Conference abstract:
Objectives: To evaluate physician’s knowledge and adherence to asthma guideline adherence (GINA 2011) at emergency department of Hospital Pulau Pinang, Malaysia and to calculate cost of adhered and non-adhered prescriptions
Methods: A cross-sectional survey was conducted to evaluate knowledge of GINA, 2011 asthma guideline at emergency department of Hospital Pulau Pinang, Malaysia. A total of 810 patient prescriptions of 27 doctors (30 prescriptions per doctor) were viewed to asses doctor’s guideline adherence. Patients’ prescriptions were categorised in terms of asthma severity as mild, moderate and severe. Prescriptions were labelled as adhered or non-adhered in terms of doctor treatment according to patient asthma severity as recommended by CPG (GINA 2011). Cost of adhered and non-adhered was calculated according to asthma severity.
Results: Twenty two (81.5%) doctor’s had adequate GINA, 2011 asthma guideline knowledge (Mean 16.7, SD ± 1.5). Six hundred and twenty eight (77.5%) patients received guideline (GINA 2011) adhered pharmacotherapy. Six hundred and seventy eight (83.7%) patients asthma were classified as mild asthma, 128 (15.8%) patients were classified as moderate asthma and 4 (0.5%) patients were classified as severe asthma. Pearson correlation indicated no statistical significant association between asthma guideline adherence and asthma guideline knowledge score (p=0.27). Univariate analysis indicate that patients with age group 25-35 years and with hypertension as co-morbidity received significantly better pharmacotherapy (p=0.04, p=0.03 respectively). Total cost of 628 adhered prescriptions was RM 5792.87 whereas cost of 182 non-adhered prescriptions was RM 1759.09. Cost of single mild asthma adhered prescription (RM 9.18) was less as compared to non adhered mild asthma prescription (RM 10.39).
Conclusions: Emergency doctor’s had adequate GINA, 2011 asthma guideline knowledge. Majority of patients received GINA, 2011 asthma guideline adhered pharmacotherapy. Cost effective medication can significantly reduce socioeconomic burden related to asthma.
BACKGROUND/AIM: Multiple asthma guidelines have been developed to reduce asthma mortality, morbidity, and cost associated with asthma worldwide. In Malaysia, within this context, it is relatively unknown to what extent doctors adhere to the asthma guidelines. This study aimed to assess guideline adherence and calculate the cost of adhered and nonadhered prescriptions by medical doctors in a public tertiary health care facility.
MATERIALS AND METHODS: A cross-sectional study was carried out at Hospital Pulau Pinang, Malaysia. One hundred and eighty patients, a total of 30 patients per doctor, were enrolled to assess guideline adherence. The patients were followed for a second visit to assess their lung function. The costs of adhered and nonadhered prescriptions were calculated.
RESULTS: One hundred and forty-three patients (79%) received guideline (Global Initiative for Asthma 2011)-adhering pharmacotherapy. In the majority of patients (n = 133, 73.9%) asthma control was classified as partially controlled. There was no significant association observed between patient asthma control and patient demographics; however, there was a significant difference (P < 0.001) between lung function values from the first and second visits. The cost of adhered prescription was higher (70.1 Malaysian ringgit) than that of nonadhered prescription (13.74 Malaysian ringgit).
CONCLUSION: Fair levels of guideline adherence were observed. Emphasis should be placed on identifying appropriate cost-effective medication regimens based on patient asthma control and constant feedback from patients.
Study site: Respiratory clinic, Hospital Pulau Pinang, Pulau Pinang, Malaysia
This study aimed to assess the knowledge of blood-borne diseases transmitted through needle stick injuries amongst health-care workers in a tertiary teaching hospital. We also aimed to assess the practices of universal precautions amongst these workers and its correlation with the facts. We carried out a cross-sectional study from January to July 2008 involving various levels of health-care workers in Serdang Hospital, Selangor, Malaysia. A self-administered questionnaire assessing knowledge of blood-borne diseases and universal precautions, and actual practice of universal precautions was used. Two hundred fifteen respondents participated in this study; 63.3% were staff nurses. The mean knowledge score was 31.84 (SD 4.30) and the mean universal practice score was 9.0 (SD 2.1). There was a small, positive correlation between knowledge and actual practice of universal precautions (r = 0.300, n = 206, p < 0.001) amongst the cohort studied. Factors such as age and years of experience did not contribute towards acquisition of knowledge about blood-borne illnesses or the practice of universal precautions.
Increasing risk of HIV infections among health care workers has been a continuing concern. The study was designed to identify the compliance of glove utilization, and factors related to non-compliance. A sample of 150 staff nurses were recruited from the study population of 550 nurses in Hospital Universiti Sains Malaysia. Data were collected by using a structured self-administered questionnaires. The response rate was 98.4%. The study revealed a low compliance (13.5%) of glove utilization (for all 9 procedures), which varied among different procedures (27-97%). Younger nurses and those with shorter duration of working experience had better knowledge of Universal Precautions. Nurses in intensive care unit and operation theatre were better in both knowledge and compliance of glove utilization. The three commonest misconceptions were identified as "selective use of gloves for high risk groups and suspected cases", and "tendency to depend on HIV prevalence". Nurses reported practical problems including administrative and personal related such as "stock irregularity" (46%), "glove not available at the emergency sites" (44%), and "reduction of tactile sensation" (39%). It was concluded that poor knowledge and practical problems were possible responsible factors for the low compliance. A good training for nurses comprising principle and practice of Universal Precautions, updated knowledge of blood and body fluid borne infections and risk and its management, will probably improve the compliance.
AIM: We audited indications and outcomes of antiphospholipid syndrome (APS) screening in the pregnant population at our centre.
METHOD: Prospective and observational. All APS test results returned were audited for validity of indication and subsequent outcome.
RESULT: 24 of a total of 146 (16%) of requests for the antiphospholipid antibodies and lupus anticoagulant were not indicated. Two positive results returned for a total of 116 "indicated" requests (1.7%).
CONCLUSION: There needs to be increased awareness among obstetricians on the indications for screening for antiphospholipid syndrome (APS). The prevalence of antiphospholipid syndrome with obstetric manefestations in the study population is lower than rates published in the literature.
Spontaneous pneumothorax (SP) is a common medical condition but continues to be a frequent management problem among doctors. Despite the availability of guidelines on management of SP, studies have shown that the compliance with the guidelines is low. The various treatment options available in treating this condition further confuse doctors on the right approach in managing SP. The objective of this study is to investigate the awareness of the availability of these existing guidelines and to investigate how the doctors involved in the initial management of SP would manage this condition. A self completed questionnaire which included three case scenarios were distributed among doctors in two teaching university hospitals and two large Ministry of Health hospitals. This study showed that there is a lack of awareness of the existing guidelines even among the senior doctors and there is a variation in the initial management of SP. Therefore a locally produced guideline may be beneficial to standardise and improve the management of SP.
A self-answered, anonymously completed, nationwide questionnaire survey was conducted between June 2002 and May 2003 among Malaysian doctors through post and at medical meetings. Findings based on 116 government and 110 private doctors who satisfactorily completed the forms (effective respondent rate: 30.1%) showed that more than 70% of government and private doctors claimed familiarity with asthma CPGs but proportionately more private doctors considered them "unworkable" and were reluctant to adopt them in their practice setting, quoting cost as the primary reason. Between those who frequently adopted the CPGs and those who did not, there was an equally high proportion of inappropriate prescribing. Despite the shortcomings of such a survey, our findings suggest that medicinal cost and practitioner's prescribing practices are important in the acceptance and execution of asthma CPGs recommendations.
A cross-sectional study was conducted among 517 patients with diabetes mellitus at all health centres in Melaka Tengah District to examine whether these patients and their associated cardiovascular risk factors were managed according to current guidelines. All patients had Type 2 diabetes mellitus with mean age of 57.9 +/- 10.5 years and the mean duration of diabetes was 7.2 +/- 6.0 years. The glycaemic control was poor with 53.6% of the patients having HbAlc above 8% (mean = 8.5%) and 24% of them had microalbuminuria. Among these patients with poor glycaemic control, about 47.6% of them were on monotherapy. Three hundred and fifty (67.7%) patients had hypertension but only 11 (3.1%) achieved target blood pressure of less than 130/80 mmHg. Only 18.3% of the diabetics with hypertension were prescribed angiotensin converting enzyme inhibitors and 0.3% with angiotensin receptor blockers. Nearly two-third of them had low-density lipoprotein cholesterol greater than 2.6 mmol/l (mean = 3.4 mmol/l) but only 6.8% were prescribed lipid-lowering agents. Aspirin was prescribed to 8.2% of diabetics aged above 40 years. Sixteen percent of the patients smoked, 53% did not do any exercise, and the mean BMI was 26.8 kg/mn. The management of diabetes mellitus and its associated cardiovascular risk factors was suboptimal on the basis of current clinical guidelines. A greater effort in educating doctors in the health centres about these management and adherence to the guidelines is important in reducing patients' risk of cardiovascular disease and its associated morbidity and mortality.
The study was conducted to determine whether the clinical targets for the control of diabetes recommended by American Diabetes Association can be met in the context of routine diabetes practice. This cross-sectional study was undertaken on 211 type 2 diabetic patients at the Outpatients Diabetes Clinic, Hospital Universisti Sains Malaysia (HUSM) Kubang Kerian, Kelantan between the year 2001-2002. Patients' physical examination and their medical history as well as their family history were obtained by administering a structured questionnaire. Samples of patients' venous blood during fasting were taken and analysed for plasma glucose, glycated haemoglobin and lipid profile. Analysis showed that many patients had comorbidities or complications. A large number of them had poor glycaemic control (73%). Systolic and diastolic blood pressures of 75% and 85% subjects were > or = 130 and > or = 80 mmHg, respectively. Body Mass Index (BMI) values of 66% of the patients were outside the clinical target (BMI > or = 25 in male and > or = 24 kg/m2 in female). The lipid profile showed that 96% of the patients had at least one lipid value outside the clinical target level. In this study, 70% of the patients had total cholesterol > or = 5.2 mmol/L, 87% had LDL cholesterol > or = 2.6 mmol/L, 57% had HDL cholesterol less than the normal range, < or = 1.15 mmol/L in men and < or = 1.4 mmol/L in women, while 46% had triglycerides > or = 1.71 mmol/L. Complications of diabetes were observed in 48% of the total number of patients. As for the patients' systolic blood pressure, age and duration of diabetes were found to have significant effects. Older subjects with a longer duration of diabetes were more hypertensive. Variables that had significant effects on BMI were age, duration of diabetes, glycaemic control and gender. Younger females and newly diagnosed subjects with better glycaemic control (A1C < 7%) were found to have higher BMI values. The overall clinical targets were suboptimal. The prevalence of hyperlipidaemia and hypertension was high. It is imperative that better treatment strategies and methods be adopted to enhance diabetes control and reduce long-term complications of the disease.
Study site: Outpatients Diabetes Clinic, Hospital Universisti Sains Malaysia (HUSM)
This is a study of patients referred to the Scoliosis Service of Hospital Kuala Lumpur. Three hundred and thirty five (335) consecutive patients who were seen between 1985 and 2000 were reviewed to determine the presentation of scoliosis, the treatment received and the compliance to follow up. Data were determined by measuring the frontal spinal radiographs. Two hundred and ninety eight (298) patients met inclusion criteria. Idiopathic scoliosis accounted for 203 patients (68.1%), 31 (10.4%) were neuromuscular scoliosis; and 44 (14.8%) had congenital scoliosis. Twenty-five point five percent of patients had surgery, 10.4% were treated with brace, while the remaining 69.1% of patients were observed, or had no treatment at all. Congenital scoliosis patients had better compliance compared to idiopathic or neuromuscular scoliosis patients.
The Malaysian Society of Anaesthesiologists published a document entitled "Recommendations for Standards of Monitoring during Anaesthesia and Recovery" in 1993. This paper examines the results of two surveys, carried out in 1995 and 1996 respectively; to determine compliance with published Monitoring Standards in Malaysian public and private hospitals. In the private sector, compliance with the recommended standards during anaesthesia varied greatly. Of the 28 government hospitals surveyed in 1996, compliance with monitoring standards during anaesthesia was almost 100%. Standards in recovery areas were less than ideal. The majority of anaesthesiologists thought that the current recommended standards were adequate.
The treatment preferences of 109 general practitioners (GPs) for childhood asthma were determined. Availability and adherence to clinical practice guidelines (CPG) for the treatment of childhood asthma was also assessed. Ninety eight (90%), 60 (55%) and 33 (30%) GPs considered nocturnal symptoms > 2 times/week, exercise induced wheeze and cough respectively as indications for preventer therapy. An oral preparation was preferred for relief medication [72 (66%) for 2-5 years, 60 (55%) for > 5 years]. An inhaled preparation was however preferred for preventer medication [60 (55%) for 2-5 years, 85 (78%) for > 5 years]. The oral form was more likely prescribed for asthmatic children 2-5 years (p < 0.001). Corticosteroids and ketotifen were the commonest inhaled and oral preventer treatment prescribed respectively. Only 36(33%) GPs have a CPG copy for reference. Children with asthma symptoms that require preventer therapy may not always be identified in general practice. The oral route remains important for asthma medication especially in young children. The accessibility to the CPG among GPs is disappointing.
Study site: General practitioners attending a pharmaceutical industry sponsored asthma management workshop
BACKGROUND: blood pressure (bP) control among Malaysian is poor and doctor's adherence to clinical practice guideline (cPG) has been a well-known factor that may improve it. this study was designed to evaluate patients' bP control, doctors' adherence to the latest hypertension cPG and their association. Factors associated with bP control and cPG adherence was also examined.
METHODS: A cross-sectional study was conducted in Kuala Muda district's health clinics. 331 medical records were selected using stratified random sampling and standard proforma was used for data collection. the latest edition of the Malaysian cPG on hypertension was employed to define related variables.
RESULTS: A total of 160 patients (48.3%) had controlled bP and it was significantly associated with patients' age (adjusted Odds ratio, aOr= 1.03, 95% cI: 1.004, 1.05, p= 0.016) and systolic bP at presentation (aOr= 0.95, 95% cI: 0.93, 0.96, p< 0.001). About 60.7% of the medical records showed doctor's good level of cPG adherence. this adherence has significant association with presence of chronic kidney disease (aOr= 0.51, 95% cI: 0.31, 0.85, p= 0.007) and cardiovascular disease (aOr= 2.68, 95% cI: 1.04, 6.95, p= 0.030) in the patients and physicians' treatment intensification (aOr= 2.00, 95% cI: 1.26, 3.19, p= 0.009). However, no association was found between bP control and cPG adherence.
CONCLUSION: Hypertension control in this study was poor and the prevalence of physicians with good level of cPG adherence was slightly above average. these findings are important for relevant stakeholders to strategise an action plan to improve hypertension management outcome.
The management of acne in South-East Asia is unique, as Asian skin and local variables require a clinical approach unlike that utilized in other parts of the world. There are different treatment guidelines per country in the region, and a group of leading dermatologists from these countries convened to review these guidelines, discuss current practices and recent advances, and formulate consensus guidelines to harmonize the management of acne vulgaris in the region. Emphasis has been placed on formulating recommendations to impede the development of antibiotic resistance in Propionibacterium acnes. The group adopted the Acne Consensus Conference system for grading acne severity. The group recommends that patients may be treated with topical medications including retinoids, benzoyl peroxide (BPO), salicylic acid, a combination of retinoid and BPO, or a combination of retinoids and BPO with or without antibiotics for mild acne; topical retinoid with topical BPO and a oral antibiotic for moderate acne; and oral isotretinoin if the patient fails first-line treatment (a 6- or 8-week trial of combined oral antibiotics and topical retinoids with BPO) for severe acne. Maintenance acne treatment using topical retinoids with or without BPO is recommended. To prevent the development of antibiotic resistance, topical antibiotics should not be used as monotherapy or used simultaneously with oral antibiotics. Skin care, comprised of cleansing, moisturizing and sun protection, is likewise recommended. Patient education and good communication is recommended to improve adherence, and advice should be given about the characteristics of the skin care products patients should use.
BACKGROUND: The National Institute for Health and Care Excellence guidelines and the Quality Outcomes Framework require practitioners to use cardiovascular risk scores in assessments for the primary prevention of cardiovascular disease.
AIM: To explore GPs understanding and use of cardiovascular risk scores.
DESIGN AND SETTING: Qualitative study with purposive maximum variation sampling of 20 GPs working in Oxfordshire, UK. Method Thematic analysis of transcriptions of face-to-face interviews with participants undertaken by two individuals (one clinical, one non-clinical).
RESULTS: GPs use cardiovascular risk scores primarily to guide treatment decisions by estimating the risk of a vascular event if the patient remains untreated. They expressed considerable uncertainty about how and whether to take account of existing drug treatment or other types of prior risk modification. They were also unclear about the choice between the older scores, based on the Framingham study, and newer scores, such as QRISK. There was substantial variation in opinion about whether scores could legitimately be used to illustrate to patients the change in risk as a result of treatment. The overall impression was of considerable confusion.
CONCLUSION: The drive to estimate risk more precisely by qualifying guidance and promoting new scores based on partially-treated populations appears to have created unnecessary confusion for little obvious benefit. National guidance needs to be simplified, and, to be fit for purpose, better reflect the ways in which cardiovascular risk scores are currently used in general practice. Patients may be better served by simple advice to use a Framingham score and exercise more clinical judgement, explaining to patients the necessary imprecision of any individual estimate of risk.
Appropriate drug selection and dosing for patients with chronic kidney disease (CKD) is important to avoid unwanted drug effects and ensure optimal patient outcomes.
BACKGROUND: The insufficient adoption of internationally accepted clinical guidelines may lead to less than adequate patient care of patients with asthma.
OBJECTIVE: To evaluate the knowledge and treatment compliance with Global Initiative of Asthma (GINA, 2011) asthma treatment guidelines among emergency physicians (EPs) at a referral hospital in northern Malaysia.
METHODS: A cross-sectional study was designed in the territory-level referral hospital in northern Malaysia. Twenty-seven EPs were asked to complete an asthma guideline questionnaire to assess their knowledge regarding GINA 2011 asthma treatment guidelines. A total of 810 patients were enrolled, and 30 patients were selected per physician. The authors evaluated the physicians' compliance with GINA 2011 asthma treatment guidelines.
RESULTS: Of 27 EPs, 20 (74.1%) had adequate knowledge of GINA 2011 asthma treatment guidelines. A total of 615 (75.9%) patients received guideline-recommended emergency treatment. Shortness of breath (n = 436, 53.8%) was the most frequently reported chief complaint. Furthermore, there was a significant but weak association between knowledge of the guideline and treatment compliance among emergency doctors (P = 0.003, φ = 0.110). Moreover, there was no significant change in therapy for patients with comorbid conditions. The mean age of respondents was 27.3 years.
CONCLUSIONS: Overall, a fair level of guideline knowledge and treatment compliance was noted among EPs. Doctors with adequate guideline knowledge were more likely to comply with GINA 2011 asthma treatment guidelines.
Although heart failure (HF) management is available at primary and secondary care facilities in Malaysia, the optimisation of drug therapy is still suboptimal. Although pharmacists can help bridge the gap in optimising HF therapy, pharmacists in Malaysia currently do not manage and titrate HF pharmacotherapy. The aim of this study was to develop treatment algorithms and monitoring protocols for angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and spironolactone based on extensive literature review for validation and utilization by pharmacists involved in HF management.