Effectiveness of Wait Time Targets and Patient Satisfaction Feedback in Decreasing Wait Times for Prescription Services in an Outpatient Pharmacy.

Background: Long wait times for prescription services at the Outpatient Pharmacy of the Dr. OEN SOLO BARU Hospital in Indonesia have led to high numbers of complaints. In response, to decrease these wait times, the hospital undertook an intervention to determine wait time targets and provide feedback on patient satisfaction to personnel in the Outpatient Pharmacy. Objective: To measure the impact of providing wait time targets and patient satisfaction feedback to pharmacists in terms of decreasing wait times for prescription services at the Outpatient Pharmacy. Methods: This quasi-experimental research study had a single-group interrupted time-series design. Data on wait times and patient satisfaction were collected from "waiting patients". The study participants were 35 employees (6 pharmacists and 29 technicians), and the intervention entailed provision of wait time targets and patient satisfaction feedback to the participants every week for 5 consecutive weeks. Results: The wait times for prescription services decreased by 11.13 minutes (17%) for compounded prescriptions and by 12.70 minutes (37%) for noncompounded prescriptions. There was a significant change in average wait time for both compounded and noncompounded prescription services from week 0 to week 4 (p < 0.001). There was also a significant change in patient satisfaction from week 0 to week 4 (p < 0.001). Patient satisfaction increased significantly in conjunction with the decrease in wait times for prescription services. Conclusions: The intervention of providing wait time targets and feedback on patient satisfaction to pharmacists helped to reduce wait times for prescription services.

Contexte: Les longs délais d'attente pour les services de délivrance de médicaments sur ordonnance à la pharmacie ambulatoire de l'Hôpital Dr. OEN SOLO BARU en Indonésie ont donné lieu à un nombre élevé de plaintes. En réponse, afin de réduire ces temps d'attente, l'hôpital a cherché à déterminer des objectifs de temps d'attente et à fournir des commentaires sur la satisfaction des patients au personnel de la pharmacie ambulatoire. Objectif: Mesurer l'incidence, sur le temps d'attente pour la délivrance de médicaments sur ordonnance à la pharmacie ambulatoire, de la remise aux pharmaciens d'objectifs de temps d'attente et de commentaires sur la satisfaction des patients. Méthodes: Cette étude de recherche quasi-expérimentale était conçue selon une série temporelle interrompue à groupe unique. Les données sur les temps d'attente et sur la satisfaction des patients ont été recueillies auprès des « patients en attente ¼. Au total, 35 employés (6 pharmaciens et 29 techniciens) ont participé à l'étude, et l'intervention consistait à remettre aux pharmaciens des objectifs de temps d'attente et des commentaires sur la satisfaction des patients chaque semaine pendant 5 semaines consécutives. Résultats: Les temps d'attente pour les services de délivrance de médicaments sur ordonnance ont diminué de 11,13 minutes (17 %) pour les ordonnances relatives aux préparations magistrales et de 12,70 minutes (37 %) pour les ordonnances relatives aux préparations non magistrales. Une différence significative a été observée entre les semaines 0 et 4 (p < 0,001) concernant le temps d'attente moyen pour les services de délivrance de médicaments sur ordonnance relatifs aux préparations magistrales et ceux relatifs aux préparations non magistrales. Une différence significative a également été observée dans la satisfaction des patients entre les semaines 0 et 4 (p < 0,001). La satisfaction des patients a augmenté de manière significative parallèlement à la diminution du temps d'attente pour les services de délivrance de médicaments sur ordonnance. Conclusions: La remise aux pharmaciens d'objectifs en matière de temps d'attente ainsi que de commentaires sur la satisfaction des patients a permis de réduire les temps d'attente des services de délivrance de médicaments sur ordonnance.

Influence of Solute Carrier Family 22 Member 1 (SLC22A1) Gene Polymorphism on Metformin Pharmacokinetics and HbA1c Levels: A Systematic Review.

BACKGROUND: Solute Carrier Family 22 Member 1 (SLC22A1, also known as OCT1) protein has a vital role in the metabolism of metformin, a first-line anti-diabetes medication. Genetic polymorphism in SLC22A1 influences individual response to metformin. OBJECTIVE: This review aims to compile the current knowledge about the effects of SLC22A1 genetic polymorphism on metformin pharmacokinetics and HbA1c levels. METHODS: We followed the PRISMA 2020 standards to conduct a systematic review. We searched the publications for all appropriate evidence on the effects of SLC22A1 genetic polymorphism on metformin pharmacokinetics and HbA1c from January 2002 to December 2022. RESULTS: Initial database searches identified 7,171 relevant studies. We reviewed 155 titles and abstracts after deleting duplicates. After applying inclusion and exclusion criteria, 23 studies remained. CONCLUSION: Three studies found that rs12208357, rs34059508, and G465R had a considerable impact (p < 0.05) on metformin pharmacokinetics, resulting in increased metformin plasma (Cmax), a higher active amount of drug in the blood (AUC), and lower volume of distribution (Vd) (p<0.05). SLC22A1 polymorphisms with effects on HbA1c include rs628031 (four of seven studies), rs622342 (four of six studies), rs594709 (one study), rs2297374, and rs1867351 (one of two studies), rs34130495 (one study), and rs11212617 (one study) (p < 0.05).

Treatment Outcomes of Multidrug-Resistant Tuberculosis Patients in East Java, Indonesia: A Retrospective Cohort Analysis.

Background: The drug regimen for the treatment of multidrug-resistant tuberculosis (MDR-TB) has lower potency, is more costly, and has a greater risk of adverse effects than first-line anti-TB drugs. We aimed to compare the treatment outcomes of patients using standard shorter regimen (STR regimen) versus bedaquiline (BDQ)-containing individual regimen in a high TB-burden setting. Methods: This was a retrospective cohort study using secondary data from the medical records in the hospital. The study population were patients with MDR-TB who started treatment in 2016-2018. Treatment outcomes were classified as successful (cured/completed treatment) or unsuccessful (failure/death/loss to follow-up/not evaluated). Categorical data were presented as frequencies and percentage, whereas continuous data were presented as mean± standard deviations. Risk ratio (RR) was obtained by using the Chi-square statistical test with 95% confidence interval (CI) and P < 0.05 set as a significant result. Results: We included 99 patients out of 444 registered patients in 2016-2018. The overall success proportion was 41.4%. Success was more likely in patients who received BDQ regimen than those receiving STR regimen (52.9% vs. 35.4%, RR: 1.496, 95% CI: 0.948-2.362). Factors that influenced the treatment outcomes were smear status and sputum culture status. Conclusions: The success rate of the STR regimen and the BDQ regimen in this study is still below the national and global figures due to the high rate of lost to follow-up. The success was higher in the BDQ regimen, although not statistically significant. Further research is needed on adverse effects, quality of life, and costs during treatment.

Exploring the Experiences and Needs of Patients With Type 2 Diabetes Mellitus in Sleman Regency, Yogyakarta, Indonesia: Protocol for a Qualitative Study.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a chronic disease that can cause adverse effects if not managed effectively. The prevalence of T2DM will continue to rise every year, and data from the International Diabetes Federation show that the number of patients diagnosed with T2DM in Indonesia is predicted to increase from 10.3 million in 2017 to 16.7 million in 2045. Managing T2DM properly is a challenge for the patients because they need to implement lifestyle changes that involve the self-monitoring of blood glucose, consuming prescribed medication properly, maintaining a healthy diet, getting sufficient physical training, keeping a healthy sleeping pattern, managing stress properly, and consulting medical professionals regularly. The worldwide intervention for T2DM focuses on self-management education. The varied results in studies about interventions show that no particular intervention method can be regarded as the most effective. In Indonesia, there are limited studies on educational interventions to improve the quality of life and health of patients with T2DM. OBJECTIVE: This study aims to explore the experiences and needs of patients with T2DM in Sleman Regency, Yogyakarta, Indonesia, to develop effective self-management education. METHODS: The study will use the phenomenology method with purposive sampling to collect data. The inclusion criteria are patients in the Chronic Disease Self-Management Program at the Sleman Regency Public Health Center who are aged ≥18 years, diagnosed with T2DM for more than a year, with hemoglobin A1c levels ≤7.5% and >7.5%, capable of communicating verbally and literate in the Indonesian language, not deaf, and willing to participate. The data collection is based on the Social Cognitive Theory, which involves selecting assessment targets and analyzing personal factors, environment, and behavior that determine the knowledge, attitude, and adherence of persons with T2DM. Researchers will collect the data through in-depth, face-to-face interviews to learn about knowledge, self-efficacy, outcome expectancy, outcome experience, worry, illness belief, treatment belief, diet, physical activity, medicine intake, treatment pattern, support system, as well as ethnic and cultural influences. The results will be taken from unstructured and open-ended questions written in Indonesian according to the interview guidelines. The data analysis process will go through several stages: reading the data thoroughly; coding; sorting the categories; creating the themes; making general descriptions; and presenting the data in charts, narratives, and recorded quotations from the interviews. RESULTS: This study received a grant in May 2021 and gained permission from the Medical and Health Research Ethics Committee of Universitas Gadjah Mada, Indonesia, on July 1, 2021. Data collection started on August 12, 2021, and the results are expected to be published in 2022. CONCLUSIONS: The results of this study will be used to design an educational intervention model to improve the knowledge, attitude, and adherence of patients with T2DM. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37528.

Does Trastuzumab Offer Good Value for Money for Breast Cancer Patients with Metastasis in Indonesia?

OBJECTIVE: Breast cancer is the most common cancer in Indonesia, with Indonesia's breast cancer mortality rate being the highest among Southeast Asian countries. This study aims to evaluate the cost-effectiveness and budget impacts of adding trastuzumab to chemotherapy versus chemotherapy alone for HER2-positive breast cancer patients in Indonesia. METHODS: We performed a Markov model-based economic evaluation to assess cost-effectiveness, cost-utility, and budget impact. Utility data, direct medical costs, and indirect costs were obtained primarily from interviewing patients. Clinical effectiveness data, on the other hand, were obtained from systematic reviews and real-world data and represented through progression free survival, overall survival, and quality-adjusted life years (QALYs). RESULT: From a healthcare provider's perspective, the total costs for the combined group were USD 14,516, while chemotherapy alone cost USD 7,489. While the cost-effectiveness analysis showed that the combination group had a higher total cost by USD 7,027, PFS was longer in the chemotherapy alone group, with a difference of 2.2 months. The ICER was USD 17,307 for every QALY gained. The total cost of adding trastuzumab over a 5-year period was USD 589 million. CONCLUSION: In conclusion, this economic evaluation suggests that the addition of trastuzumab to standard chemotherapy is not cost-effective in terms of PFS and OS compared with chemotherapy alone.
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Case studies for implementing MCDA for tender and purchasing decisions in hospitals in Indonesia and Thailand.

BACKGROUND: A multi-criteria decision analysis (MCDA) approach has been suggested for helping purchasers in low- and middle-income countries in an evidence-based assessment of multi-source pharmaceuticals to mitigate potential adverse consequences of price-based decisions on patient access to effective medicines. Six workshops for developing MCDA-instruments for purchasing were conducted in Indonesia, Kazakhstan, Thailand, and Kuwait in 2017-2020. In Indonesia and Thailand, two pilot-initiatives aimed to implement the instruments for hospital drug purchasing decisions. OBJECTIVE: By analysing and comparing the experiences and progress from the MCDA-workshops and the two case-examples for hospital implementation in Indonesia and Thailand, we aim to gain insights, which will support future implementation. METHODS: The selection of criteria and their average weight were compared quantitatively across the MCDA-instruments developed in all four countries and settings. Implementation experiences from two case-examples were studied, which included (1) testing the instrument across a variety of drugs in seven hospitals in Thailand and (2) implementation in one specialty hospital in Indonesia. Semi-structured interviews were conducted via web-conferences with four diverse stakeholders in the pilot implementation projects in Thailand and Indonesia. The open responses were evaluated through qualitative content analysis and synthesis using grounded theory coding. RESULTS: Drivers for implementation were making 'better' decisions, achieving transparency and a rational selection process, reducing drug shortages, and assuring consistent quality. Challenges were seen on the technical level (definition or of criteria, scoring methods, access to data) or change-related challenges (resistance, perception of increased workload, lack of competencies or capabilities, lack of resources). The comparison of the MCDA instruments revealed high similarity, but also clear need for local adaptations in each specific case. CONCLUSION: A set a of measures targeting challenges related to utility, methodology, data requirements, capacity building and training as well as the broader societal impact can help to overcome challenges in the implementation. Careful planning of implementation and organizational change is recommended for ensuring commitment and fit to local context and culture. Designing a collaborative change program for each application of MCDA-based purchasing will enable healthcare stakeholders to maximally benefit in terms of quality and effectiveness of care and access for patients.

Economic Evaluation of Adding Bevacizumab to Chemotherapy for Metastatic Colorectal Cancer (mCRC) Patients in Indonesia.

OBJECTIVE: Since 2016, bevacizumab has been widely used to treat metastatic colorectal cancer (mCRC) in Indonesia. Nevertheless, the high cost of bevacizumab has raised the question of whether the therapy is considered cost-effective and should be included in the national health insurance system. This study aimed to assess the cost-effectiveness of bevacizumab plus chemotherapy versus chemotherapy alone for the treatment of mCRC patients. METHODS: A Markov model was applied using the perspective of the Indonesian healthcare system to assess cost-effectiveness. The health outcomes were expressed in terms of quality-adjusted life years (QALY) using the validated EuroQoL-5D-5L instrument. Data for medical costs were collected from hospital billings in four hospitals located in three different cities in Indonesia. Meanwhile, data for utility were obtained from interviewing 90 patients who came to the hospital. We compared those mCRC patients who received chemotherapy alone either with FOLFOX or FOLFIRI, versus patients who received the addition of bevacizumab. RESULTS: With the perspective of societal, the incremental cost-effectiveness ratio (ICER) of adding bevacizumab was USD 49,312 per QALY gained using secondary data and USD 28,446 per QALY using real world data. CONCLUSION: Using either a healthcare or societal perspective, the addition of bevacizumab for mCRC treatment was considered not cost-effective.

Cost-effectiveness analysis of genotyping for HLA-B*15:02 in Indonesian patients with epilepsy using a generic model.

Carbamazepine (CBZ)-induced Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are strongly associated with the HLA-B*15:02 allele. Screening HLA-B*15:02 before CBZ administration might prevent CBZ-induced SJS/TEN by enabling clinicians to prescribe alternative therapy for positive patients. Similar to other Southeastern Asian countries, HLA-B*15:02 is highly prevalent in Indonesia. Therefore, we assessed the economic value of HLA-B*15:02 screening before CBZ prescription to patients with epilepsy in Indonesia. A generic cost-effectiveness model and decision support tool, developed to enable users to perform an initial cost-effectiveness analysis from a healthcare provider/payer perspective, were used to assess the value of HLA-B*15:02 genotyping. The incremental cost-effectiveness ratio of adopting universal HLA-B*15:02 screening was 656,444,671 Indonesian Rupiah (IDR)/quality-adjusted life year (QALY) gained for patients compared with 2,634,975,574 IDR/QALY gained for providing valproic acid (alternative drug) without screening. Thus, neither HLA-B*15:02 screening nor substitution with VPA meets the Indonesian threshold for cost effectiveness. However, the improved outcomes with this test in other Asian countries may inform the desirability of implementation in Indonesia even with suboptimal cost-effectiveness.

Rationing for medicines by health care providers in Indonesia National Health Insurance System at hospital setting: a qualitative study.

BACKGROUND: Universal Health Coverage (UHC) in Indonesia is planned to be fully implemented in 2019 through the National Health Insurance (NHI) launched in January 2014. However, limited financial resources cause health care providers (HCPs) to perform rationing in providing medicine services. The purpose of this study was to analyze rationing strategies performed by HCPs for potentially beneficial essential medicines due to financial constraints and other reasons in the Indonesian NHI Plan and evaluate its fairness. METHODS: A qualitative study was conducted to find out the rationing performed by 24 HCPs in NHI medicine services at hospital setting. Research methods included semi-structured interviews with eight physicians, eight pharmacists and eight nurses, and observations of prescriptions undergoing dispensing process. Respondents were purposively selected, and interview results were analyzed thematically. The strategies for rationing were categorized using the matrix developed by Maybin and Klein (denial, selection, delay, deterrence, deflection, and dilution), while contradictions in fairness were evaluated using the four conditions of accountability for reasonableness (relevance, publicity, appeals, and enforcement). RESULTS: The results showed that the most frequent rationing performed by physicians was dilution (to replace medicines with others which were perceived by physicians as less effective or less safe), denial (not to provide medicines not listed in the National Formulary and/or expensive medicine), and deterrence (to encourage patients to pay for medicine). Among pharmacists, the most frequently rationing performed was dilution (to reduce the amount of medicines), denial, and deterrence as performed by physicians. Almost no rationing strategy was performed by nurses. No formal procedure was available to guide the rationing. The rationale for rationing strategies, especially for non-clinical reasons, was often not communicated to patients, and there were few opportunities for patients to appeal the rationing strategies applied to them. There was no difference between the government and private hospitals in the rationing strategies adopted. CONCLUSIONS: Although rationing strategies were facilitating the implementation of National Formulary, they potentially raise problems related to the principles of medical ethics and distort a national health system's ability to progress towards UHC. If performed in the more standardized decision-making process, rationing would be of great benefits to patients and the system. Guidance for more explicit, fair and transparent of rationing should be developed at the hospital level.

Economic burden of dengue in Indonesia.

BACKGROUND: Dengue is associated with significant economic expenditure and it is estimated that the Asia Pacific region accounts for >50% of the global cost. Indonesia has one of the world's highest dengue burdens; Aedes aegypti and Aedes albopictus are the primary and secondary vectors. In the absence of local data on disease cost, this study estimated the annual economic burden during 2015 of both hospitalized and ambulatory dengue cases in Indonesia. METHODS: Total 2015 dengue costs were calculated using both prospective and retrospective methods using data from public and private hospitals and health centres in three provinces: Yogyakarta, Bali and Jakarta. Direct costs were extracted from billing systems and claims; a patient survey captured indirect and out-of-pocket costs at discharge and 2 weeks later. Adjustments across sites based on similar clinical practices and healthcare landscapes were performed to fill gaps in cost estimates. The national burden of dengue was extrapolated from provincial data using data from the three sites and applying an empirically-derived epidemiological expansion factor. RESULTS: Total direct and indirect costs per dengue case assessed at Yogyakarta, Bali and Jakarta were US$791, US$1,241 and US$1,250, respectively. Total 2015 economic burden of dengue in Indonesia was estimated at US$381.15 million which comprised US$355.2 million for hospitalized and US$26.2 million for ambulatory care cases. CONCLUSION: Dengue imposes a substantial economic burden for Indonesian public payers and society. Complemented with an appropriate weighting method and by accounting for local specificities and practices, these data may support national level public health decision making for prevention/control of dengue in public health priority lists.

Development of multi-criteria decision analysis (MCDA) framework for off-patent pharmaceuticals - an application on improving tender decision making in Indonesia.

BACKGROUND: Off-patent pharmaceuticals (OPPs) hold vital importance in meeting public health objectives, especially in developing countries where resources are limited. OPPs are comprised of off-patent originals, branded generics and unbranded generics; nonetheless, these products are not identical and often there are differences in their equivalence, manufacturing quality standards and reliability of supply. This necessitates reconsideration of the lowest price policy objective in pharmaceutical decision making. The aim of this study was to develop a Multi-Criteria Decision Analysis (MCDA) framework through a pilot workshop to inform the national procurement of OPPs in Indonesia. METHODS: An initial list of potentially relevant criteria was identified based on previous work and a literature review. In a 2-day pilot policy workshop, twenty local experts representing different stakeholder groups and decision-making bodies selected the final criteria, approved the scoring function for each criterion, and assigned weights to each criterion. RESULTS: An MCDA framework was proposed for OPP drug decision making in developing countries, which included price and 8 non-price criteria. Based on the pilot policy workshop 6 + 1 criteria were considered relevant for Indonesia: pharmaceutical price (40% weight), manufacturing quality (18.8%), equivalence with the reference product (12.2%), product stability and drug formulation (12.2%), reliability of drug supply (8.4%), real world clinical or economic outcomes, such as adherence or non-drug costs (4.2%) and pharmacovigilance (3.6%). CONCLUSIONS: According to the pilot policy workshop, other criteria apart from price need to be strengthened in the tendering process. The introduction of additional criteria for OPP procurement in an MCDA framework creates incentives for manufacturers to invest into improved manufacturing standards, equivalence proof, product quality, reliability of supply or even additional real-world data collection, which ultimately may result in more health gain for the society.

Association of the HLA-B alleles with carbamazepine-induced Stevens-Johnson syndrome/toxic epidermal necrolysis in the Javanese and Sundanese population of Indonesia: the important role of the HLA-B75 serotype.

Carbamazepine (CBZ) is a common cause of life-threatening cutaneous adverse drug reactions such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Previous studies have reported a strong association between the HLA genotype and CBZ-induced SJS/TEN. We investigated the association between the HLA genotype and CBZ-induced SJS/TEN in Javanese and Sundanese patients in Indonesia. Nine unrelated patients with CBZ-induced SJS/TEN and 236 healthy Javanese and Sundanese controls were genotyped for HLA-B and their allele frequencies were compared. The HLA-B*15:02 allele was found in 66.7% of the patients with CBZ-induced SJS/TEN, but only in 29.4% of tolerant control (p = 0.029; odds ratio [OR]: 6.5; 95% CI: 1.2-33.57) and 22.9% of healthy controls (p = 0.0021; OR: 6.78; 95% CI: 1.96-23.38). These findings support the involvement of HLA-B*15:02 in CBZ-induced SJS/TEN reported in other Asian populations. Interestingly, we also observed the presence of the HLA-B*15:21 allele. HLA-B*15:02 and HLA-B*15:21 are members of the HLA-B75 serotype, for which a greater frequency was observed in CBZ-induced SJS/TEN (vs tolerant control [p = 0.0078; OR: 12; 95% CI: 1.90-75.72] and vs normal control [p = 0.0018; OR: 8.56; 95% CI: 1.83-40]). Our findings suggest that screening for the HLA-B75 serotype can predict the risk of CBZ-induced SJS/TEN more accurately than screening for a specific allele.

Economic evaluation of policy options for dialysis in end-stage renal disease patients under the universal health coverage in Indonesia.

OBJECTIVES: This study aims to assess the value for money and budget impact of offering hemodialysis (HD) as a first-line treatment, or the HD-first policy, and the peritoneal dialysis (PD) first policy compared to a supportive care option in patients with end-stage renal disease (ESRD) in Indonesia. METHODS: A Markov model-based economic evaluation was performed using local and international data to quantify the potential costs and health-related outcomes in terms of life years (LYs) and quality-adjusted life years (QALYs). Three policy options were compared, i.e., the PD-first policy, HD-first policy, and supportive care. RESULTS: The PD-first policy for ESRD patients resulted in 5.93 life years, equal to the HD-first policy, with a slightly higher QALY gained (4.40 vs 4.34). The total lifetime cost for a patient under the PD-first policy is around 700 million IDR, which is lower than the cost under the HD-first policy, i.e. 735 million IDR per patient. Compared to supportive care, the incremental cost-effectiveness ratio of the PD-first policy is 193 million IDR per QALY, while the HD-first policy resulted in 207 million IDR per QALY. Budget impact analysis indicated that the required budget for the PD-first policy is 43 trillion IDR for 53% coverage and 75 trillion IDR for 100% coverage in five years, which is less than the HD-first policy, i.e. 88 trillion IDR and 166 trillion IDR. CONCLUSIONS: The PD-first policy was found to be more cost-effective compared to the HD-first policy. Budget impact analysis provided evidence on the enormous financial burden for the country if the current practice, where HD dominates PD, continues for the next five years.

NAT2 variants are associated with drug-induced liver injury caused by anti-tuberculosis drugs in Indonesian patients with tuberculosis.

Drug-induced liver injury (DILI) is the most common adverse drug reaction in the treatment of tuberculosis (TB). Several studies showed that patients with TB and the slow-acetylator phenotype caused by NAT2 variants are highly susceptible to DILI caused by anti-TB drugs, hereafter designated AT-DILI. However, the role of NAT2 variants in AT-DILI has never been assessed for an Indonesian population. We recruited 50 patients with TB and AT-DILI and 191 patients with TB but without AT-DILI; we then used direct DNA sequencing to assess single-nucleotide polymorphisms in the coding region of NAT2. NAT2*6A was significantly associated with susceptibility to AT-DILI (P=7.7 × 10(-4), odds ratio (OR)=4.75 (1.8-12.55)). Moreover, patients with TB and the NAT2-associated slow-acetylator phenotype showed higher risk of AT-DILI than patients with the rapid- or intermediate-acetylator phenotypes (P=1.7 × 10(-4), OR=3.45 (1.79-6.67)). In conclusion, this study confirms the significance of the association between slow-acetylator NAT2 variants and susceptibility to AT-DILI in an Indonesian population.