the term chronic obstructive pulmonary disease or COPD. The word 'asthma' was used synonymously with COPD by both patients and doctors. Most patients experienced difficulties in their psychosocial and physical functions such as breathlessness, fear and helplessness. Most patients were not confident in self-managing their illness and prefer a more passive role with doctors directing their care. CONCLUSIONS: In conclusion, our study showed that knowledge of COPD is generally poor. There was mislabelling of COPD as asthma by both patients and physicians. This could have resulted in the lack of understanding of treatment options, outcomes, and prognosis of COPD. The misconception that cough due to COPD was contagious, and breathlessness that resulted from COPD, had important physical and psychosocial impact, and could lead to social isolation. Most patients and physicians did not favour self-management approaches, suggesting innovations based on self-management may be of limited benefit.

Efficacy and safety of long-acting intramuscular testosterone undecanoate in aging men: a randomised controlled study.

OBJECTIVE: To evaluate the efficacy and safety of long-acting i.m. testosterone undecanoate (TU) in Malaysian men with testosterone deficiency (TD). PATIENTS AND METHODS: A total of 120 men, aged 40-70 years, with TD (serum total testosterone [TT] ≤ 12 nmol/L) were randomised to receive either i.m. TU (1000 mg) or placebo. In all, 58 and 56 men in the placebo and treatment arm, respectively, completed the study. Participants were seen six times in the 48-week period and the following data were collected: physical examination results, haemoglobin, haematocrit, TT, lipid profile, fasting blood glucose, sex hormone-binding globulin, liver function test, prostate- specific antigen (PSA) and adverse events. RESULTS: The mean (sd) age of the participants was 53.4 (7.6) years. A significant increase in serum TT (P < 0.001), PSA (P = 0.010), haematocrit (P < 0.001), haemoglobin (P < 0.001) and total bilirubin (P = 0.001) were seen in the treatment arm over the 48-week period. Two men in the placebo arm and one man in the treatment arm developed myocardial infarction. Common adverse events observed in the treatment arm included itching/swelling/pain at the site of injection, flushing and acne. Overall, TU injections were well tolerated. CONCLUSIONS: TU significantly increases serum testosterone in men with TD. PSA, haemoglobin and haematocrit were significantly elevated but were within clinically safe limits. There was no significant adverse reaction that led to the cessation of treatment.

Correlates between risk perceptions of cervical cancer and screening practice.

OBJECTIVES: To identify the correlates between risk perceptions and cervical cancer screening among urban Malaysian women. METHOD: A cross-sectional household survey was conducted among 231 women in Petaling Jaya city in 2007. The association of risk perceptions of cervical cancer and screening practice was analyzed using Poisson regression. RESULTS: 56% of the respondents ever had a Pap smear test. Knowledge of signs and symptoms (aPR=1.11, 95% CI=1.03-1.19), age (aPR=1.02, 95% CI=1.01-1.03), number of pregnancies (aPR=1.06, 95% CI=1.01-1.11), marital status, education level and religion were found to be significant correlates of Pap smear screening. Respondents who were never married were less likely to have had a Pap smear. Those who had no education or primary education were less likely to have had a Pap smear compared to those with degree qualification. The prevalence of screening was significantly higher among Christians and others (aPR=1.35; 95% CI=1.01-1.81) and Buddhists (aPR=1.38; 95% CI=1.03-1.84), compared to Muslims. CONCLUSION: Eliminating anecdotal beliefs as risks via targeted knowledge on established risk factors and culturally sensitive screening processes are strategic for increasing and sustaining uptake of Pap smear screening versus current opportunistic screening practices.

How useful is a history of rubella vaccination for determination of disease susceptibility? A cross-sectional study at a public funded health clinic in Malaysia.

BACKGROUND: Identification of pregnant women susceptible to rubella is important as vaccination can be given postpartum to prevent future risks of congenital rubella syndrome. However, in Malaysia, rubella antibody screening is not offered routinely to pregnant women in public funded health clinics due to cost constraint. Instead, a history of rubella vaccination is asked to be provided to establish the women's risk for rubella infection. The usefulness of this history, however, is not established. Thus, this paper aimed to determine the usefulness of a history of rubella vaccination in determining rubella susceptibility in pregnant women. METHODS: A cross-sectional study was conducted on 500 pregnant women attending a public funded health clinic. Face-to-face interviews were conducted, and demographic data and history of rubella vaccination were obtained. Anti-rubella IgG test was performed. RESULTS: A majority of the women (66.6%) had a positive vaccination history. Of these, 92.2% women were immune. A third (33.4%) of the women had a negative or unknown vaccination history, but 81.4% of them were immune to rubella. The sensitivity and specificity of a history of rubella vaccination in identifying disease susceptibility was 54.4% (95% CI: 40.7, 67.4%) and 69.3% (95% CI: 64.7, 73.5%) respectively; the positive predictive value was 18.6% (95% CI: 13.1, 25.5%) and the negative predictive value was 92.2% (95% CI: 88.6, 94.7%). CONCLUSIONS: A vaccination history of rubella had a poor diagnostic value in predicting rubella susceptibility. However, obtaining a vaccination history is inexpensive compared with performing a serological test. A cost-utility analysis would be useful in determining which test (history versus serological test) is more cost-effective in a country with resource constraint.

Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations.

Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.

Factors associated with all-cause mortality in tuberculosis patients in a Malaysian tertiary hospital.

INTRODUCTION: The all-cause mortality for tuberculosis is 1 in every 10 patients in Malaysia. The currently available national surveillance database does not record patients' variables such as socio-economic factors, existing co-morbidities, and risk behavior for investigation. An electronic medical record system can capture this missing information and use it to determine all-cause mortality factors more accurately. Our study aims to determine the factors associated with all-cause mortality in a cohort of tuberculosis patients in a Malaysian tertiary hospital which is equipped with an electronic medical record system. METHODOLOGY: Records of patients diagnosed with tuberculosis from 1st January 2018 to 30th September 2019 were retrieved. Sociodemographic and clinical data were extracted. Treatment outcomes and all-cause mortality were recorded at 1 year after diagnosis. Univariate, multivariate, and stepwise regression were used to determine the factors associated with all-cause mortality. RESULTS: Four-hundred and seventy-one patients were reviewed. The mean age was 46.6 ± 19.7 years. The all-cause mortality rate at one year of diagnosis was 15.3%. Factors identified were age [aOR 1.026 (95% CI: 1.004-1.049)], chronic kidney disease [aOR 3.269 (1.508-7.088)], HIV positive status [aOR 4.743 (1.505-14.953)], active cancer [aOR 5.758 (1.605-20.652)], liver disease [aOR 6.220 (1.028-37.621)], and moderate to advanced chest X-ray findings [aOR 3.851 (1.033-14.354)]. CONCLUSIONS: On average, one in seven patients diagnosed with TB died within a year in a Malaysian tertiary hospital. Identification of this vulnerable group using the associated factors found in this study may help to reduce the risk of mortality through early intervention strategies.