Systematic review of adherence to direct oral anticoagulants in patients with atrial fibrilation in clinical practice

Direct oral anticoagulants (DOACs), such as dabigatran and rivaroxaban, have in the past decade replaced vitamin k antagonists (VKAs), such as warfarin, as standard treatment for thrombosis prophylaxis and stroke prevention in patients with atrial fibrillation (AF). Adherence to DOACs is crucial to optimise clinical outcomes in patients with AF. The aim of this review is to systematically evaluate published evidence describing adherence to DOACs in patients with AF in real world clinical practice. A systematic search combining terms for direct oral anticoagulants, atrial fibrilation and relevant adherence measurement tools was conducted in PubMed in March 2018 to identify related English language publications. All observational cohort studies that assessed adherence of DOACs in patients with AF by using healthcare institution databases, including pharmacy records, medical claims datasets, and other relevant data were reviewed for inclusion. Data describing study characteristics and adherence profile were extracted and summarised using qualitative methods. The PubMed search identified 278 citations. After screening the titles and abstracts, full articles were obtained for 36 articles and of these, 22 articles were included. These 22 studies involved around 300,000 AF patients, described the adherence of DOACs in clinical practice in the United States, Europe, and Turkey and were published between 2013 to 2018. Proportion of days covered (PDC) was the most commonly used tool for adherence measurement followed by medicine possession ratio (MPR). Adherence to DOACs was found to be good in most studies, defined as PDC ≥80% and MPR ≥80%. While these published evidence indicated that adherence to DOACs in real world clinical practice is generally good, clinical outcomes can be optimised by identifying AF patients with sub-optimal adherence and developing interventions to improve adherence in these patients within clinical practice

Productivity losses and its associated factors among end stage renal disease patients receiving dialysis treatment in Kuantan, Pahang

Introduction: In Malaysia, the economic burden of end stage renal disease (ESRD) patients receiving haemodialysis (HD) and peritoneal dialysis (PD) treatment, in terms of productivity loss from the societal perspectives, is unknown. Thus, this study intended to investigate the extent of productivity losses of these patients and factors associated with productivity losses. Methodology: A multi-centre, cross-sectional study was conducted between September 2019 and February 2020 in Kuantan, Pahang. Time loss due to dialysis treatment was measured among working-age ESRD patients and was multiplied with the gross national income for the year 2020 to estimate productivity losses. Factors associated with productivity loss was determined using multivariate regression analyses. Results: Among 284 working-age ESRD patients receiving dialysis treatment, 27.8% (n=79) were in paid employment while 48.9% (n=139) were on unpaid work. The productivity loss of HD patients was significantly higher than that of PD patients (MYR 11,968.93 versus MYR 7,214.92 per patient-year, p<0.05). The annual productivity losses at the local level were MYR2.34 million, and the estimated annual productivity losses at the state and national level were MYR12 million and MYR 234 million, respectively. HD treatment, post-dialysis side effects, post-dialysis recovery period and iron administration were significantly associated with a higher productivity loss (p<0.05). Conclusion: This study applauds the national strategic policy to increase PD uptake for eligible ESRD patients because PD led to a lower productivity loss compared to HD. Additionally, a proper clinical management policy for anaemic patients and patients suffering from post-dialysis side effects requiring post-dialysis recovery may improve productivity for ESRD patients

Estimating the population size of people who inject drugs in Malaysia for 2014 and 2017 using the benchmark-multiplier method

Background: As hepatitis C elimination efforts are launched, national strategies for screening and treatment scale-up in countries, such as Malaysia, must be designed and implemented. Strategic information, including estimates of the total number of patients chronically-infected with hepatitis C virus (HCV) and the size of key populations, such as people who inject drugs (PWID), is critical to informing these efforts. For Malaysia, the estimate of the PWID population size most frequently reported in global systematic reviews is for the year 2009. Objectives: To support ongoing national HCV planning efforts, we aimed to estimate the national population size of active PWID in Malaysia, for the years 2014 and 2017. Methods: To estimate the PWID population size, we applied standard benchmark-multiplier methodology, frequently used for PWID population size estimation, and extended it by adjusting for cessation of injecting drug use within the benchmark and calculating statistical uncertainty intervals. Results: The estimated active PWID population size was 153,000 (95% uncertainty interval (UI): 136,000-172,000) for 2014 and 156,000 (95% UI: 137,000-188,000) for 2017. Conclusions/importance: This updated estimate of the active PWID population size in Malaysia will help inform effective planning for the scale-up of HCV screening and treatment services. The proposed methodology is applicable to other countries that maintain national HIV registries and have conducted Integrated Biological and Behavioral Surveys among active PWID

Assessing adherence and persistence to non-vitamin k antagonist oral anticoagulants (NOACs) among patients with atrial fibrillation in tertiary-care referral centers in Malaysia

Introduction: Non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran and rivaroxaban, are now available for stroke prevention in patients with atrial fibrillation (AF) and are often clinically preferred over vitamin K antagonists (VKAs), such as warfarin. Data describing adherence and persistence to NOACs in real-life clinical practice in Malaysia are scarce. This study aimed to assess adherence and persistence to NOACs in patients with AF in two tertiary-care referral centers: Hospital Kuala Lumpur (HKL) and Hospital Serdang (HSDG). Materials and Methods: This was a retrospective cohort study that included all patients with AF who were treated with NOACs (dabigatran or rivaroxaban) in HKL and HSDG. Data were obtained from medical records and pharmacy databases. Adherence was assessed using proportion of days covered (PDC) over a 1-year duration. High adherence was defined as PDC ≥80%. A gap of >60 days between two consecutive refills was used to define non-persistence. Result: There were 281 patients who met the inclusion criteria, with 54.1% (n = 152) male. There were 75.1% (n = 211) patients on dabigatran and others on rivaroxaban. Only 66.9% (n = 188) of patients achieved high adherence with PDC ≥80% and 69.8% (n = 196) were persistence with >60-day gap over 12 months. Adherence and persistence were both influenced by treatment center, whereas polypharmacy only influenced adherence. Conclusion: Overall adherence and persistence to NOACs were suboptimal and varied between treatment centers, potentially due to institution-specific administrative and clinical practice differences. Clinical care and outcomes can potentially be optimized by identifying factors affecting adherence and persistence and by implementing interventions to improving the

Assessing adherence to direct oral anticoagulants (DOACs) among patients with atrial fibrillation in tertiary-care referral centers in Malaysia

INTRODUCTION Direct oral anticoagulants (DOACs), such as dabigatran and rivaroxaban, are now available for stroke prevention in patients with atrial fibrillation (AF) and are often clinically preferred over vitamin K antagonists (VKAs), such as warfarin. Data describing adherence to DOACs in real-life clinical practice in Malaysia are scarce. OBJECTIVES This study aimed to assess adherence to DOACs in patients with AF at Hospital Kuala Lumpur (HKL) and Hospital Serdang (HSDG), tertiary-care referral centers. METHODOLOGY This was a retrospective cohort study that included all AF patients who were treated with DOACs (dabigatran or rivaroxaban) in HKL and HSDG. Data were obtained from medical records and pharmacy database. Adherence was assessed by using proportion of days covered (PDC) over a 1-year duration and was calculated as the number of days that the medication was on hand over the total number of days in the time period. Good adherence was defined as PDC ≥80% RESULTS There were 281 patients who met the inclusion criteria, male 54.1% (n=152), with 75.1% (n=211) patients on dabigatran and others on rivaroxaban. The ethnic distribution was Chinese 49.8% (n=140), Malay 41.6% (n=117), and Indian 8.5% (n=24). Only 66.9% of patients achieved good adherence with PDC ≥ 80%. Adherence by institution was good in HKL with 85.2% (n=69/81) but poor in HSDG with 59.5% (n=119/200) [p<0.05]. CONCLUSION Overall adherence to DOACs was poor but it varied between institutions, potentially due to institution-specific administrative and clinical practice differences. Clinical care can potentially be optimized by identifying factors affecting adherence and implementing adherence-improving interventions

Projections of the healthcare costs and disease burden due to hepatitis C infection under different treatment policies in Malaysia, 2018-2040

The World Health Organisation (WHO) has set ambitious goals to reduce the global disease burden associated with, and eventually eliminate, viral hepatitis

Projections of the current and future disease burden of hepatitis C virus infection in Malaysia

The prevalence of hepatitis C virus (HCV) infection in Malaysia has been estimated at 2.5% of the adult population. Our objective, satisfying one of the directives of the WHO Framework for Global Action on Viral Hepatitis, was to forecast the HCV disease burden in Malaysia using modelling methods.An age-structured multi-state Markov model was developed to simulate the natural history of HCV infection. We tested three historical incidence scenarios that would give rise to the estimated prevalence in 2009, and calculated the incidence of cirrhosis, end-stage liver disease, and death, and disability-adjusted life-years (DALYs) under each scenario, to the year 2039. In the baseline scenario, current antiviral treatment levels were extended from 2014 to the end of the simulation period. To estimate the disease burden averted under current sustained virological response rates and treatment levels, the baseline scenario was compared to a counterfactual scenario in which no past or future treatment is assumed.In the baseline scenario, the projected disease burden for the year 2039 is 94,900 DALYs/year (95% credible interval (CrI): 77,100 to 124,500), with 2,002 (95% CrI: 1340 to 3040) and 540 (95% CrI: 251 to 1,030) individuals predicted to develop decompensated cirrhosis and hepatocellular carcinoma, respectively, in that year. Although current treatment practice is estimated to avert a cumulative total of 2,200 deaths from DC or HCC, a cumulative total of 63,900 HCV-related deaths is projected by 2039.The HCV-related disease burden is already high and is forecast to rise steeply over the coming decades under current levels of antiviral treatment. Increased governmental resources to improve HCV screening and treatment rates and to reduce transmission are essential to address the high projected HCV disease burden in Malaysia

The Burden of Out-of-Pocket Expenditure Related to Gynaecological Cancer in Malaysia

This study aimed to estimate the economic burden on gynaecological cancer patients and their households, in terms of out-of-pocket expenditure, catastrophic health expenditure (CHE) and poverty impact. A cross-sectional study was conducted at an academic tertiary-care health centre in an upper-middle-income country. Data were obtained via structured interviews of 120 gynaecological cancer patients alongside review of medical charts. Mean (SD) and median (IQR) annual household out-of-pocket expenditures were USD 2780 (SD = USD 3926) and USD 1396 (IQR = 3013), respectively. Two thirds (n = 77/120, 64%) of households experienced CHE and 17% (n = 20/120) were impoverished due to out-of-pocket expenditure related to gynaecological cancer. Factors associated with CHE, explored using multivariate logistic regression analysis, estimated that the highest income quintile households, Q5, were 90% less likely to incur CHE compared to the lowest income quintile households, Q1 (adjusted odds ratio = 0.100; p-value &lt; 0.05) and that patients who were not receiving chemotherapy were 88% less likely to incur CHE compared to those receiving chemotherapy (adjusted odds ratio = 0.120; p-value &lt; 0.05). These results indicate the necessity to broaden the coverage of existing financial assistance for patients from low- and middle-income households, such as extending coverage to adult patients of all ages and to those treated in all public hospitals, including academic health centres