Do health preferences differ among Asian populations? A comparison of EQ-5D-5L discrete choice experiments data from 11 Asian studies.

INTRODUCTION: Many countries have established their own EQ-5D value sets proceeding on the basis that health preferences differ among countries/populations. So far, published studies focused on comparing value set using TTO data. This study aims to compare the health preferences among 11 Asian populations using the DCE data collected in their EQ-5D-5L valuation studies. METHODS: In the EQ-VT protocol, 196 pairs of EQ-5D-5L health states were valued by a general population sample using DCE method for all studies. DCE data were obtained from the study PI. To understand how the health preferences are different/similar with each other, the following analyses were done: (1) the statistical difference between the coefficients; (2) the relative importance of the five EQ-5D dimensions; (3) the relative importance of the response levels. RESULTS: The number of statistically differed coefficients between two studies ranged from 2 to 16 (mean: 9.3), out of 20 main effects coefficients. For the relative importance, there is not a universal preference pattern that fits all studies, but with some common characteristics, e.g. mobility is considered the most important; the relative importance of levels are approximately 20% for level 2, 30% for level 3, 70% for level 4 for all studies. DISCUSSION: Following a standardized study protocol, there are still considerable differences in the modeling and relative importance results in the EQ-5D-5L DCE data among 11 Asian studies. These findings advocate the use of local value set for calculating health state utility.

Health-related quality of life of Malaysian patients with chronic non-malignant pain and its associated factors: a cross-sectional study.

BACKGROUND: Chronic pain has a major impact on a patient's quality of life, affecting physical and psychological functioning. It has debilitating consequences on social and economic aspects too. This study aimed to explore the status of health-related quality of life (HRQoL) of Malaysian patients suffering from chronic non-malignant pain. METHODS: Four hospitals offering pain clinic services were involved in this multicentre cross-sectional study conducted between June and September 2020. Adult patients who had been diagnosed with non-malignant chronic pain lasting for at least three months and able to communicate in English or Malay language were recruited in this study. Participants were informed about the study and were made aware that their participation was entirely voluntary. A battery of questionnaires consists of the EuroQol-5 dimensions-5 levels questionnaire (EQ-5D-5L) and the EuroQol visual analogue scale (EQ VAS), the Pain Self-Efficacy questionnaire (PSEQ) and the Pain Catastrophizing Scale (PCS) were self-administered by the patients. Besides, a structured questionnaire was used to collect their socio-demographic information, pain condition, sleep quality and working status. Participants' usage of pain medications was quantified using the Quantitative Analgesic Questionnaire (QAQ). RESULTS: A total of 255 patients participated in this study. A median EQ-5D index value of 0.669 (IQR: 0.475, 0.799) and a median EQ VAS score of 60.0 (IQR: 50.0, 80.0) were recorded. Malay ethnicity (Adj. B: 0.77; 95% CI: 0.029, 0.126; p = 0.002) and a higher level of self-efficacy (Adj. B: 0.008; 95% CI: 0.006, 0.011; p < 0.001) were predictors of a better HRQoL, while suffering from pain in the back and lower limb region (Adj. B: -0.089; 95% CI: - 0.142, - 0.036; p = 0.001), the use of a larger amount of pain medications (Adj. B: -0.013; 95% CI: - 0.019, - 0.006; p < 0.001), and a higher degree of pain magnification (Adj. B: -0.015; 95% CI: - 0.023, - 0.008; p < 0.001) were associated with a poorer HRQoL. CONCLUSIONS: These findings suggested that Malay ethnicity and a higher level of self-efficacy were predictors of a better HRQoL in patients with chronic pain, whereas pain-related factors such as higher usage of medication, specific pain site and pain magnification style were predictors of poorer HRQoL.

EQ-5D-3L health state utility values in transfusion-dependent thalassemia patients in Malaysia: a cross-sectional assessment.

PURPOSE: There is a gap of information describing the health state utility values (HSUVs) of transfusion-dependent thalassemia (TDT) patients in Malaysia. These values are useful in the assessment of health-related quality of life (HRQoL), economic evaluations and provide guidance to disease management decisions. The objective of this study was to estimate and derive HSUVs associated with the treatment and complications of TDT patients in Malaysia using the EQ-5D-3L instrument. METHODS: A cross-sectional survey using the EQ-5D-3L instrument was conducted between May to September 2018 across various public hospitals in Malaysia. Using a multi-stage sampling, patients diagnosed with TDT and receiving iron chelating therapy were sampled. The findings on the EQ-5D-3L survey were converted into utility values using local tariff values. A two-part model was used to examine and derive the HSUVs associated with the treatment and complications of iron overload in TDT. RESULTS: A total of 585 patients were surveyed. The unadjusted mean (SD) EQ-5D-3L utility value for TDT patients were 0.893 (0.167) while mean (SD) EQ VAS score was 81.22 (16.92). Patients who had more than two iron overload complications had a significant decline in HRQoL. Patients who were on oral monotherapy had a higher utility value of 0.9180 compared to other regimen combinations. CONCLUSION: Lower EQ-5D-3L utility values were associated with patients who developed iron overload complications and were on multiple iron chelating agents. Emphasizing compliance to iron chelating therapy to prevent the development of complications is crucial in the effort to preserve the HRQoL of TDT patients.

Health-related quality of life among children with transfusion-dependent thalassemia: A cross-sectional study in Malaysia.

BACKGROUND: The treatment of children with transfusion-dependent thalassemia (TDT) in Malaysia has progressed since 2005. This study provides an updated health-related quality of life (HRQoL) assessment for children with the disorder and the factors affecting the HRQoL. METHODS: A cross-sectional HRQoL survey of Malaysian children with TDT was conducted using the PedsQL™ 4.0 Generic Core Scales. Patients with non-transfusion dependent thalassemia and other haemoglobinopathies were excluded. Parent-proxy and self-reported HRQoL scores were obtained using a multi-stage convenient sampling. The relationship between HRQoL scores and demographic factors were tested using association, correlation and regression analysis. RESULTS: A total of 368 patients were recruited. The mean (SD) Total Summary Score (TSS) was 80.12(13.87). Predictors for a lower TSS was an increasing age group and the use of dual chelating agents (R2 = 0.057, F (4, 359) = 5.40, p = < 0.001). The mean (SD) Physical Health Summary Score (PHSS) was 82.21 (16.82). Predictors of a higher PHSS score was being male, while predictors of a lower score was an increasing age group and parent-proxy reports(R2 = 0.075, F (5,358) = 5.80, p = < 0.001). The mean (SD) Psychosocial Health Summary Score (PCHS) was 79.39 (14.81). Predictors for a lower PCHS was the use of dual chelating agents(R2 = 0.041, F (1, 362) = 15.60, p = < 0.001). The school functioning score had the lowest mean (SD) score of 69.52(20.92) in the psychosocial dimension. CONCLUSION: The HRQoL of TDT children in Malaysia has improved over the last decade owing to the better access in treatment. However, further effort is needed to improve the school functioning dimension.

Real-world data for health technology assessment for reimbursement decisions in Asia: current landscape and a way forward.

There is growing interest globally in using real-world data (RWD) and real-world evidence (RWE) for health technology assessment (HTA). Optimal collection, analysis, and use of RWD/RWE to inform HTA requires a conceptual framework to standardize processes and ensure consistency. However, such framework is currently lacking in Asia, a region that is likely to benefit from RWD/RWE for at least two reasons. First, there is often limited Asian representation in clinical trials unless specifically conducted in Asian populations, and RWD may help to fill the evidence gap. Second, in a few Asian health systems, reimbursement decisions are not made at market entry; thus, allowing RWD/RWE to be collected to give more certainty about the effectiveness of technologies in the local setting and inform their appropriate use. Furthermore, an alignment of RWD/RWE policies across Asia would equip decision makers with context-relevant evidence, and improve timely patient access to new technologies. Using data collected from eleven health systems in Asia, this paper provides a review of the current landscape of RWD/RWE in Asia to inform HTA and explores a way forward to align policies within the region. This paper concludes with a proposal to establish an international collaboration among academics and HTA agencies in the region: the REAL World Data In ASia for HEalth Technology Assessment in Reimbursement (REALISE) working group, which seeks to develop a non-binding guidance document on the use of RWD/RWE to inform HTA for decision making in Asia.

Psychometric performance assessment of Malay and Malaysian English version of EQ-5D-5L in the Malaysian population.

PURPOSE: To determine the psychometric properties and performance of Malay and English versions of the EQ-5D-5L descriptive instrument in the general Malaysian population. METHODS: 1137 members of the Malaysian general public were sampled in this national study. Respondents were recruited by quota sampling of urbanicity, gender, age, and ethnicity. In face-to-face interviews, respondents first answered the EQ-5D-5L questionnaire administered using the EQ-Valuation Technology software, and then completed the EQ-5D-3L questionnaire on paper. A subgroup of the respondents were given paper form of EQ-5D-5L for completion within 2 weeks for test-retest reliability. Ceiling effects, response redistribution, informativity, and convergent validity were compared between EQ-5D-5L and ED-5D-3L separately by Malay and English language versions. RESULTS: The proportion of 'full health' responses (11111) drastically decreased by 25.55% and 15.74% in the Malay and English language versions indicating lower ceiling effects in EQ-5D-5L. Inconsistencies from response redistribution was below 6% for all dimensions across languages. The measure of relative informativity was comparatively higher in EQ-5D-5L than in EQ-5D-3L in both language versions, with the exception of dimensions mobility and pain/discomfort in the English version. Convergent validity in terms of correlation with EQ-VAS was relatively better for EQ-5D-5L dimensions, with pain/discomfort of the Malay version having the strongest correlation (|r| = 0.37). Also, reliability testing revealed moderate to poor agreements on all 5L dimensions. CONCLUSIONS: EQ-5D-5L fared better in terms of psychometric performance compared to EQ-5D-3L for both language versions. This encourages the application of the EQ-5D-5L in health-related research in Malaysia.

Landscape analysis of health technology assessment (HTA): systems and practices in Asia.

This paper explores the characteristics of health technology assessment (HTA) systems and practices in Asia. Representatives from nine countries were surveyed to understand each step of the HTA pathway. The analysis finds that although there are similarities in the processes of HTA and its application to inform decision making, there is variation in the number of topics assessed and the stakeholders involved in each step of the process. There is limited availability of resources and technical capacity and countries adopt different means to overcome these challenges by accepting industry submissions or adapting findings from other regions. Inclusion of stakeholders in the process of selecting topics, generating evidence, and making funding recommendations is critical to ensure relevance of HTA to country priorities. Lessons from this analysis may be instructive to other countries implementing HTA processes and inform future research on the feasibility of implementing a harmonized HTA system in the region.

Systematic review of economic burden of heart failure.

The aim of this study is to perform a systematic review of the costing methodological approaches adopted by published cost-of-illness (COI) studies. A systematic review was performed to identify cost-of-illness studies of heart failure published between January 2003 and September 2015 via computerized databases such as Pubmed, Wiley Online, Science Direct, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Costs reported in the original studies were converted to 2014 international dollars (Int$). Thirty five out of 4972 studies met the inclusion criteria. Nineteen out of the 35 studies reported the costs as annual cost per patient, ranging from Int$ 908.00 to Int$ 84,434.00, while nine studies reported costs as per hospitalization, ranging from Int$ 3780.00 to Int$ 34,233.00. Cost of heart failure increased as condition of heart failure worsened from New York Heart Association (NYHA) class I to NYHA class IV. Hospitalization cost was found to be the main cost driver to the total health care cost. The annual cost of heart failure ranges from Int$ 908 to Int$ 40,971 per patient. The reported cost estimates were inconsistent across the COI studies, mainly due to the variation in term of methodological approaches such as disease definition, epidemiological approach of study, study perspective, cost disaggregation, estimation of resource utilization, valuation of unit cost components, and data sources used. Such variation will affect the reliability, consistency, validity, and relevance of the cost estimates across studies.

Using a dynamic adherence Markov model to assess the efficiency of Respiratory Medication Therapy Adherence Clinic (RMTAC) on asthma patients in Malaysia.

BACKGROUND: Respiratory Medication Therapy Adherence Clinic (RMTAC) is an initiative by the Ministry of Health (MOH) Malaysia to improve patients' medication adherence, as an adjunct to the usual physician care (UC). This study aimed to evaluate the cost-effectiveness of combined strategy of RMTAC and UC (RMTAC + UC) vs. UC alone in asthma patients, from the MOH Malaysia perspective. METHODS: A lifetime horizon dynamic adherence Markov model with monthly cycle was developed, for quality-adjusted life year (QALY) gained and hospitalization averted outcomes. Transition probabilities of composite asthma control and medication adherence, utilities, costs, and mortality rates due to all causes were measured from local data sources. Effectiveness, exacerbation rates, and asthma mortality rates were taken from non-local data sources. One-way sensitivity analysis (SA) was conducted for assessing parameter uncertainties, whereas probabilistic SA (PSA) was conducted on a different set of utilities and effectiveness data. Costs were adjusted to 2014 US dollars ($). Both costs and benefits were discounted at a 3% rate annually. RESULTS: RMTAC + UC was found to be a dominant alternative compared to UC alone; $- 13,639.40 ($- 109,556.90 to $104,445.54) per QALY gained and $- 428.93 ($- 521.27 to ($- 328.69)) per hospitalization averted. These results were found to be robust against changes in all parameters except utilities in the one-way SA, and for both scenarios in PSA. CONCLUSIONS: RMTAC + UC is more effective and yet cheaper than UC alone, from the MOH perspective. For the benefit of both MOH and patients, RMTAC is thus recommended to be remained, and expanded to more healthcare settings where possible.

The acceptance and willingness to pay (WTP) for hypothetical dengue vaccine in Penang, Malaysia: a contingent valuation study.

BACKGROUND: Malaysia has been experiencing an escalation in dengue cases since the past 5 years. As the dengue vaccine pipeline continues to develop steadily with strong public interests, this study had been sought to elicit the acceptance and the willingness to pay (WTP) for hypothetical dengue vaccine in Malaysia. METHODS: This study adopted the cross-sectional, contingent valuation study that involved 400 respondents in Penang, Malaysia. The double-bounded dichotomous choice via bidding game approach was employed to elicit the WTP value for two hypothetical 3-doses dengue vaccines (Vaccines A and B with 5- and 10-years' protection, respectively against dengue). A univariate logistic regression model was employed to assess the key determinants of vaccine acceptance, while the mean WTP value and its associated factors were measured by using the parametric two-part model (TPM). RESULTS: Dengue vaccine appeared to be highly acceptable (88.4%) among the population in Penang, Malaysia. Respondents who were of Chinese ethnicity (OR 0.36, p = 0.017), with higher dengue knowledge score (OR 1.43, p = 0.016), and higher vaccination attitude score (OR 1.91, p < 0.001) were more likely to accept the vaccine. The first step logit estimation from TPM displayed that pensioners (OR 2.37, p = 0.036), respondents who were self-employed or working in the private sector (OR 1.21, p = 0.002), respondents with higher education level (OR 2.09-3.29, p < 0.05), and those who accepted the vaccine (OR 3.23, p = 0.001) were more likely to pay for the vaccine. The adjusted mean WTP value for the vaccine was MYR39.21 (USD9.45) per dose. Next, the second-stage regression from TPM revealed the key factors that significantly affected the WTP value, which were composed of age, gender, occupation, household income, dengue prevention practice, and protection duration of the vaccine. The pensioners and those with better dengue prevention practice were willing to pay more for the vaccines. Additionally, all the respondents elicited a higher WTP amount toward the vaccine with longer protection duration (Vaccine B). CONCLUSION: Strong acceptance toward dengue vaccine reflects the high value of the vaccine in Malaysia. The WTP estimates offer quantification of the private benefit in reducing occurrences of the disease. Besides, the people's preferences-based WTP value for the vaccine tends to complement scientific decision-making and prioritization in the management of dengue in the country.

HISTORICAL DEVELOPMENT OF THE HTAsiaLINK NETWORK AND ITS KEY DETERMINANTS OF SUCCESS.

OBJECTIVES: The aim of this study was to describe the historical development of the HTAsiaLink network, draw lessons for other similar initiatives globally, and to analyze key determinants of its success and challenges for its future development. METHODS: This study is based on the collective and direct experiences of the founding members of the HTAsiaLink Network. Data were collected from presentations they made at various international forums and additional information was reviewed. Data analysis was done using the framework developed by San Martin-Rodriguez et al.Results and Conclusions:HTAsiaLink is a network of health technology assessment (HTA) agencies in Asia established in 2011 with the aim of strengthening individual and institutional HTA capacity, reducing duplication and optimizing resources, transfer and sharing of HTA-related lessons among members, and beyond. During its 6 years, the network has expanded, initiating several capacity building activities and joint-research projects, raising awareness of the importance of HTA within the region and beyond, and gaining global recognition while establishing relationships with other global networks. The study identifies the determinants of success of the collaboration. The systemic factors include the favorable outlook toward HTA as an approach for healthcare priority setting in countries with UHC mandates. On organizational factors, the number of newly established HTA agencies in the region with similar needs for capacity building and peer-to-peer support was catalytic for the network development. The interactional aspects include ownership, trust, and team spirit among network members. The network, however, faces challenges notably, financial sustainability and management of the expanded network.

Relationship between self-efficacy, self-care behaviour and glycaemic control among patients with type 2 diabetes mellitus in the Malaysian primary care setting.

BACKGROUND: Self-efficacy has been shown to be positively correlated with self-care behaviour and glycaemic control among patients with type 2 diabetes mellitus. However, such evidence is lacking in the Malaysian primary care setting. The objectives of this study were to i) determine the levels of self-efficacy, self-care behaviour and glycaemic control among patients with type 2 diabetes mellitus in the Malaysian primary care setting ii) determine the relationship between self-efficacy, self-care behaviour and glycaemic control iii) determine the factors associated with glycaemic control. METHODS: This was a cross-sectional study involving patients with type 2 diabetes mellitus from two public primary care clinics in Malaysia. Self-efficacy and self-care behaviour levels were measured using previously translated and validated DMSES and SDSCA questionnaires in Malay versions, respectively. Glycaemic control was measured using HbA1c. RESULTS: A total of 340 patients with type 2 diabetes mellitus were recruited. The total mean (±SD) of self-efficacy and self-care behaviour scores were 7.33 (±2.25) and 3.76 (±1.87), respectively. A positive relationship was found between self-efficacy and self-care behaviour (r 0.538, P < 0.001). Higher self-efficacy score was shown to be correlated with lower HbA1c (r - 0.41, P < 0.001). Multiple linear regression analysis demonstrated that higher self-efficacy scores (b - 0.398; 95% CI: -0.024, - 0.014; P < 0.001), shorter duration of diabetes (b 0.177; 95% CI: 0.002, 0.007; P < 0.001) and smaller waist circumference (b 0.135; 95% CI: 0.006, 0.035; P = 0.006), were significantly associated with good glycaemic control. CONCLUSION: This study demonstrated that higher self-efficacy was correlated with improved self-care behaviour and better glycaemic control. Findings of this study suggest the importance of including routine use of self-efficacy measures in the management of type 2 diabetes mellitus in primary care.

Determination of Cost-Effectiveness Threshold for Health Care Interventions in Malaysia.

BACKGROUND: One major challenge in prioritizing health care using cost-effectiveness (CE) information is when alternatives are more expensive but more effective than existing technology. In such a situation, an external criterion in the form of a CE threshold that reflects the willingness to pay (WTP) per quality-adjusted life-year is necessary. OBJECTIVES: To determine a CE threshold for health care interventions in Malaysia. METHODS: A cross-sectional, contingent valuation study was conducted using a stratified multistage cluster random sampling technique in four states in Malaysia. One thousand thirteen respondents were interviewed in person for their socioeconomic background, quality of life, and WTP for a hypothetical scenario. RESULTS: The CE thresholds established using the nonparametric Turnbull method ranged from MYR12,810 to MYR22,840 (~US $4,000-US $7,000), whereas those estimated with the parametric interval regression model were between MYR19,929 and MYR28,470 (~US $6,200-US $8,900). Key factors that affected the CE thresholds were education level, estimated monthly household income, and the description of health state scenarios. CONCLUSIONS: These findings suggest that there is no single WTP value for a quality-adjusted life-year. The CE threshold estimated for Malaysia was found to be lower than the threshold value recommended by the World Health Organization.

Development, feasibility, and validity of a computer-based utility assessment tool for measuring asthma-specific health utilities in Malaysia using the standard gamble method.

OBJECTIVES: To develop and test the feasibility and validity of a computer-based utility assessment tool that used standard gamble (SG) method for measuring asthma-specific health utilities. METHODS: A computer-based SG (CBSG) tool was developed using Microsoft® PowerPoint 2007 to value asthma-specific health states in Malaysia. Eight hypothetical health states were considered, including two anchor states (healthy and dead), three chronic (C) states and three temporary (T) states (each numbered 1 through 3, with increasing severity) in addition to the subject's current health state. Twenty adult asthma patients completed the CBSG tool in addition to paper-based Asthma Control Test, three health status measures (EQ-5D, EQ-VAS, and Mini Asthma Quality of Life Questionnaire (MiniAQLQ)), and VAS utility assessment tool. Patients and interviewers rated the difficulty of the VAS and CBSG tools. Correlations between current health state values derived from the various measures were determined. RESULTS: The SG and the VAS received similar difficulty ratings. 17 patients completed the CBSG tool within 30 minutes. The mean utilities determined by the CBSG tool for the T1-T3 asthma health states met the expected logical order of 1>2>3, but those for the C1-C3 states did not. Correlation between current health state values derived from the CBSG tool and other measurement tools was poor. CONCLUSION: The CBSG tool developed for measuring utilities of asthma health states showed acceptable feasibility and overall validity.

Building intentions with the theory of planned behaviour: a qualitative assessment of salient beliefs about pharmacy value added services in Malaysia.

OBJECTIVE: To improve pharmaceutical care delivery in Malaysia, the Ministry of Health (MOH) had introduced the concept of value added services (VAS). Despite its reported convenience and advantages, VAS utilization rate is low in the country. The study aims to explore patients' understanding, beliefs and expectations towards VAS in Malaysia using the theory of planned behaviour (TPB) as the theoretical model. METHODS: A qualitative methodology was used whereby face-to-face interviews were conducted with 12 patients who collected partial medicine supplies from government pharmacies. Participants were recruited using purposive and snowball sampling method in the state of Negeri Sembilan, Malaysia. Interviews were audio-recorded. Verbatim transcription and thematic content analysis were performed on the data. RESULTS: Thematic content analysis yielded five major themes: (i) attitudes towards using VAS, (ii) subjective norms, (iii) perceived behavioural control, (iv) lack of knowledge and understanding of VAS and (v) expectations towards VAS. CONCLUSION: The interviews explored and informed new information about salient beliefs towards pharmacy VAS. The findings suggest that VAS is still in its infancy and a more robust and effective advertising and marketing campaign is needed to boost the adoption rate. Behavioural attitudes, subjective norms and perceived control elements were discussed and serve as important variables of interest in future study. Expectations towards VAS serve as an important guideline to further improve patient-oriented services.

Effectiveness of the EMPOWER-PAR Intervention in Improving Clinical Outcomes of Type 2 Diabetes Mellitus in Primary Care: A Pragmatic Cluster Randomised Controlled Trial.

BACKGROUND: The chronic care model was proven effective in improving clinical outcomes of diabetes in developed countries. However, evidence in developing countries is scarce. The objective of this study was to evaluate the effectiveness of EMPOWER-PAR intervention (based on the chronic care model) in improving clinical outcomes for type 2 diabetes mellitus using readily available resources in the Malaysian public primary care setting. METHODS: This was a pragmatic, cluster-randomised, parallel, matched pair, controlled trial using participatory action research approach, conducted in 10 public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Patients who fulfilled the criteria were recruited over a 2-week period by each clinic. The obligatory intervention components were designed based on four elements of the chronic care model i.e. healthcare organisation, delivery system design, self-management support and decision support. The primary outcome was the change in the proportion of patients achieving HbA1c < 6.5%. Secondary outcomes were the change in proportion of patients achieving targets for blood pressure, lipid profile, body mass index and waist circumference. Intention to treat analysis was performed for all outcome measures. A generalised estimating equation method was used to account for baseline differences and clustering effect. RESULTS: A total of 888 type 2 diabetes mellitus patients were recruited at baseline (intervention: 471 vs. CONTROL: 417). At 1-year, 96.6 and 97.8% of patients in the intervention and control groups completed the study, respectively. The baseline demographic and clinical characteristics of both groups were comparable. The change in the proportion of patients achieving HbA1c target was significantly higher in the intervention compared to the control group (intervention: 3.0% vs. CONTROL: -4.1%, P < 0.002). Patients who received the EMPOWER-PAR intervention were twice more likely to achieve HbA1c target compared to those in the control group (adjusted OR 2.16, 95% CI 1.34-3.50, P < 0.002). However, there was no significant improvement found in the secondary outcomes. CONCLUSIONS: This study demonstrates that the EMPOWER-PAR intervention was effective in improving the primary outcome for type 2 diabetes in the Malaysian public primary care setting. TRIAL REGISTRATION: Registered with: ClinicalTrials.gov.: NCT01545401 . Date of registration: 1st March 2012.

Treatment outcome of new smear positive pulmonary tuberculosis patients in Penang, Malaysia.

BACKGROUND: According to the World Health Organization's recent report, in Malaysia, tuberculosis (TB) treatment success rate for new smear positive pulmonary tuberculosis (PTB) patients is still below the global success target of 85%. In this study, we evaluated TB treatment outcome among new smear positive PTB patients, and identified the predictors of unsuccessful treatment outcome and longer duration of treatment (i.e., > 6 months). METHODS: The population in this study consisted of all new smear positive PTB patients who were diagnosed at the chest clinic of Penang General Hospital between March 2010 and February 2011. During the study period, a standardized data collection form was used to obtain socio-demographic, clinical and treatment related data of the patients from their medical charts and TB notification forms (Tuberculosis Information System; TBIS). These data sources were reviewed at the time of the diagnosis of the patients and then at the subsequent follow-up visits until their final treatment outcomes were available. The treatment outcomes of the patients were reported in line with six outcome categories recommended by World Health Organization. Multiple logistic regression analysis was used to find the independent risk factors for unsuccessful treatment outcome and longer treatment duration. Data were analyzed using the PASW (Predictive Analysis SoftWare, version 19.0. Armonk, NY: IBM Corp). RESULTS: Among the 336 PTB patients (236 male and 100 female) notified during the study period, the treatment success rate was 67.26% (n = 226). Out of 110 patients in unsuccessful outcome category, 30 defaulted from the treatment, 59 died and 21 were transferred to other health care facilities. The mean duration of TB treatment was 8.19 (SD 1.65) months. In multiple logistic regression analysis, risk factors for unsuccessful treatment outcome were foreign nationality, male gender and being illiterate. Similarly, risk factors for mortality due to TB included high-grade sputum and presence of lung cavities at the start of treatment, being alcoholic and elderly. Likewise, concurrent diabetes, presence of lung cavities at the start of the treatment and being a smoker were the significant predictors of longer treatment duration. CONCLUSION: Our findings indicated that the treatment success rate among the new smear positive PTB patients was less than the success target set by World Health Organization. The proportion of patients in the successful outcome category may be increased by closely monitoring the treatment progress of the patients with aforementioned high risk characteristics. Similarly, more aggressive follow-up of the treatment defaulters and transferred out patients could also improve the TB treatment success rate.

Impact of tuberculosis treatment on health-related quality of life of pulmonary tuberculosis patients: a follow-up study.

BACKGROUND: At present, much of the attention within tuberculosis (TB) management is spent on microbiological cure, and its impact on health-related quality of life (HRQoL) is either undervalued or seldom considered. The aim of this study was to evaluate the impact of TB treatment on HRQoL of new smear positive pulmonary tuberculosis (PTB) patients. Moreover, we also aimed to determine whether the selected socio-demographic and clinical variables were predictive of variability in the HRQoL scores over time. METHODS: This was a prospective follow-up of new smear positive PTB patients who were diagnosed at the chest clinic of Penang General Hospital between March 2010 and February 2011. All eligible patients (i.e., a new case of smear positive PTB, literate and aged 18 years or above) were asked to self-complete the SF-36v2 questionnaire at the start of their treatment, and then subsequently after the intensive phase and at the end of the treatment. A score on a health domain or component summary measure that was less than 47 norm-based scoring (NBS) point was considered indicative of impaired function within that health domain or dimension. Likewise, an individual having mental component summary (MCS) score ≤ 42 NBS point was considered to be at the risk of depression. Repeated measures ANOVA test was performed to examine how the summary scores varied over time, and to determine whether independent variables were predictive of variability in the physical component summary (PCS) and MCS scores over time. RESULTS: A total of 216 patients completed the SF-36v2 questionnaire at the start of their treatment. Out of these, 177 and 153 completed the questionnaire at the second and third follow-ups, respectively. The mean PCS scores at the start of the treatment, after the intensive phase and at the end of treatment were 41.9 (SD 5.1), 45.8 (SD 4.8) and 46.0 (SD 6.9), respectively. Similarly, the mean MCS scores at the start of the treatment, after the intensive phase and at the end of the treatment were 39.9 (SD 7.3), 45.0 (SD 6.8) and 46.8 (SD 7.8), respectively. More than 23% of the patients were at the risk of depression at the end of their TB treatment. Patient's age and being a smoker were predictive of differences in the PCS scores. Similarly, monthly income, being a smoker and TB-related symptoms at the start of the treatment were predictive of differences in the MCS scores. CONCLUSION: Although HRQoL improved with the treatment, the scores on component summary measures showed compromised physical and mental health among study patients even at the end of their TB treatment.

A cross-sectional assessment of health-related quality of life (HRQoL) among hypertensive patients in Pakistan.

OBJECTIVE: To describe the health-related quality of life (HRQoL) profile of hypertensive population in Pakistan. METHODS: A cross-sectional descriptive study was undertaken with a cohort of 385 hypertensive patients attending two public hospitals in Quetta city, Pakistan. The EuroQoL EQ-5D scale was used for the assessment of HRQoL. EQ-5D is a standardized instrument for use as a measure of health outcome and is used in the clinical and economic evaluation of health care as well as population health surveys. The HRQoL was scored using values derived from the UK general population survey. P ≤ 0.05 was taken as significant. RESULTS: Two hundred and sixty-five (68.85%) respondents were men with 3.01 ± 0.939 years of history of hypertension. Majority (n = 186, 48.3%) were categorized in age group of 28-37 years with mean age of 39.02 ± 6.596. Education, income and locality had significant relation with HRQoL score. HRQoL was measured poor in our study patients (0.4674 ± 0.2844). CONCLUSION: Hypertension has an adverse effect on patients' well-being and HRQoL. Results from this study could be useful in clinical practice, particularly in early treatment of hypertension, at point where improving HRQoL is still possible.

Resource utilization pattern and cost of tuberculosis treatment from the provider and patient perspectives in the state of Penang, Malaysia.

BACKGROUND: Studies from both developed and developing countries have demonstrated a considerable fluctuation in the average cost of TB treatment. The objective of this study was to analyze the medical resource utilization among new smear positive pulmonary tuberculosis patients. We also estimated the cost of tuberculosis treatment from the provider and patient perspectives, and identified the significant cost driving factors. METHODS: All new smear positive pulmonary tuberculosis patients who were registered at the chest clinic of the Penang General Hospital, between March 2010 and February 2011, were invited to participate in the study. Provider sector costs were estimated using bottom-up, micro-costing technique. For the calculation of costs from the patients' perspective, all eligible patients who agreed to participate in the study were interviewed after the intensive phase and subsequently at the end of the treatment by a trained nurse. PASW was used to analyze the data (Predictive Analysis SoftWare, version 19.0, Armonk, NY: IBM Corp.). RESULTS: During the study period, 226 patients completed the treatment. However, complete costing data were available for 212 patients. The most highly utilized resources were chest X-ray followed by sputum smear examination. Only a smaller proportion of the patients were hospitalized. The average provider sector cost was MYR 992.34 (i.e., USD 325.35 per patient) whereby the average patient sector cost was MYR 1225.80 (i.e., USD 401.90 per patient). The average patient sector cost of our study population accounted for 5.7% of their annual family income. In multiple linear regression analysis, prolonged treatment duration (i.e., > 6 months) was the only predictor of higher provider sector costs whereby higher patient sector costs were determined by greater household income and persistent cough at the end of the intensive phase of the treatment. CONCLUSION: In relation to average provider sector cost, our estimates are substantially higher than the budget allocated by the Ministry of Health for the treatment of a tuberculosis case in Malaysia. The expenses borne by the patients and their families on the treatment of the current episode of tuberculosis were not catastrophic for them.