Malaysian Clinical Practice Guidelines Research Articles

Baseline treatments and metabolic control of 288,913 type 2 diabetes patients in a 10-year retrospective cohort in Malaysia

Diabetes is one of the quickest-growing global health emergencies of the twenty-first century, and data-driven care can improve the quality of diabetes management. We aimed to describe the formation of a 10-year retrospective open cohort of type 2 diabetes patients in Malaysia. We also described the baseline treatment profiles and HbA1c, blood pressure, and lipid control to assess the quality of diabetes care. We used 10 years of cross-sectional audit datasets from the National Diabetes Registry and merged 288,913 patients with the same identifying information into a 10-year open cohort dataset. Treatment targets for HbA1c, blood pressure, LDL-cholesterol, HDL-cholesterol, and triglycerides were based on Malaysian clinical practice guidelines. IBM SPSS Statistics version 23.0 was used, and frequencies and percentages with 95% confidence intervals were reported. In total, 288,913 patients were included, with 62.3% women and 54.1% younger adults. The commonest diabetes treatment modality was oral hypoglycaemic agents (75.9%). Meanwhile, 19.3% of patients had ≥ 3 antihypertensive agents, and 71.2% were on lipid-lowering drugs. Metformin (86.1%), angiotensin-converting enzyme inhibitors (49.6%), and statins (69.2%) were the most prescribed antidiabetic, antihypertensive, and lipid-lowering medications, respectively. The mean HbA1c was 7.96 ± 2.11, and 31.2% had HbA1c > 8.5%. Only 35.8% and 35.2% attained blood pressure < 140/80 mmHg and LDL-cholesterol < 2.6 mmol/L, respectively. About 57.5% and 52.9% achieved their respective triglyceride and HDL-cholesterol goals. In conclusion, data integration is a feasible method in this diabetes registry. HbA1c, blood pressure, and lipids are not optimally controlled, and these findings can be capitalized as a guideline by clinicians, programme managers, and health policymakers to improve the quality of diabetes care and prevent long-term complications in Malaysia.

Dietary Patterns Associated with Abnormal Glucose Tolerance following Gestational Diabetes Mellitus: The MyNutritype Study.

Abnormal glucose tolerance (AGT), which includes type 2 diabetes and pre-diabetes, is highly prevalent in women post gestational diabetes mellitus (post-GDM). Dietary patterns have been associated with the risk of developing AGT in women post-GDM, but evidence in Asian populations is sparse. This study aimed to determine the association between a posteriori dietary patterns and AGT in women post-GDM. This cross-sectional study recruited 157 women post-GDM (mean age 34.8 years) from Seri Kembangan Health Clinic and Universiti Putra Malaysia. AGT was diagnosed according to the Malaysian Clinical Practice Guidelines using a 75 g 2 h oral glucose tolerance test or HbA1c. Food intake was assessed using the 2014 Malaysian Adult Nutrition Survey food frequency questionnaire. Five dietary patterns were derived using principal component analysis: 'Unhealthy', 'Fish-eggs-fruits-vegetables', 'Cereals-confectionaries', 'Legumes-dairy', and 'Meat-sugar-sweetened-beverages'. After adjusting for sociodemographic characteristics and total energy intake, the 'Cereals-confectionaries' dietary pattern was significantly associated with AGT (adjusted odds ratio 1.536, p = 0.049). Targeted lifestyle modification, including dietary intervention, for women post-GDM is warranted to reduce their risk of AGT and its complications.

Frequency and predictors of inappropriate medication dosages for cardiovascular disease prevention in chronic kidney disease patients: A retrospective cross-sectional study in a Malaysian primary care clinic

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular events. This study aimed to assess the frequency of inappropriate medication dosages (IMD) for cardiovascular disease prevention among patients with CKD and its predictors in an urban academic primary care clinic in Selangor, Malaysia. All patients who attended the clinic from April to June 2019 and fulfilled the inclusion criteria were included in this cross-sectional study, except for those with an estimated glomerular filtration rate (eGFR) of more than 90 ml/min, diagnosed with urinary tract infection, pregnant or were on dialysis for end stage renal disease. Their prescriptions on the electronic medical record (EMR) system were evaluated for appropriateness using the dose adjustment recommendations based on the 2018 Malaysian Clinical Practice Guidelines on management of CKD. A total of 362 medical records were included in this study. 16.6% (95% Confidence Interval [CI]: 12.9–20.8) or 60 out of 362 of the patient records analysed contained medications prescribed with inappropriate dosages. Patients with higher stages of CKD were associated with higher odds of IMD, namely CKD stage G3b (adjusted Odds Ratio [aOR] 10.41; 95% CI: 2.31–46.88) and CKD stage 4–5 (aOR 15.76; 95% CI: 3.22–77.28). Other predictors of IMD were diagnosis of diabetes mellitus (aOR 6.40; 95% CI: 2.15–19.01), number of prescribed medications of 5 or more (aOR 4.69; 95% CI: 1.55–14.20), and eGFR reduction of more than 25% over one year (aOR 2.82; 95% CI: 1.41–5.65). Within the limitations of this study, we conclude that the occurrence of IMD for CVD prevention was low in CKD patients in this primary care clinic. Medications with inappropriate dosages identified in this study include simvastatin, fenofibrate, hydrochlorothiazide, spironolactone, metformin, gliclazide, sitagliptin, dapagliflozin and empagliflozin. Clinicians should consider the predictors of inappropriate medication dosages listed above when prescribing to patients with CKD to reduce the risk of medications-related toxicities and adverse effects. Limitations of this study should be considered when interpreting the findings presented.

PS-P03-1: THE EFFECTIVENESS OF SHORT EDUCATIONAL VIDEOS ON PROPER HOME BLOOD PRESSURE MONITORING KNOWLEDGE AMONG MEDICAL STUDENTS: A PILOT STUDY

Objective: Hypertension is a major global public health problem. It is often poorly controlled leading to many health complications. The use of home blood pressure monitoring (HBPM) is an effective tool for assisting clinicians in diagnosing and managing patients with hypertension. HBPM has been proven to improve BP levels for at least twelve months when used in conjunction with co-inventions such as educational interventions or support from health care. Around 15% of those with hypertension are young adults; aged between 18–39 years. Developing hypertension at a young age puts this group at risk of earlier onset cardiovascular events. Challenges in treating hypertension in young adults include the perception that it is a disorder for older people; lack of health education; shortage of suitable educational materials; and limited health resources. Short videos are one of the ways to address this problem. Hence, this study aimed to determine the effectiveness of short videos on knowledge of HBPM among medical students. Design and method: This is a pre-post interventional pilot study. It was done among 13 first year medical students in the Universiti Putra Malaysia from January to April 2022. The students were given a two-part online questionnaire on HBPM pre and immediately post intervention. The questionnaire was adapted from the Malaysian clinical practice guidelines on the management of hypertension and content validation was done by a panel of experts. It consisted of 20 questions, with one point for each correct answer. A higher score indicates better knowledge. The intervention consists of three short 1 minute videos on (1) things to avoid before taking blood pressure, (2) how to take proper HBPM and (3) how to take proper BP. Results: Thirteen students took part in the study. Most of the respondents were female n = 10, 76.9% and Malay ethnicity n = 12, 92.%, and mostly family income of &lt;RM2000 (approximately USD 460); n = 6,46.2%. There were 30.8% that practised monitoring their own BP and 69.2% assist family members in monitoring their BP. There was a significant increase in the mean knowledge score pre-test, and post-test which was 10.85 (+3.63), and 16.15 (±2.27) respectively (p &lt; 0.001). Conclusions: We found our short educational videos were effective in increasing knowledge of HBPM among first year medical students. This has great potential as an intervention for not only health sciences students but those with a different educational background, and later on to the public.

Comparison of the factors that influence the pattern of procurement and usage of antithrombotic drugs

Antithrombotics are used for many indications in prophylaxis and therapeutic treatment. It is often associated with a higher risk of adverse effects; hence a drug utilization evaluation is essential. The main aim was to describe the utilization of antithrombotic drugs. The specific objectives are to compare the pattern of procurement and usage of antithrombotic drugs, estimate the Defined Daily Dose (DDD), and to compare the usage of antithrombotic drugs with the WHO recommended standard. This was a retrospective study evaluating the utilization of antithrombotics at a public tertiary care hospital in the urban city of Klang Valley, Malaysia. A defined daily dose (DDD) per 1000 inhabitants/day was calculated to estimate patients with thromboembolic disorders receiving standard treatment on a daily basis. Expenditures on all antithrombotic drugs were also assessed. The DDD was examined for correlation with gender, race, and age group. Malaysian Clinical Practice Guideline on the Prevention and Treatment of Venous Thromboembolism was used as a tool to evaluate the quality of prescribing. During the study period, among anticoagulants prescribed, warfarin was the most commonly utilized for treatment and prophylaxis in various disciplines, with 1.82 DDD. Enoxaparin was the second most utilized anticoagulant, with 1.05 DDD, followed by tinzaparin, with 0.39 DDD. For antiplatelet drugs, acetylsalicylic acid was the most utilized antiplatelet with 8.5 DDD followed by clopidogrel (1.42 DDD) and ticlopidine (0.16 DDD). The utilization pattern for all the antithrombotic drugs was in accordance with the WHO DDD guidelines. The pattern of antithrombotic drug procured was based on the demand for the drug supplies. Age, gender, and race weredeterminant factors that influenced the choice of antithrombotic drugs and further affected the antithrombotic drug utilization pattern. Still, additional information regarding patient’s status and concomitant disease condition is needed to establish the impact of utilization of antithrombotics fully. DDD analysis is an excellent practice to be conducted at planned intervals. It is a tool to update the changing or even new pattern of drug usage, which will assist in the justification of rational use of drugs. The mean difference in terms of DDDs of the studied antithrombotic drugs impacts patient demographic characteristics, smokinghistory, presence of atherosclerotic diseases and peripheral artery diseases, comorbidity, patient compliance, and bleeding history. It is useful to evaluate trends and expenditures, which will ultimately avoid untoward adverse effects and unnecessary costs.

Case scenario: Management of major depressive disorder in primary care based on the updated Malaysian clinical practice guidelines.

Major depressive disorder (MDD) is a common but complex illness that is frequently presented in the primary care setting. Managing this disorder in primary care can be difficult, and many patients are underdiagnosed and/or undertreated. The Malaysian Clinical Practice Guidelines (CPG) on the Management of Major Depressive Disorder (MDD) (2nd ed.), published in 2019, covers screening, diagnosis, treatment and referral (which frequently pose a challenge in the primary care setting) while minimising variation in clinical practice.

Association Between Adherence to Clinical Practice Guidelines for Adjuvant Therapy for Breast Cancer and Survival in a Resource-Limited Setting.

PURPOSEAddressing unwarranted clinical variation in oncology practices is expected to lead to improved cancer outcomes. Particularly, the application and impact of treatment guidelines on breast cancer outcomes are poorly studied in resource-limited settings. We measured adherence to a set of locally developed adjuvant treatment guidelines in a middle-income setting. Importantly, the impact of guidelines adherence on survival following breast cancer was determined.METHODSData of 3,100 Malaysian women with nonmetastatic breast cancer diagnosed between 2010 and 2017 were analyzed. Adherence to the Malaysian Clinical Practice Guidelines for Management of Breast Cancer second Edition was measured. Outcomes comprised overall survival and event-free survival.RESULTSGuideline adherence for chemotherapy, radiotherapy, hormonal therapy, and targeted therapy were 61.7%, 79.2%, 85.1%, and 26.2%, respectively. Older age was generally associated with lower adherence to guidelines. Compared with patients who were treated according to treatment guidelines, overall survival and event-free survival were substantially lower in patients who were not treated accordingly; hazard ratios for all-cause mortality were 1.69 (95% CI, 1.29 to 2.22), 2.59 (95% CI, 1.76 to 3.81), 3.08 (95% CI, 1.94 to 4.88), and 4.48 (95% CI, 1.98 to 10.13) for chemotherapy, radiotherapy, hormone therapy, and targeted therapy, respectively. Study inferences remain unchanged following sensitivity analyses.CONCLUSIONOur study findings appear to suggest that adherence to treatment guidelines that have been adapted for resource-limited settings may still provide effective guidance in improving breast cancer outcomes.

Case scenario: Management of major depressive disorder in primary care based on the updated Malaysian clinical practice guidelines

Major depressive disorder (MDD) is a common but complex illness that is frequently presented in the primary care setting. Managing this disorder in primary care can be difficult, and many patients are underdiagnosed and/or undertreated. The Malaysian Clinical Practice Guidelines (CPG) on the Management of Major Depressive Disorder (MDD) (2nd ed.), published in 2019, covers screening, diagnosis, treatment and referral (which frequently pose a challenge in the primary care setting) while minimising variation in clinical practice.

Changes in body mass index, glycosylated hemoglobin A1C, blood pressure, and LDL-cholesterol among type 2 diabetes patients in Malaysia: A population-based longitudinal study.

This study aimed to describe changes in body mass index, glycosylated hemoglobin A1C, blood pressure, and low-density lipoprotein (LDL)-cholesterol among type 2 diabetes patients in Malaysia. A five-year retrospective cohort study was conducted using data from the National Diabetes Registry. Type 2 diabetes patients aged ≥18 years and had ≥2 clinical audits between 2013 and 2017 were included in the analysis. The first audit information formed the baseline characteristics, and the last audit information was used for comparison. Individualized A1C, blood pressure, and LDL-cholesterol goals were adapted from Malaysian Clinical Practice Guidelines on Type 2 Diabetes Management 2020, American Diabetes Association 2020, and European Association for the Study of Diabetes 2019. Of the 18 341 patients, 55.8% were female and 64.9% Malay ethnicity. The baseline mean age was 59.3 ± 10.6 years. During an average of 2.5 person-years of follow-up, the mean body mass index dropped by 0.16 kg/m2 to 27.9kg/m2 , A1C increased by 0.16% to 8.0%, systolic blood pressure increased by 1.4 mm Hg to 136.2 mm Hg, diastolic blood pressure decreased by 1.0 mm Hg to 77.3 mm Hg and LDL-cholesterol reduced by 0.12 mmol/L to 2.79 mmol/L, P < 0.001 for all. Out of eight categories of individualized goals, most patients achieved the A1C goal of ≤8.0%. The new LDL-cholesterol goal of <1.4 mmol/L was least likely to be achieved. The body mass index, A1C, blood pressure, and LDL-cholesterol performance remained suboptimal. Standards of care for these clinical parameters remain to be achieved by the majority of diabetes patients.

A Malaysian Delphi consensus on managing knee osteoarthritis

BackgroundThe 2013 Malaysian Clinical Practice Guidelines on the Management of Osteoarthritis (OA) recommend a linear step-up approach to manage knee OA. However, patients with knee OA often require a multimodal approach to address OA-related pain symptoms and functional limitations. This consensus aimed to provide doctors with an updated set of evidence-based, clinical experience-guided recommendations to manage knee OA.MethodsA multi-speciality expert panel consisting of nine Malaysian physicians from different healthcare settings who manage a diverse OA patient population was convened. Using a combination of the ADAPTE process and modified Delphi method, the panel reviewed current evidence on the management of knee OA and synthesised a set of nine recommendations on the management of knee OA, supported by an algorithm that summarises the consensus’ core messages.ResultsA multimodal intervention strategy is the mainstay of OA management and the choice of any single or multimodal intervention may vary over the course of the disease. Overall, a non-pharmacological core treatment set of patient education, weight loss and exercise is recommended for all patients. When pharmacotherapy is indicated, symptomatic slow-acting drugs for osteoarthritis are recommended at the early stage of disease, and they can be paired with physical therapy as background treatment. Concurrent advanced pharmacotherapy that includes non-steroidal anti-inflammatory drugs, intraarticular injections and short-term weak opioids can be considered if patients do not respond sufficiently to background treatment. Patients with severe symptomatic knee OA should be considered for knee replacement surgery. Management should begin with specific treatments with the least systemic exposure or toxicity, and the choice of treatment should be determined as a shared decision between patients and their team of healthcare providers.ConclusionsThis consensus presents nine recommendations that advocate an algorithmic approach in the management of patients living with knee OA. They are applicable to patients receiving treatment from primary to tertiary care providers in Malaysia as well as other countries.

UNIVERSAL SCREENING FOR GESTATIONAL DIABETES MELLITUS IN ANTENATAL MOTHERS IMPROVES ANTENATAL MANAGEMENT AND OUTCOMES – SINGLE CENTRE EXPERIENCE

This study examined the impact of universal screening in diagnosing and managing gestational diabetes (GDM) amongst antenatal mother and associated neonatal outcomes. It is a single-centre, retrospective study on routinely collected data of antenatal women in Health Clinic Seremban over one year in 2018. All women diagnosed with GDM, who were not known sufferers of type 1 or type 2 diabetes were included in this study. Participants were stratified according to risk factors for GDM to compare the performance of a selective high-risk screening approach to that of universal screening for detecting GDM. Subjects were categorized as high-risk for GDM based on the guidelines recommended by the Malaysian Clinical Practice guidelines. It was found that through universal screening, 246 antenatal mothers were tested positive for GDM out of the 987 of these mothers without prior diabetes, giving a prevalence of 24.9%. If selective screening using traditional risk factors had been employed, 54 (22%) of the antenatal mothers diagnosed with GDM would have been missed. It was established that risk factors for GDM included advancing age, other ethnicities (patients that are not of Malay, Chinese nor Indian ethnicities), obesity, history of abortion or GDM and family history of diabetes mellitus. Neonatal outcomes of those with GDM as compared to those without were similar. This study highlights that universal screening improved GDM detection rates amongst antenatal mothers. The increased detection helped facilitate an earlier intervention which may have contributed to better antenatal management and outcomes for neonates and their mothers.

Malaysian clinical practice guidelines for management of diabetic foot: A synopsis for the primary care physician.

Diabetic foot requires careful attention and coordinated management by a dedicated team. Screening, prevention, adequate assessment, and appropriate referral are crucial to prevent complications. Multimodal treatment and rehabilitation are recommended to ensure a better quality of life and reduction of amputation rate in people with diabetic foot.

The Use of Breast Cancer Survivor Patients as Part of Patient-Centred Education in the Training of Breast Cancer Care Nurses

INTRODUCTION: Breast cancer is the most common cancer worldwide. Patients diagnosed with breast cancer face many psychological and social distress that might affect their quality of life and indirectly might affect the disease outcome. Patient-centred education has been found to have a positive influence on the quality of management and anxiety reduction. A one-day workshop involving breast cancer survivor patients was designed as a preliminary step to improve the quality of care provided by oncology nurses in University Kebangsaan Malaysia Medical Centre (UKMMC). The objectives of the workshop were to train the nurses in providing patient-centred education using breast cancer survivor patients and to implement the breast cancer Malaysian Clinical Practice Guidelines (CPG) recommendation. MATERIALS AND METHODS: One-day workshop was designed to meet specific learning outcomes. The patient education program was introduced with special emphasis on a patientcentred approach through the involvement of breast cancer survivor patients. Twenty-one staff nurses and two breast cancer survivor patients have participated in this workshop. The workshop was conducted by a breast cancer surgeon, oncologist, dietitian, family physician, and medical educators. RESULT: Overall, all participants found the workshop was very useful, particularly with the involvement of breast cancer survivor patients. Sixty – two percent of the participants agreed that the objectives of the workshop were met and 76 % of them found the workshop relevant to their work. CONCLUSION: The involvement of breast cancer survivor patients in this workshop was a valuable learning experience that enhanced the patient-centred approach in medical education.

Metformin Use in Gestational Diabetes: Awareness, Attitude, and Practice among Healthcare Professionals in Malaysia.

Background:Metformin has been added in the Malaysian clinical practice guideline (CPG) as one of the first-line options in the management of gestational diabetes mellitus (GDM); however, the uptake on this practice among healthcare professionals is unknown.Objective:The objective of the study is to determine the awareness, attitude, and practice and their predictors on the use of metformin for GDM among healthcare professionals in Malaysia.Materials and Methods:This was a multicenter, cross-sectional study in three tertiary hospitals in Malaysia. Medical doctors and pharmacists working in several departments were invited to participate in a survey using self-administered questionnaires.Results:From 350 questionnaires distributed, 225 were completed by medical doctors (43.1%), pharmacists (40.4%), and specialists (7.5%). Less than 30% of them were aware on the option of using metformin as one of the first-line agents in GDM. Education level, department, and profession were found to be associated with the awareness level (P = 0.016, P = 0.004, and P = 0.001, respectively). 70.2% of the respondents showed a positive attitude toward metformin use in GDM. Only 64 (28.4%) of the respondents have prescribed/dispensed metformin for GDM before, although more than half will consider doing so in the future. Having postgraduate qualifications increased the likelihood of having a good awareness (odds ratio [OR]: 2.44, 95% confidence interval [CI] 1.23–4.85) and to consider prescribing/dispensing metformin for GDM patients (OR: 2.27, 95% CI 1.08–4.78).Conclusion:Despite a positive attitude toward metformin use in GDM among healthcare professionals in Malaysia, their awareness level on this practice was low as they currently prefer the use of insulin over metformin.

The vital sign and haematological profile of adult dengue fever: a retrospective study

<abstract> Monitoring clinical symptoms of dengue fever based on vital signs and blood profile in each phase of the disease is crucial for the early case detection, and the management of serious cases with adequate care minimizes dengue mortality. To assess changes in vital signs and blood profile in acute dengue infection, the vital signs and haematological parameters of 63 dengue patients were retrospectively analysed between day 3 and day 8 of illness. These patients visited the emergency department and were admitted to Canselor Tunku Muhriz Hospital, Pusat Perubatan Universiti Kebangsaan Malaysia between Jan 2015 and 2016; classification was done according to the World Health Organization and the Malaysian Clinical Practice Guidelines. The data were analysed using SPSS Version 23 and visualized with MATLAB R2020a based on the severity of dengue fever and day of illness. On day 3 of illness, there is a significant trend in heart rate of dengue patients of all categories, with a significant difference of p = 0.030. On day 4 of illness, there is a statistical difference in the platelet (p = 0.028) and white blood cell count (p = 0.019) of dengue female patients in the category with warning signs and severe dengue recovery. On the other hand, there is a significant difference in vital signs namely heart rate, body temperature and diastolic on day 5 of illness, with the p-value of 0.011, 0.019 and 0.016, respectively. On day 6 of dengue illness, there is a significant difference in the heart rate (p = 0.015), systolic (p = 0.006) and diastolic (p = 0.027) in dengue patients of all categories. A significant difference can only be observed in the heart rate (p = 0.011) of all patients and haematocrit (p = 0.023) of female patients on day 7 and 8 of illness, respectively. This paper reports the trend in key signs and blood profile of dengue patients classified according to the latest WHO case description, based on the day of illness. </abstract>

The Quality of Malaysian Clinical Practice Guidelines and Relevance to The Care of Older People

Clinical Practice Guidelines (CPGs) are key instruments in providing the most appropriate decision in the treatment of any disease. CPG was developed to improve health care by increasing the incorporation of evidence-based treatments to reduce the use of unnecessary, ineffective or harmful interventions. This study assessed 5 Malaysian CPGs using Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument which could help the stakeholders to decide if further improvement or modification is needed. AGREE-II is an international instrument that aids in CPG development. It comprises of 23-items under 6 different domains. The κ statistics was used to look for agreement between 3 appraisers across these domains. The relevance of the Malaysian CPG to the care of older people in this study was also assessed using an instrument that have been developed by a previous study (Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions). This instrument evaluated if the guidelines addressed the treatment for older people, the burdens to the patients and caregivers as well as patient-centered aspects such as patients’ preferences and their quality of life. This study showed that all 5 Malaysian CPGs are of good quality and acceptable to clinical settings according to the AGREE instrument. However, it was found that none of the CPG considered patients’ preferences in developing CPGs. In terms of the CPGs’ relevance to the care of older people, our results showed that there is poor relevance on the patients’ burden of treatment. Only two CPGs (Management of Type 2 Diabetes Mellitus and Management of Hypertension) had a higher agreement between the appraisers compared to other CPGs in relation to management of medical conditions in older patients. As a conclusion it was found all 5 Malaysian CPGs evaluated were in good quality but need improvement in terms of involving stakeholder in the development of CPGs at par with other developed countries.

Estimating the Costs of Managing Complications of Type 2 Diabetes Mellitus in Malaysia

This study aimed to estimate current direct costs for managing type 2 diabetes mellitus (T2DM)-related complications including ischaemic heart diseases (IHD), myocardial infarction (MI), stroke, heart failure (HF), amputation, blindness, renal failure (RF) requiring haemodialysis (end-stage renal disease) and diabetic foot ulcer in the event year and subsequent year. Initially, diabetes-related complications are defined based on the Malaysian Clinical Practice Guidelines (CPGs) or published literatures while each resource unit was valued using local costing obtained from the public hospital or other sources. The interventions for the management of complications were supported by evidence in the Malaysian CPGs or local literature and confirmed by the physicians related to the field who are working at the public hospital. All costs were converted to the value of USD currency in the year 2016. On the whole, macrovascular diseases incurred the highest management cost with MI employing the highest management cost (USD4,528.37) in the event year, while the management of heart, failure disease incurs the highest management cost at USD524.79 for subsequent year management. End-stage renal disease was associated with the highest annual per-patient costs, with mean first year and subsequent year costs for haemodialysis estimated at USD9,905.37 and USD9,233.89. In studying the costs of managing of diabetes-related complications, these data are vital economic evaluation for diabetes interventions, particularly in managing complications to macrovascular and microvascular functions, as it contributes significantly to the economic burden in Malaysia’s public healthcare; hence significantly affecting the proportion of the overall healthcare costs.

Effectiveness of the EMPOWER-PAR Intervention on Primary Care Providers’ Adherence to Clinical Practice Guideline on the Management of Type 2 Diabetes Mellitus: A Pragmatic Cluster Randomised Controlled Trial

AIM: The objective of this study was to evaluate the effectiveness of the EMPOWER- participatory action research (PAR) intervention, a multifaceted strategy based on the chronic care model (CCM) on primary care providers (PCP)’ adherence to type 2 diabetes mellitus (T2DM) clinical practice guideline (CPG) in the Malaysian primary care setting.&#x0D; METHODS: This was a pragmatic cluster randomized controlled trial –PAR conducted in ten public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. The outcome measure was the absolute change in the proportion of PCP’s adherence to T2DM CPG captured using the “Indicators of Care Pro forma,” based on the recommendation by the Malaysian CPG on the Management of T2DM. Data were collected from the patients’ medical records, at baseline and at 1-year follow-up; and were analyzed using mixed method model.&#x0D; RESULTS: A total of 888 patients were recruited at baseline; 471 were in the intervention and 417 were in the control group. There was no significant demographic difference between the two groups at baseline except for ethnicity. At 1-year, 455 (96.6%) and 406 (97.3%) patients in the intervention and control groups completed the study, respectively. There were significant improvements in the absolute change in the proportion of PCPs’ adherence to T2DM CPG in the intervention group compared to the control group at 1-year follow-up in several indicators of care. These included the recording of BMI (0.6% vs. −1.8%, p&lt;0.001); performing foot examination (2.4% vs. 0.6%, p&lt;0.001); performing funduscopy/fundus photography (1.5% vs. 0.3%, p&lt;0.001); monitoring renal profile (0.9% vs. −0.6%, p=0.001); measuring urine protein (1.2% vs. 0.6%, p&lt;0.001), and giving lifestyle modification and self-management advice (1.2% vs. −0.3%, p&lt;0.001) in the intervention versus control groups, respectively.&#x0D; CONCLUSION: The EMPOWER-PAR intervention has been proven to be effective in improving the PCPs’ adherence to T2DM CPG in several indicators of care. Findings from this study provided objective evidence of the effectiveness of multifaceted intervention based on the CCM in the Malaysian public primary care setting.&#x0D; TRIAL REGISTRATION: Registered with: ClinicalTrials.gov: NCT01545401. Date of registration: 1st March 2012.

Adherence to the Malaysian clinical practice guideline for depression by general practitioners in private practice in Penang.

Most primary care in Malaysia is provided by general practitioners in private practice. To date, little is known about how Malaysian General Practitioners (GPs) manage patients with depression. We surveyed privately practising primary care physicians in the state of Penang, Malaysia, in relation to their experience of the Malaysian Clinical Practice Guideline (CPG) in Major Depressive Disorder, their current practice and perceived barriers in managing depression effectively. A questionnaire based on the study aims and previous literature was developed by the authors and mailed to all currently registered GPs in private clinics in Penang. Survey responses were analysed using SSPS version 21. From a total of 386 questionnaires distributed, 112 (29%) were returned. Half of the respondents were unaware of the existence of any CPG for depression. One quarter reported not managing depression at all, while one third used anxiolytic monotherapy in moderate-severe depression. Almost 75 % of respondents reported making referrals to specialist psychiatric services for moderate-severe depression. Time constraints, patient non-adherence and a lack of depression management skills were perceived as the main barriers to depression care. Our findings highlight the need to engage privately practising primary care physicians in Malaysia to improve their skills in the management of depression. Future revisions of the Malaysian Depression CPG should directly involve more GPs from private practices at the planning, development and implementation stages, in order to increase its impact.

The right eye abducens nerve palsy as a cranial neuropathy of dengue fever: The benefit of corticosteroids in an unusual dengue sequela

Dengue fever is very common in tropical climate countries and the number of reported cases in Malaysia shows an increasing trend recently, according to the Malaysian Clinical Practice Guidelines. Although dengue fever is common, cranial nerve mononeuropathy is a very rare manifestation in relation to other neurological-associated syndromes. We report a rare case of cranial mononeuropathy of dengue fever in Malaysia and highlight the option of steroid usage as an alternative treatment to hasten the neurological recovery. The patient, a 25-year-old healthy policeman, presented with symptomatic viral fever, which was serologically confirmed as dengue fever. He developed acute-onset binocular diplopia, which was secondary to right eye isolated abducens nerve palsy during the critical phase of dengue fever. His visual acuity was 6/6 in both eyes with slightly restricted abduction of the right eye, consistent with right abducens nerve palsy, which was confirmed with a Hess test. There was corresponding diplopia over the right paracentral visual field. Urgent contrasted brain imaging was done, which ruled out the life-threatening intracranial pathology; therefore, a diagnosis of possible subclinical inflammatory changes causing sixth nerve palsy was made. Subsequently, he was treated with intravenous methylprednisolone 500 mg daily for 3 days and regained full extraocular muscle movement after 1 week. Oral steroid was not initiated. In conclusion, although the isolated unilateral cranial mononeuropathy may improve spontaneously within a certain period of time, a short course of systemic corticosteroids may be considered to hasten the recovery, as it has a favourable outcome.