Assessing the Availability of Teleconsultation and the Extent of Its Use in Malaysian Public Primary Care Clinics: Cross-sectional Study

Background: The integration of teleconsultation into health care systems as a complement to existing approaches to care is growing rapidly. There is, however, limited information on the extent of its implementation across low- and middle-income countries. Objective: The aim of this study was to determine the availability and the extent of teleconsultation in Malaysian primary care clinics. Methods: A cross-sectional study of public primary care clinics in Malaysia was conducted between November 2020 and December 2020. All clinics in Malaysia that see more than 300 daily patients were recruited. A web-based, self-administered questionnaire including questions on availability of the service, whether it uses video or telephone, and the types of services it provides was distributed to the medical officer in charge of each clinic. Results: In total, 97.6% (249/255) of the clinics responded. Out of these clinics, 45.8% (114/249) provided teleconsultation. A majority of the clinics providing consultation (69/114, 60.5%) provided only telephone consultation, while 24.6% (28/114) of the clinics offered video and telephone consultation, and 14.9% (17/114) offered only video consultation. Eighty percent (92/114) of the clinics were located in urban areas. A breakdown by state showed that 17.5% (20/114) and 16.7% (19/114) of the clinics were from two larger states; other states comprised less than 10% each (range 7-9/114). For the clinics providing video consultation, funding for the service came mostly (42/45, 93%) from the Ministry of Health. Conversely, nearly 1 out of 4 (23/97) clinics that provided telephone consultation funded the service either from donations or through self-funding. Most of the clinics provided teleconsultation for diabetes and hypertension. Less than 50% of the clinics with teleconsultation used it for follow up with allied health care providers or pharmacists (video consultation, 20/45; telephone consultation, 36/97). Conclusions: Our findings show that telephone consultation is more widely used than video consultation, despite a quarter of its funding being self-subsidized or obtained through donations. Also, teleconsultation was less utilized by allied health care providers and pharmacists. Plans for the expansion of teleconsultation in Malaysian primary health care should take into consideration these findings to ensure a better and more cost-effective implementation of the service

Translation and Validation of the Questionnaire on Acceptance to Telemedicine from the Technology Acceptance Model (TAM) for Use in Malaysia

The COVID-19 pandemic has accelerated implementation of telemedicine in healthcare facilities for delivery of care. Healthcare providers' acceptance of the telemedicine services is important for successful implementation of this new system. A questionnaire based on the Technology Acceptance Model (TAM) has been used to measure user acceptance of telemedicine service. The aim of this study was to translate and validate the English version of the questionnaire into Malay, to extend the availability and utilization of this questionnaire in Malaysia. A forward and backward translation of the questionnaire was conducted to produce the TAM in the Malay version (Malay-TAM). Panel experts assessed content validity. Internal consistency reliability was determined using Cronbach's alpha. Confirmatory factor analysis based on structural equation modelling was performed to validate the factor structure. The questionnaire was then tested on and completed by 149 healthcare workers from several public health clinics across Malaysia. The Malay-TAM demonstrated good reliability with Cronbach's alphas ranging from 0.823 to 0.912. Factor analysis showed good convergent validity but relatively poor discriminant validity. All five constructs were retained to preserve content validity. The findings suggest that the Malay-TAM can serve as a reliable and valid instrument to measure acceptance to telemedicine

Stroke thrombolysis in a middle-income country: A case study exploring the determinants of its implementation

Introduction: Translation of evidence into clinical practice for use of intravenous thrombolysis in acute stroke care has been slow, especially across low- and middle-income countries. In Malaysia where the average national uptake was poor among the public hospitals in 2018, one hospital intriguingly showed comparable thrombolysis rates to high-income countries. This study aimed to explore and provide in-depth understanding of factors and explanations for the high rates of intravenous stroke thrombolysis in this hospital. Methods: This single case study sourced data using a multimethod approach: (1) semi-structured in-depth interviews and focus group discussions, (2) surveys, and (3) review of medical records. The Tailored Implementation of Chronic Diseases (TICD) framework was used as a guide to understand the determinants of implementation. Twenty-nine participants comprising the Hospital Director, neurologists, emergency physicians, radiologists, pharmacists, nurses and medical assistants (MAs) were included. Thematic analyses were conducted inductively before triangulated with quantitative analyses and document reviews. Results: Favorable factors contributing to the uptake included: (1) cohesiveness of team members which comprised of positive interprofessional team dynamics, shared personal beliefs and values, and passionate leadership, and (2) facilitative work process through simplification of workflow and understanding the rationale of the sense of urgency. Patient factors was a limiting factor. Almost two third of ischemic stroke patients arrived at the hospital outside the therapeutic window time, attributing patients' delayed presentation as a main barrier to the uptake of intravenous stroke thrombolysis. One other barrier was the availability of resources, although this was innovatively optimized to minimize its impact on the uptake of the therapy. As such, potential in-hospital delays accounted for only 3.8% of patients who missed the opportunity to receive thrombolysis. Conclusions: Despite the ongoing challenges, the success in implementing intravenous stroke thrombolysis as standard of care was attributed to the cohesiveness of team members and having facilitative work processes. For countries of similar settings, plans to improve the uptake of intravenous stroke thrombolysis should consider the inclusion of interventions targeting on these modifiable factors

Identifying factors in the provision of intravenous stroke thrombolysis in Malaysia: a multiple case study from the healthcare providers’ perspective

Background: Translation into clinical practice for use of intravenous thrombolysis (IVT) for the management of ischemic stroke remains a challenge especially across low- and middle-income countries, with regional inconsistencies in its rate. This study aimed at identifying factors that influenced the provision of IVT and the variation in its rates in Malaysia. Methods: A multiple case study underpinning the Tailored Implementation for Chronic Diseases framework was carried out in three public hospitals with differing rates of IVT using a multiple method design. Twenty-five in-depth interviews and 12 focus groups discussions were conducted among 89 healthcare providers, along with a survey on hospital resources and a medical records review to identify reasons for not receiving IVT. Qualitative data were analysed using reflective thematic method, before triangulated with quantitative findings. Results: Of five factors identified, three factors that distinctively influenced the variation of IVT across the hospitals were: 1) leadership through quality stroke champions, 2) team cohesiveness which entailed team dynamics and its degree of alignment and, 3) facilitative work process which included workflow simplification and familiarity with IVT. Two other factors that were consistently identified as barriers in these hospitals included patient factors which largely encompassed delayed presentation, and resource constraints. About 50.0 – 67.6% of ischemic stroke patients missed the opportunity to receive IVT due to delayed presentation. Conclusions: In addition to the global effort to explore sustainable measures to improve patients’ emergency response for stroke, attempts to improve the provision of IVT for stroke care should also consider the inclusion of interventions targeting on health systems perspectives such as promoting quality leadership, team cohesiveness and workflow optimisation

Impact of COVID-19 Pandemic on Antibiotic Utilisation in Malaysian Primary Care Clinics: An Interrupted Time Series Analysis

The COVID-19 pandemic has resulted in a dramatic change in the delivery of primary healthcare across the world, presumably changing trends in consultations for infectious diseases and antibiotic use. This study aimed at describing and evaluating the impact of COVID-19 on antibiotic use in public primary care clinics in Malaysia between 2018 and 2021. Data from the nationwide procurement database of systemic antibiotics from public primary care clinics in Malaysia between January 2018 and December 2021 were analysed using interrupted time series analysis. The monthly number of defined daily doses per 1000 inhabitants per day (DID) was calculated and grouped by antibiotic class. The trend of antibiotic utilisation rates had been decreasing by 0.007 DID monthly before March 2020 (p = 0.659). With the introduction of national lockdown due to COVID-19 beginning March 2020, there was a significant reduction in the level of antibiotic utilisation rates of 0.707 (p = 0.022). Subsequently, the monthly trend showed a slight upward change until the end of the study period (p = 0.583). Our findings indicate that there was a significant decrease in antibiotic utilisation for systemic use in primary care following the COVID-19 pandemic compared with the preceding years (January 2018–March 2020)

Myocarditis/pericarditis following vaccination with BNT162b2, CoronaVac, and ChAdOx1 among adolescent and adult in Malaysia

This study evaluates 21-day risk of myocarditis/pericarditis following COVID-19 vaccination among those aged 12 years and older in Malaysia. We used data from nationwide COVID-19 vaccine registry linked to hospital episode database to identify individuals vaccinated with BNT162b2, CoronaVac, or ChAdOx1 and hospitalised for myocarditis/pericarditis between 1 February 2021 and 28 February 2022. There were 87 myocarditis/pericarditis cases identified within 1–21 days after vaccination. Most cases were reported following BNT16262 vaccination (77.0%) with absolute risk of 0.33 cases/100,000 vaccinated persons or 1.73 per million doses administered. Highest risk was observed following second dose and in younger, male individuals. The risk of myocarditis/pericarditis following CoronaVac and ChAdOx1 were much lower compared to BNT162b2. The findings on higher risk observed among younger following mRNA vaccine were consistent with literature and important for targeted surveillance

Thrombocytopenia and venous thromboembolic events after BNT162b2, CoronaVac, ChAdOx1 vaccines and SARS-CoV-2 infection: a self-controlled case series study

Abstract This study assessed the association between COVID-19 vaccines, SARS-CoV-2 infection and the risk of thrombocytopenia and venous thromboembolism (VTE). This self-controlled case series study used hospital records between 1st February 2021 and 28th February 2022 linked to the national immunisation registry and COVID-19 surveillance data in Malaysia. Conditional Poisson regression was used to estimate incidence rate ratios (IRR) of events in the risk period (day 1–21 post-exposure) relative to control period with the corresponding 95% confidence interval (CI) adjusted for calendar period. We found no significant increased risk of thrombocytopenia in 1–21 days following BNT162b2, CoronaVac and ChAdOx1 vaccines while the risk was increased following SARS-CoV-2 infection (IRR 15.52, 95% CI 13.38–18.00). Similarly, vaccination with BNT162b2, CoronaVac, or ChAdOx1 was not associated with an increased risk of VTE during the 1–21 days risk period. SARS-CoV-2 infection was associated with increased risk of VTE (IRR 39.84, 95% CI 27.45–32.44). Our findings showed low event rates of thrombocytopenia and VTE following booster vaccination with comparable safety profiles between those who received homologous and heterologous booster combinations. Our findings showed the risk of thrombocytopenia and VTE was not increased after COVID-19 vaccination while the risks were substantially higher after SARS-CoV-2 infection

Impact evaluation of guidelines on antibiotic utilisation & appropriateness in Malaysian public primary care: an interrupted time series analysis

Background: The National Antimicrobial Guidelines (NAG) 2014 and NAG2019 in Malaysia targeted rational and judicious use of antimicrobials. In this study, we assessed the change in antibiotic utilisation and appropriateness due to the guidelines that were implemented from 2011 to 2019.Methods: Interrupted time series analyses on rates of antibiotic appropriateness and utilisation were performed using prescription data from public primary care clinics in Malaysia between January 2011 and December 2019. Rates of antibiotic utilisation, reported as Defined Daily Dose (DDD) per 1000 patients per day, were stratified by antibiotic classes.Results: Of the 16,081,492 prescriptions recorded during the study period, 4.98% (n = 800,899) contained antibiotics. NAG2014 resulted in a significant increase in antibiotic utilisation trend by 0.029 (p < 0.0001) while NAG2019 had a substantial impact on antibiotic utilisation, decreasing DDD by 1778 and increasing appropriateness by 54.6% (p < 0.0001). Variation in the number of antibiotic molecules being prescribed also decreased after NAG2019.Conclusion: Our findings indicate that the introduction of NAG2019 led to a substantial improvement in antibiotic appropriateness. At the same time, antibiotic utilisation decreased. Further research is needed to ascertain and ensure the sustainability of these changes and to establish targeted improvement strategies focusing on reducing inappropriate and unnecessary prescribing