Poor blood pressure control and its associated factors among older people with hypertension: a cross-sectional study in six public primary care clinics in Malaysia

Introduction: Hypertension is highly prevalent in the older people. Chronic disease care is a major burden in the public primary care clinics in Malaysia. Good blood pressure (BP) control is needed to reduce the morbidity and mortality of cardiovascular disease (CVD). This study aimed to determine the status of BP control and its associated factors among older people with hypertension in public primary care clinics. Materials and methods: A cross-sectional study on hypertensive patients aged 18 years and above was conducted in six public primary care clinics in Federal Territory, Malaysia. A total of 1107 patients were selected via systematic random sampling. Data from 441 (39.8%) patients aged 60 years and more were used in this analysis. BP control was determined from the average of two BP readings measured twice at an interval of 5 min. For patients without diabetes, poor BP control was defined as BP of ≥140/90 mm Hg and ≥150/90 for the patients aged 80 years and more. For patients with diabetes, poor control was defined as BP of ≥140/80 mm Hg. Results: A total of 51.7% (n = 228) of older patients had poor BP control. The factors associated with BP control were education level (p = 0.003), presence of comorbidities (p = 0.015), number of antihypertensive agents (p = 0.001) and number of total medications used (p = 0.002). Patients with lower education (less than secondary education) (OR = 1.7, p = 0.008) and the use of three or more antihypertensive agents (OR = 2.0, p = 0.020) were associated with poor BP control. Conclusion: Among older people with hypertension, those having lower education level, or using three or more antihypertensive agents would require more attention on their BP control

The changing face of primary care: a cross sectional study in Malaysia

There has been an epidemiological transition in morbidity and mortality patterns in developing countries. This study aimed to determine whether there was an accompanying change in disease presentation in primary care. This was a cross-sectional study conducted at 12 public primary care clinics in Malaysia. Outpatient medical records were randomly selected and reviewed to identify patients’ reasons for encounter. The overall retrieval of records was 99.1% (n=1,753; range 95.7-100.0%). The mean age was 33.1 (SD 22.2) years. For all ages, the most common reasons for patient encounter (RFE) were cough (21.1%; 95% CI 16.5, 25.8), follow-up care for chronic diseases (19.6%; 95% CI 12.7, 26.6) and fever (18.4%; 95% CI 14.2, 22.5). The top RFE in West Malaysia was follow-up care for chronic diseases while in East Malaysia, the most common RFE was cough (25.2%; 95% CI 16.8, 33.6) and fever (21.7%; 95% CI 14.3, 29.0). In conclusion, there is a change in the presentation of diseases, with chronic disease emerging as one of the top RFE in primary care. In adults, for all age groups over 40 years old, care for chronic diseases has overtaken acute disease care. However, acute respiratory problems remain the overall top RFE at public primary care clinics in Malaysia. There are major differences in morbidity patterns and reasons for encounter for different age groups and geographical areas and this could be utilized for better health care planning

Is family history still underutilised? exploring the views and experiences of primary care doctors in Malaysia

Family history has long been recognised as a non-invasive and inexpensive tool to identify individuals at risk of genetic conditions. Even in the era of evolving genetic and genomic technology, the role of family history in predicting individual risk for genetic testing and guiding in preventive interventions is still relevant, especially in low-resource countries. The aim of this study was to explore primary care doctors' views and experiences in family history taking and how they utilised family history in day-to-day clinical consultations in Malaysia. Four focus group discussions and six in-depth interviews involving 25 primary care doctors were conducted. Three themes emerged from the analysis: (1) primary care doctors considered family history as an important part of clinical assessment, (2) proactive versus reactive approach in collecting family history and (3) family history collection was variable and challenging. Family history was documented in either free text or pedigree depending on the perception of its appropriateness during the consultation. This study highlighted the need to improve the approach, documentation and the implementation of family history in the Malaysian primary care settings. Integrating family filing concept with built-in clinical decision support into electronic medical records is a potential solution in ensuring effective family history taking in primary care

Blood pressure control among hypertensive patients with and without diabetes mellitus in six public primary health care clinics in Malaysia

Hypertension is a common comorbidity among diabetic patients. This study aimed to determine blood pressure (BP) control among hypertensive patients with and without diabetes. This was a cross-sectional study in 6 public primary care clinics in Wilayah Persekutuan, Malaysia. Hypertensive patients aged ≥18 years and attending the clinics were selected via systematic random sampling. The BP control target was defined as <130/80 mm Hg for diabetic patients and <140/90 mm Hg for nondiabetic patients. A total of 1107 hypertensive patients participated in this study and 540 (48.7%) had diabetes. About one fourth (24.3%) of the hypertensive patients with diabetes achieved BP control target, compared with 60.1% patients without diabetes (P < .001). Being diabetic and on ≥2 antihypertensive treatments were associated with poor BP control. Attention needs to be given to these groups of patients when managing patients with hypertension

Reducing medical errors in primary care using a pragmatic complex intervention

This study aimed to develop an intervention to reduce medical errors and to determine if the intervention can reduce medical errors in public funded primary care clinics. A controlled interventional trial was conducted in 12 conveniently selected primary care clinics. Random samples of outpatient medical records were selected and reviewed by family physicians for documentation, diagnostic, and management errors at baseline and 3 months post intervention. The intervention package comprised educational training, structured process change, review methods, and patient education. A significant reduction was found in overall documentation error rates between intervention (Pre 98.3% [CI 97.1-99.6]; Post 76.1% [CI 68.1-84.1]) and control groups (Pre 97.4% [CI 95.1-99.8]; Post 89.5% [85.3-93.6]). Within the intervention group, overall management errors reduced from 54.0% (CI 49.9-58.0) to 36.6% (CI 30.2-43.1) and medication error from 43.2% (CI 39.2-47.1) to 25.2% (CI 19.9-30.5). This low-cost intervention was useful to reduce medical errors in resource-constrained settings

What are the barriers faced by patients using insulin? a qualitative study of Malaysian health care professionals' views

BACKGROUND: Patients with type 2 diabetes often require insulin as the disease progresses. However, health care professionals frequently encounter challenges when managing patients who require insulin therapy. Understanding how health care professionals perceive the barriers faced by patients on insulin will facilitate care and treatment strategies. OBJECTIVE: This study explores the views of Malaysian health care professionals on the barriers faced by patients using insulin. METHODS: Semi-structured qualitative interviews and focus group discussions were conducted with health care professionals involved in diabetes care using insulin. Forty-one health care professionals participated in the study, consisting of primary care doctors (n = 20), family medicine specialists (n = 10), government policymakers (n = 5), diabetes educators (n = 3), endocrinologists (n = 2), and one pharmacist. We used a topic guide to facilitate the interviews, which were audio-recorded, transcribed verbatim, and analyzed using a thematic approach. RESULTS: FIVE THEMES WERE IDENTIFIED AS BARRIERS: side effects, patient education, negative perceptions, blood glucose monitoring, and patient adherence to treatment and follow-up. Patients perceive that insulin therapy causes numerous negative side effects. There is a lack of patient education on proper glucose monitoring and how to optimize insulin therapy. Cost of treatment and patient ignorance are highlighted when discussing patient self-monitoring of blood glucose. Finally, health care professionals identified a lack of a follow-up system, especially for patients who do not keep to regular appointments. CONCLUSION: This study identifies five substantial barriers to optimizing insulin therapy. Health care professionals who successfully identify and address these issues will empower patients to achieve effective self-management. System barriers require government agency in establishing insulin follow-up programs, multidisciplinary diabetes care teams, and subsidies for glucometers and test strips

Translation, adaptation and pilot testing of the Pictorial Fit-Frail Scale (PFFS) for use in Malaysia – The PFFS-Malay version (PFFS-M)

Background: Frailty is an important health issue in an aging population; it is a state of vulnerability that renders the elderly susceptible to adverse health outcomes, including disability, hospitalization, long-term care admission and death. Early frailty stages are recognizable through screening and are reversible with targeted interventions. To date, however, there is no screening tool for use in Malaysia. The English Pictorial Fit-Frail Scale (PFFS) is a visual tool that assesses a person’s fitness-frailty level in 14 health domains, with higher scores indicating higher frailty. Objective: The aim was to translate and adapt the English PFFS for use in Malaysian clinical settings. Methods: The original English PFFS underwent forward and backward-translation by two bilingual translators to and from the Malay language. A finalized version, the PFFS-Malay (PFFS-M), was formed after expert reviewers’ consensus and was pilot tested with 20 patients, 20 caregivers, 16 healthcare assistants, 17 nurses and 22 doctors. Score agreement between patients and their caregivers and among healthcare professionals were assessed. All participants rated their understanding of the scale using the feasibility survey forms. Results: A total of 95 participants were included. There were high percentages of scoring agreements among all participants on the scale (66.7% to 98.9%). Overall feedback from all respondents were positive and supported the face validity of the PFFS-M. Conclusion: The PFFS-M reflects an accurate translation for the Malaysian population. The scale is usable and feasible and has face validity. Reliability and predictive validity assessments of the PFFS-M are currently underway

The Pictorial Fit-Frail Scale Malay Version (PFFS-M): Predictive Validity Testing in Malaysian Primary Care

The purpose of this study was to evaluate the association between Pictorial Fit Frail Scale-Malay version (PFFS-M) and adverse outcomes,such as falls, new disability, hospitalisation, nursing home placement,and/or mortality, in patients aged 60 and older attending Malaysian public primary care clinics. We assessed the baseline PFFS-M levels of 197 patients contactable by phone at 18 months to determine the presence of adverse outcomes. 26 patients (13.2%) reported at least one adverse outcome, including five (2.5%) who fell, three (1.5%) who became disabled and homebound, 15 (7.6%) who were hospitalized, and three (1.5%) who died. Using binary multivariable logistic regression adjusted for age and gender, we found that patients who were at-risk of frailty and frail at baseline were associated with 5.97(95% CI [1.89- 18.91]; P=0.002) and 6.13 (95% CI [1.86-20.24]; P= 0.003) times higher risk of developing adverse outcomes at 18 months,respectively, than patients who were not frail. The PFFS-M was associated with adverse outcomes

Hajj health examination for pilgrims with asthma in Malaysia:An ethnographic study

BACKGROUND: Asthma was one of the top causes of hospitalization and unscheduled medical attendances due to acute exacerbations and its complications. In Malaysia, all pilgrims must undergo a mandatory health examination and certified fit to perform pilgrimage. We studied the current organisational and clinical routines of Hajj health examination in Malaysia with a focus on the delivery of care for pilgrims with asthma. METHODS: We conducted non-participant observation to obtain ethnographic understanding of Hajj health examination activities for 2019. Observations were guided by a checklist and recorded as notes that were analysed thematically. The study was conducted at 11 public (from each region in Malaysia, namely, North, South, East, West of Peninsular Malaysia, and Sabah and Sarawak of East Malaysia) and two private primary care clinics. RESULTS: We observed considerable variation in the implementation and practice of Hajj health examinations among the 11 public clinics but no marked variation among the private clinics. The short time span of between three to four months was inadequate for disease control measures and had put pressure on health care providers. They mostly viewed the Hajj health examination as merely a certification of fitness to perform the pilgrimage, though respiratory health assessment was often inadequate. The opportunity to optimise the health of pilgrims with asthma by providing the appropriate medications, asthma action plan and asthma education including the preventive measures was disregarded. The preliminary health screening, which aimed to optimise pilgrims’ health before the actual Hajj health examination was not appreciated by either pilgrims or health care providers. CONCLUSIONS: There is great potential to reform the current system of Hajj health certification in order to optimise its potential benefits for pilgrims with asthma. A systematic approach to restructuring the delivery of Hajj health examination could address the time constraints, clinical competency of primary health care providers and resources limitations