การพัฒนาและทดสอบความเชื่อมั่นของเครื่องมือในการประเมินแผลกดทับ บนพื้นฐานทางการแพทย์แผนไทย Development and Reliability Testing of an Assessment Tool for Pressure Ulcers Based on Thai Traditional Medicine

วัตถุประสงค์: เพื่อพัฒนาเครื่องมือในการประเมินแผลกดทับทางการแพทย์แผนไทย และเพื่อทดสอบความเชื่อมั่นของเครื่องมือระหว่างผู้ประเมิน วิธีการศึกษา: แบ่งเป็น 4 ขั้นตอน ได้แก่ 1) บันทึกประสบการณ์การประเมินแผลกดทับทางการแพทย์แผนไทย 2) สังเกตการรักษาแผลกดทับในผู้ป่วย 24 ราย สังเกตและวิเคราะห์ลักษณะของแผลกดทับ 47 แผล เพื่อเป็นชุดข้อมูลสำหรับใช้พัฒนาเครื่องมือ 3) เปรียบเทียบลักษณะของแผลกดทับที่ใช้ในทางการแพทย์แผนไทยและการแพทย์แผนปัจจุบัน ลักษณะแผลที่มีความเป็นวัตถุวิสัยและเข้าคู่กันได้ทั้งทางการแพทย์แผนไทยและการแพทย์แผนปัจจุบันจะถูกคัดเลือกเพื่อใช้ในเครื่องมือประเมิน 4) ทดสอบความเชื่อมั่นของเครื่องมือระหว่างผู้ประเมิน จากผู้ประเมิน 17 คน โดยคำนวณจากร้อยละของความเหมือนเปรียบเทียบกับการประเมินโดยผู้เชี่ยวชาญ ร้อยละของความเหมือนโดยรวม และ การใช้สถิติแคปปา ผลการศึกษา: แผลกดทับที่สังเกตได้รับการประเมินทางการแพทย์แผนไทย เป็น แผลวาตะ 37 แผล (ปัญหาของระบบไหลเวียน) และแผลปิตตะ 10 แผล (มีความร้อนที่มากเกินไป) ลักษณะของแผลในทางการแพทย์แผนไทย 8 ลักษณะ เข้าคู่ได้กับกลุ่มลักษณะของแผลทางการแพทย์แผนปัจจุบัน 9 กลุ่ม โดยมีเพียง 4 กลุ่ม ที่เป็นวัตถุวิสัยและถูกคัดเลือกเพื่อใช้ในเครื่องมือประเมินแผลกดทับทางการแพทย์แผนไทย (TTM-PUAT) ได้แก่ 1) โพรงของแผล 2) เนื้อตาย 3) ระดับความรุนแรงของแผล 4) การอักเสบ ผลการประเมินความเชื่อมั่นของเครื่องมือ TTM-PUAT ได้แก่ 78.8% ของความเหมือนเมื่อเปรียบเทียบกับการประเมินโดยผู้เชี่ยวชาญ, 73.09% ของความเหมือนโดยรวม และสถิติแคปปา 0.46 แสดงความเหมือนระดับปานกลาง สรุป: TTM-PUAT เป็นเครื่องมือในการประเมินแผลกดทับ ที่เชื่อมโยงลักษณะของแผลกดทับผ่านมุมมองทางการแพทย์แผนไทยและแผนปัจจุบัน คำสำคัญ: การแพทย์ทางเลือก, การแพทย์ผสมผสาน, เครื่องมือการประเมิน, แผลกดทับAbstract Objective: To develop a tool for pressure ulcer assessment based on Thai traditional medicine (TTM) and to determine interrater reliability of the tool. Method: There were 4 processes to develop the tool for pressure ulcer assessment. First, documentation of an experience of TTM pressure evaluation. Second, observation on pressure ulcers treatment from 24 patients. A total of 47 pressure ulcers were observed and analyzed their characteristics. Observed pressure ulcers data were used to develop the tool. Third, comparisons of wound characteristics recognized by TTM with those of modern medicine. Objective characteristics of TTM matched with modern medicine were selected to use in the tool. Fourth, evaluation of the tool’s interrater reliability by 17 raters. The interrater reliability was calculated by % agreement by expert assessment, % overall agreement and Kappa statistics. Results: Based on TTM, the observed pressure ulcers were assessed as 37 Wata wounds (circulation problems), and 10 Pitta wounds (excessive heat). There were 8 wound characteristics in TTM matched with 9 domains of those in modern medicine. Only four domains were classified as objective characteristics and selected to establish a Thai Traditional Medicine Pressure Ulcer Assessment Tool (TTM-PUAT) inlcuidng 1) undermining, 2) necrotic tissue, 3) pressure ulcer staging and 4) inflammation. The TTM-PUAT showed interrater reliability with 78.8% expert agreement, 73.09% overall agreement, and a moderate agreement with a Kappa coefficient of 0.46. Conclusion: The TTM-PUAT is an assessment tool for pressure ulcer based on TTM that link characteristic of pressure ulcer through both perspectives of TTM and modern medicine. Keywords: alternative medicine, complementary medicine, assessment tool, pressure ulcer

Performance of Thailand's universal health coverage scheme: Evaluating the effectiveness of annual public hearings.

BACKGROUND: Legislative provisions in Thailand's National Health Security Act 2002 mandate annual public hearings for providers, beneficiaries and other stakeholders in order to improve the performance of the Universal Health Coverage Scheme (UCS). OBJECTIVE: This study aims to explore the annual public hearing process, evaluate its effectiveness and propose recommendations for improvement. METHOD: In-depth interviews were conducted with 29 key informants from various stakeholder groups involved in annual public hearings. RESULTS: The evaluation showed that the public hearings fully met the criteria of influence over policy decision and partially met the criteria of appropriate participation approach and social learning. However, there are rooms for improvement on public hearing's inclusiveness and representativeness of participants, adequacy of information and transparency. CONCLUSIONS: Three recommendations were proposed a) informing stakeholders in advance of the agenda and hearing process to enable their active participation; b) identifying experienced facilitators to navigate the discussions across stakeholders with different or conflicting interests, in order to reach consensus and prioritize recommendations; and c) communicating policy and management responses as a result of public hearings to all stakeholders in a timely manner

Participatory and responsive governance in universal health coverage: an analysis of legislative provisions in Thailand.

Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met. In Thailand, UHC constitutes of three public insurance schemes: Civil Servant Medical Benefit Scheme, Social Health Insurance and Universal Coverage Scheme. Each scheme is governed through individual laws. This study aimed to identify, analyse and compare the legislative provisions related to participatory and responsive governance within the three public health insurance schemes and draw lessons that can be useful for other low-income and middle-income countries in their legislative process for UHC. The legislative provisions in each policy document were analysed using a conceptual framework derived from key literature. The results found that overall the UHC legislative provisions promote citizen representation and involvement in UHC governance, implementation and management, support citizens' ability to voice concerns and improve UHC, protect citizens' access to information as well as ensure access to and provision of quality care. Participatory governance is legislated in 33 sections, of which 23 are in the Universal Coverage Scheme, 4 in the Social Health Insurance and none in the Civil Servant Medical Benefit Scheme. Responsive governance is legislated in 24 sections, of which 18 are in the Universal Coverage Scheme, 2 in the Social Health Insurance and 4 in the Civil Servant Medical Benefit Scheme. Therefore, while several legislative provisions on both participatory and responsive governance exist in the Thai UHC, not all schemes equally bolster citizen participation and government responsiveness. In addition, as legislations are merely enabling factors, adequate implementation capacity and commitment to the legislative provisions are equally important

Developing a Thai national critical care allocation guideline during the COVID-19 pandemic: a rapid review and stakeholder consultation.

BACKGROUND: At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. METHODS: The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. RESULTS: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay. CONCLUSIONS: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries

Prioritizing critical-care resources in response to COVID-19: lessons from the development of Thailand's Triage protocol.

As COVID-19 ravages the world, many countries are faced with the grim reality of not having enough critical-care resources to go around. Knowing what could be in store, the Thai Ministry of Public Health called for the creation of an explicit protocol to determine how these resources are to be rationed in the situation of demand exceeding supply. This paper shares the experience of developing triage criteria and a mechanism for prioritizing intensive care unit resources in a middle-income country with the potential to be applied to other low- and middle-income countries (LMICs) faced with a similar (if not more of a) challenge when responding to the global pandemic. To the best of our knowledge, this locally developed guideline would be among the first of its kind from an LMIC setting. In summary, the experience from the Thai protocol development highlights three important lessons. First, stakeholder consultation and public engagement are crucial steps to ensure the protocol reflects the priorities of society and to maintain public trust in the health system. Second, all bodies and actions proposed in the protocol must not conflict with existing laws to ensure smooth implementation and adherence by professionals. Last, all components of the protocol must be compatible with the local context including medical culture, physician-patient relationship, and religious and societal norms