How Much Does Management of an Asthma-Related Event Cost in a Malaysian Suburban Hospital?

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

BACKGROUND

In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia.

METHODS

This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis.

RESULTS

We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors.

CONCLUSION

The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship.

Emerging Roles of Malaysian Pharmacists in Asthma Management Amidst the COVID-19 Pandemic: A Narrative Review

The arrival of COVID-19 pandemic in March 2020 adversely affected every aspect of human life, including the management of asthma. The pandemic has forced clinicians to revisit the application of high-risk aerosol-generating procedures in asthma management, including spirometry and nebuliser therapy. The use of commercial spacers with pressurised metered-dose inhalers to replace nebulisation is limited by the high cost and pandemic-induced stock unavailability of these inhalers. The need for social distancing, healthcare reserves reallocation, and scarce personal protective equipment has promote increased telemedicine uptake for patients' asthma control and monitoring. Malaysian pharmacists have been providing long-term care of asthma through the introduction of the respiratory Medication Therapy Adherence Clinic (MTAC) to empower patients' general health literacy, train and regularly evaluate their inhalation technique, and reinforce the importance of medication compliance. To minimise the use of unplanned healthcare resources and avoidable COVID-19 infection exposure, Malaysian pharmacists need to better support asthma self-management via increased uptake of written Asthma Action Plans (AAPs). Pharmacist-led asthma treatment step-down to attain the lowest effective dose of inhaled corticosteroids (ICS) has become increasingly relevant during the pandemic, as its prolonged use carries risk of numerous side effects and possible hospitalisation. Telepharmacy offers a promising model for exploration and an alternative to the traditional service delivery of asthma education. Despite not being authorised as vaccinators, Malaysian pharmacists hold strong positions in COVID-19 immunisation programmes for pharmacovigilance and advocacy. The pandemic demands an increased role for pharmacists within medication management to prevent patients from the stockpiling that can cause adverse effects on pharmaceutical supply chain. This review intends to summarise the impact of COVID-19 on asthma management, with a focus on the transitional roles of Malaysian pharmacists before and after the pandemic era.

Asthma control and care among six public health clinic attenders in Malaysia: A cross-sectional study

Background and Aims

Asthma is common in Malaysia but neglected. Achieving optimal asthma control and care is a challenge in the primary care setting. In this study, we aimed to identify the risk factors for poor asthma control and pattern of care among adults and children (5-17 years old) with asthma attending six public health clinics in Klang District, Malaysia.

Methods

We conducted a cross-sectional study collecting patients' sociodemographic characteristics, asthma control, trigger factors, healthcare use, asthma treatment, and monitoring and use of asthma action plan. Descriptive statistics and stepwise logistic regression were used in data analysis.

Results

A total of 1280 patients were recruited; 85.3% adults and 14.7% children aged 5-17 years old. Only 34.1% of adults had well-controlled asthma, 36.5% had partly controlled asthma, and 29.4% had uncontrolled asthma. In children, 54.3% had well-controlled asthma, 31.9% had partly controlled, and 13.8% had uncontrolled asthma. More than half had experienced one or more exacerbations in the last 1 year, with a mean of six exacerbations in adults and three in children. Main triggers for poor control in adults were haze (odds ratio [OR] 1.51; 95% confidence interval [CI] 1.13-2.01); cold food (OR 1.54; 95% CI 1.15-2.07), extreme emotion (OR 1.90; 95% CI 1.26-2.89); air-conditioning (OR 1.63; 95% CI 1.20-2.22); and physical activity (OR 2.85; 95% CI 2.13-3.82). In children, hot weather (OR 3.14; 95% CI 1.22-8.11), and allergic rhinitis (OR 2.57; 95% CI 1.13-5.82) contributed to poor control. The majority (81.7% of adults and 64.4% of children) were prescribed controller medications, but only 42.4% and 29.8% of the respective groups were compliant with the treatment. The importance of an asthma action plan was reported less emphasized in asthma education.

Conclusion

Asthma control remains suboptimal. Several triggers, compliance to controller medications, and asthma action plan use require attention during asthma reviews for better asthma outcomes.

Feasibility of supported self-management with a pictorial action plan to improve asthma control

Supported self-management reduces asthma-related morbidity and mortality. This paper is on a feasibility study, and observing the change in clinical and cost outcomes of pictorial action plan use is part of assessing feasibility as it will help us decide on outcome measures for a fully powered RCT. We conducted a pre-post feasibility study among adults with physician-diagnosed asthma on inhaled corticosteroids at a public primary-care clinic in Malaysia. We adapted an existing pictorial asthma action plan. The primary outcome was asthma control, assessed at 1, 3 and 6 months. Secondary outcomes included reliever use, controller medication adherence, asthma exacerbations, emergency visits, hospitalisations, days lost from work/daily activities and action plan use. We estimated potential cost savings on asthma-related care following plan use. About 84% (n = 59/70) completed the 6-months follow-up. The proportion achieving good asthma control increased from 18 (30.4%) at baseline to 38 (64.4%) at 6-month follow-up. The proportion of at least one acute exacerbation (3 months: % difference -19.7; 95% CI -34.7 to -3.1; 6 months: % difference -20.3; 95% CI -5.8 to -3.2), one or more emergency visit (1 month: % difference -28.6; 95% CI -41.2 to -15.5; 3 months: % difference -18.0; 95% CI -32.2 to -3.0; 6 months: % difference -20.3; 95% CI -34.9 to -4.6), and one or more asthma admission (1 month: % difference -14.3; 95% CI -25.2 to -5.3; 6 months: % difference -11.9; 95% CI -23.2 to -1.8) improved over time. Estimated savings for the 59 patients at 6-months follow-up and for each patient over the 6 months were RM 15,866.22 (USD3755.36) and RM268.92 (USD63.65), respectively. Supported self-management with a pictorial asthma action plan was associated with an improvement in asthma control and potential cost savings in Malaysian primary-care patients.Trial registration number: ISRCTN87128530; prospectively registered: September 5, 2019, http://www.isrctn.com/ISRCTN87128530 .

From Evidence to Policy: Economic Evaluations of Healthcare in Malaysia: A Systematic Review

OBJECTIVE

To identify and describe the various economic evaluation studies in Malaysia and to determine the range of incremental cost-effectiveness ratios (ICERs) as reported in these studies.

METHODS

A comprehensive search of the scientific electronic databases was conducted (Medline, EBM Reviews, Embase, and hand search) to identify all published economic evaluation studies related to Malaysian healthcare. Two researchers assessed the quality of selected studies using the Critical Appraisal Skills Programme (CASP) checklist and Quality of Health Economic Studies instrument. The assessment was also reviewed by expert members of the Technical Advisory Committee of Health Technology Economic Evaluations (TACHTEE).

RESULTS

A total of 64 full-text articles were assessed for eligibility and included in this systematic review. Thirty studies were partial economic evaluations; the full economic evaluations included 17 cost-effectiveness analyses and 17 cost-utility analyses. From all the reported ICERs, the majority (68%) were categorized as highly cost-effective (ICER of less than 1 gross domestic product (GDP) per capita per quality-adjusted life-years or disability-adjusted life-years gained).

CONCLUSION

This review identifies information gaps and loopholes in health economics research in Malaysia. Additionally, this study provides the information that the majority of published interventions in Malaysia fell within the cost-effectiveness threshold of 1 GDP per capita per quality-adjusted life-years or disability-adjusted life-years gained.

Milk Powder Fortified with Potassium and Phytosterols to Decrease the Risk of Cardiovascular Events among the Adult Population in Malaysia: A Cost-Effectiveness Analysis

This study evaluated the cost-effectiveness of the consumption of a milk powder product fortified with potassium (+1050.28 mg/day) and phytosterols (+1200 mg/day) to lower systolic blood pressure and low-density lipoprotein cholesterol, respectively, and, therefore, the risk of myocardial infarction (MI) and stroke among the 35-75-year-old population in Malaysia. A Markov model was created against a do-nothing option, from a governmental perspective, and with a time horizon of 40 years. Different data sources, encompassing clinical studies, practice guidelines, grey literature, and statistical yearbooks, were used. Sensitivity analyses were performed to evaluate the impact of uncertainty on the base case estimates. With an incremental cost-effectiveness ratio equal to international dollars (int$) 22,518.03 per quality-adjusted life-years gained, the intervention can be classified as very cost-effective. If adopted nationwide, it would help prevent at least 13,400 MIs, 30,500 strokes, and more than 10,600 and 17,100 MI- and stroke-related deaths. The discounted cost savings generated for the health care system by those who consume the fortified milk powder would amount to int$8.1 per person, corresponding to 0.7% of the total yearly health expenditure per capita. Sensitivity analyses confirmed the robustness of the results. Together with other preventive interventions, the consumption of milk powder fortified with potassium and phytosterols represents a cost-effective strategy to attenuate the rapid increase in cardiovascular burden in Malaysia.

A systematic review and meta-analysis of the impact of collaborative practice between community pharmacist and general practitioner on asthma management

Objective: This systematic review aims to investigate the impact of collaborative practice between community pharmacist (CP) and general practitioner (GP) in asthma management. Methods: A systematic search was performed across 10 databases (PubMed, Medline/Ovid, CINAHL, Scopus, Web of Science, Cochrane central register of controlled trials, PsycARTICLES®, Science Direct, Education Resource Information Centre, PRO-Quest), and grey literature using selected MeSH and key words, such as "community pharmacist", "general practitioner", and "medicine use review". The risk of bias of the included studies was assessed by Cochrane risk of bias tool. All studies reporting any of the clinical, humanistic, and economical outcomes using collaborative practice between CPs and GPs in management of asthma, such as CPs conducting medications reviews, patient referrals or providing education and counseling, were included. Results: A total of 23 studies (six RCTs, four C-RCT, three controlled interventions, seven pre-post, and three case control) were included. In total, 11/14 outcomes were concluded in favor of CP-GP collaborative interventions with different magnitude of effect size. Outcomes, such as asthma severity, asthma control, asthma symptoms, PEFR, SABA usage, hospital visit, adherence, and quality of life (QoL) (Asthma Quality-of-Life Questionnaire [AQLQ]; Living with Asthma Questionnaire [LWAQ]) demonstrated a small effect size (d≥0.2), while inhalation technique, ED visit, and asthma knowledge witnessed medium effect sizes (ES) (d≥0.5). In addition to that, inhalation technique yielded large ES (d≥0.8) in RCTs subgroup analysis. However, three outcomes, FEV, corticosteroids usage, and preventer-to-reliever ratio, did not hold significant ES (d<0.2) and, thus, remain inconclusive. The collaboration was shown to be value for money in the economic studies in narrative synthesis, however, the limited number of studies hinder pooling of data in meta-analysis. Conclusion: The findings from this review established a comprehensive evidence base in support of the positive impact of collaborative practice between CP and GP in the management of asthma.

A Stepwise Approach to a National Hepatitis C Screening Strategy in Malaysia to Meet the WHO 2030 Targets: Proposed Strategy, Coverage, and Costs

BACKGROUND

In Malaysia, more than 330 000 individuals are estimated to be chronically infected with hepatitis C virus (HCV), but less than 2% have been treated to date.

OBJECTIVES

To estimate the required coverage and costs of a national screening strategy to inform the launch of an HCV elimination program.

METHODS

We designed an HCV screening strategy based on a "stepwise" approach. This approach relied on targeting of people who inject drugs in the early years, with delayed onset of widespread general population screening. Annual coverage requirements and associated costs were estimated to ensure that the World Health Organization elimination treatment targets were met.

RESULTS

In total, 6 million individuals would have to be screened between 2018 and 2030. Targeting of people who inject drugs in the early years would limit annual screening coverage to less than 1 million individuals from 2018 to 2026. General population screening would have to be launched by 2026. Total costs were estimated at MYR 222 million ($58 million). Proportional to coverage targets, 60% of program costs would fall from 2026 to 2030.

CONCLUSIONS

This exercise was one of the first attempts to conduct a detailed analysis of the required screening coverage and costs of a national HCV elimination strategy. These findings suggest that the stepwise approach could delay the onset of general population screening by more than 5 years after the program's launch. This delay would allow additional time to mobilize investments required for a successful general population screening program and also minimize program costs. This strategy prototype could inform the design of effective screening strategies in other countries.

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.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0156-1) contains supplementary material, which is available to authorized users.