Prescribing patterns for upper respiratory tract infections : a prescription-review of primary care practice in Kedah, Malaysia and the implications

Introduction and aims: It is necessary to ascertain current prescribing of antibiotics for upper respiratory tract infections (URTIs) to address potential overuse. A retrospective analysis was conducted of all prescriptions for URTIs among ten public primary healthcare centres in Kedah, Malaysia from 1st January to 31st March 2014. Results: A total of 123,524 prescriptions were screened and analysed. Of these, 7129 prescriptions were for URTI, with 31.8% (n=2269) containing antibiotics. Macrolides were the most commonly prescribed antibiotic constituting 61% (n=1403) of total antibiotics prescribed. There was a statistically significant association between different prescribers and diagnoses (p=0•001) and a weak positive trend suggesting family medicine specialists are more competent in antibiotic prescribing, followed by medical officers and assistant medical officers (τ=0•122).. Conclusions: Prescribing practices of some prescribers were inconsistent with current guidelines encouraging resistance development. National antimicrobial stewardship programmes and further educational initiatives are ongoing in Malaysia to improve antibiotic us

Are new models needed to optimize the utilization of new medicines to sustain healthcare systems?

Medicines have made an appreciable contribution to improving health. However, even high-income countries are struggling to fund new premium-priced medicines. This will grow necessitating the development of new models to optimize their use. The objective is to review case histories among health authorities to improve the utilization and expenditure on new medicines. Subsequently, use these to develop exemplar models and outline their implications. A number of issues and challenges were identified from the case histories. These included the low number of new medicines seen as innovative alongside increasing requested prices for their reimbursement, especially for oncology, orphan diseases, diabetes and HCV. Proposed models center on the three pillars of pre-, peri- and post-launch including critical drug evaluation, as well as multi-criteria models for valuing medicines for orphan diseases alongside potentially capping pharmaceutical expenditure. In conclusion, the proposed models involving all key stakeholder groups are critical for the sustainability of healthcare systems or enhancing universal access. The models should help stimulate debate as well as restore trust between key stakeholder groups

Cost effectiveness analysis of erythropoietin therapy in the ministry of health dialysis programme

End-stage renal failure patients are normally anaemic due to failure of renal to produce endogenous erythropoietin (EPO). Erythropoietin is used to treat anaemia in these patients but the drug is expensive. The drug is also used in cancer and thalassemia patients and it makes EPO in high demand and thus increasing the budget for the government. The objectives of this study were to determine the life expectancy, the improvement in haemoglobin levels of anaemic patients associated with EPO therapy, the improvement in quality of life associated with haemoglobin, the utility oi the dialysis patients, the additional costs associated with EPO therapy and the cost effectiveness of MOH dialysis program, measured as cost per quality-adjusted life year saved. The instruments used for health-related quality of life questionnaires were EQ- 50 and Spitzer's quality of life index, and also the time trade-off method. The costs were valued in terms of year 2004 RM. The National Renal Registry (NRR) database for period 1997- 2004 formed the basis of patient selection, where data was not available the NRR database was used as the sampling frame to obtain the list of patients for the survey. Erythropoietin therapy improved the mean haemoglobin level of anaemic haemodialysis patients by 9.39% (8.97 g/dl to 9.81 g/dl) and CAPO patients 8.48% (8.96 g/dl to 9.72 g/dl) at the range of 8 to 1 0 g/dl. Mean dose of EPO prescribed at baseline haemoglobin level between 8 to 10 g/dl was 4679 U per week for haemodialysis patients and 44 77 U per week for CAPO patients. The mean cost to raise 1 g/dl haemoglobin per patient per year was RM527 4 for haemodialysis patients and RM4887 for CAPO patients at same haemoglobin levels. Overall life expectancy on dialysis was 10.13 years with superior life expectancy for haemodialysis (11.37 years) compared to CAPO. (7.94 years). Age at commencement of dialysis, diabetic status, haemoglobin level, albumin level and dialysis modality were significant predictors of life expectancy. Quality of life of CAPO patients was higher among the dialysis patients (0.79 to 0.93) of perfect health equivalent compared to haemodialysis patients (0.79 to 0.89) of perfect health equivalent. The cost of dialysis was RM33,958 for haemodialysis and RM33,243 for CAPO per patient per year. The cost per quality-adjusted life years was RM43,000 for haemodialysis and • RM41 ,000 for CAPO. The incremental QAL Ys gained for haemodialysis and CAPO patients at ha~moglobin baseline were 2.04 and 0.27, respectively. The incremental cost per QALY gained of EPO was RM66,000 and RM137,000 for haemodialysis and CAPO patients, respectively at the same average baseline haemoglobin level between 8 g/dl and 10 g/dl. In conclusion, haemodialysis is more cost effective modality with the current state of utilisation of EPO therapy. Keywords: Haemodialysis, Continuous Ambulatory Peritoneal Dialysis, Erythropoietin, Anaemia, Cost-effectiveness, Quality of Life, TTO, Qualityadjusted Life Years, Ministry of Healt

Development and Practical Application of a Multiple-Criteria Decision Analysis Framework on Respiratory Inhalers: Is It Always Useful in the MOH Malaysia Medicines Formulary Listing Context?

Objectives. The current health technology assessment used to evaluate respiratory inhalers is associated with limitations that have necessitated the development of an explicit formulary decision-making framework to ensure balance between the accessibility, value, and affordability of medicines. This study aimed to develop a multiple-criteria decision analysis (MCDA) framework, apply the framework to potential and currently listed respiratory inhalers in the Ministry of Health Medicines Formulary (MOHMF), and analyze the impacts of applying the outputs, from the perspective of listing and delisting medicines in the formulary. Methods. The overall methodology of the framework development adhered to the recommendations of the ISPOR MCDA Emerging Good Practices Task Force. The MCDA framework was developed using Microsoft Excel 2010 and involved all relevant stakeholders. The framework was then applied to 27 medicines, based on data gathered from the highest levels of available published evidence, pharmaceutical companies, and professional opinions. The performance scores were analyzed using the additive model. The end values were then deliberated by an expert committee. Results. A total of eight main criteria and seven subcriteria were determined by the stakeholders. The economic criterion was weighted at 30%. Among the noneconomic criteria, “patient suitability” was weighted the highest. Based on the MCDA outputs, the expert committee recommended one potential medicine (out of three; 33%) be added to the MOHMF and one existing medicine (out of 24; 4%) be removed/delisted from the MOHMF. The other existing medicines remained unchanged. Conclusions. Although this framework was useful for deciding to add new medicines to the formulary, it appears to be less functional and impactful for the removal/delisting existing medicines from the MOHMF. The generalizability of this conclusion to other formulations remains to be confirmed

Pharmaceutical care issues identified by pharmacists in patients with diabetes, hypertension or hyperlipidaemia in primary care settings

<p>Abstract</p> <p>Background</p> <p>The roles of pharmacists have evolved from product oriented, dispensing of medications to more patient-focused services such as the provision of pharmaceutical care. Such pharmacy service is also becoming more widely practised in Malaysia but is not well documented. Therefore, this study is warranted to fill this information gap by identifying the types of pharmaceutical care issues (PCIs) encountered by primary care patients with diabetes mellitus, hypertension or hyperlipidaemia in Malaysia.</p> <p>Methods</p> <p>This study was part of a large controlled trial that evaluated the outcomes of multiprofessional collaboration which involved medical general practitioners, pharmacists, dietitians and nurses in managing diabetes mellitus, hypertension and hyperlipidaemia in primary care settings. A total of 477 patients were recruited by 44 general practitioners in the Klang Valley. These patients were counselled by the various healthcare professionals and followed-up for 6 months.</p> <p>Results</p> <p>Of the 477 participants, 53.7% had at least one PCI, with a total of 706 PCIs. These included drug-use problems (33.3%), insufficient awareness and knowledge about disease condition and medication (20.4%), adverse drug reactions (15.6%), therapeutic failure (13.9%), drug-choice problems (9.5%) and dosing problems (3.4%). Non-adherence to medications topped the list of drug-use problems, followed by incorrect administration of medications. More than half of the PCIs (52%) were classified as probably clinically insignificant, 38.9% with minimal clinical significance, 8.9% as definitely clinically significant and could cause patient harm while one issue (0.2%) was classified as life threatening. The main causes of PCIs were deterioration of disease state which led to failure of therapy, and also presentation of new symptoms or indications. Of the 338 PCIs where changes were recommended by the pharmacist, 87.3% were carried out as recommended.</p> <p>Conclusions</p> <p>This study demonstrates the importance of pharmacists working in collaboration with other healthcare providers especially the medical doctors in identifying and resolving pharmaceutical care issues to provide optimal care for patients with chronic diseases.</p